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28/08/2015
Sarcoid
CMT
Dermatology
Urticaria
Dr Rachel Gardner
Glasgow Royal Infirmary
Objectives
• Comfortable identifying common dermatoses
• Consider more unusual derm conditions
• Differentiate between malignant and benign
lesions
Erythroderma
CMT Dermatology Teaching
• Dermatology terms
• Medical dermatology
• Surgical / lesion dermatology
• Skin conditions seen in systemic diseases
• Emergency referrals
• Summary / Questions
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28/08/2015
CMT Dermatology Teaching
• Dermatology terms
• Medical dermatology
• Surgical / lesion dermatology
• Skin conditions seen in systemic diseases
• Emergency referrals
• Summary / Questions
2
28/08/2015
ECZEMA
Mod –high dose steroids
Dermovate
Diprosone
Synalar
Frequent Greasy emollient
occlusion ICZ/ tubifast
Sedating antihistamines
Swab +Tx infection
33% resistance to Fucibet
Infantile atopic eczema
Common site for eczema in children
Exclude impetigo / herpes – bacterial + viral swabs
Treat with steroid/anti fungal combination Daktacort, Trimovate
Soap substitute
Emollient ++ 3-4 times/day 250g /wk
Occasionally marker for dietary allergy if large facial component
Emollients
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Quantity required in adults for twice daily
application for 1 week:
Face and neck 15-30g
Both hands 15-30g
Scalp 15-30g
Both arms 30-60g
Both legs 100g
Trunk 100g
Groins and genitalia 15-30g
Relieves itch
Individual preferences
Useful in all dry skin conditions
Reduce need for topical steroids
Available as bath additives, soap substitutes,
creams + ointments
• Large quantities eg 500g
• Apply liberally + frequently
Question 1
A 24 year-old male presents with a history of scaly plaques, that
bleed if they are picked, over the extensor aspects of his limbs.
The rash is mildly itchy and he also complains of increased
dandruff.
Hand eczema
Commonest subtype – Irritant, then allergic contact
Can be confused with hand psoriasis
Exclude tinea manum (fungal infection) esp if unilateral
Mainstay of treatment Emollient++, Soap / Perfume free regime / Gloves
Other treatments – Potent topical steroids, UVB /PUVA, altretinoin (Rare)
1 FTU = 0.5g
Topical Steroids
Mild eg 1% hydrocortisone
Moderate eg eumovate
Potent eg elocon
Super potent eg dermovate
Cream or ointment
Side effects
Apply 20-30 mins
after emollient
1 FTU will cover a surface area
equivalent to the palmer surface of
2 adult hands (including fingers).
30g tube = 60 FTUs
100g tube = 200 FTUs
1-2 year old child:
Entire face + neck
Entire arm + hand
Entire leg+ foot
Entire front of chest + abdomen
Entire back including buttocks
1.5 FTU
2 FTUs
3 FTUs
3 FTUs
3.5FTUs
Which nail sign would you least
expect to find with this
presentation?
A) Subungal hyperkeratosis
B) Onycholysis
C) Nail pitting
D) White spotting
E) Oil drop or Salmon spot
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Which nail sign would you least
expect to find with this presentation?
A) Subungal hyperkeratosis
B) Onycholysis
C) Nail pitting
D) White spotting
E) Oil drop or Salmon spot
Chronic Plaque
Psoriasis
Stubborn chronic recurrent disease
PASI DLQI
10% develop psoriatic arthritis
Recent association with metabolic syndrome , high cholesterol
Treatment- Emollient ++, Tar, Dithranol, Vitamin D analogues,
Tacrolimus
Phototherapy
Retinoids (Acitretin)
Immunosuppression (Methotrexate, Ciclosporin)
Biologics (Infliximab, Ustikunimab)
Scalp psoriasis
Question 2
A 30 year old man recently experiences a flare of
his psoriasis. Which one of the following
medications is least likely to cause a flare of
psoriasis?
