Dermatology in 2hrs

Naresh Rati
Basic Anatomy
 Dermatological History
• History of lesions? • General health
• Skin site of first • Occupational and
presentation? recreational history
• Degree of itching? • Family History
• Any pain? • Contact history
• Any burning? • Provocative factors
• Oral and topical • Travel History
medications?
 Dermatological Examination
• Distribution
• Size
• Type of lesions
• Colour
• Symmetrical
• Hair
• Nails
 Skin Morphology
• Macule • Lichenification
• Papule • Atrophy
• Nodule • Annular
• Papule • Tubercules
• Keratoses
• Plaque
• Warts
• Vesicle
• Vegetations
• Bulla
• Scales
• Excoriation • Crusts
• Ulceration • Fissures
• Sclerosis
ECZEMA
 Introduction
• Atopic Eczema • Varicose Eczema
• Seborrhoeic Eczema • Allergic contact
• Discoid Eczema dermatitis
• Lichen simplex • Irritant contact
• dermatitis
Eczema craquelee
 Atopic Eczema
• Chronic Itchy disorder
• Unknown cause
• Common in children but may occur at any
age
• Occurs with an 'atopic tendency'.
• A family history of asthma, eczema or hay
fever is particularly useful in diagnosing
atopic dermatitis in infants.
 Epidemiology

• Affects 15-20% school children and 2-3%

adults UK

• Onset 3-5m of age in 60% and first 5 years

85%

• 75% children clear by age 15

 Prevalence
18
16
14
12
10 UK
8 West Mids
6 W Europe
4
2
0
1940 1960 1980 2000
 Aetiology

• Increased affluence
• Genetic susceptibility
• Environmental triggers
 Impact

• Sleep disturbance
• Schooling/work affected
• Career choices affected
• Repercussions on family members
The characteristic pattern of
atopic eczema in childhood
Histology
 Immunology
• Triggers bind to allergen specific IgE
• Induce T-lymphocyte activation
• Release of cytokines
• Eczematous hypersensitivity response
The Itch-scratch cycle

inflammation Itching

Scratching
 Investigations
• Prick testing demonstrates immediate-type
hypersensitivity
• Role in eczema dubious due to multiple
positive reactions
• Total IgE just supports clinical diagnosis
• Specific IgE not sensitive enough
 House Dust Mite
• Important role in
atopic eczema
• Time consuming
eradication measures
• Laminate
floors/blinds/special
bed linen
 Other allergens
• Milk • Wheat
• Cat dander • Fish
• Soya • Nuts
• Additives • Eggs
 Super Antigens
• Staph. Aureus found on 90% of patients
with atopic eczema vs. 5% of normal
subjects.
• Produce endotoxins which have
superantigenic properties
• Exacerbation of Eczema
 Bacterial Infection
• Weeping
• Oozing
• Crusting
• Pustules
• Exudative lesions
• Low threshold for
diagnosing secondary
infection
 Viral Infection
• Herpes simplex virus
• Widespread vesicular
rash
• Eczema herpeticum
• Systemic antiviral
therapy
 Yeast Infection
• Malasessia yeasts
• Provide constant
stimulation to the
immune system
resulting in chronic
inflammation.
 Stress

• Exacerbation in eczema secondary to

physical, mental or social stress.
• Illness including a mild cold may cause a
flare in eczema.
 Climate
• Cold, damp climates may cause eczema
to become more resistant to treatment.
• Keeping the temperature even throughout
the house is probably helpful.
• Eczema better in summer months. Partly
due to increased exposure to UV light,
SEBORRHOEIC ECZEMA

AFFECTS AREAS WHERE SEBACEOUS GLANDS ARE NUMEROUS;

SCALP, EYEBROWS, CHEST AND BEHIND THE EARS

•AFFECTS MEN MORE THAN WOMEN

• USUALLY PRECEDED BY DANDRUFF
•PRESENTS AS PINK/RED SCALY PATCHES
•AGGRAVATED BY HOT, HUMID CLIMATES

Cause:

THOUGHT TO BE DUE TO YEAST INFECTION

– PITYROSPORUM OVALE
 INFANTILE

•AFFECTS BABIES UNDER AGE OF ONE

* USUALLY PRESENTS IN FIRST 3 MONTHS

* NAPPY AREA OFTEN AFFECTED FIRST

* CAN SPREAD QUICKLY TO SCALP, FACE, NECK, ARMPITS AND TRUNK

* OFTEN MORE UPSETTING FOR THE PARENTS THAN THE INFANT!

