4. Mildly potent Hydrocortisone (0.5-1.0%)
Topical steroids can be combined to use in ointments (for dry skin) or creams (for weeping or wet skin). They have therapeutic use in both eczema and psoriasis.
Side effects: - epidermal atrophy (thinning)
telangiectasia (blood vessels)
striae (stretch marks)
premature aging due to collagen loss
exacerbation of skin infection
2. a) Lupus erythematosus is an autoimmune disorder which occurs in two main forms-SLE (systemic lupus erythematosus), which affects both the skin and internal organs, and discoid lupus erythematosus (DLE), in which the skin alone is affected. A small proportion of people suffering from DLE may subsequently develop SLE. A third variant, SCLE (subacute cutaneous lupus erythematosus) is characterized by distinctive skin lesions which MAY be associated with systemic features.
b) Dermatomyositis is an autoimmune inflammatory disease of skin and muscle which may occur in childhood or adult life. There are no differences in the manifestations of the disease of these two age groups, although only the adult variant may be associated with systemic malignancy (and may not) and the childhood variant shows vasculitis and calcinosis, which are NOT seen in the adult variant.
- violaceous (violet color) erythema on face and anterior neck. This is known as “heliotrope erythema”
erythema to dorsa of hands, dorsa of fingers, over knees and elbows
erythematous papules on knuckles
CHILDHOOD variant has vasculitis whichskin ulceration in axillae and groins
- anywhere from no muscle disease to profound muscle weakness can be found.
proximal, symmetrical weakness and wasting.
Arthralgia, pulmonary fibrosis may be present
c) There are two forms of neurofibromatosis, NFT-1 (chromosome 17) and NFT-2 (chromosome 22) both autosomal dominantly inherited syndromes with cutaneous manifestations.
NFT-2 cataracts, bilateral acoustic neuromas and CNS tumors
Tuberous sclerosis is a dominantly inherited disorder, but many cases are sporadic and represent new mutations. There are hamartomatous malformations in skin and internal organs. The condition contains cutaneous and non-cutaneous lesions:
- numerous pink papules on face (aka adenoma sebaceum) which are angiofibromas (CT and small blood vessels)
CT naevus on back (aka shagreen patch)
Hypopigmented macules (aka ash-leaf macules)
Ash leaf macules present at birth usually, but the other lesions (adenoma sebaceum and shagreen patch) present about age 5-6.
Non-cutaneous: mental retardation, epilepsy, hamartomas (pulmonary, renal) and cardiac rhabdomyomas.
d) Graves disease is a form of hyperthyroidism, whose cutaneous signs may include:
- pretibial myxoedema (subcutaneous deposition of excessive amounts of mucopolysaccharide leading to erythema and thickening over shins and dorsa of foot.
- Pruritis (seen in hypothyroidism and hyperthyroidism)
HyPOthyroidism leads to:
- dry thick skin due to subcutaneous mucin deposition (myxoedema)
- yellowish skin due to carotene deposition
- periorbital edema
- thin hair
- loss of outer part of eyebrow
There is NO significant association between classical Granuloma annulare and diabetes, but in a much RARER generalized form of granuloma annulare there IS an association with diabetes. Typically, lesions are firm skin-colored papules arranged in rings, occurring on the dorsa of hands and feet. CUTANEOUS manifestations of diabetes mellitus include:
necrobiosis lipoidica diabeticorum (erythematous yellowish brown, atrophic, typically on shins. May ulcerate).
Diabetic dermopathy (small brown scar like lesions on shins, thought to be associated with diabetic microangoipathy)
Diabetic bullae (uncommon)
Xanthomas (due to hyperlipidemia)
Acanthosis nigricans (associated with insulin resistance)
Characteristics of dermatological lesions can be summarized as:
Macule: circumscribed FLAT area of skin discoloration
Papule: circumscribed ELEVATION of skin LESS than 0.5 cm in diameter.