A) Propanolol
B) Hydroxychloroquine
C) Ibuprofen
D) Risperidone
E) Lithium
Can be only site of psoriasis - may just present as mild “dandruff”
Difficult to treat
High score DLQI
Hairline, plaques, ears, chronic otitis externa, eyebrows
Treatment options Salicylic acid, Etrivex steroid shampoo, Dovonex, Xamiol,
Clarelux foam, Trimovate, Tacrolimus (Protopic), immunosuppression
Antifungals ie Nizoral unhelpful
Messy Tx Olive Oil, Cade Oil, Sebco/Cocois
Flexural (inverse)
Psoriasis
Question 3
A 24 year old chinese student presented with an intensely itchy
widespread rash over the lateral aspects of the trunk and back.
The rash began with a patch that remains prominent on his
thigh. He has been systemically well and reports no intercurrent
illnesses.
Difficult to treat
Often very symptomatic ( high DLQI score)
Aggravated by coexisting yeast/fungal infection
Steroid / Antifungal combination Trimovate, Lotriderm
Topical tacrolimus
Barrier creams
Immunosuppression, Biologics ( ie infliximab)
Closer inspection reveals a fir-tree distribution on his back and
fine collarettes of scale around some of the papules and plaques.
He has no history of atopy, but his mother and cousin are
asthmatic.
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What is the most likely diagnosis?
A) Guttate psoriasis
B) Atopic eczema
C) Pityriasis rosea
D) Pityriasis versicolor
E) Measles
What is the most likely diagnosis?
A) Guttate psoriasis
B) Atopic eczema
C) Pityriasis rosea
D) Pityriasis versicolor
E) Measles
Pityriasis Rosea
Tinea
Common
Adolescents and young adults
Self limiting
Mild itch
Associated with recent viral illness
Herald patch on trunk
Spares face, palm + soles
Christmas tree distribution
6-8 weeks to clear
Suspect if:
Unilateral
Worse with steroids
Usual sites
Skin scrapings / Nail
clippings
Topical and oral terbinafine
Pulsed itraconazole
Secondary Id reactions
Guttate psoriasis would have a
thicker silvery scale and plaques do What should you do?
not follow Christmas tree pattern. Check drug history to exclude a drug eruption
Reassure patient and wait!
Sore throat? FH psoriasis?
Erythema multiforme
Usually reactive, self limiting
Occasionally chronic / recurrent
Viral trigger ie HSV
Oral involvement
Treat symptomatically
? Aciclovir
Sunblock lips
Unusual progression to SJS
Keratosis Pilaris
Common
Rough follicular spots
Outer upper arms
Teenagers (babies and persist into adult life)
Hereditary
More common in atopic dermatitis
Rx Urea based creams, topical retinoids
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Lichen planus
Question 4
A 55 year old lady presents with patchy hair loss.
Examination shows smooth white patches of
scalp hair loss. At the edges of the patches there
is scale and redness around each hair follicle.
Which is the most likely diagnosis?
The 5 “p’s”
Oral / genital involvement
Pruritus +++
Idiopathic, drug induced
Wrists and ankles, symmetrical, localised or generalised
Scalp variant (Lichen planopilaris)
Sedating anti-histamines, potent topical steroids, occlusion
Rarely immunosuppression
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A Androgenetic alopecia
B Lichen Planopilaris
C Traction Alopecia
D Trichotillomania
E Alopecia Areata
Scabies
Itchy +++ papular rash
Wrists, finger webs, nipples, genitalia
Soles palms infants Check for lice too
Treat with permethrin (Lyclear dermal cream), Derbac M (malathion)
Neck down 8hrs repeated 7 days, incl head infants
Treat close contacts
Symptomatic relief with topical steroids, Eurax (chrotamitin) unhelpful
Itch can last >6 weeks post treatment
Ivermectin orally (unlicensed)
A Androgenetic alopecia
B Lichen Planopilaris
C Traction Alopecia
D Trichotillomania
E Alopecia Areata
Cutaneous
Lupus
SLE, chronic discoid lupus, subacute cutaneous lupus
Discoid lupus stubborn, less photosensitive
Scalp involvement
Scarring
Potent topical steroids, calcineurin inhibitors, hydroxychlorquine, sunscreens
Stop smoking
Discoid lupus <5% will develop SLE ANA / ENA normally -ve
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Question 5
Question 5
Photosensitivity is LEAST likely to be associated with which one of the following?