 Contact Irritant Eczema
• Repeat contact with substance
• MOST COMMON ON THE
HANDS
AFFECTS CHEFS,
CATERERS,
CLEANERS,HAIRDRESSERS
, SURGICAL NURSES AND
CONSTRUCTION WORKERS

• Irritation and skin damage

– Detergents
– Shampoos
– Household cleaning products
 Contact Allergic Dermatitis
• Type IV allergic
reaction
• Occupational History
• Social History
• COMMON
ALLERGENS
– COBALT,NICKEL,
– RUBBER,
– FRANGRANCES,
– PLANTS,
– HAIR BLEACHING AND PERM
SOLUTIONS
 Other investigations

• Unilateral rash..
– Skin scrapings
for mycology
 DISCOID ECZEMA

* MORE COMMON IN ADULTS

* PRESENTS AS DISCS OF ECZEMA

* USUALLY STARTS ON LEGS OR ARMS

•LATER STAGES, BECOME SCALY

• BEGIN TO CLEAR FROM
THE CENTRE

CAUSE
UNCLEAR

PREVIOUS HISTORY OF DRY SKIN IN MAJORITY OF CASES,

WHICH MAY BE TRIGGER
 Eczema Craquelée
• Dry eczema
• Imprecise margins
• Reminiscent of ‘crazy
paving’
• Fissuring and
bleeding
 Lichen Simplex
• Response to repeated
rubbing
• No underlying skin
disorder

• Rx with:
– potent topical steroids
or occlusive
bandaging
 VARICOSE ECZEMA

* ALSO KNOWN AS STASIS ECZEMA AND

GRAVITATIONAL ECZEMA

•AFFECTS THE LOWER LEGS

•COMMON IN MID TO LATE YEARS

* CAN PRESENT AS REDDISH BROWN SPECKLES ON THE

THE SKIN, USUALLY AROUND THE ANKLE OR RED, SCALY
IRRITATING PATCHES

* COMMON COMPLICATIONS INCLUDE ULCERS,

HYPERPIGMENTATION, ATROPHE BLANCHE
 Treatment
• First Line - Emollients
Topical steroids
Antibiotics

• Second Line - PUVA

UVB

• Third Line - Oral steroids

Cyclosporin A
Gamma interferon
 SEVERITY
DISEASE
A conventional treatment strategy

Itching and / or early

Dry skin Flare
signs of inflammation
TREATMENT

Topical steroids

Emollients

1. Raimer SS. Clin Pediatr 2000; 39: 1–14.

 Emollients
• Regular Moisturisation
• Soap Avoidance
• Steroid sparing effect
• Whole body applications require
– 500g or more/week for adults
– 250g or more/week for children
 Bath Emollients
• Bathing daily in tepid water
• Bath additive added e.g.. Balneum
• 10-15mins for effective rehydration
• Use soap substitutes e.g.. Aqueous
• Apply emollient within 5mins of exiting
bath ideally while skin still damp
 Antihistamines
• Histamine not dominant mediator of itch in
eczema
• Work due to sedative effects
• Tolerance becomes problem in long term
use
• Newer non sedating antihistamines act
on eosinophilic chemotaxis and may
improve pruritis
 Ichthammol and Tar
• Anti-inflammatory
• Anti-pruritic
• Usually as paste
bandages for 24h
• Useful for: lichenified
eczema
nodular prurigo
Chinese Herbal Medicine
 Chinese Herbal Medicine
• Beneficial effect in some patients
• Practitioners are unregulated
• Steroid derivatives often isolated
• Hepatic toxicity reported
• Unpalatable taste
 Complementary Therapies
• Homeopathy
• Acupuncture
• Herbalism
• Reflexology
• Behavioural modification
 Topical Corticosteroids
• Anti-inflammatory
• Immunosuppressive
• Vasoconstrictive
• Inhibit Epidermal Cell turnover
• Affect Fibroblast Function
 Steroid Vehicle
Ointments vs. Creams/lotions
– Better occlusion – Cosmetically
– Better penetration acceptable
– Can block eccrine – Useful in hair bearing
pores in hot weather area/face/ intriginous
areas
– Used in weepy
eczema
 Steroid Potency

• Mild (hydrocortisone acetate)

• Moderate (clobetasone butyrate)
• Potent (betamethasone valerate)
• Very Potent (clobetasol propionate)
 How much to prescribe?

• Extent of disorder - examples:

– 15g whole body single application of cream to 10 year old
– 30g whole body single application of ointment to 70 kg adult
– 30g for face bd for 10 days
– 30g for hands or feet bd for 10 days
– 150g for trunk bd for 5 days
– 150g for both legs for 5 days
– 150g for both arms for 10 days
 Steroid Therapy
• Duration of therapy
– variable (ultra potent should ordinarily be used for
two weeks or less)

