primary care dermatology dr mick mckernan. description of skin lesions papule macule nodule patch...
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Primary Care Dermatology
Dr Mick McKernan
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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 >2cm
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vesicle Small fluid filled blister < 1/2cm
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Bulla A large fluid filled blister > 1/2cm
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ECZEMA
=dermatitis 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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Atopic eczema individual must have: An itchy skin condition in the last 12
months+ three or more of: Onset before 2 years of age History of flexural involvement or flexural eczema currently present History of generally dry skin History of other atopic disease or FH
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Exacerbating factors Infection Teething Stress Cat and dog fur ? House dust mite ? Food allergens
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Clinical features Itchy erythematous patches Flexures of knees and elbows Neck Face in infants Exaggerated skin markings Lichenification Nail – pitted
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complications Bacterial infection Viral infections – warts, molluscum,
eczema herpeticum ( refer stat). Keratoconjunctivitis Retarded growth
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Prognosis Most grow out of it 15% may come back – often very
mildly Chronic skin dryness common after
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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- the least potent
that controls the symptoms. Bath oils – 2-3 capfuls per bath
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FTU Finger tip unit Helps to give estimation of topical
steroid amount used To avoid over and under use of
steroid
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FTU
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FTU 2 FTU = nearly 1 gram Enough for twice size of adult hand
A hand and fingers (front and back) = 1FTU A foot (all over) + 2FTU Front of chest and abdomen = 7FTU Back and buttocks = 7FTU Face and neck = 2.5 FTU An entire arm and hand = 4 FTU An entire leg and foot = 8 FTU
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Discoid eczema Variant of eczema 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 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 or dentinox shampoo Emollients Soap substitutes
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Venous eczema Gravitational = stasis eczema Lower legs Venous hypertension Inflammation Purpura pigmentation
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Clinical features Older women Past history DVT Haemosiderin deposition often misdiagnosed as cellulitis.
Cellulitis is nearly always unilateral, tender and has a well demarcated edge
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treatment Emollients Topical moderately potent steroids Soap substitutes Compression – check arterial
supply first Leg elevation
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Champagne bottle appearance of lipodermatosclerosis
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Lipodermatosclerosis and venous leg ulcer
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Cellulitis – unilateral painful and well demarcated.
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Asteatotic eczema =eczema craquele Dry skin 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 –bleaches and chemicals
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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 =Neurodermatitis 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 Step 1:Prescribe copious emollients - make the skin
more comfortable and reduce the amount of scale Step 2:Dovobet is the most effective vitamin D analogue
Avoid on areas of thin skin eg the face, flexures and the genitalia. Also consider dithranol and tar. Flares use topical steroids 2 weeks- erythroderma or generalised pustular psoriasis if overused.
Step 3 : for hospitals. Phototherapy , cyclosporin , UV, methotrexate
Step 4: biologicals : Etanercept, Infliximab, Adalimumab and Ustekinumab belong to the class of biological medicines called tumour necrosis factor (TNF) blockers. These work by blocking the activity of TNF.
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Erythrodermic and pustular psoriasis More severe > 90% involvement 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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ACNE VULGARIS
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Acne Vulgaris
Common facial rash Usually adolescents 3% may persist after 25yrs especially
women.
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Clinical features Increased seborrhoea Open comedones= blackheads Closed comedones= whiteheads Inflammatory papules Pustules Nodulocystic lesions scars
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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 Antibiotics – clindamycin, erythromycin,
steimycin Retinoids – adapalene
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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. 3 to 4 months before any improvement
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Antibiotics Oxytetracycline 500mg bd Tetracycline 500mg bd Doxycycline 100mg od Erythromycin 500mg bd Lymecycline 408mg od
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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 – caution ++ at this point.
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Oral retinoids Hospital only Long list of side effects Teratogenic Very effective Suicide- no proven link
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www.pcds.org.uk
Rashes are difficult!