Nodule: circumscribed ELEVATION of skin MORE than 0.5 cm in diameter
Plaque: circumscribed, disc-shaped, elevated area of skin:
Small LESS than 2 cm diameter
Large MORE than 2 cm diameter
Vesicle: small visible collection of fluid (less than 0.5 cm diameter)
Bulla: large visible collection of fluid (more than 0.5 cm diameter)
Pustule: Visible accumulation of pus
Ulcer: loss of epidermis, often with loss of underlying dermis and subcutis as well
Weal: Circumscribed elevated area of cutaneous edema
Dermatitis is not characteristically scaly-it’s characteristically itchy
Typically scaly is psoriasis
Golden yellow crust on the skin refers to impetigo. Impetigo is a highly infectious skin disease in children, which presents as weeping, exudative areas with a honey- colored crust on the surface. It’s spread by direct contact. Group A -Strep (aka Strep.pyogenes) and Staph Aureus are the causative agents.
Violaceous lesions are found in dermatomyositis. Since dermatomyositis is a autoimmune connective tissue disorder causing erythematous regions on elbows, knees, knuckles, face and neck, this statement is true.
Bulla is a large visible collection of fluid more than 0.5 cm in diameter, while vesicle is a small visible collection of fluid less than 0.5 cm in diameter.
Weals are pathognomic of urticaria
Small pus-filled blisters are called pustules
Urticaria is the clinical term for disorders characterized by formation of “weals.” (swellings of skin which disappear leaving no visible sign). The main pathological change is dermal edema due to vascular dilatation, often in response to histamine released by mast cells. The skin itches and stings-weals develop and lesions become extensive and appear in many sites at once- “always clear spontaneously within a few hours. A plaque is a raised flat lesion.
Malignant tumors may metastasize to the skin, and tumors of the kidneys, ovaries, gastrointestinal system, breast and bronchus are most likely to do so.
Scalp metastases may produce areas of alopecia (alopecia neoplastica)
Alopecia areata is an autoimmune form of alopecia and is NOT associated with neoplasm
Lymphatic extension to skin can produce erythematous induration called carcinoma erysipeloides.
Metastases of ovarian and git can spread via ligamentum teres and present as an umbilical nodule (Sister Joseph’s nodule).
Cutaneous signs of underlying malignancy include:
hypertrichosis lanuginosa (sudden growth of profuse vellus hair over the face and body)
6. Patch testing is based on the delayed type (Type 4) hypersensitivity, mediated by macrophages and T-cells. It is useful in allergic drug reactions and eczema (dermatitis). Since occupational dermatitis may include a contact allergic component, patch testing may be useful. Since patch testing is to evaluate type four hypersensitivity, latex allergy (type 1) is not effectively evaluated using patch testing. Likewise, atopic dermatitis and food allergies are type 1, IgE mediated hypersensitivity and thus patch testing is not useful for their diagnosis.
The principal symptom of eczema is itching. Erythema, edema, papules, vesicles and exudation are common. Chronic forms may show lichenification. Eczema is classified into exogenous and endogenous groups, with the following included in each:
Exogenous: - primary irritant contact dermatitis
- allergic contact dermatitis
Endogenous: - atopic eczema (IgE mediated, associated with atopic asthma and allergic rhinitis)
seborrheic dermatitis (involved Mallasezia yeasts, most commonly on scalp, face, flexures and upper back; no cure but steroid lotions, ketoconazole shampoo and combinations of steroid/imidazole may be useful)
discoid eczema (scattered and well-demarcated exuding/crusting eczema of unknown cause)
varicose eczema (chronic venous HTNeczematous changes on legs which spreads to forearms. Treatment=topical steroid)
palmoplantar eczema (long term topical steroids treat)
asteatotic eczema (“eczema craquele” (paving pattern over legs usually, secondary to aging effect on decreasing lipid content of stratum corneum)
Acne is seen on face, neck (posterior mostly), upper back, anterior chest, shoulders and ears. Severe acne may extend to the arms. The skin appears greasy due to increased production of sebum. Lesions include comedones (whiteheads and blackheads), papules, pustules, nodules, scars and cysts.
Androgens stimulate increased sebum production
Hair follicles in sebaceous gland block (not narrow) with hyperkeratinization
The closed comedo results
Within the follicle, obligate anaerobe (Propionibacterium acnes) proliferates.
Propionibacterium acnes acts on sebum, releasing inflammatory chemicals
Inflammatory chemicals leak into the dermis
Body mounts an acute inflammatory response, leaving a pustule, papule or nodule.
