Dermatology

impetigo - managment

Advice and information

• Usually heals completely and without scarring, serious complications rare

• Hygiene measures (soap and water, topical 1% hydrogen peroxide cream, wash with antimicrobial emollient eg Dermol, avoid scratching, wash hands after touching or applying cream, avoid sharing towels, flannels etc.)

• Stay away from school/work until lesions dry/scabbed, or for 48hrs after Rx started

• Follow-up if no improvement after 7 days

Topical Rx (localised infection)

• Fusidic acid tds-qds 5-7/7

Oral Rx (extensive or at risk of complications, bullous impetigo)

• Flucloxacillin qds 5-7/7

• Erythromycin or clarithromycin if penicillin allergy

Tinea corporis (ringworm)

• common where?

• common organisms

Infection on trunk legs or arms

Trichophyton rubrum

Microsporum canis (acute red patches with pustules)

Tinea corporis (ringworm)

• presentations

Single or multiple lesions

Grow slowly

Erythematous, scaly with annular border

Can be central clearing

White lines in lesion when organism very inflammatory

Can be itchy

Tinea corporis (ringworm)

• treatment

Treat associated tinea pedis (feet)

Topical antifungal cream

• Terbinafine - ≥ 12 years

• Miconazole - ≥ 2 years

Oral antifungal (extensive or pustular)

• Terbinafine - ≥ 2 years

Tinea cruris

• where

• common organism

Groin, upper thigh and buttocks

Commonly bilateral

Trichophyton rubrum

Epidermophyton floccosum

Tinea cruris

• presentation

Red scaly expanding patch

Diagnosis and treatment as for tinea corporis

can itch

Tinea cruris

• treatment

Treat associated tinea pedis

Dry groin separate towel

Avoid occlusive or synthetic clothing

Lose weight

Add hydrocortisone for itching if needed

Tinea pedis

• presentations

• organism

Dry scaling lesion on the sole, heel and sides of foot

Blisters and pustules on sides of feet or instep

Moist peeling itchy skin in interdigital space (athlete’s foot)

Red scaly patches on the dorsum of foot

Trichophyton rubrum

Trichophyton interdigitale

Tinea pedis

• treatment

Topical antifungal (terbinafine 2 weeks; miconazole 2-4 weeks now a single dose terbinafine film forming solution)

Systemic treatment if nail involved

Keep feet well ventilated

Prophylactic topical treatment once or twice a week

Tinea capitis

• where

• organism

Scalp

common in children

common in boys

Trichophyton tonsurans

Microsporum canis

Tinea capitis

• presentation

Single or multiple patches of hair loss

Scaling erythema and pustules are variable

Scaling can occur without hair loss

Can be itchy

Can see black dot pattern

Can form a kerion: inflamed boggy mass – refer

Can Fluoresce under Wood’s light

Tinea capitis

• treatment

Risk of scarring alopecia – systemic agents used

• Oral antifungal

  • Terbinafine

  • Itraconazole (second line)

  • Griseofulvin (second line children)

At least twice weekly topical ketoconazole for first 2 weeks reduces transmission

Treat family members with shampoo too

Kerions use oral antifungal, can be for 12-16 weeks

Onychomycosis

• causes

Dermatophytes – tinea unguium

• Trichophyton rubrum

• Trichophyton interdigitale

Yeasts

Moulds

Onychomycosis

• clincial finding

• Toenails more than fingers

• Single or multiple nails affected

• Tinea unguium associated with interdigital infection, tinea pedis or tinea manuum

• Can be white or yellow opaque line on side of nail

• Subungal hyperkeratosis: scaly thickening

• Distal onycholysis: nail lifts and end crumbles

• Superficial involvement: white powdery surface

Onychomycosis

• treatment

Topical treatment

• Low cure rate

• Distal nail infection up to 50% nail

• ≤ 2 nails involved

• Superficial infection

• Amorolfine 5%: 6 months fingers 9-12months toes

• Tioconazole solution twice daily for 6-12 months

Oral antifungal

• Terbinafine 250mg once a day 6 weeks for fingernail 12-16 weeks for toenails

• Treat associated tinea pedis

• Keep nails short

• Replace old footware - spores

• Once or twice weekly topical antifungal to feet if recurrent

Pityriaisis versicolor

• caused by what

• where

Caused by the yeast-like fungus Malassezia furfur (Pityrosporum ovale )

