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SKIN DISORDERS

Part 1Part 1

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MaculeMaculeA macule is a localized area of A macule is a localized area of color or textural change in the color or textural change in the skin. Can be- hypo pigmented: skin. Can be- hypo pigmented: vitiligo pigmented : freckle (a) Or vitiligo pigmented : freckle (a) Or erythematous (red): erythematous (red): capillary hemangioma (b).capillary hemangioma (b).

PapulePapulesmall solid elevation small solid elevation less than 5 mm in diameter-less than 5 mm in diameter-flat topped: lichen planusflat topped: lichen planusDome shaped: xanthomasDome shaped: xanthomas

NoduleNoduleLike a papule but larger Like a papule but larger (greater than5 mm in diameter), (greater than5 mm in diameter), dermato-fibroma and secondary dermato-fibroma and secondary depositsdeposits..

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VesicleVesicle

A vesicle is a small blister (less than 5 A vesicle is a small blister (less than 5 mm in diameter) consisting of clear mm in diameter) consisting of clear fluid accumulated within or below the fluid accumulated within or below the epidermis.epidermis.

BullaBulla

A bulla is similar to vesicle but larger:A bulla is similar to vesicle but larger:

greater than 5 mm in diameter. greater than 5 mm in diameter.

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PustulePustuleA pustule is a visible collection of freeA pustule is a visible collection of freepus in a blister. Pustules may indicatepus in a blister. Pustules may indicateinfection (e.g. a furuncle), infection (e.g. a furuncle), Cyst:Cyst:A cyst is a nodule consisting of anA cyst is a nodule consisting of anepithelial-lined cavity filled with fluidepithelial-lined cavity filled with fluidor semi-solid material. An epidermalor semi-solid material. An epidermal('sebaceous') cyst is shown below.('sebaceous') cyst is shown below.

WhealWhealA wheal is a transitory, compressibleA wheal is a transitory, compressiblepapule or plaque of dermal edema,papule or plaque of dermal edema,red or white in color and usuallyred or white in color and usuallysignifying urticaria.signifying urticaria.

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PlaquePlaqueA plaque is a palpable, plateau-like elevation more than 2 cm A plaque is a palpable, plateau-like elevation more than 2 cm in diameter. Plaques are rarely more than 5 mm in height in diameter. Plaques are rarely more than 5 mm in height and can be considered as extended papules. and can be considered as extended papules.

ScaleScale..Scales usually indicate inflammatory change Scales usually indicate inflammatory change andthickening of the epidermis. andthickening of the epidermis.

Fine- 'pityriasis' (much smaller)Fine- 'pityriasis' (much smaller)Large and fish-like, as seen in ichthyosis.Large and fish-like, as seen in ichthyosis.

UlcerUlcerAn ulcer is a circumscribed area of skin lossAn ulcer is a circumscribed area of skin lossUlcers are usually the result of impairment Ulcers are usually the result of impairment of the vascular or nutrient supply to the skin, of the vascular or nutrient supply to the skin, due to peripheral arterial disease.due to peripheral arterial disease.

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Presenting complaint

An 18-year-old male bank clerk An 18-year-old male bank clerk developed a scaly erythematous plaque developed a scaly erythematous plaque on the left elbow six months ago. on the left elbow six months ago.

It spread to involve the other elbow and It spread to involve the other elbow and both knees, but both knees, but was not itchywas not itchy..

He developed scaliness in the scalp and He developed scaliness in the scalp and nail dystrophy. nail dystrophy.

His mother once had a similar rash.His mother once had a similar rash. What would be the most likely What would be the most likely

condition?condition?

PSORIASISPSORIASIS

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Past medical history A 29-year-old woman pulmonary sarcoidosis. A 29-year-old woman pulmonary sarcoidosis. Three weeks previously she had developed Three weeks previously she had developed

tender, warm erythematous nodules on the shins. tender, warm erythematous nodules on the shins. She was on no medication. An incisional biopsy She was on no medication. An incisional biopsy

confirmed the clinical impression.confirmed the clinical impression. List possible causes for red lumps (erythema List possible causes for red lumps (erythema

nodosum):nodosum): Sulfa drugs, sulfurous ingredients in foods.