• Frequency of application
– usually once or twice daily
– sometimes once or twice weekly
 Application under “Wet Wrap”
Dressings
• Steroid under an inner wet layer and outer
dry layer of cotton tubular dressing.
• More effective than non-occluded therapy
with potent steroids
• Increases unwanted local and systemic
effects
 Topical steroid/antibiotic
combination
• No clinical advantage cf. steroid alone
• Increase risk of contact allergy
• Encourage antibiotic resistance
• More appropriate to prescribe oral
antibiotics with overt signs of clinical
infection
 Unwanted Effects of Steroids
• Increase with:
potency
area treated (site and size)
duration of treatment
degree of skin penetration
degree of absorption (occlusion)
 Referral to Hospital
• Diagnostic doubt
• Failure to respond with moderately potent
steroids
• Extensive disease requiring 2nd line Rx
• Dietary manipulation indicated
• Specialist opinion in counselling family
 Failure of Treatment
• Non compliance
• Under use of steroids
• Inadequate explanation
• Resistance to topical treatment
 New Immunomodulators
Tacrolimus Vs Pimecrolimus

• Effective in moderate • Effective in mild to

moderate eczema
to severe eczema
• No skin atrophy
• No skin atrophy
• Well tolerated
• Well tolerated
• No systemic S/E
• No systemic S/E
• Flare prevention
• Flare prevention • Comparative cost
• Comparative cost
 Indications
Tacrolimus Pimecrolimus

• Facial/ Peri-ocular • Facial/ Peri-ocular

involvement involvement

• Requirement for • Prevention of flares

maintenance treatment
with potent topical
steroids
 Psoriasis
• Chronic relapsing condition
• Abnormally enhanced proliferation of
epidermis
• Concurrent immune activation
• Rapid skin cell turnover
 Nail Changes

Present in up to 50%
of pts with psoriasis
– Pitting
– Subungual Keratosis
– Onycholysis

Usually bilateral
 Guttate Psoriasis

• Small plaque droplets

• Usually younger pts
• Streptococcal
infection present in
2/3rd cases
• Usually go on to
develop chronic
disease
 Palmoplantar Pustulosis

• Thickened epidermis
• Painful fissuring
• Pustules rather than
vesicles
• Strong assoc with
cigarette smoking
• Difficult to treat
 Flexural & Genital Psoriasis

• Sharply demarcated
erythema
• Absence of scale and
satellite lesions
• Secondary fungal or
yeast infection is
common
 Erythrodermic Psoriasis

• Potentially life
threatening
 Scalp Psoriasis
• Capasal Shampoo
• Diprosalic Ointment
• Cocois Co
• Dovonex scalp
Solution
• Betnovate Scalp
Solution
• Cade(Juniper) oil
 Treatment

• Emollients
• Tar based preparations
– Alphosyl
– Exorex
• Topical steroids
– Risk of relapse with potent steroids
 Treatment cont’d
• Dithranol preparations
– Dithrocream
– Micanol

Start with lowest strength

Applied daily for 15-30mins then wash off
Increase strength weekly – 0.1% to 2.0%
 Treatment cont’d
• Topical Retinoid
– Tazarotene

Useful in limited disease

 Treatment cont’d
• Climatotherapy
– Dead sea

High intensity UVA with weak burning

spectrum

– Laser Rx
• Excimer laser
 Vitamin D Analogues
• Apply generously up to 100g/week
• Useful continuous long term or intermittent
• Considered first line
• Normalise cell growth
• Inhibit cell proliferation
– Dovonex / Dovobet
– Silkis
– Curatoderm
 Referral to Hospital
• Diagnostic doubt
• Failure of topical treatment
• Extensive disease (>30% BSA)
• Difficult treatment sites e.g. nails
• Eryhtroderma
• Associated arthropaty
 Acne - mild

• Open and closed

comedomes
• Some papules
• A few pustules
 Acne - moderate

• Numerous papules
• More pustules
• Mild scarring
 Acne - severe

• Papules and pustules

• Nodules
• Cysts
• Extensive scarring
• Post inflammatory
pigment changes
 Treatment

• Topical Preparations
• Systemic Preparation
• Physical Treatments
• Roaccutane
 Benzoyl Peroxide

• Oxidisation of Anaerobic P. Acne

• No resistance can develop
• 2.5%-10% gel, cream or wash
• Irritancy and bleaching
 Topical retinoids e.g.. adapalene

• Comedonal acne esp. open comedones

• Cream, gel and lotions
• Apply at night because of photosensitivity
• Avoid in pregnancy
 Azelaic acid

• Antimicrobial and anticomedonal agent

• Well tolerated
• Mild bleaching agent so useful for
secondary hyperpigmentation
 Nicotinamide

• Vitamin B derivative
• Inflammatory acne
• No resistance risks
 Topical Antibiotics
• Few reliable ‘head to head’ trials
• Generally well tolerated
• More expensive than some systemic
antibiotics
• Resistance reduced by combing with
retinoids or zinc or benzoyl peroxide
 Systemic Antibiotics
• Use for minimum of 3-6 months
• Max 9-12 months
• Combine with non antibiotic topical treatments
– Oxytetracycline
– Lymecycline
– Minocycline MR
– Doxycycline
– Erythromycin
– Trimethoprim
 Hormonal treatments