Usually found on back and chest, can spread onto upper arms, neck and abdomen

asymptomatic sometimes itchy

Appears slowly, may take months to be noticed – not contagious

Pityriaisis versicolor

• presenations

Oval lesions

Spread and become confluent

Fawn colour or pink in light skin

Pale in dark skin

Fine surface scale

Asymptomatic sometimes itchy

Fluoresce under Wood’s light

Pityriaisis versicolor

• treatment

Small area

• Ketoconazole shampoo lathered daily on skin and left for 5 minutes for 5 days

• Do not use topical or oral steroids – can exacerbate the condition

Treatment failure or widespread

• Itraconazole orally 200mg daily for 7 days also if widespread

• Can take several months for skin to gain original colour sometimes a lot longer

Recurrent episodes

• Continue ketoconazole shampoo once every 2-4 weeks for 6 months

Oral Candidiaisis

• presentations

White patches that peel leaving raw skin

Smooth red patches on tongue with sore mouth

Oral candidiasis

• treatment

Miconazole oral gel or nystatin suspension

Angular cheilitis

• diagnosis/ Ix

Check FBC, ferritin and vitamin B12

Swab if think secondary bacterial infection

Angular cheilitis

• presentation

• Treatment

Painful cracking and fissures

Thick emollient for dribbling

Miconazole oral gel

With steroid if significant inflammation

Fucidin if staphylococcal isolated

Treat any oral infection and dentures at night

Candidal intertrigo

• where

Between toes (athlete’s foot)

Web spaces of hands

Under breasts

Groin

Under abdominal skin folds

Napkin dermatitis

Candidal intertrigo

• mangement

Swab or skin scrapings for diagnosis

Keep area dry and clean

Topical antifungal and topical steroid (Daktacort cream BD 2-4 weeks)

Consider Trimovate cream if significant inflammation

Pityriasis rosea

• can minic what

secondary syphilis but this has lesions on soles and palms

Can be itchy

Reported to be associated with miscarriage in early pregnancy

Sometimes follows URTI

Pityriasis rosea

• presentations

Herald patch appears first

Bright red with fine scale

Sharp border

2-5cm diameter

Few days (1-20) later multiple dull pink oval patches appear on trunk and limbs occasionally face in children

Runs along Langers lines parallel to ribs

Gives xmas tree distribution

Brown discolouration can last for few months more

Hyperpigmentation (black and pale skin) or less commonly hypopigmentation in black skin

Does not involve scalp, palms or soles, rarely the face in children

Consider secondary syphilis as differential

Pityriasis rosea

• treatment

Use emollients and mild topical steroids for itch

Recurrence uncommon (1-3%) triggered by another infection

Inoculation herpes simplex

• finger and face

Fingertips – whitlow; sometimes recurrent

Face - rugby players ‘scrumpox’

Hand, foot and mouth disease

• where

• cause

Acute viral illness characterised by vesicular eruptions in/around mouth and papulovesicular lesions on the extremities

Commonly due to coxsackie A16 virus (A10 and echovirus)

children <10yrs age, most common in <4 year olds

hand, foot and mouth disease

• presentations

Prodrome may last 12-36hrs (low grade fever, anorexia, malaise, cough)

Sore mouth with or without fever before the rash appears

Ulcerative lesions in the mouth – hard palate, tongue, buccal mucosa

Macules to papules to vesicles to yellow-grey ulcer

May coalesce; tongue can be red and oedematous

Resolve 5-7 days

Erythematous, macules or papules appear on hands > feet

Can have a grey central vesicle

May be asymptomatic or painful

Lesions crust

Resolve 5-10 days

Buttock, groin and leg areas may also be affected

hand, foot and mouth disease

• mangement

Reassurance and advice (hygiene, avoid close contact, do not pierce blisters, exclude from school initially while unwell)

