Dermatology approach

Dermatology

Approach

Fayza Rayes

MBBCh. Msc. MRCGP (UK)Consultant Family Physician

Joint Program of Family & Community Medicine – Jeddah

www.fayzarayes.com

[email protected]

Dermatology Approach:1. Skin Rash

2. Skin pruritus

3. Mouth Condition

4. Palm & Sole Lesions

5. Nail Diseases

6. Nappy rash

7. Acne

8. Skin Pigmentations

Prepared by dr. Fayza Rayes

Generalized -- Viral exanthema & drugs Extensor -- Psoriasis, SLE,

-- Soles keratosis, ichthyosis Flexor -- Atopic dermatitis Lower extremities -- Erythema nodosum

-- Stasis dermatitis Sites of pressure -- Urticaria Site of trauma -- Psoriasis

-- Lichen planus, -- Molluscum, Warts.

Site and/or Distribution of The Lesions

DD. Of Generalized Skin Rash

Drug eruptionAmpicillin rash

Viral exanthemaMeasles

Molluscum contaguasum

Lichen

planus

Psoriasis

Warts.

DD. Of Rash at Site of Trauma

Tinea versicolor Pityreasis rosea

DD. Of Truncal Lesions Rash

Secondary syphilis

Palms & Soles Conditions

Dermatology Arrangement of lesions

Arrangement

• Isolated

• Scattered

• Grouped

• Grouped of vesicles

• Annular (ring)

• Linear

Examples• Melanoma, Keratoacanthoma

• Molluscam contagiosum, common warts

• Lichen planer, insect bites

• Herpes simplex, herpes zoster (Dermatomal )

• Tinea corporis, erythema multiform, drug eruptions. Lupus erythomatosus, 2ry syphilis, pityriasis rosea.

• Contact dermatitis, linear scleroderma, keposi sarcoma

Approach to Patient with skin Rash

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Diffuse Erythema Differential Diagnosis

Infectious :Streptococcal infection (Scarlet fever)Staphylococcal infection (Toxic syndrome)Enteroviral infection

Non-infectious Causes:– Allergy -- Vasodilatation– Eczema -- Psoriasis– Pityrosis rubra -- Lymphoma

Scarlet fever

Scarlet feverIncubation period: 2 - 4 days

RashSore throat

Complications:

Otitis mediaCervical adenitisRhinitisSinusitis

Rare:Rheumatic feverAcute nephritis

Days of illness

Maculo-papular Rash with FeverDifferential Diagnosis

Infection :-- Measles -- Interoviral infection

-- Chickenpox -- Mononucleosis

-- Rubella -- Typhoid fever

-- Rubeola (Red measles) -- Secondary syphilis

-- Erythema infectious (5th) -- HIV (Primary)

-- Adenoviral exanthema -- Early meningitis

Non-infectious Causes :-- Allergy -- Erythema multiform

-- SLE -- Erythema margenatum

-- Dermatomyositis -- Serum sickness

-- Drug rash

Chickenpox

Mononucleosis

Measles

DD of Maculo-papular Rash with Fever

Common Exanthematous Diseases

Measles

IP (10-14 days)

Rubella

IP (14-21 days)

Chickenpox

IP (1-14 days)

Maculopapular (5 days)

Koplik’s spots, Prodromal illness,

complications are common.

Macular --> maculopapular (3 ds)

Malaise, little or no fever

Maculer --> Papules --> Viscles --> Crust (7ds)

No other symptoms apart from rash & low grade fever

Measles

Complications:

Secondary infection

Rare:

Encephalomyelitis

Incubation period: 1-14 days

Chickenpox

German measlesIncubation period: 14-21 days

RashIng. NodesMalaiseURTI

Progression over 4 days

Maculopapular

Complications

Rare:

Arthritis

Encephalitis

Purpura

Days of illness

This 32-year-old extravenous drug abuser complained of headaches and arthralgia & maculopapular rash

This may occur shortly before seroconversion in HIV-infected individuals

DD. Of Generalized Skin Rash

Typhoid fever


Typhoid fever

Distribution of rose-spot rash: The typical rash of

typhoid fever may appear towards the end of the first week but it has been recorded as late as the 20th day. It is present in about half the adults with typhoid but is less common in children. Rose spots are difficult to detect on dark skins.