• Anti-androgenic properties of dianette

• Reduces sebum production
• Also an effective contraceptive!
• Data supports safe in long term use
• Yasmin may be as effective as dianette
 Referral to hospital
• Severe nodulo-cystic acne
• Significant scarring
• Dysmorphophobia
• Failure with 2 or 3 systemic treatment
cycles
• Diagnostic doubt
 Roaccutane
• Down regulation of sebaceous gland
activity
• Usually 4m course
• High side effect profile
– Myalgia, dry skin and lips, headaches
– Liver function and lipid profile abnormality
– Teratogenic
– Depression?
 Post Acne Scarring
• Injecting steroid into Nodules/cysts
• Laser resurfacing
• Dermabrasion
• Chemical peels
• Collagen injections
• Hypopigmenting agents
 Rosacea
• Dry and peeling skin
• Telangectasia
• Rhinophyma
• Facial flushing made worse by:
– Alcohol
– Spicy foods
– Emotion
 Treatment
• Systemic antibiotics 6-12 weeks
– Tetracyclines
– Erythromycin
• Topical antibiotics
– Rosex
• Laser Rx
– Dye laser
 Skin Malignancies

• Increasing incidence of all skin cancers

• 80-90% due to sun exposure
• One episode of sun burn in childhood is
regarded as significant risk factor for MM
 Prevention is better than cure!
• Sunscreens
– Reduce sunburn
– Reduce photoageing
– Reduce photocarinogenesis
• But increase sun exposure!!
• Hats and other clothing
 Sunscreens
• >SPF 15 probably reduces risk of SCC
• ? Increase risk of MM
• Over emphasis on UVB protection
• Newer sun screens include UVA rating
system as well

Graham-Brown RAC Sun Education in the UK. Clinics in dermatology 1998;16:523-525

 Basal Cell Carcinoma
• Incidence: increase 75% in last 10 yrs
• Risk relates to cumulative UV exposure
• Typical nodular cystic lesion with
– rolled edge
– Ulcerative core
– Telangectasia overlying
 Superficial BCC

• Common on trunk
• Well circumscribed
• Erythematous
• Often missed as
inflammatory lesions
• Can treat with LN2
 Pigmented BCC

• Usually nodulo-cystic
• Can be confused with
MM
 Cystic BCC

• Well defined
• Smooth
• Domed
 Morphoeic BCC

• Varied appearance
• Degree of invasion
often very advanced
• Moh’s surgery
indicated
 Treatment

• Cryotherapy
• Surgical excision
• PDT
• Radiotherapy
• 5-fluorouracil
 Cryotherapy
• Temp -50 to -150
• Destroys atypical cells
• Up to 99% cure
• Scarring/infection/ hypopigmentation
• Avoid in areas of poor healing
 Efudix

• Topical fluorouracil
• Interferes with DNA/RNS synthesis
• 3-4 week Rx
• Burns++
• Avoid sunlight during Rx
 Photodynamic therapy

• Photosensitise skin with ALA

• Light irradiation 4-6 hrs later
• Erythema/burning
• May need second treatment
• Expensive
 Radiotherapy

• Alternative to surgery
• 5-10% recurrence rate
• Long term cosmetic implications
 Squamous Cell Carcinoma
• M:F = 2:1
• >70yrs
• 30% increase in last 10 yrs
• Pre-malignant lesions at risk of developing
into SCCs
• Cumulative UV exposure
• Impaired immunity
 Clinical presentation

• Indurated
• Inflammatory
• Ulcerated
• Dorsum of hand
• Face
• Can metastasise
 Treatment

• Excision surgery
– Rx of choice
– 4mm margins
– Up to 95% cure rates
• Radiotherapy
– For pts not suitable for surgery
Malignant Melanoma
 Malignant Melanoma

• 5000 new diagnoses/year

• 1500 deaths annually
• Peak age of incidence = 40-50yrs
• 300% rise in last 20yrs
 Risk factors
• Intermittent sun exposure
• Higher social class
• FH in 1st degree relative
• Large numbers of benign melanocytic
naevi
• Dysplastic naevus syndrome
 Presentation
• Changing lesion over few months (90%)
• Often 3 shades/colours
• 50% arise de novo
• Commonest on back in males
• Commonest on lower limbs in females
 Glasgow seven point checklist
• Growth
• Change in shape
• Change in colour
• Itching
• Oozing/crusting/bleeding
• Inflammation
• >5mm diameter
Mackie R et al. Primary Cutaneous Malignant Melanoma; P8
 Referral
• If at least one major or two minor criteria
present.

