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Primary Care Dermatology Dr Mick McKernan. Description of skin lesions Papule Macule Nodule Patch Vesicle Bulla Plaque.

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Presentation on theme: "Primary Care Dermatology Dr Mick McKernan. Description of skin lesions Papule Macule Nodule Patch Vesicle Bulla Plaque."— Presentation transcript:

1 Primary Care Dermatology Dr Mick McKernan

2 Description of skin lesions Papule Macule Nodule Patch Vesicle Bulla Plaque

3 Papule Small palpable circumscribed lesion <0.5cm

4 Macule Flat, circumscribed non-palpable lesion

5 Pustule Yellowish white pus-filled lesion

6 Nodule Large papule >0.5cm

7 plaque Large flat topped elevated palpable lesion

8 patch Large macule >2cm

9 vesicle Small fluid filled blister < 1/2cm

10 Bulla A large fluid filled blister > 1/2cm

11 ECZEMA =dermatitis 10% of population at any one time 40% of population at some time

12 Features of eczema Itchy Erythematous Dry Flaky Oedematous Crusted Vesicles lichenified

13 Types of eczema Atopic Discoid eczema Hand eczema Seborrhoeic eczema Varicose eczema Contact and irritant eczema Lichen simplex

14 Atopic eczema Endogenous Atopic i.e asthma, hay fever 5% of population 10-15% of all children affected at some time

15 Atopic eczema individual must have: An itchy skin condition in the last 12 months+ three or more of: Onset before 2 years of age History of flexural involvement or flexural eczema currently present History of generally dry skin History of other atopic disease or FH

16 Exacerbating factors Infection Teething Stress Cat and dog fur ? House dust mite ? Food allergens

17 Clinical features Itchy erythematous patches Flexures of knees and elbows Neck Face in infants Exaggerated skin markings Lichenification Nail – pitted

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23 complications Bacterial infection Viral infections – warts, molluscum, eczema herpeticum ( refer stat). Keratoconjunctivitis Retarded growth

24 Prognosis Most grow out of it 15% may come back – often very mildly Chronic skin dryness common after

25 Treatment Avoid irritants especially soap Frequent emollients Topical steroids Sedating antihistamines – oral hydroxyzine Treat infections Bandages Second line agents

26 Triple combination of therapy Topical steroid bd as required Emollient frequently Bath oil and soap substitute

27 Principles of treatments Creams Ointments Amounts required Potential side effects Soap substitutes

28 creams Cosmetically more acceptable Water based Contain preservatives Soap substitutes

29 ointments Oil based Don ’ t contain preservative Feel greasy Good for hydrating

30 Topical steroids Mild – “ hydrocortisone Moderate – “ eumovate ” Potent – “ betnovate ” Very potent – “ dermovate ”

31 Amounts required Emollients – 500g per week for total body FTU – steroids- the least potent that controls the symptoms. Bath oils – 2-3 capfuls per bath

32 FTU Finger tip unit Helps to give estimation of topical steroid amount used To avoid over and under use of steroid

33 FTU

34 2 FTU = nearly 1 gram Enough for twice size of adult hand A hand and fingers (front and back) = 1FTU A foot (all over) + 2FTU Front of chest and abdomen = 7FTU Back and buttocks = 7FTU Face and neck = 2.5 FTU An entire arm and hand = 4 FTU An entire leg and foot = 8 FTU

35 Discoid eczema Variant of eczema Easily confused with psoriasis Well demarcated scaly patches Limbs Often infective component (staph aureus)

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38 Hand eczema Pompholoyx – itchy vesicles or blisters of palm and along fingers Diffuse erythematous scaling and hyperkeratosis of palms Scaling and peeling at finger tips

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40 Hand eczema Not unusual in atopic More common in non atopics Cause often uncertain Irritants Chemicals Occupational history Consider patch testing – 10% positive

41 Seborrhoeic eczema Over growth of yeast (pityrosporum ovale, hyphal form malassezia furfur) Strong cutaneous immune response More common in Parkinson ’ s and HIV

42 Clinical features Infancy – cradle cap, widespread rash, child unbothered, little pruritus Young adults – erythematous scaling eyebrows, nasolabial folds, forehead scalp Elderly – more extensive

43 Treatment Suppressive Mild steroid and antifungal combination Ketoconazole or dentinox shampoo Emollients Soap substitutes