Encourage oral fluid intake and soft diet

Symptomatic relief for painful oral lesions

• Paracetamol

• Oral ulcer gels

• Saline mouth rinses

• Benzydamine spray

Molluscum contagiosum

• cause

Skin disease rather than rash as may only have a single lesion

Caused by a pox virus - 4 distinct classes, molluscum contagiosum virus type 1 (MCV-1) causes most

Molluscum contagiosum

• presentations

Characteristic flesh-coloured, umbilicated pearly papules

Molluscum contagiosum

• mangement

Reassure that it is a self-limiting condition

Avoid sharing towels, baths etc. advise not to scratch lesions

Treatment not usually recommended

Can be treated with trauma (squeezing or piercing after a warm bath)

Cryotherapy may be used in older children or adults

Warts and verrucae

• caused by what

Small rough growths caused by infection of keratinocytes by certain strains of Human Papilloma Virus (HPV)

Warts

• mangement

Pairing – Soak in warm water 5-10mins; pare away with disposable file or emery board; repeat 1-2 times per week

Salicylic acid

Duct tape

Cryotherapy

Curettage and cautery – filiform warts especially on the face; other warts; 30% recurrence rate

Laser treatment

Anogenital warts – usually seen in adults, consider GUM referral for full screening (treated with cryo or antimitotics eg podophyllotoxin)

Plantar warts - management

Difficult to treat

Pain is usually caused by pressure on thickened skin – paring

Exceptional circumstances:

Cryotherapy – not generally recommended – high failure rate, many cycles for cure, painful with blistering

Formaldehyde gel – applied once a day for 6 weeks; expensive

Scabies

• causes

Caused by mite, Sarcoptes scabiei var. Hominis

Scabies

• presentations

Itch effects trunk and limbs and is worse at night

In first episode itch appears 4-6 weeks after infestation, within hours of subsequent episodes

Generalised erythematous papular rash: hypersensitivity reaction; commonly on fingers, flexor surfaces wrist; axillae; abdomen; buttocks and genitals

Papules or nodules: shaft of penis, scrotum groin virtually pathognomonic in men

Itchy nipples with papular rash common; characteristic in women

Burrows: irregular tracks common on sides of fingers, in web spaces, borders of hands, wrists and feet; pathognomonic if found

Face and scalp rarely involved except infant and bed-bound elderly

Vesicles and pustules more common in infants especially on palms and soles

scabies

• treatment

5% permethrin cream

scabies

• Itch can persist for up to 6 weeks after eradication

  • treatemnt

Eurax

Hydrocortisone

scabies

• Rash can persist for several weeks

  • treatment

Moderately potent steroid cream

Crusted scabies

• treatment

Frequent applications of permethrin

Oral ivermectin single dose

lice

• presentation

Scalp itch, usually not affect sleep

Bites especially around nape of neck

Inflammation on scalp from scratching or reaction to bites

Lymphadenopathy sometimes

hair lice

• treatment

Topical insecticides

• 4% dimeticone lotion (Hedrin)

• Isopropyl myristate and cyclomethicone (Full Marks solution)

• Coconut, anise and ylang ylang spray (Lyclear Spray Away)

• 0.5% malathion aqueous liquid

Pubic lice

• treatment

Topical insecticide: 0.5% malathion; 5% permethrin

Treat eyelashes with simple eye ointment

Viral Exanthems

• what is it?

• presetnation

Widespread rash

Febrile child especially if >72 hours or high >39o

Cough

Rash, even if child getting better

Not eating

Vomiting and/or diarrhoea

Confirmation of diagnosis

Roseola Infantosum

• what is it?