• NB. Suspected SCC and MM fall under

Government’s two week cancer screening
initiative
Superficial spreading melanoma

• 80% of MM
 Nodular melanoma

• 10% of MM
 Acral / subungual melanoma
• Soles of feet
• Palms of hands
• Under nails
 Amelanotic melanoma

• Pigment absent
or diminished
 Treatment
• Surgery
– 1cm margin per 1mm depth

• Radiotherapy
– Palliative for metastatic disease
– Lymph nodes, liver, lung, brain, bones
 Prognosis
Indicator Significance

Depth of tumour - < 1.5mm good

>3.5mm poor
Sex - F>M
Age - Worse >50yrs
Site - Worse on trunk, arms
Ulceration - Poor prognosis
Scabies
 Scabies

• Mite sarcoptes
scabiei var. hominis
• Skin-skin contact with
an infested person
• Usually > one family
member afflicted
 Clinical features
• Widespread papular
eruption
• Can be eczematous
• Or urticarial
• Pruritic esp. axillae,
peri-areola, umbilicus
and buttocks
• Inflammatory nodules
on penis/scrotum
Distribution
Penile nodules
 Burrows

• Fertilised female mite

• Through stratum
corneum
• 2mm/day
• 2-3 eggs/day
• 2-3w to mature
 Presentation

• No itching for 4-6w

• Pruritis+++ esp. at
night
• Face not affected
except in infancy
 Treatment

• Malathion 0.5%
• Left on for 24hrs
• ?Rpt 1w later
• Can be used in
infants
• Use sponge or brush
 Treatment (2)

• Permethrin 5%
• Lyclear dermal cream
• Apply for 8-12 hrs
• ?one application
enough
• Use dermal rinse for
infants face/scalp
 Therapeutic tips
• Post Rx use eurax-hc
• Re-apply Rx after washing hands
• Once Rx washed off, then change clothes-
nightclothes, bed sheets, pillow cases and
towels
• No need to disinfect – ordinary washing ok
• Pruritis can take 4-6w to settle
• Rpt applications can cause irritant eczema!
 Treatment failure?

• New tracks or pustules within 1m of Rx= re-treatment for

pt and contacts.
• Other contacts that were not treated first time round?
• Do they need scalp treatment?
• Did they treat anogenital regions & beneath nails?
• Do they need someone to help them apply treatment?
• Theoretically, double treatment, 7 days apart may catch
newborn scabies that were not sensitive in the egg
phase
Headlice
 Head lice- facts and myths
• Do they live on or close to scalp or shaft?
• Can they hop or jump?
• Only affects long hair?
• Only affects dirty hair?
• Can you catch it from hats?
• What about chairs or head rests?
• Are nits the same as lice?
 Presentation

• Pediculus Humanus Capitis

• Itchy Scalp: sides - back – generalised
• Secondary infections
• Smelly, matted hair
• LN enlargement
• Louse droppings, (fine black powder) may be
seen on pillows or sheets
 How to detect

• Easier to detect on wet hair.

• Hair should be combed in sections using a special nit
comb – available from pharmacists.
• May be easier to comb if conditioner is used.
• Important to comb the entire length of the hair from
root to tip.
• After each stroke, the comb should be checked for
lice.
 Treatments

• Insecticides
• Thorough and frequent combing
• "Alternative" treatments
 Insecticides
• Shampoos are not considered effective.
• Most effective are alcohol-based lotions.
• Water-based Rinses recommended for young
children and asthmatics.
• Resistance to insecticides has been reported. If
one treatment fails, then another should be tried.
• The treatment involves rubbing the insecticide
lotion onto the scalp and hair and leaving it for a
minimum of 12 hours before washing out.
• The treatment should be repeated a week later
to destroy any lice that have hatched since.
 Wet Combing ( Bug Busting!)
• Removing lice with the regular use of a fine-toothed
comb.
• Success has been reported where families are highly
motivated and follow the instructions carefully.
• A "bug-busting" kit is produced by the Community
Hygiene Concern charity.
• This treatment method requires four sessions over two
weeks.
• It avoids the use of strong chemicals, and lice cannot
become resistant to it.
• It can also be used for routinely checking the hair for
infection.
 Alternative Treatments
• Treatments containing essential oils (including
tea-tree), herbal extracts or homeopathic
tinctures.
• Little robust evidence for these treatments, but
some people find them helpful.
• Even ‘natural’ chemicals can cause side-
effects, such as irritating the scalp.
• A follow up check using a nit comb should be
carried out a few days afterwards.
 Sunburn
• Amount of sun
exposure > ability of
melanin to protect.
• May occur <15
minutes of midday
sun exposure.
• Deaths have resulted
from acute sun
exposure.
 Sunburn (2)

• Not immediately
apparent
• Blistering in severe
cases.
• Swelling is common.
 Sunburn with peeling

• Painful and red, the

damage has been
done.
• The pain >6-48 hrs
post exposure.
• Peeling several days
later
 Sunscreens

• Protection against
sun burn
• Risk of skin cancer
• Ageing and wrinkling
• More time in the sun!!
 Why not?