Wine often as sulfur something in it. Aspirin Ulcerative colitis Sarcoidosis

African americans most at risk for this. Thyrotoxicosis Ulcerative colitis (on the shin)

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Social/ Occupational history

A 45-year-old male printer engineer gave a A 45-year-old male printer engineer gave a 6 month history of hand dermatitis 6 month history of hand dermatitis

A few months previously he had started to A few months previously he had started to use the solvent trichloroethylene in his job. use the solvent trichloroethylene in his job.

Patch testing was negative. On substituting Patch testing was negative. On substituting a different solvent the eruption cleared.a different solvent the eruption cleared.

What would be the most likely condition?What would be the most likely condition?

CONTACT DERMATITISCONTACT DERMATITIS

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Family history

A 25-year-old female shop assistant complained A 25-year-old female shop assistant complained of brownish maculesof brownish macules

During her teens, she had developed several soft During her teens, she had developed several soft pinkish, painless nodules on the trunk, some of pinkish, painless nodules on the trunk, some of which had become pedunculated. Her father and which had become pedunculated. Her father and one of her two brothers had brown patches on his one of her two brothers had brown patches on his skin.skin.

What would be the most likely condition?What would be the most likely condition?

NEUROFIBROMAS NEUROFIBROMAS

(von Recklinghausen's Disease)(von Recklinghausen's Disease)

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Family history

A 15-year-old schoolboy gave a A 15-year-old schoolboy gave a three-month history of an three-month history of an intensely itchy papular eruption intensely itchy papular eruption affecting the hands, wrists and affecting the hands, wrists and penis Several lesions were penis Several lesions were excoriated.excoriated.Treatment with a potent topical Treatment with a potent topical steroid was of little benefit. His steroid was of little benefit. His mother and sister had also mother and sister had also recently developed itchy lesions. recently developed itchy lesions. Close examination showed Close examination showed burrows in the skin.burrows in the skin.

Symptom Symptom Intensely itchy Intensely itchy eruptioneruptionPossible conditions:Possible conditions:√ √ ScabiesScabies√ √ Lichen planusLichen planus√ √ Dermatitis herpetiformisDermatitis herpetiformis√ √ UrticariaUrticaria√ √ EczemaEczema√ √ Insect bitesInsect bites

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Drug history An 18-year-old female secretary was given griseofulvin for a An 18-year-old female secretary was given griseofulvin for a

fungal infection. She went sun-bathing and 12 hours later fungal infection. She went sun-bathing and 12 hours later developed an eruption with a distribution in light-exposeddeveloped an eruption with a distribution in light-exposedareasareas

Drug induced photosensitivityDrug induced photosensitivity

A 68-year-old woman had a minor irritating eruption on her A 68-year-old woman had a minor irritating eruption on her forehead. She applied an antihistamine-containing cream which she forehead. She applied an antihistamine-containing cream which she bought in a chemists. Within 24 hours of applying it, her face bought in a chemists. Within 24 hours of applying it, her face became severely swollen.became severely swollen.

Abnormal anaphylactic rx. Abnormal anaphylactic rx.

Patch testing carried out laterPatch testing carried out latershowed an allergic reaction to the cream.showed an allergic reaction to the cream.

What would be the most likely condition?What would be the most likely condition?

Drug induced photosensitivityDrug induced photosensitivity

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Skin conditions by location SCALP: Psoriasis/ Seborrheic SCALP: Psoriasis/ Seborrheic

Dermatitis/ Contact Dermatitis/ Dermatitis/ Contact Dermatitis/ Nevus/ Epidermal cystNevus/ Epidermal cyst

FACE: Acne/ Rosacea/Impetigo/ FACE: Acne/ Rosacea/Impetigo/ Seborrhea Dermatitis/ Contact Seborrhea Dermatitis/ Contact Dermatitis/ Lupus/ Nevus/ Dermatitis/ Lupus/ Nevus/ Keratosis/ Warts/ Basal CancerKeratosis/ Warts/ Basal Cancer

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Skin conditions by location GENITALIA: Herpes Simplex/ GENITALIA: Herpes Simplex/

Scabies/ Psoriasis/ Syphilis/ Viral Scabies/ Psoriasis/ Syphilis/ Viral Warts/ Molluscum ContagiosumWarts/ Molluscum Contagiosum

GROIN: Tinea Cruris/ Psoriasis/ GROIN: Tinea Cruris/ Psoriasis/ Hidradenitis Suppurativa / Hidradenitis Suppurativa / Seborheic Dermatitis/ Skin Tag/ Seborheic Dermatitis/ Skin Tag/ Seborrheic WartSeborrheic Wart

