dermatology in general practice dr lynne rees. description of skin lesions papule macule nodule...
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Dermatology in General Practice
Dr Lynne Rees
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Description of skin lesions
Papule Macule Nodule Patch Vesicle Bulla Plaque
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Papule
Small palpable circumscribed lesion <0.5cm
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Macule
Flat, circumscribed non-palpable lesion
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Pustule
Yellowish white pus-filled lesion
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Nodule
Large papule >0.5cm
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plaque
Large flat topped elevated palpable lesion
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patch
Large macule
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vesicle
Small fluid filled blister
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Bulla
A large fluid filled blister
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ECZEMA
Synonymous with dermatitis Large proportion of skin disease in
developed world 10% of population at any one time 40% of population at some time
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Features of eczema
Itchy Erythematous Dry Flaky Oedematous Crusted Vesicles lichenified
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Types of eczema
Atopic Discoid eczema Hand eczema Seborrhoeic eczema Varicose eczema Contact and irritant eczema Lichen simplex
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Atopic eczema
Endogenous Atopic i.e asthma, hay fever 5% of population 10-15% of all children affected at some
time
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Exacerbating factors
Detergents Infection Teething Stress Cat and dog fur ???? House dust mite ???? Food allergens Theory of protection from parasite
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Clinical features
Itchy erythematous scaly patches Flexures of knees and elbows Neck Face in infants Exaggerated skin markings Lichenification Nail – pitted ridged
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complications
Bacterial infection Viral infections – warts, molluscum,
herpes Keratoconjunctivitis Retarded growth
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investigations
Clinical ??IgE ??RAST
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Prognosis
Most grow out of it! 15% may come back – often very mildly
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Treatment
Avoid irritants especially soap Frequent emollients Topical steroids Sedating antihistamines – oral hydroxyzine Treat infections Bandages Second line agents
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Triple combination of therapy
Topical steroid bd as required Emollient frequently Bath oil and soap substitute
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Principles of treatments
Creams Ointments Amounts required Potential side effects Soap substitutes
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creams
Cosmetically more acceptable Water based Contain preservatives Soap substitutes
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ointments
Oil based Don’t contain preservative Feel greasy Good for hydrating
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Topical steroids
Mild – “hydrocortisone Moderate – “eumovate” Potent – “betnovate” Very potent – “dermovate”
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Amounts required
Emollients – 500g per week for total body
FTU – steroids Bath oils – 2-3 capfuls per bath
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Discoid eczema
Variant of eczema Atopic and non atopic Easily confused with psoriasis Well demarcated scaly patches Limbs Often infective component (staph
aureus)
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Hand eczema
Pompholoyx – itchy vesicles or blisters of palm and along fingers
Diffuse erythematous scaling and hyperkeratosis of palms
Scaling and peeling at finger tips
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Hand eczema
Not unusual in atopic More common in non atopics Cause often uncertain Irritants Chemicals Occupational history Consider patch testing – 10% positive
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Seborrhoeic eczema
Over growth of yeast (pityrosporum ovale, hyphal form malassezia furfur)
Strong cutaneous immune response More common in Parkinson’s and HIV
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Clinical features
Affects body sites rich in sebacceous glands
Infancy – cradle cap, widespread rash, child unbothered, little pruritus
Young adults – erythematous scaling eyebrows, nasolabial folds, forehead scalp
Elderly – more extensive
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Treatment
Suppressive Mild steroid and antifungal combination Ketoconazole shampoo Emollients Soap substitutes
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Venous eczema
Lower legs Venous hypertension Endothelial hyperplasia Extravasation of red and white cells Inflammation Purpura pigmentation
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Clinical features
Older women Past history DVT Haemosiderin deposition
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treatment
Emollients Topical moderately potent steroids Soap substitutes Compression – check arterial supply
first Leg elevation
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Asteatotic eczema
Dry skin Repeated soaping Worse in winter Hypothyroidism Avoid soap Emollients Bath oils