• common cause

• presentations

sixth disease; erythema subitum

Caused by human herpesvirus (HHV) 6B and 7

Sudden high fever (around 39 ° C); lasts for 3-5 days

Sore throat

Coryza

Cough

Swollen eyelids

Lymphadenopathy in the neck

Mild diarrhoea and/or vomiting

Appetite loss

Malaise

Many HHV infections are asymptomatic; some do not have rash

Roseola infantosum

• rash charateritis

Develops as fever settles (3-4 days)

Some other symptoms may persist

Blanching rose-pink papules and patches

Some may have a white surround

Starts on and spreads over trunk, to limbs

Tends to spare the face and feet

Lasts ~2 days

Roseola infantosum

• mangement

Bed rest

Fluids – little and often

Antipyretics :

• Paracetamol

• Ibuprofen

Antibiotics?

• Do not give antibiotics

• Contagious from ~2 days before the fever until 1-2 days after the fever has settled, symptoms may continue

Erythema Infectiosum

• caused by what?

• presentation

fifth disease; slapped-cheek syndrome

Caused by Parvovirus B19

Fever (around 38 °C)

Coryza

Headache

Myalgia

Mild nausea and/or diarrhoea

Pruritus especially soles

rash

Arthralgia:

• Adults, especially women

• Small joints of hands and feet

• Symmetrical pain/stiffness for 1-3 weeks, sometimes months

Erythema Infectiosum

• rash apperance

Slapped-cheek rash appears 5-7 days after start of prodrome illness

Lace-like maculopapular rash on trunk and limbs after a further 1-2 days; can be itchy

Rashes fade after 1-2 weeks

Trunk rash can recur with heat, exercise, stress for a few weeks

Erythema infectiosum

• Investigations and management

Serology: pregnancy; at risk complications

Rest

Fluids

Paracetamol/Ibuprofen:

• Antipyretic

• Myalgia

Antihistamine and/or emollients

• Itch

Contagious from start of illness until the rash appears – children

Healthy adults – not need to stay off work if symptoms controlled – avoid pregnant women

Erythema infectiosum

• complication: transient aplastic crisis

  • Sx

  • Tx

Erythropoiesis stops

Associated with:

• Chronic haemolytic conditions - Sickle cell; thalassaemia

• Immunodeficiency

Shortness of breath

Fainting

Pale

Tired

Confused

Transfusions

Immunosuppressants stopped – if possible

Erythema infectiosum

• complication in pregancy

Foetal disease

Hydrops fetalis

No evidence of long term abnormalities if survive

Intrauterine transfusions

Chicken pox

• cause

• reactivations gives what?

Chicken pox

• clinical features

Fever

Rash

After 1-2 days:

• Coryza

• Headache

• Nausea

• Myalgia

• Itch

• Malaise

• Appetite loss

Chicken pox

• rash appearce

Chicken pox

• ix and Mangement

chicken pox

• complications - secondary bacterial infection to what?

Measles

• cause

Also called first disease

Morbillivirus of paramyxovirus family

Measles

• clincila features

measels rash appearnce

Koplik’s spots

• what is it

• seems in what and where

measles - Dx

IgM antibodies

PCR – oral fluid, urine, throat swab

measels - Tx

Mumps

• cause

• Sx

Virus from paramyxovirus family

More common in winter and spring

Fever

Headache

Anorexia

After 24 hours

• Earache

• Ipsilateral parotid gland pain and swelling over 2-3 days

• Contralateral parotid swelling within 2 days

  • Unilateral ~25%

• Usually settles within 1 week

Munps

• mangement

Rest

Fluids; avoid citrus juices

Paracetamol/ibuprofen

Contagious for up to 7 days after onset of parotid swelling

Rubella

• cuase

Virus of the togavirus family

rash

Children

• Asymptomatic

• Mild Fever

Adults

• Fever

• Headache

• Sore throat

• Coryza

• Conjunctivitis

• Malaise

Lymphadenopathy

• Occipital; posterior auricular; cervical

• Tender and can be all over the body

• May appear before the rash

• Can last >2 weeks after rash settled

Arthralgia

Rubella rash

• presentations

May be first sign in children

Maculopapular rash starting behind ears

Spreads to face; neck; then trunk; extremities

Non-confluent

Lasts 3-5 days

May be itchy in adults

Difficult to distinguish from other viral infections

Rubella

• Mangement

Rest

Fluids

Paracetamol/ibuprofen

Contagious for up to 1 week after rash appears (6 days); moderately contagious

Avoid pregnant women: congenital rubella syndrome (CRS)