Photosensitivity is LEAST likely to be associated with which one of the following?
•A Systemic Lupus Erythematosus
•A Systemic Lupus Erythematosus
•B Acute intermittent porphyria
•B Acute intermittent porphyria
•C Porphyria cutanea tarda
•C Porphyria cutanea tarda
•D Amiodarone therapy
•D Amiodarone therapy
•E Pellagra
•E Pellagra
Urticaria
Not Erythema Multiforme !
Most idiopathic
Unusual to have dietary trigger
Not usually “allergic”
Drugs – NSAIDs, opiates
High dose antihistamines
Montelukast
Investigations unnecessary
Prednisolone for severe flare
Chronic urticaria 5-10 years
Secondary CarePhototherapy
Rarely immunosuppression
CMT Dermatology Teaching
• Dermatology terms
• Medical dermatology
• Surgical / lesion dermatology
• Skin conditions seen in systemic diseases
• Emergency referrals
• Summary / Questions
Urticaria NOT allergic in nature therefore needs more than hayfever/allergy doses
Example standard antihistamine regime
Telfast 180 (Fexofenidine) 1 tab bd with Piriton 4mg 4-6 hrly,
Atarax (hydroxyzine) 25mg nocte
add cetirizine 10mg if needed +/- ranitidine (H2 blocker) 150mg bd
doxepin 25mg potent antihistamine but very sedating
Seborrhoeic
Keratosis
Actinic Keratoses
Common
Sun exposed sites partic scalp
Small erosions, hyperkeratosis
Rare to progress to SCC
Tx – cryotherapy, Efudix, Aldara
Field effect
Sun protection, hat
Benign
Common
Genetic and Sun exposure aetiology
Warty on trunk and limbs, flat on face
Mild itch
No treatment required
Cosmetic - do not refer for treatment !
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Bowen’s Disease
Nodular
Basel Cell
Carcinoma
Lower limbs commonest
Non specific scaly patch
Non healing, occ can ulcerate
Slowly progressive
SCC in situ
<1% progress to SCC
Primary care – Efudix, imiquimod, cryo
Secondary care Tx – PDT, Surgery
UV induced, exposed sites, head and neck
High risk sites nose, lips, ears
Don’t metastasize
Treatment – surgical excision (4mm margin), RXT
Background sun damage, history of sun burn childhood
Sun protection advice
Superficial
Basal Cell
Carcinoma
Squamous Cell
Carcinoma
Deep, ulcerating, more rapidly enlarging
Sun exposed sites
Can spread to local LN
Treatment – surgical excision
Radiotherapy
cw BCC
Non specific non healing inflammatory patch
Common trunk and limbs
Treatment, cryotherapy, surgical excision, PDT, imiquimod
Solar Lentigo
Superficial
Spreading
Melanoma
Lentigo maligna melanoma
Common
Back of hands, forearms, face
“Sun spot”
Can be quite large
Well demarcated, regular pigment
If large should sample biopsy
Exclude Lentigo maligna /melanoma
Numbers increasing
Men- back, Females- limbs
ABCDE checklist
Thickness (Breslow) – prognosis <1mm good
Excision needs 1cm margin at least
Can spread and kill incl young adults
No available adjuvent treatment chemo trials
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Question 6
Question 6
What is the most accurate prognostic indicator in
primary melanoma?
What is the most accurate prognostic indicator in
primary melanoma?
A) Lesion diameter
B) Degree of cytological atypia
C) Mitotic rate
D) Breslow thickness
E) Presence of ulceration
A) Lesion diameter
B) Degree of cytological atypia
C) Mitotic rate
D) Breslow thickness
E) Presence of ulceration
Amelanotic
Melanoma
Pyogenic
Granuloma
Exclude an underlying
pigmented lesion: Ask was
there a ‘mole’ at the site or
did it arise on normal skin?