Benzoyl peroxide (reduces comedones)
Sulfur and astringents
Topical antiseptics, antibiotics and combination products
Antibiotics (Tetracyclines and erythromycins)
Iso-t-retinoin (Vitamin A derivative-may affect LFTs)
Cyproterone acetate (only in women-acts as anti-androgen)
Rosacea is a common inflammatory rash affecting the face. Onset is middle age and it’s commoner in women. Cause is unknown. Clinically, it causes flushing, papules, pustules affecting nose, forehead and cheeks. There are NO comedones, but there MAY be telangiectasia, blepharitis, conjunctivitis. In men, keratitis and sebaceous gland hypertrophy of the nose causes rhynophyma.
Treatment - topical metronidazole
oral iso-t-retinoin (in resistant cases)
**steroids must be AVOIDED as they exacerbate or trigger this condition**
Syphilis is a chronic systemic disease, acquired or congenital. The causative organism, Treponema pallidum, is acquired by close sexual contact or transplacentally. The disease is split into primary, secondary and tertiary stages
Exposure to pathogen
10-90 days passes
Primary: - papule develops at site of inoculation
papule ulcerates to form painless firm chancre
30-70 days pass
Secondary: - General: fever, sore throat, malaise and arthralgia. Generalized lymphadenopathy is common (50%)
Maculopapular NONitchy rash
Condyloma lata (warty, plaque-like lesions in perianal area and other moist sites
Ulcerated mucosal surfaces
Latency period may occur (may last 2 years)
Tertiary:- Gummas (granulomatous ulcerating lesion) found in skull, clavicle, tibia, fibula and viscera`
Cardiovascular and neurosyphilis can occur
Alopecia can occur
The herpes viruses have several subtypes, each of which has a unique clinical presentation:
- includes: HSV-1 cold sores on lips and face
HSV-2 genital herpes
While the trends above are generally true, there is NOT a rigid territorial demarcation and lesions anywhere may be caused by either antigenic type
Contact with HSV-1 is usually contracted in early childhood. Developing lesions are most often mild. RARELY, a severe gingivostomatitis develops with painful erosions on buccal mucosa and lips. Genital herpes results from sexual transmission of HSV-2 or orogenital transmission of HSV-1. Physical contact in sport can also cause HSV transmission.
HSV settles in sensory ganglia and is triggered by immunocompromise, etc.
Recurrent HSV can trigger erythema multiforme (target lesions). Prophylactic oral acyclovir is of great benefit in these cases.
Eczema herpeticum: widespread herpes simplex infection occurring in atopic eczema lymphadenopathy in head and neck
If extensive, admit and give IV Aciclovir.
Herpes zoster (shingles):
Chicken pox and shingles are both caused by the VZV (varicella zoster virus). Following chicken pox, virus remains dormant in dorsal root ganglia until something restimulates it, causing shingles in the distribution of a dermatome, most often in abdomen or thorax. “grouped vesicles on an erythematous base” Immunocompromise may result in multiple dermatomes being affected.
Postherpetic neuralgia is the persistence of pain after the lesions have healed, associated with herpes zoster.
12. Candida infection: Candidiasis is a term applied to infections of the skin and mucous membranes by yeast of genus Candida. The yeast Candida albicans is commonest and is normally commensal in gastrointestinal tract. In pathogenic forms, budding and mycelial forms are usually present. When situations favor its multiplicationHerHerHer (topical and systemic steroids, immunosuppression, broadspectrum antibiotics, diabetes, etc), it can cause:
- buccal mucosal candidiasis (oral thrush)
- angular cheilitis (inflammatory process at corners of mouth)
- paronychia (thickened erythematous nail fold+loss of cuticle)
- balanitis and vulvovaginitis: creamy vaginal discharge and itchy vulval erythema.
- diaper rash
Generally, lozenge or topical nystatin or imidazoles are helpful in treatment.
Kerion is a nodular, boggy, exudative, circumscribed lesion covered in pustules, occurring usually in association with tinea barbae and tinea capitis, but occasionally by other fungi. It is more common in those of African origin and is often accompanied by severe alopecia.
referred to as “ringworm of the”, followed by “feet,” “groin,” “scalp,” etc, or can also be referred to as “tinea” followed by “pedis” (foot), “cruris” (groin),”capitis” (head), “manuum” (hand), “unguium” (toenail), etc.
belong to one of three genus (Microsporum, Trichophyton, Epidermophyton).