LIMBS: Atopic eczema/ Psoriasis/ LIMBS: Atopic eczema/ Psoriasis/ Erythema multiforme/ Lichen Erythema multiforme/ Lichen Planus/ Nevus/ Dermatofibroma/ Planus/ Nevus/ Dermatofibroma/ Seborrheic WartSeborrheic Wart

FEET: Tinea pedis/ Contact FEET: Tinea pedis/ Contact Dermatitis/ Psoriasis/ Viral Warts/ Dermatitis/ Psoriasis/ Viral Warts/ Corn/ NevusCorn/ Nevus

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AXILLA: Hidradenitis AXILLA: Hidradenitis Suppurativa/ Suppurativa/

Tinea Corporis/ Seborheic Tinea Corporis/ Seborheic Dermatitis/ Skin Tag/ Dermatitis/ Skin Tag/

TRUNK: Acne/ Psoriasis/ TRUNK: Acne/ Psoriasis/ Pityriasis Rosea/ Tinea Pityriasis Rosea/ Tinea Versicolor/ Drug Eruption/ Versicolor/ Drug Eruption/ Nevus/Seborheic Wart/ Skin Nevus/Seborheic Wart/ Skin Tag/ Keloid/ Tag/ Keloid/

HANDS: Contact Dermatitis/ HANDS: Contact Dermatitis/ Atopic Eczema/ Psoriasis/ Atopic Eczema/ Psoriasis/ Scabies/ Viral Wart/ Actinic Scabies/ Viral Wart/ Actinic Keratosis/ KeratocarcinomaKeratosis/ Keratocarcinoma

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Folliculitis and Related Conditions Folliculitis Folliculitis is an acute pustularinfection of is an acute pustularinfection of

multiple hair follicles, multiple hair follicles, Furuncle (boil) Furuncle (boil) is an acute abscess is an acute abscess

formation in adjacent hair follicles, and formation in adjacent hair follicles, and Carbuncle (deep abscess) Carbuncle (deep abscess) is a deep abscess is a deep abscess

formed in a group of follicles giving a formed in a group of follicles giving a painful suppurating mass.painful suppurating mass.

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ImpetigoEtiology: caused by- Staphyloccocus aureus or

Group A beta-hemolytic Streptococcus

Spread by direct contact and most common in children

Highly contagious. Usually asymptomatic.

Physical: Superficial pustules covered by moist, honey-colored crusts; lesions may be localized or extensive; face and extremities commonly affected. Pt. nontoxic.

Saline compresses prn to remove crust.Consider intranasal mupirocin (bid x 5

—7 d) if recurrent.

Course: Generally self-limited; risk of post-strep glomerulonephritis (caused by strep)

Investigations: Culture and sensitivity.

DDx: Herpes simplex, eczema, contact dermatitis, scabies.

ManagementLocalized: Topical antibiotics (mupirocin

or fusidic acid tid).Generalized: Oral cephalexin, cloxacillin,

or erythromycin 7-10 d.

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Chickenpox (Varicella)Etiology: Varicella zoster virus Etiology: Varicella zoster virus

(VZV) causes chickenpox; after (VZV) causes chickenpox; after primary infection, herpes zoster primary infection, herpes zoster (shingles).(shingles).

History: Often pruritic. Usually mild, History: Often pruritic. Usually mild, self-limited illness in children; self-limited illness in children; more severe in adults; rarely more severe in adults; rarely complicated by staph/strep complicated by staph/strep bacterial super infection, bacterial super infection, pneumonia, cerebellar ataxia, pneumonia, cerebellar ataxia, encephalitis.encephalitis.

Physical: Characteristic exanthem—Physical: Characteristic exanthem—Crops of erythematous macules Crops of erythematous macules progress to edematous papules progress to edematous papules and finally vesicles over 24—48 and finally vesicles over 24—48 hr. Vesicles resemble “dew drops hr. Vesicles resemble “dew drops on rose petals.” Lesions are in on rose petals.” Lesions are in different stages (polymorphous).different stages (polymorphous).

Incubation: 10—21 d. Infectious from 4 d Incubation: 10—21 d. Infectious from 4 d prior to onset of lesions to crusting of prior to onset of lesions to crusting of final lesion (5 d after onset).final lesion (5 d after onset).