Secondary syphilis

Erythema infectious (5th)

Early meningitis


Early rash of meningitis:Fleeting macular or papular rash. This may occur alone or proceeding hemorrhagic eruption by few hours

Suspected Meningococcal Infection

Immediate Treatment

Adult and children older that 10 years 1200 mg Benzyl penicillin. IM

Children aged 1-9 years 600 mg Benzyl penicillin. IM

Infants aged less than 1 year 300 mg Benzyl penicillin. IM

The rash may be papules or pustules and crusts

Secondary Syphilis-rash

Secondary syphilisDD of Papulosquamous Exanthems

* Figure 5. Drug eruption

* Figure 6. Erythrodermic drug eruption

* Figure 7. Psoriasis

* Figure 8. Lichen planus

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DD of Papulosquamous Exanthems

* Figure 1,2,3 & 4

Secondary syphilis

* Figure 5.

Drug eruption

* Figure 6.

Erythrodermic drug eruption

* Figure 7. Psoriasis


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DD of Papulosquamous Exanthems

SLE Erythema margenatum

DD of Non-infectious Causes of Maculo-papular Rash

DD of Non-infectious Causes of Maculo-papular Rash

Steven-Johnson Syndrome

Erythema Multiforme with “bulls eyes” target lesions

Classification of Pustular Lesions

Local Infections :• Bacterial : impetigo, folliculitis

• Viral : herpes simplex, herpes zoster,

• Fungal : dermatophyte infection, candida

Systemic Infections :• Bacterial

• Meningococcaemia, Gonococcaemia & Staphylococcaemia

• Viral : varicella, enteroviral infection, HIV

Non-infective conditions :Generalized pustular psoriasis or localized pustular psoriasis. Acne vulgaris and rosacea, Eczema, Pemphigus, Porphyria, Erythema multiform, Erythema bullosum.

Impetigo

Herpes simplex

herpes zoster

DD of Pustular Lesions - Local Infections

Generalized pustular psoriasis

Erythema multiforme

DD of Pustular Lesions

Non-infective Conditions

Large, tense blisters in bullous pemphigoid



Bullous pemphigoid with tense vesicles and bullae

on an erythematous, urticarial base.

Pemphigus vulgaris demonstrating flaccid bullae which are easily ruptured, resulting in multiple erosions and crusted plaques.

Linear blistering lesions in primula dermatitis

Bullae occurring as a reaction to flea bites on the ankle



Vasculobullous lesions on the palm, Characteristic

of pompholyx

Phototoxic bullae associated with nalidixic acid

Blisters

Septicemia, probably gonococcal.


Infective Conditions

Purpuric or Petechial Rash Differential Diagnosis

Infections : Bacteremia (with or without DIC)

o Infectious endocarditiso Meningococcemiao Gonococcemia or other pathogenic

bacteria Enteroviral infection Dengue fever Hepatitis Rubella Infectious Mononucleosis

Rash of meningitis

DD of Purpuric or Petechial Rash

Non-infectious causes : Allergy Low platelets of any cause Scurvy Henoch-Schonlain purpura Vasculitis Acute rheumatic fever Hyperglobulinemia

Purpuric or Petechial Rash

Differential Diagnosis

Purpuric Rash

Henoch-Schonlein disease

meningococcal septicemia - often sparse and need to be looked for carefully

Bruises (ecehymoses) in a patient with coagulation defects due to acute hepatic necrosis

Vasculitis. Palpable purpuric papules on the lower legs are seen in this patient with coetaneous small vessel vasculitis.

Purpuric Rash

Patient with rash Warning Presentation

Associated symptoms suggestive of serious illness.

Purpuric or petechial rash

Generalized pustular rash

Infection in dangerous area

E.g.. eyes, dangerous area of the face.

Very toxic patient

Approach to Patient with skin Pruritus

2

Pruritus History

Duration, localization & character of the itch.

Provocating factors

Diurnal variation

Sleep disturbance

Occupational history

Itchy contact

Pruritus Examination & warning presentation

Examination : Patient general condition Characteristic of the skin lesion e.g.

o Burrows of scabieso Lichenification of eczemao Skin discolorationo Scaly lesion

Warning presentation : No overt skin disease Ill elderly patient (cancer)

Systemic Causes of Pruritus

1. Cholestasis :-- Primarily biliary cirrhosis -- Pregnancy

-- Extrahepatic obstruction -- Drugs e.g. Contracep.