Non specific red friable nodule
No pigment
Usually presents later
Poorer prognosis
Diff Dx ?
Normally post traumatic
Rapidly enlarging granulation vascular tissue
Benign
Spontaneously resolve
Treatment- topical steroid, surgical curettage
Dermatofibroma
CMT Dermatology Teaching
Proliferation of fibroblasts
probably triggered by minor
trauma i.e. insect bite
Young adults, female
Brownish red dermal nodule 0.51cm
Arm, shoulder, thigh or leg
Firm
‘Dimple sign’
• Dermatology terms
• Medical dermatology
• Surgical / lesion dermatology
• Skin conditions seen in systemic diseases
• Emergency referrals
• Case discussions / Questions
Leave alone, reassure
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Neurofibromatosis
Acanthosis Nigricans
Diagnostic criteria (≥ 2 or
more of the following):
Flexural skin is hyperpigmented,
thickened and has a velvety
texture
Skin tags common
≥ 6 café au lait spots
Axillary / inguinal freckles
≥ 2 neurofibromas
≥ 2 Lisch nodules
Optic glioma
Insulin resistance
Obesity
Malignancy (gastric Ca)
Ist degree relative with ≥ 2
of the preceding criteria
Epilepsy / learning difficulties
Phaeochromocytoma
Neurofibromas elsewhere
RAS / CVD
Dermatomyositis
Multi-system autoimmune disease
Females
Can involve skin, muscle or both
Skin is itchy and painful
Heliotrope rash around eyes
Periorbital oedema
Gottron’s papules
Perungal erythema
Proximal myopathy
UV sensitive
? Interstitial lung disease
? Symptoms of malignancy (20-25% of
adults develop a malignancy within 2
yrs)
Question 7
A 53 year-old man presents with a rapidly evolving painful
ulcer on the lower leg. His PMH includes IHD, T2DM and he
smokes 40 cpd. He reports weight loss over the last few
weeks with increased bowel movements.
Examination reveals a 10cm ulcer on the anterior shin with a
violaceous border and undermined edges. CRT=3 secs.
Investigations include an ABPI=1.10.
What is the most likely diagnosis?
What is the most likely diagnosis?
A) Pyoderma gangrenosum
B) Arterial ulceration
C) Venous ulceration
D) Neuropathic ulceration
E) Calciphylaxis
A) Pyoderma gangrenosum
B) Arterial ulceration
C) Venous ulceration
D) Neuropathic ulceration
E) Calciphylaxis
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Pyoderma
Gangrenosum
Neutrophilic inflammatory dermatosis
Ulcerated, raised violaceous edge
Legs common, can be anywhere
Commonly assoc with systemic disease
Inflammatory bowel, haem malignancy
TB, idiopathic, trauma /surgery
Need full systemic underlying screen
Treatment difficult – topical steroids,
oral steroids, ciclosporin, infliximab
CMT Dermatology Teaching
• Dermatology terms
• Medical dermatology
• Surgical / lesion dermatology
• Skin conditions seen in systemic diseases
• Emergency referrals
• Questions
Eczema
Herpeticum
Erythroderma
Management
Erythema ≥90% of body surface
Take swabs for bacterial +
viral cultures
Aciclovir 800mg x 5/day
Flucloxacillin
Topical antiseptics, pain relief
Consider admission
Treat eczema
Dermatitis, psoriasis, drugs, CTCL,
PRP, idiopathic
Itchy, erythematous scaly skin
Oedema, pustules, blisters,
lymphadenopathy, fever, malaise
Stop drugs, swabs, emollients, SS,
sedating anti-histamine, treat
infection
Objectives
CMT Dermatology Teaching
• Comfortable identifying common dermatoses
• Consider more unusual derm conditions
• Differentiate between malignant and benign
lesions
• Recent cases for discussion?
• General Questions
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