Investigations: Direct fluorescent antibody Investigations: Direct fluorescent antibody testing on fluid from vesicle basetesting on fluid from vesicle base

DDx: Other viral exanthema, drug eruption, DDx: Other viral exanthema, drug eruption, herpes simplex, insect bites.herpes simplex, insect bites.

Prevention: Vaccine now available.Prevention: Vaccine now available.TxTx

Supportive/symptomatic treatment in Supportive/symptomatic treatment in children.children.VZIG if immunocompromised or VZIG if immunocompromised or exposed neonate within 96 hr.exposed neonate within 96 hr.Oral antiviral therapy (acyclovir, Oral antiviral therapy (acyclovir, valacyclovir, famcyclovir) in selected valacyclovir, famcyclovir) in selected patient populations (diabetes, CF, HIV, patient populations (diabetes, CF, HIV, inborn errors of metabolism, severe inborn errors of metabolism, severe fulminant skin disease, & visceral fulminant skin disease, & visceral involvement).involvement).

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Herpes simplex and herpes zoster

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Herpes simplexHerpes simplex Type 1 infection: usually oro-Type 1 infection: usually oro-

facial, childhood onset.facial, childhood onset. Type 2 infection: mostly Type 2 infection: mostly

genital, adult onset.genital, adult onset. Characterized by recurrent Characterized by recurrent

bouts at the same locus.bouts at the same locus.

Herpes zosterHerpes zoster Recrudescence of dormant Recrudescence of dormant

Varicella zoster Varicella zoster virus.virus. Dermatomal, especially Dermatomal, especially

thoracic and trigeminal thoracic and trigeminal distributions.distributions.

Neuralgia may complicate, Neuralgia may complicate, mainly in the elderly. mainly in the elderly. Dissemination suggests Dissemination suggests underlying immuno- underlying immuno- suppressionsuppression

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Skin signs and the progressive stages of HIV infection (Centers for Disease Control

Group 1 (Primary phase)Group 1 (Primary phase) Transient maculopapularTransient maculopapular

eruption on trunkeruption on trunk II (Early phase: asymptomatic)II (Early phase: asymptomatic) Hypersensitivity reactions,Hypersensitivity reactions,

onset or worsening ofonset or worsening of

eczemas, psoriasis oreczemas, psoriasis or

folliculitis, wart virusfolliculitis, wart virus

and fungal infectionsand fungal infections

III (Persistent generalizedIII (Persistent generalized

Lymphadenopathy)Lymphadenopathy)

Herpes zoster, eczemas worsen, Herpes zoster, eczemas worsen, candidiasis, Kaposi's sarcomacandidiasis, Kaposi's sarcoma

IV (Symptomatic: AIDS)IV (Symptomatic: AIDS)

Candidiasis, opportunistic infections, Candidiasis, opportunistic infections, Kaposi's sarcoma, lymphomaKaposi's sarcoma, lymphoma

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Candidiasis Etiology: Etiology: Candida albicans Candida albicans yeast. yeast.

immunosuppressed patients, diabetics, after immunosuppressed patients, diabetics, after use of antibiotics, corticosteroids, or use of antibiotics, corticosteroids, or immunosuppressive agents; heat, humidity, immunosuppressive agents; heat, humidity, and shear friction promote infection.and shear friction promote infection.

History: History: warm and moist environment. warm and moist environment. Pruritic red rash. Pruritic red rash.

Investigations: Investigations: KOH microscopy KOH microscopy confirmatory fungal culture.confirmatory fungal culture.

DDx: DDx: Eczema, psoriasis, seborrhea dermatitis.Eczema, psoriasis, seborrhea dermatitis. Candidal intertrigo Candidal intertrigo groin and gluteal folds, groin and gluteal folds,

tinframammary region, axilla and the tinframammary region, axilla and the interdigital spaces of the hands and feet interdigital spaces of the hands and feet affected.affected.

Oral candidiasis Oral candidiasis thrush thrush Candida paronychia:Candida paronychia:Painful red swelling of Painful red swelling of

periungual skinperiungual skin

Management: Management: Avoid heat, humidity, Avoid heat, humidity, and tight-fitting clothing.and tight-fitting clothing.