2. Endocrine :-- Thyrotoxiosis -- Myxoedema

-- Hyperparathyroidism -- DM

3. Hematological / Myeloproliferative :-- Iron deficiency -- Polycythemia

-- Hodgkin’s disease -- Multiple myeloma

4. Chronic Renal Failure :

5. Malignancy / Miscellaneous : -- Gout -- Psychological -- Old age.

Some common dermatological conditions associated with itching

Severe Infestation : Scabies, lice Insect bites Eczema Articaria Dermatitis herpetiformis Lichen planus Lichen simplex Drug reactions

Moderate Psoriasis Fungal infections Pityriasis rosea Pemphigiod Xerosis (dry skin)

Localized Itching Pruritus ani Pruritus vulvae


Severe Infestation : Scabies, lice

Insect bites

Eczema

Urticaria

Dermatitis herpetiformis

Lichen planus

Lichen simplex

Drug reactions

The head louse: Physical evidence of living lice is required before treatment begins, but they con be difficult to detect

Head lice need relatively prolonged head-to-bead contact. Estimates suggest it takes of least 30 seconds for lice to move from one beside to another

Childhood atopic eczema. Facial atopic eczema.

Dermatological conditions associated with severe itching

(Ring) dermatitisInfected hand eczema

Vesicular hand dermatitis (pompholyx).

Hyperkeratotic hand eczema.

EczemaDermatological conditions associated with severe itching

Urticaria


Urticaria showing characteristic discrete and confluent, edematous, erythematous papules and plaques.


Widespread pruritis rash of scabies. Characteristic burrow of scabies..

ScabiesDermatological conditions associated with severe itching

Herpes simplex infection associated with atopic dermatitisIt was misdiagnosed as pyoderma and treated with antibiotics for more than 2 weeks

Dermatitis herpetiformisDermatological conditions associated with severe itching

Dermatitis herpetiformis manifested by pruritic, grouped vesicles in a typical location. The vesicles are often excoriated and may occur on knees, buttocks, and posterior scalp.


Flat-topped violaceous papules of lichen planus.

Wickham's striae (lichen planus).

lichen planusDermatological conditions associated with severe itching

Lichen planus showing multiple flat-topped, violaceous papules and plaques. Nail dystrophy as seen in this patient's thumbnail may also he a feature.


lichen simplex chronicus

Lichenification from constant rubbing

Lichen simper of scrotum

Lichen simplexDermatological conditions associated with severe itching

Angio-edemaMost drugs have the potential to cause angio-edema, urticaria, pruritus and maculopopular rash


Widespread urticaria Severe angio-oedema



Moderate:

Psoriasis

Fungal infections

Pityriasis rosea

Pemphigiod

Xerosis (dry skin)

Pityriasis roseaPsoriasis

Some common dermatological conditions associated

with moderate itching

Pruritus ani - perianai dermatitis.

Common Cause of Local Itching

Herpes simplex of the anus.

Mouth Conditions

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Month Ulcers Differential Diagnosis

Trauma (dentures)

Aphthous ulcers

Candida infection

Herpes simplex

Erythema multiform

(from drugs)

Pemphigus

Lichen planus

Carcinoma

DD. Of Oral Conditions

Lichen planus

Erythema multiform

Aphthous ulcers

Bullous erythema multiforme lesions of palm.

Typical target lesions

Erythema multiforme: mucosal involvement

Erythema multiforme

Aphthous ulcers: Small ulcers, 1 – 4 mm in diameter may occur on healthy persons as a recurrent, painful, self-limiting problem lasting five to six days, aetiology unknown. An aphthous-like ulcer may occur on the pharynx in infectious mononucleosis

Aphthus Ulcer

Aphthus Ulcer

Pemphigus

DD. Of Oral Conditions

Oral thrush Leukoplakia

lichen planus on the tongue, resembling

leukoplakia

Smooth tongue

Angular stomatitis

Iron deficiency

anemia

Differential Diagnosis of

Mucous Membrane Lesions

Figure 1. Secondary syphilis

Figure 2. Lichen planus

Figure 3. Scrotal tongue

Figure 4. Geographic tongue

Figure 5. Aphthus ulcer

Figure 6. Black hairy tongue

Figure 7. Pyogenic granuloma

Figure 8. Median rhomboid glossitis

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1) Angular stomatitis2) Herpes labialis

3) Carcinoma of lip4) Hereditary hemorrhagic telangiectasia

5) Peutz-Jeghers syndrome

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Palm & Sole Lesions

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Tinea pedis

plantar warts

dyshydrotic dermatitis

DD. Of Acral Lesions

Unilateral scaling of the palm(tinea manuum).