Tinea unguium causes thick, discolored brittle nails (onychomycosis)
All dermatophytes secrete keratinase, which digests keratin, thus forming scaling of skin, loss of hair and crumbling of nails.
small areas of skin for tinea pedis/ corporis/ cruris/ manuum:
Tinea Capitis: MUST use oral griseofulvin. Terbinafine and Imidazoles are less effective against tinea capitis, probably because Trichophyton rubrum isn’t associated, instead it’s Trichophyton tonsurans or Microsporum that are implicated.
Tinea unguium: nail infections are not responsive to topical treatments and long-term oral therapy is needed with oral terbinafine for 6 weeks in fingernails and 12 weeks in toenail infections. Contraindications to terbinafine should use oral itraconazole pulse therapy.
See question 8:
There is no evidence that changing diet alters acne vulgaris. Current treatments include: TOPICAL
retinoids and retinoid-like agents
sulfur and astringents (make skin flaky and unblock hair follicles)
topical antiseptics, antibiotics (tetracyclines, erythromycin and clindamycin) or combinations
cyproteron acetate (anti-androgen, use only in women)
iso-t-retinoin (Vitamin A derivative)
steroids (esp. in acne fulminans)
Onychomycosis is another term for tinea unguium (ringworm of the nail).
Since ringworms are in fact fungi, onychomycosis is in fact a fungal nail infection.
The population prevalence of fungal nail infections (tinea unguium) is between 2 and 8%, according to the Australian Association of dermatology (online)
Fungal nail infections do not respond well to topical treatments, unless the nail is thin and the infection is minimal (usually fungal infections make the nail thick, however, rendering the topical treatments useless). Effective treatment of tinea unguium requires 6 weeks (fingernail) or 12 weeks (toe-nail) oral terbinafine or oral pulse itraconazole.
Tinea capitis can cause alopecia of a non-scarring variety (on its own). However, tinea capitis is associated with kerion formation, and kerion can cause scarring alopecia.
Gianotti crosti syndrome (aka infantile acrodermatitis, popular acrodermatitis of childhood): a generally benign and self-limited disease of young children, characterized by nonpruritic, red, flat topped firm papules forming symmetrical eruption on face, buttocks and limbs (INCLUDES palms and soles!). Associated with malaise, low grade fever. Cause is viral infection, often Hepatitis B.
Kawasaki disease: syndrome of unknown cause, usually affecting young children, associated with vasculitis of large coronary vessels, causing cervical lymphadenopathy, and maculoerythematous skin eruption. Skin becomes indurated and edematous. Aneurysms of coronary vessels is common and thus echocardiography must be performed after resolution of symptoms
Varicella Zoster virus (VZV) causes chicken pox and shingles. Chicken pox most commonly, after a 2 week incubation period, causes fever, headache and rash. The rash starts on the face and trunk and spreads to cover the whole body, including mucus membranes. In immunocompromised, pneumonia (inflammation of lungs with consolidation) and encephalitis may occur. Pneumonitis (inflammation of lungs) thus also occurs.
Guttate psoriasis often develops suddenly, and may follow an infection, especially “strep throat.” It’s a common way for psoriasis to present in young adults. “Gutta” means “drop,” as most lesions are about 1cm in diameter and paler in color than established plaque psoriasis. The main differential for guttate psoriasis is pityriasis rosea. These can be distinguished as below:
Guttate psoriasis Pityriasis rosea
- parakeratotic scale - “herald patch” of large red oval scaly
- round lesion - oval lesion
Leishmania is zoonotic, carried by rodents,dogs and foxes, transmitted to humans by the bite of the sandfly. Following transmission, the leishmania invades phagocytic cells and multiplies within the phagocytic cells in the lymph nodes, spleen, liver and bone marrow (reticuloendothelial system). Leishmaniasis can form three different clinical pictures depending on the T-cell response of the host.
A skin ulcer develops at the site of the sandfly bite, heals within a year if host responses are intact (simple cutaneous leishmaniasis). If immune system is deficient, nodular skin lesion arises without ulceration. Numerous nodular lesions are found across the body, especially around the nose (diffuse cutaneous leishmaniasis).