Prevention TxPrevention Tx

■ ■ Identify and control underlying Identify and control underlying diseases, e.g., diabetes.diseases, e.g., diabetes.

■ ■ Topical antifungals: E.g., nystatin, Topical antifungals: E.g., nystatin, ketoconazole, clotrimazole, bid x 2 ketoconazole, clotrimazole, bid x 2 wkwk

■ ■ Oral antifungals in extensive Oral antifungals in extensive mucocutaneous infections: E.g., mucocutaneous infections: E.g., ketoconazole 200 mg po qd x 10 d.ketoconazole 200 mg po qd x 10 d.

■ ■ Vaginal candidiasis: Single dose Vaginal candidiasis: Single dose oral fluconazole 150 mg effective; oral fluconazole 150 mg effective; topical & suppositories can be tried.topical & suppositories can be tried.

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Fungal Infections

Tinea Tinea Corporis Corporis RingwormRingworm

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Tinea (Dermatophyte) Infections Etiology: Etiology: infect skin, nails, and hair; incubation 1—3 wkinfect skin, nails, and hair; incubation 1—3 wk..

Trichophyton, Microsporum, Epidermophyton Trichophyton, Microsporum, Epidermophyton species commonly species commonly involved. Human-to-human /animal-to-human / soil-to human spread.involved. Human-to-human /animal-to-human / soil-to human spread.

Risk Factors: Risk Factors: Hot, humid environments, sweating or maceration of the Hot, humid environments, sweating or maceration of the skin, occlusive footwear, diabetes mellitus, immunosuppression (e.g., skin, occlusive footwear, diabetes mellitus, immunosuppression (e.g., AIDS).AIDS).

History: History: occasionally mild pruritus.occasionally mild pruritus. Physical: Physical: Scalp hair and general body surfaces mostly affected during Scalp hair and general body surfaces mostly affected during

childhood; hand, foot, or nail infections are more common after puberty.childhood; hand, foot, or nail infections are more common after puberty. Investigations: Investigations: Skin scraping analysis with KOH prep/ culture (~4 wk to Skin scraping analysis with KOH prep/ culture (~4 wk to

ID dermatophyte species); biopsy—PAS or GMS stain can reveal presence ID dermatophyte species); biopsy—PAS or GMS stain can reveal presence of fungal elements.of fungal elements.

DDx: DDx: Eczema, granuloma annulare, psoriasis.Eczema, granuloma annulare, psoriasis.

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Tineas: Management Patient education: Avoid factors which predispose to infection, Patient education: Avoid factors which predispose to infection,

absorbent powders in intertriginous areas, e.g., for tinea pedis— absorbent powders in intertriginous areas, e.g., for tinea pedis— shower-shoes in public facilities.shower-shoes in public facilities.

Topical antifungals for tinea corporis/cruris/pedis (unless lesions are Topical antifungals for tinea corporis/cruris/pedis (unless lesions are extensive): Terbinafine, ciclopirox, clotrimazole, ketoconazole applied extensive): Terbinafine, ciclopirox, clotrimazole, ketoconazole applied qd or bid x 3 wk, or continue 1 wk until after resolution of lesions.qd or bid x 3 wk, or continue 1 wk until after resolution of lesions.

Systemic antifungals for tinea capitis.Systemic antifungals for tinea capitis.1. 1. Terbinafine (Lamisil)Terbinafine (Lamisil) 20 kg 62.5 mg po qd, 20—40 kg 20 kg 62.5 mg po qd, 20—40 kg

125 mg po qd, 40 mg 250 mg po qd x 2—4 wk.125 mg po qd, 40 mg 250 mg po qd x 2—4 wk.2. Micronized griseofulvin with food: 20 mg/kg/d po x 8 wk; 2. Micronized griseofulvin with food: 20 mg/kg/d po x 8 wk;

adults: 500 mg po qd x 1 mo.adults: 500 mg po qd x 1 mo.3. Patient and household contacts should use an antifungal shampoo, 3. Patient and household contacts should use an antifungal shampoo, such as selenium sulfide or ketoconazole to reduce spread.such as selenium sulfide or ketoconazole to reduce spread.