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47 Venous eczema Gravitational = stasis eczema Lower legs Venous hypertension Inflammation Purpura pigmentation

48 Clinical features Older women Past history DVT Haemosiderin deposition often misdiagnosed as cellulitis. Cellulitis is nearly always unilateral, tender and has a well demarcated edge

49 treatment Emollients Topical moderately potent steroids Soap substitutes Compression – check arterial supply first Leg elevation

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51 Champagne bottle appearance of lipodermatosclerosis

52 Lipodermatosclerosis and venous leg ulcer

53 Cellulitis – unilateral painful and well demarcated.

54 Asteatotic eczema =eczema craquele Dry skin Worse in winter Hypothyroidism Avoid soap Emollients Bath oils

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56 Contact and irritant eczema Exogenous Unusual Worse at workplace History of exacerbations

57 irritant Can occur in any individual Repeated exposure to irritants Common in housewives, hairdressers, nurses –bleaches and chemicals

58 contact Occurs after repeated exposure but only in susceptible individuals Allergic reaction Common culprits – nickel, chromates, latex etc Patch testing

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61 Lichen simplex =Neurodermatitis Cutaneous response to rubbing Thickened scaly hyperpigmentation Emotional stress May need biopsy to diagnose

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63 treatment Stop rubbing! Very potent steroids Occlusion

64 PSORIASIS

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66 Psoriasis Affects 2% of population Well-demarcated red scaly plaques Skin inflamed and hyperproliferates Males and females equally Two peaks of onset (16- 22) and later (55-60) Usually family history

67 Chronic plaque Extensor surfaces Sacral area Scalp Koebners phenomenon

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72 Guttate psoriasis Raindrop Children and young adults Associated with streptococcal sore throats Not all go onto get chronic plaque May resolve spontaneously over 1-2 months

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75 Guttate psoriasis

76 Flexural psoriasis Later in life Well demarcated red glazed plaques Groin Natal cleft Sub mammary area No scale

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79 Treatment Step 1:Prescribe copious emollients - make the skin more comfortable and reduce the amount of scale Step 2:Dovobet is the most effective vitamin D analogue Avoid on areas of thin skin eg the face, flexures and the genitalia. Also consider dithranol and tar. Flares use topical steroids 2 weeks- erythroderma or generalised pustular psoriasis if overused. Step 3 : for hospitals. Phototherapy, cyclosporin, UV, methotrexate Step 4: biologicals : Etanercept, Infliximab, Adalimumab and Ustekinumab belong to the class of biological medicines called tumour necrosis factor (TNF) blockers. These work by blocking the activity of TNF.

80 Erythrodermic and pustular psoriasis More severe > 90% involvement Need dermatologist! Usually need oral therapy

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86 Associated features Arthritis Nail changes- onycholysis, pitting, discolouration, subungal hyperkeratosis

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89 prognosis Chronic plaque tends to be lifelong Guttate – 2/3 further attacks, or develop chronic plaque

90 ACNE VULGARIS

91 Acne Vulgaris Common facial rash Usually adolescents 3% may persist after 25yrs especially women.

92 Clinical features Increased seborrhoea Open comedones= blackheads Closed comedones= whiteheads Inflammatory papules Pustules Nodulocystic lesions scars

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97 Acne distribution

98 Treatment Consider site Compliance Inflammatory/non inflammatory lesions Scarring Fertility Psychological effect

99 Topical treatments Benzoylperoxidase – OTC, PanOxyl 5 to 10%, Azelaic acid – skinoren Antibiotics – clindamycin, erythromycin, steimycin Retinoids – adapalene

100 Oral therapy Use if topical therapy ineffective or inappropriate Anticomedonal topical treatment may be required in addition Don ’ t combine topical with oral antibiotic as encourages resistance. 3 to 4 months before any improvement

101 Antibiotics Oxytetracycline 500mg bd Tetracycline 500mg bd Doxycycline 100mg od Erythromycin 500mg bd Lymecycline 408mg od

102 Hormone treatment for acne Dianette - not if COCP contraindicated Withdraw when acne controlled VTE occurs more frequently in women taking dianette than other COCP – caution ++ at this point.

103 Oral retinoids Hospital only Long list of side effects Teratogenic Very effective Suicide- no proven link

104 Rashes are difficult!


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