Dermal ulcer at site of sandfly bite is followed by erosion of nasal septum, soft palate, and lips.
Sandfly transmits leishmania who months later complains of abdominal discomfort and distension, low-grade fevers and weight loss. Invasion of the reticuloendothelial cells cause hepatomegaly and MASSIVE splenomegaly.
Psoriasis affects up to 2% of the population of Western countries. Psoriasis generally doesn’t present until youth or early adulthood.
While one psoriasis variant is palmo-plantar pustulosis (erythematous patches with pustules on palms and plantar surfaces, that turn brown and scaly then peel off), most cases of psoriasis do NOT involve the palm.
Guttate psoriasis commonly presents after “strep throat” particularly in young adults.
Although a family history is common, there is no clear cut inheritance pattern and the “genetic” explanation may not be readily understood by patients.
The Koebner phenomenon (aka “isomorphic” phenomenon) is a cutaneous response of lesions on uninvolved skin typical of skin disease at sites of trauma, scars or points of pressure. It is seen in psoriasis (general plaque psoriasis), lichen planus, infectious eczematous dermatitis and plane warts (HPV virus is inoculated into scratches and abrasions).
Dermatitis herpetiformis, aka linear IgA disease, is associated with celiac disease, and most often presents with erythematous papules and vesicles on elbows, knees, shins, shoulders and scalp. The itch may result in excoriations, secondary eczematization and lichenification.
18. Dithranol is a first choice, but patient lifestyle or side-effects may make it impractical. If so, vitaminD analogues or topical steroids (with or without tar/salicylic acid) are often used. UV may help. Extensive lesions or poor response lead to PUVA, retinoid (2nd line) or cytotoxic drug use. Under no circumstances should oral steroids be used.
19. Drugs that can aggravate psoriasis include lithium, chloroquine and hydroxychloroquine, beta-blockers, NSAIDs and ACE inhibitors.
While difficult to quantify, it is generally agreed that stress can aggravate psoriasis.
Sun can exacerbate psoriasis in some patients, even though UV is more often helpful in psoriasis.
Dithranol is a first choice in plaque psoriasis and works by an unknown mechanism. It is often so effective that the plaque disappears completely. However, it can exacerbate psoriasis in some patients, especially when applied to previously non-affected skin.
Actinic or solar keratoses are areas of dysplastic squamous epithelium without invasion, but they DO have low-grade malignant potential and their presence indicates unstable epithelium.
Red scaly patches wax and wane with time.
Common sites:light exposed areas (face, forearms, dorsa of hands, lower legs, bald scalp).
Treatment: For small numbers of lesions, use cryotherapy.
For large areas of face and scalp affected, use topical antimitotic agent 5-fluorouracil.
In elderly, may be best to do nothing
(old bastards croak before actinic keratosesSCC)
It is estimated (by www.skincancer.org/ak/index.ahp) that 2-5% of all actinic keratoses progress to SCC, but this usually takes a very long time.
Basal cell carcinomas are the commonest malignant skin tumor and are also known as “rodent ulcers.”
Clinically: - rolled edge (spreads outward leaving central depression)
metastases are extremely rare but local invasion is extensive and destructive (can spread along bone into skull)
affects predominantly the face, but can be anywhere on sun-exposed areas (esp. scalp, behind ear, on trunk)
can be pigmented, superficial, or morphemic (ivory waxy) as well.
Treatment depends on type:
- SUPERFICIAL curettage, cryotherapy or photodynamic therapy
- Morphoeic or other excision, biopsy and radiotherapy
SCCs are locally invasive and metastasize to regional lymph nodes and beyond. UV radiation is an important cause as is smoking (lip and mouth SCC) and HPV (genital SCC).
Clinically keratotic lump OR
Polypoid mass OR
SCC may be surrounded by actinic keratoses.
Sites: lips, mouth, genitals, sun-exposed areas (legs)
Treatment surgical removal and radiotherapy
Photosensitive reactions have been reported for several drugs. Clinically, patients complain that sun exposure is followed by a burning sensation (not on urination), followed by erythema, swelling and eczematous changes on light-exposed areas.