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Onychomycosis (Tinea Unguium) History: History: Change in nail color and more brittle; usually asymptomatic.Change in nail color and more brittle; usually asymptomatic. Physical:Physical:Yellow discoloration, thickening, nail dystrophy, subungual Yellow discoloration, thickening, nail dystrophy, subungual

hyperkeratosis, onycholysis. Toenails fingernails. hyperkeratosis, onycholysis. Toenails fingernails. Patterns Patterns include the include the distal subungual form (most common), the proximal white subungual distal subungual form (most common), the proximal white subungual form (may be a sign of HIV disease), and the white superficial form.form (may be a sign of HIV disease), and the white superficial form.

ManagementManagement■ ■ Topical antifungals much less effective. Ciclopirox (Penlac®) nail Topical antifungals much less effective. Ciclopirox (Penlac®) nail

lacquer lacquer ■ ■ Important to culture fungus prior to initiating oral Important to culture fungus prior to initiating oral TxTx■ ■ Terbinafine (Lamisil) 250 mg po qd x 6 wk for fingernails, x 12 wk Terbinafine (Lamisil) 250 mg po qd x 6 wk for fingernails, x 12 wk

for toenails; for toenails; Itraconazole (Sporanox) 200 mg po bid x 7 d, then 3 wk off—2 pulses Itraconazole (Sporanox) 200 mg po bid x 7 d, then 3 wk off—2 pulses for fingernails, 3 pulses for toenails.for fingernails, 3 pulses for toenails.

■ ■ Other less common options: Griseofulvin (esp. in kids), fluconazole.Other less common options: Griseofulvin (esp. in kids), fluconazole.

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Nevi and Malignant mealnomas (ABCD rule)

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Melanoma

Etiology: Etiology: Melanocyte-derived skin cancer. May arise Melanocyte-derived skin cancer. May arise within a previously existing nevus or dysplastic nevus, but within a previously existing nevus or dysplastic nevus, but ~70% arise ~70% arise de novo.de novo.

History:History:

Risk factorsRisk factors

■ ■ Fair complexion: Red/blonde hair, blue/green eyes, Fair complexion: Red/blonde hair, blue/green eyes, tendency to freckle and burn.tendency to freckle and burn.

■ ■ Sun exposure, particularly blistering sunburns during Sun exposure, particularly blistering sunburns during childhood.childhood.

■ ■ Personal or family history of melanoma; Genes involved in Personal or family history of melanoma; Genes involved in some cases:some cases:

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SKIN TUMOURS

Premalignant conditionPremalignant condition

Actinic keratosis Actinic keratosis

Intraepidermal carcinomaIntraepidermal carcinoma

?Dysplastic naevus?Dysplastic naevus

Malignant tumourMalignant tumour

Basal cell carcinomaBasal cell carcinoma

Squamous cell carcinomaSquamous cell carcinoma

Malignant melanomaMalignant melanoma

Kaposi's sarcomaKaposi's sarcoma

SecondarySecondary

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Basal Cell Carcinoma (BCC)

DDx: Melanoma, nevus, SCC.Investigations: Biopsy must beperformed to confirm diagnosis andclassify subtype.Advise that metastases and death areextremely rare. Vast majority cause nomajor problem, but should be treated.■ Tx options: Liquid nitrogencryotherapy/ curettage &electrodessication (most commonTx), excision, imiquimod (Aldara™)cream for superficial subtype, 5-FU,CO2 laser, radiation therapy.■ Advise on sun protection, regular Total

Body Self Exam.

Most common skin cancer Etiology: Chronic UV exposure, radiation, immuno suppression, genetics History: Persistent, non healing papule or nodule that ulcerates or bleeds. Common in elderly Caucasians.Physical: Pearly papule or nodule with telangiectases, rolled border; central crust or ulceration. Distributed mostly on sun-exposed areas, i.e., head and neck (85%).Variants: Cystic, superficial, nodular, sclerosing (morphea form), pigmented.

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Squamous Cell Carcinoma (SCC)2nd most common2nd most common form of skin cancer arising in sun exposed areas in elderly; form of skin cancer arising in sun exposed areas in elderly; Etiology: Etiology: Chronic UV-damage, immuno suppression, burns, leg ulcers, chemical Chronic UV-damage, immuno suppression, burns, leg ulcers, chemical

carcinogens (e.g., tar), HPV; can occur in discoid lupus, lichen sclerosus, & carcinogens (e.g., tar), HPV; can occur in discoid lupus, lichen sclerosus, & any scarring processes.any scarring processes.