Tinia pedis

Dermatophyte infection spreading out from the toes

DD. Of Palm & Sole Lesions

Pustular psoriasis on sole of foot

Psoriasis nail with ridging and pitting

DD. Of Palm & Sole Lesions

Nail Diseases

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Differential Diagnosis

of Nail Diseases

* Figure 1. Fungal infection

* Figure 2. Paronychia.

* Figure 3. Posttraumatic

hematoma

* Figure 4. Ingrown toenail

* Figure 5. Onychogryposis


* Figure 7& 8. Psoriasis

Splinter hemorrhages of the nails

Tinea Infection

Longitudinal section of distal phalanx to show nail.Brittle nails may be a sign of peripheral vascular insufficiency, anemia or hypothyroidism

Nappy Rash6

Nappy Rash Differential Diagnosis & Management

Contact dermatitis -- Emollient, frequent changing & cleaning.

-- Zincoxide paste + Topical steroids Atopic dermatitis -- Emollient, Local steroids, Systemic

antihistamine for pruritus antibiotics. Seborrhoeic dermatitis -- Local steroids / Antiseptic.

Cleaning cream. Candiasis -- Topical antifungal e.g.. Nystatin &

Unidazole or Hydrocortisone / Unidazole combination.

Napkin rash

Bright red area (involving flexures) spread from prenial area

Erythema and ulcers on expose surfaces (sparing flexures)

Napkin dermatitis Candidiasis

Ammoniacal napkin rash

Sebarrhoeic dermatitis of infants

Napkin Eruptions

Napkin Eruptions

Candidal intertrigoGranuloma gluteale infantum (candida).

Psoriasiform napkin rash

Acne7

Acne - Lesions / Stages

Primary comedones

Mildly inflammatory : Comedones and papules

Moderate or severe Inflammatory :

Many papules , pustules & some cysts

Conglobate abscesses (large cysts) & severe scarring

Acne

Acne

Gray discoloration in the numerous old

acne scar of the face as side effect of

Minocycline

Acne

Rosacea is easily confused with acne, acne vulgaris tends to occur in a younger age group and comedones are usually present. Comedones are not seen in rosacea

Typical case of rosacea: small papules and pustules on an erythematous, telangiectatic background. The most common sites are the central cheeks, forehead, tip of the nose and chin

Acne rosacea. Commoner in women, esp. those with Celtic skin. Cruciate distribution

Rhinophyma. Enlargement of the nose due to hypertrophy of sebaceous glands.

Acne Therapy Guide

• Primary comedones

• Mildly inflammatory : Comedones and papules

• Moderate or severe Inflammatory :

Many papules & pustules, some cysts

• Conglobate abscesses, severe scarring

• Retinoic acid cream / gel

• Topical antibiotic or benzoyl peroxide lotion or gel (sometimes retinoic acid)

• Benzoyl peroxide & oral or topical antibiotic (sometimes retinoic acid)

• Referral of treatment failures

• Referral

Lesion / Stage Therapy

Skin Pigmentation

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* Figure 1. Pigmented basal cell carcinoma

* Figure 2. Blue nevus

* Figure 3. Lentigo maligna

* Figure 4. Superficial spreading melanoma

Differential Diagnosis of Pigmented Skin Lesions

* Figure 5.

Nodular

melanoma

* Figure 6. Seborrhoeic keratosis

* Figure 7. Dermatofibroma

* Figure 8. Angiokeratoma

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•Figure 1. Pigmented basal cell

carcinoma

•Figure 2. Blue nevus

•Figure 3. Lentigo maligna

•Figure 4. Superficial spreading

melanoma

* Figure 5. Nodular melanoma

* Figure 6. Seborrhoeic keratosis

* Figure 7. Dermatofibroma

* Figure 8. Angiokeratoma

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Oral Kaposi’s Sarcoma

Coetaneous Kaposi’s Sarcoma in a homosexual man

Fig. 1 Acanthosis nigricans in a patient with underlying malignancy.

Fig. 2 Acanthosis nigricans (benign type).

Fig. 3 Acquired ichthyosis with underlying lymphoma.

Fig. 4 Migratory thrombophlebitis.

Skin Manifestation of Internal Malignancy

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Education

Dermatology approach