Vaccination history of contacts

No extra risk if immunocompromised

Rubella in pregnancy

Refer urgently to obstetrics if ≤ 20 weeks gestation

No treatment to prevent CRS

Other viral pathogens may be isolated:

Parvovirus B19; Varicella-zoster; Herpes simplex; Cytomegalovirus – also associated with congenital infection – seek specialist advice

Congenital rubella syndrome

• complications/presentations

Microcephaly

Learning disability

Deafness

Eye abnormalities

Congenital heart disease

Can develop type 1 DM and thyroid problems

Aggravating factors for psoriasis

Streptococcal infection — strongly associated with guttate psoriasis

Medications — eg lithium, antimalarials, beta-blockers, NSAIDs, ACEI, antibacterials eg tetracycline and penicillin).

Sun exposure — usually beneficial, but may exacerbate psoriasis in a around 10% of patients

Trauma — Koebner phenomenon

Hormone changes (eg puberty, post-partum, menopause)

Psychological stress

Excessive alcohol intake

Smoking

Obesity

Other: HIV infection and AIDS, environment (for example change in climate),

Key features of Psoriasis

symmetrically distributed

well-defined

red, scaly plaques and/or papules

Common sites: scalp, elbows and knees BUT any part of the skin can be involved

Psoriasis

• Dx and Ix

PASI Score (Psoriasis Area and Severity Index)

PGA (Physician’s Global Assessment) score

DLQI (Dermatology Life Quality Index)

PEST(Psoriasis Epidemiology Screening Tool) to assess for joint involvement

BP

Weight/BMI

Blood sugars

Lipid Profile

how is Severity of psoriasis measured?

Psoriatic - mangement

Topical Therapy

Creams, lotions, or gels are suitable for widespread psoriasis

Ointments are suitable for areas of skin with thick scale

Lotions, solutions, or gels are suitable for hair-bearing areas

Phototherapy

Systemic Therapy: Eg Methotrexate, Ciclosporin, Acitretin

Biologics: see PASI and DLQI scores - >10: eg, infliximab, interleukin antagonists

Chronic plaque psoriasis of trunk and limbs

• tx

Management of scalp psoriasis

¡Important to remove thick scale in order for Rx to work

¡Topical potent corticosteroid

¡Coal tar shampoos (but not to be used alone if scalp psoriasis severe)

¡Vitamin D analogues

¡Combination prep if poor response or refer on if further treatment advice required

Management of facial/flexural/genital psoriasis

¡Emollient

¡Short term mild or moderate topical steroid (may cause irritation and greater risk of adverse effects)

¡Topical Rx alone unlikely to  be effective if extensive disease (>10% of body involved)

¡(Topical calcineurin inhibitors – off licence)

Management of guttate psoriasis

¡If not widespread:

• ¡Reassure, self limiting condition which usually resolves in 3-4/12

• ¡Topical Rx as for trunk and limb psoriasis

¡Treatment of underlying infections

¡Refer for consideration of phototherapy if >10% BSA involvement

Management of nail psoriasis

¡Generally very difficult to treat

¡No Rx required if mild disease

¡Mainly advice:

• ¡Keep nails short — this avoids exacerbating onycholysis (detachment of the nail from the nail bed) and reduces the accumulation of material under the nail

• ¡Avoid manicure of the cuticle — this may provoke paronychia (infection of the nail bed);  Avoid prosthetic nails

¡Refer to dermatologist if severe or having major functional impact

Lichen planus

• cause

Pruritic eruption commonly associated with hepatitis C

Human herpes virus and VZV also implicated as triggers (and stress/anxiety)

Characterised by purple papules, polygonal and peripherally located (distal extremities)