History: History: Slow-growing, non healing scaly papule on sun-exposed area of head, Slow-growing, non healing scaly papule on sun-exposed area of head, neck, dorsal hands, and forearms; also affects mucous membranes (lower lip: neck, dorsal hands, and forearms; also affects mucous membranes (lower lip: M F, smokers, 10%—15% metastatic rate); rare in dark skin. Actinic keratosis M F, smokers, 10%—15% metastatic rate); rare in dark skin. Actinic keratosis is considered a precursor lesion; actinic cheilitis is the precursor on lip.is considered a precursor lesion; actinic cheilitis is the precursor on lip.

Physical: Physical: Firm indurated papule, plaque, or nodule with adherent rough scale.Firm indurated papule, plaque, or nodule with adherent rough scale.Investigations: Investigations: Biopsy (to mid-dermis) for confirmation.Biopsy (to mid-dermis) for confirmation.DDx: DDx: AK, BCC, KS, a melanotic melanoma, wart.AK, BCC, KS, a melanotic melanoma, wart.ManagementManagement

■ ■ Electrodesiccation & curettage.Electrodesiccation & curettage.■ ■ Excision.Excision.■ ■ Liquid nitrogen cryotherapy.Liquid nitrogen cryotherapy.■ ■ Micrographic surgery; less commonly topical imiquimod or radiation.Micrographic surgery; less commonly topical imiquimod or radiation.■ ■ Advice on sun protection, regular skin exams.Advice on sun protection, regular skin exams.

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PSORIASIS Chronic, non-infectious Chronic, non-infectious

inflammatory condition inflammatory condition characterized by well-characterized by well-demarcated erythematous (red) demarcated erythematous (red) plaques topped by silvery scalesplaques topped by silvery scales

Affects 1.5-3% of the Affects 1.5-3% of the population M =F (2nd-3rd and population M =F (2nd-3rd and 6th decades)6th decades)

Familial (35% of cases)Familial (35% of cases) Epidermal cell proliferation rate Epidermal cell proliferation rate

is increased 20 fold or more in is increased 20 fold or more in psoriasis (reduced from 28 days psoriasis (reduced from 28 days to 4 days)to 4 days)

Precipitating factors-Precipitating factors- Trauma to the epidermis Trauma to the epidermis

and dermisand dermis Strep throat Infection.Strep throat Infection. Drugs.Drugs. Beta-blockers, lithium Beta-blockers, lithium

and antimalarialsand antimalarials Sunlight.Sunlight. ExposureExposure Psychological stressPsychological stress..

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Eczema: 'to boil over'

Eczema is a non-infective inflammatory conditionEczema is a non-infective inflammatory condition ExogenousExogenous (contact)- Allergic, irritant, Photoreaction (contact)- Allergic, irritant, Photoreaction Endogenous- Endogenous- Atopic, Seborrhoeic, Discoid (nummular)Atopic, Seborrhoeic, Discoid (nummular)

Venous (stasis, gravitational), PompholyxVenous (stasis, gravitational), Pompholyx Unclassified- Unclassified- Lichen simplex (neurodermatitis)Lichen simplex (neurodermatitis)

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Atopic eczema ('Atopy’ defines an inherited tendency to an excessive IgE reaction )

Greek atopos meaning out of place Associated with a personal or family history of asthma, Associated with a personal or family history of asthma,

allergic rhinitis, conjunctivitisallergic rhinitis, conjunctivitis Uncontrollable scratching is prominent and the course is Uncontrollable scratching is prominent and the course is

remittingremitting

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Treatment

Emollients: Most eczema; ichthyosisEmollients: Most eczema; ichthyosis Topical steroids: Most types of eczemaTopical steroids: Most types of eczema Topical tacrolimus: Eczema e.g. hands, faceTopical tacrolimus: Eczema e.g. hands, face Tar bandage: Lichenified/excoriated eczemaTar bandage: Lichenified/excoriated eczema Oral antihistamine: PruritusOral antihistamine: Pruritus Oral antibiotic: Bacterial superinfectionOral antibiotic: Bacterial superinfection Exclusion diet: Food allergy/resistant eczemaExclusion diet: Food allergy/resistant eczema Psolaren+ UVA= PUVA, ciclosporin, and azathioprine: Psolaren+ UVA= PUVA, ciclosporin, and azathioprine:

Resistant and severe eczemaResistant and severe eczema