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Contact and irritant eczema
Exogenous Unusual Worse at workplace History of exacerbations
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irritant
Can occur in any individual Repeated exposure to irritants Common in housewives, hairdressers,
nurses
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contact
Occurs after repeated exposure but only in susceptible individuals
Allergic reaction Common culprits – nickel, chromates,
latex etc Patch testing
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Lichen simplex
Cutaneous response to rubbing Thickened scaly hyperpigmentation Emotional stress May need biopsy to diagnose
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treatment
Stop rubbing! Very potent steroids Occlusion
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PSORIASIS
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Psoriasis
Affects 2%of population Well-demarcated red scaly plaques Skin inflamed and hyperproliferates Males and females equally Two peaks of onset (16- 22) and later
(55-60) Usually family history
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Chronic plaque
Extensor surfaces Sacral area Scalp Koebners phenomenon
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Guttate psoriasis
Raindrop Children and young adults Associated with streptococcal sore
throats Not all go onto get chronic plaque May resolve spontaneously over 1-2
months
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Guttate psoriasis
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Flexural psoriasis
Later in life Well demarcated red glazed plaques Groin Natal cleft Sub mammary area No scale
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Treatment
Calcipotriol too irritant Steroid
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Erythrodermic and pustular psoriasis More severe Need dermatologist! Usually need oral therapy
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Associated features
Arthritis Nail changes- onycholysis, pitting,
discolouration, subungal hyperkeratosis
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prognosis
Chronic plaque tends to be lifelong Guttate – 2/3 further attacks, or develop
chronic plaque
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treatment
Suit patient Control rather than cure Topical therapies Light treatments Oral therapy
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Topical therapy
Emollients Vit D analogues- calcipotriol, calcitriol,
tacalcitol (dovonex, silkis, curatoderm) Tazarotene – (zorac) Coal tar – alphosyl, exorex, cocois, polytar Dithranol –dithrocream, dithranol 0.1% to 2%
for short contact Steroids – eumovate Combinations – dovobet, alphosyl HC, etc
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Light treatments
Not the same as sun beds!!!! UVB UVA
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ACNE VULGARIS
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Cause of acne
Common facial rash Usually adolescents May occur in early and mid adult life Blockage of pilosebacceaous unit with
surrounding inflammation Androgens lead to increase sebum
production Increased colonisation by propionibacterium
acnes
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Clinical features
Increased seborrhoea Open comedones Closed comedones Inflammatory papules Pustules Nodulocystic lesions
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Acne distribution
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Treatment
Consider site Compliance Inflammatory/non inflammatory lesions Scarring Fertility Psychological effect
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Topical treatments
Benzoylperoxidase – OTC, PanOxyl 5 to 10%,
Azelaic acid – skinoren ,avoid in pregnancy Antibiotics – clindamycin, erythromycin,
steimycin Retinoids – adapalene, tretinoin, avoid in
pregnancy, avoid uv light, differin, retin-A
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Combination topical treatments
Antibiotics plus benzoyl peroxidase – benzamycin
Retinoid plus antibiotic – isotrexin Antibiotic plus zinc - zineryt
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Oral therapy
Use if topical therapy ineffective or inappropriate
Anticomedonal topical treatment may be required in addition
Don’t combine topical with oral antibiotic as encourages resistance.
Consider side effects and interactions when starting antibiotics
3 to 4 months before any improvement
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Antibiotics
Oxytetracycline 500mg bd Tetracycline 500mg bd Doxycycline 100mg od Minocycline 100mg od Erythromycin 500mg bd
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Hormone treatment for acne
Dianette - not if COCP contraindicated– Withdraw when acne controlled– VTE occurs more frequently in women
taking dianette than other cocp.
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Oral retinoids
Hospital only Long list of side effects Teratogenic Very effective
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ROSACEA
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Clinical features rosacea
Onset middle age Facial flushing / erythema Inflammatory papules Pustules No comedones Telangectasia Blepharitis rhinophyma
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Treatment
Supressive rather than curative Topical metronidazole 0.075% Tetracycline 500mg bd for 3 months Metronidazole 400mg bd Roaccutane Plastic surgery and some laser therapy
for rhinophyma
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COFFEE
TIME