• Skin doesn’t burn

• Nuisance to apply
• Other measures used
• Expensive
• They want to tan!!
 Sun Protection Factor

“Ratio of least amount of UV energy

required to produce a minimal
erythema on sunscreen protected skin
cf. unprotected skin.”
 Complex chemical sunscreens
• E.g. aminobenzoic acid, oxybenzone, and ethyl
hexyl p-methoxycinnamate
• Absorb sunlight within the epidermis.
• Although very effective, may cause irritation, so
there are regulations that limit the amount of any
one sunscreen in a product.
• In order to increase protection, a mixture of
chemical sunscreen is used.
• The higher the SPF the more chemicals the
sunscreen is likely to contain, increasing the risk of
irritation.
 Non-chemical Pigments

• E.g. zinc oxide and titanium dioxide work by

forming a physical shield or barrier on the skin
that reflects sunlight away from the skin.
• Are reflectant & non-irritant and very suitable for
babies, infants and adults with a sun-sensitive
skin.
 Evidence that they work?
• >SPF 15 probably reduces risk of SCC
• ? Increase risk of MM
• Over emphasis on UVB protection
• Newer sun screens include UVA rating
system as well

Graham-Brown RAC Sun Education in the UK. Clinics in dermatology 1998;16:523-525

 Practical Tips in UK

• No need for UV protection Oct-Mar

• Daily skin care Apr-Sep incorporate SFP8-
15 creams
• SPF>30 for sunny hols/summery
weekends
 Holiday Tips
• Stay in the shade between 11am and 3pm
• Don't rely on sunscreen alone
• Wear clothes that cover arms & legs, & a wide-
brimmed hat
• Wear sunglasses that block UV light
• If on the beach, wear sun-protective clothing,
including swimsuits and wetsuits
• Remember to take extra care with children's skin
• Apply sunscreen with an SPF of 15 or more
• Never burn, as sunburn causes permanent damage
 Onychodystrophy
• Onychomycosis
• Psoriasis
• Chronic eczema
• LICHEN Planus
• Alopecia Areata
• Norwegian Scabies
• Darier’s Disease
• Old Age
• Trauma
 Onychomycosis

• Dermatophytes
(Tinea, 85-90% of
fungal nail infections)
• Yeasts (Candida
often involved in
chronic paronychia)
• Moulds
 Diagnosis
• Ideally, treatment should not be instituted
on clinical grounds alone.
• 50% of all cases of nail dystrophy are
fungal in origin
• If diagnosis is not confirmed, and
improvement does not occur, it is
impossible to tell whether this represents
treatment failure or an initial incorrect
diagnosis.
 Mycological Testing

• Nail clippings
• Scrapings of thickened crumbly material
• Skin scrapings
• 50% sensitivity!
 Why treat?

• Onychomycosis is progressive
• In the elderly the disease can give rise to
complications such as cellulitis
• It is a surprisingly significant cause of
medical consultations
• Pts don’t like look of it!!
 Topical Treatment

• Amorolfine (Loceryl) 50% cure rate

• Tioconazole (Trosyl) 30-70% cure rate

• Use for 9-12 months!!!

 Griseofulvin
• Only one licensed for children
• Taken for 9-12m for finger nails
12-18m for toe nails
• 70% cure rates for finger nails
• 30% cure rates for toe nails
• Nausea/rash in 15% of patients
 Terbinafine
• 250mg od
• 2-3m for finger nails – 90% cure rate
• 3-4m for toe nails – 80-90% cure rate
• ? LFT monitoring
• GI upset
 Itraconazole
• Pulse Treatment
• 3 pulses of 1w bd rpt monthly
• 2 cycles for finger nails - 80% cure rate
• 3 cycles for toe nails - 70% cure rate