Lichen planus

• Clinical presentation (forms)

Actinic (sun-exposed areas)

Annular (tends to affect axillae)

Hypertrophic (tends to be on shins, looks like warts)

Atrophic

Erosive

Linear

Pigmented (oval grey/brown flat marks on trunk or limbs)

Vesicular/bullous (rare, usually affects lower legs)

Scalp (patchy alopecia)

Can also affect genital area

Typical Clinical presentation of lichen planus

Papules shiny, violaceous, polygonal

Varying size 1mm to >10mm diameter

Discrete or arranged in lines or circles

May have characteristic fine white lines over surface – Wickham striae

Clinical presentation of lichen planus

Mucous membrane involvement common, may affect people without cutaneous LP

Lesions most commonly on tongue and buccal mucosa

White or grey streaks forming a reticular or linear pattern on a violaceous background

Ulcerated oral lesions may have higher incidence of malignant transformation in men

Lesions may also be found on conjunctivae, larynx, oesophagus, tonsils, bladder, vulva, vagina and throughout the gi tract

Genital involvement common in LP

Annular lesions on glans in men

Vulval involvement more variable, from papules to severe erosions; dyspareunia, burning and pruritus common

Nail findings in about 10% (eg onycholysis)

Cutaneous lesions may be accompanied by ones on scalp (lichen planopilaris)

lichen planus

• management

Self limiting disease, usually resolves in 8-18 months (some types can last for years though)

Mild cases – no Rx if no irritation

Moderate cases - potent topical steroids (0.05% clobetasol propionate) – withdraw as rash and itch begin to clear

• Steroid sparing creams eg tacrolimus for more delicate areas

More severe or widespread cases (esp with scalp, nail and mucous membrane involvement) – more intensive Rx

• Systemic steroids

• Oral or topical retinoids

• PUVA/UVB therapy

• Methotrexate, hydroxychloroquine (esp. if hair/nails affected)

• For oral lesions – steroid gel, mouthwash

Pemphigus vulgaris

• mainly in who?

Potentially fatal blistering disease

Occurs in all races but commoner in Ashkenazi Jews

Onset usually in middle age; 50-60yrs

Pemphigus vulgaris

non-itchy flaccid bullae (particularly involving trunk)

Bullae rapidly denude, leaving erythematous, weeping, painful erosions

Mucosal involvement common

Pemphigus vulgaris

• treatment

Emollients, wound care

Topical Steroids - Potent steroids in combination with oral

Systemic Steroids (mainstay of treatment) - Prednisolone 1-1.5 mg/kg/day

Adjuncts: Other immunosuppressants used as steroid-sparing agents (eg azathioprine, mycophenolate)

Bullous pemphigoid

• features

Can be very itchy

Often starts with pruritus, urticaria and erythematous lesions

Large tense bullae develop

Appear anywhere on the skin, often involves trunk, limbs, flexures

• Localised B.P can also occur. Less common and usually limited to lower extremeties

Mucosal involvement uncommon but can be present

Patients generally appear well, despite extensive blistering

Bullous pemphigoid

• Investigation & MANAGEMENT

Dermatitis herpetiformis

• associated with what?

gluten enteropathy

M > F

Dermatitis herpetiformis

• Clinical features

Symmetrical distribution

Extensor surfaces (knees, elbows, scalp, buttocks)

Small (papules / vesicles) that are intensely itchy and often grouped

Crusted erosions left behind from scratching

Remissions and exacerbations common

Dermatitis herpetiformis

• Investigation & management

Epidermolysis bullosa

• what is it?

A group of genetically determined skin fragility conditions characterised by blistering of the skin and mucosae following mild mechanical trauma

Often appears at or shortly after birth

features of Epidermolysis bullosa

management of Epidermolysis bullosa

Actinic Keratoses

• where?

• presentations

• size

Localised areas of sun damage

Present as scaly/rough areas on an erythematous base

Common on sun exposed sites

Men > women

Backs of hands, forehead, nose, upper lip,

usually < 1 cm across