• GI upset
 Yeast Infections
• Can be treated topically, esp. those associated with
paronychia.
• Antiseptics can be applied to the proximal part of the nail
and allowed to wash beneath the cuticle, thus sterilizing
thesubcuticular space.
• Applied until the integrity of the cuticle has been restored,
which may be several months.
• Clotrimazole 1% drops is also effective.
• Itraconazole is most effective oral agent
 Treatment failure
• Up to 20-30% failure rate.
• Poor compliance,
• Dermatophyte resistance
• Poor penetration of drug in adequate
concentrations.
• Partial nail removal may be indicated.
• Cure rates of up to 100% if affected nails are
avulsed prior to commencement of treatment.
 Preventative Tips
• Take off your shoes when you're at home
• Don't spend too long in trainers
• Change your socks every day.
• Wear cotton, or wool socks rather than nylon ones.
• Wear low heel shoes that fit well
• Wear shoes made from leather or canvas.
• If your shoes get sweaty, let them dry out before
wearing them again
• Dry your feet well, especially after using communal
changing areas.
• Don't walk barefoot in public areas, Wear flip-flops or
sandals
• Don't borrow other people's shoes or towels
 Nail Hygiene
• Keep nails short and cut them straight across.
• File down any thick areas.
• Never use the same scissors, files or nail clippers
on infected nails and nails that aren't infected.
• Wear rubber gloves when doing work that will keep
hands wet, especially if for a long time.
• Don't pick at the skin around the nails.
• Don't use nail polish or artificial nails if there is a
fungal nail infection.
Non-Malignant Lumps &
Bumps
 Introduction
• Epidermal origin
• Sweat gland origin
• Hair follicle origin
• Dermal origin
• Subcutaneous origin
• Vascular origin
• Cysts and other oddities
 Seborrhoeic Warts

• Basal cell papillomas

• Nodule/plaque
• Light fawn-black
• “stuck-on”
appearance
• Epidermal thickening
• Asymptomatic
• Can irritate
• Can be mistaken for
MM
• Keratinisation
• Horny cysts
• Generally >50 yrs
 Sebaceous Naevus
• Overgrown epidermis, sebaceous glands,
hair follicles, apocrine glands and
connective tissue.
• Often appear on the scalp, but may arise
on the face, neck or forehead.
• Lesions are always present at birth and do
not spread during childhood.
• Can become more raised at puberty.
 Epidermal Naevus
• Usually arise on trunk or
limbs.
• Majority are linear
• Usually unilateral.
• At birth are flat brown
marks
• As the child ages become
thickened and warty.
• May also become more
extensive
 Syringoma
• Sweat duct tumours.
• Clustered on the
eyelids
• Skin coloured or
yellowish firm
rounded papule, 1-
3mm in diameter.
• Start to appear in
adolescence
• Women > men.
 Sebaceous Adenoma
• Enlarged
sebaceous glands
• Forehead or cheeks of
the middle-aged and
elderly.
• Can be confused with
basal cell carcinoma.
• Appears as yellow
papules up to 3 mm in
diameter.
• Inspection reveals a
central hair follicle.
 Milia

• Tiny epidermoid cysts

• Upper cheeks
• White pinhead size
• Contain accretions of
horn
• Can be slit open with
sterile needle
 Sebaceous Cyst

• Epidermal cyst
• Sac filled with soft, whitish
brown keratinous debris
• Can get inflamed and painful,
• May discharge yellow pus.
• If infected, resembles a boil
requiring antibiotics (
flucloxacillin)
• Minor surgery may be needed
to relieve the pressure and
pain.
 Cylindroma
• Arise from apocrine
sweat gland
• Scalp and face of
young adults
• Oval masses of
basaloid epidermis
• Surrounded by
connective tissue
 Trichoepithelioma
• Small (<10mm), firm,
rounded and shiny.
• May be yellow, pink, brown
or bluish.
• Gradually increase in
number with age,
• Occurring on both cheeks,
eyelids and around the
nose.
• Arise form rudimentary hair
follicles
 Pilomatrixoma

• Rare, harmless, lesion derived

from hair matrix cells.
• Also known as ‘calcifying
epithelioma of Malherbe’.
• Single skin-coloured or
purplish lesions
• Arise on the head and neck,
• Characterised by calcification
within the lesion,
• Feel hard and bony, (the ‘tent’
sign).
 Eccrine Poroma

• Eccrine sweat duct

tumour
• Palms and soles of
adults
• Basaloid cells and
ducts histologically
 Skin Tags
• Appear to hang off the skin.
• Are also described as:
– Papillomas
– Soft fibromas
• Develop in both men and
women as they grow older.
• Skin coloured or darker and
range in size from 1mm to 5cm.
• Most often found in the skin
folds (neck, armpits, groin).
• Tend to be more numerous in
obese persons and in those
with type 2 diabetes mellitus.
 Dermatofibroma
• Also called fibrous histiocytoma.
• The cause is unknown but some believe it arises at the
site of a minor injury, especially an insect bite or thorn
prick.
• Most often occur on the legs and arms.
• Usually persist for years.
• Firm-feeling nodules, yellow-brown to dark brown in
colour,
• “Dimple sign”- indicates tethering of the skin to the
underlying fibrous tissue.
• Seldom causes any symptoms.
• Can be mistaken with MM;
 Leiomyoma
• Benign tumour of
muscle wall of hair
follicles or blood
vessels
• Blue/red in colour
• Can be painful in cold
weather
• Up to 30mm in
diameter
 Neurofibromatosis
• Genetic disorder that affects the
bone, soft tissue, skin and
nervous system.
• NF1 occurs in about 1 in 3000
births whilst NF2 only occurs in
about 1 in 50,000 births.
• NF1, known as von
Recklinghausen disease,
characterised by:
• 6 or more café-au-lait spots
• Multiple neurofibromas
(tumours on, under, or hanging
off the skin)
• Freckling (under the armpits
and areas of skin folds such as
the groin)
• Lisch nodules (tiny tumours on
the iris of the eye)
 Keloid Scar
• Scars enlarge
spontaneously
• Form firm, smooth, hard
growths
• May be uncomfortable or
itchy
• May be much larger than
the original wound.
• Over several months, a
scar usually becomes flat
and pale. If there is a lot
of tension on a healing
wound, the healing area
becomes hypertrophic.
• Growth occurs slowly
over several years.
• A dome-shaped or egg-
shaped lump about 2-10
cm in diameter
• Soft and smooth and is
easily moved under the
skin with the fingers
• Some have a rubbery or
doughy consistency
 Lipoma
• Most common on the
shoulders, neck, trunk and
arms,
• Most are symptomless, but
some are painful on applying
pressure.
• Lipomas that are tender or
painful are usually
angiolipomas (adiposis
dolorosa or Dercum disease).
Due to an increased number of
small blood vessels.
• Benign overgrowth
of blood vessels in
the skin.
• Proliferation of
endothelial cells.
• Are distinct from
vascular malformations
, which are less
common birthmarks
).
 Haemangioma
• Can develop in adults
too.
• 10% of babies develop
one or more
• 80% occur on the head
and neck area.
• Can grow for up to 18
months before
regressing. This can
take 3-10 years.
• Nearly all involute and
disappear without
treatment.
 Pyogenic Granuloma
• The cause unknown.
– Trauma: some cases develop at the site of a
recent minor injury
– Infection: Staphylococcus aureus is frequently
present
– Hormonal influences: occur in up to 5% of
pregnancies
– Drug-induced; systemic retinoids
– Underlying microscopic blood vessel
malformations
 Benign Naevi
• Congenital • Acquired
• Brown/black • One or two colours
• May be hairy • Anywhere on skin
• Macules/ papules • Nodules
• Histology is of • Common in
immature Caucasians
melanocytes
Warts
Warts
 Viral warts
• Tumours caused by infection with Human
Papillomavirus (HPV). More than 70 HPV
subtypes are known.
• Common in childhood
• Spread by direct contact or
autoinoculation.
• It may take as long as twelve months for
the wart to first appear.
Verruca Vulgaris
Molluscum Contagiosum
 Molluscum Contagiosum
• Viral skin infection.
• Often have a waxy, pinkish look with a
small central pit.
• Can spread by direct skin contact.
• Rarely leaves scars.
• Lesions disappear within 9-12 months.
• Tend to be more numerous and last longer
in children with atopic eczema.
Acne Keloides
 Xanthelasma

• Arcuate or linear
plaques around eyes
• Assoc with
hyperlipidaemia in 30-
40%
• Rx with trichloroacetic
acid
 Haematoma

• Consequence of the
rupture of a blood
vessel, either artery,
vein or capillary.
• Out flowing of blood
from the vessels into
surrounding tissues
Nodular Prurigo
• Very itchy lumps.
• Localised form of
neurodermatitis, which is
a type of eczema.
• Occur at all ages but
mainly in adults aged 20-
60 years.
• M=F
• Emotional stress is a
contributory factor
 Hernias
• Protrusion of an organ
through the wall that
normally contains it
• Present with a lump at an
appropriate anatomical
site
• Often increases in size on
coughing or straining
• Reduces in size or
disappears when relaxed.
Granuloma
Annulare
• Skin coloured bumps
occur in rings often
over joints, particularly
the knuckles.
• Necrobiotic
degeneration of
dermal collagen
surrounded by an
inflammatory reaction
• Resolves in 2-5 years
 Treatments
• Curettage and
Cautery
• Shave excisions
– Raised
– Dome-shaped
– Minimal scarring
Cryotherapy
 Benign Lesions
• Viral Warts • Benign Fleshy Naevi
• Verrucae • Haemangioma
• Seborrhoiec Warts
• Keloid scars
• Pyogenic Granuloma
Mucoid Cysts
• Molluscum
•
• Skin Tags
Contagiosum
• Tattoos • Xanthelasma
• Dermatofibroma
 Dermatological Surgery

• Local anaesthetic
• Appropriate facilities
• Post op care
• Histology of lesion
• Scarring
 Lasers
• superficial
vascular malformations
(port-wine stains),
facial telangiectasia,
• Haemangioma,
• Keloid and
hypertrophic scars
• Seborrhoeic keratoses
 Referral Guidelines

• Diagnostic doubt
• Treatment advice
• Treatment on the basis of
– Significant handicap due to the lesion

• Not for cosmetic reasons