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Dermatology in General Practice

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Presentation on theme: "Dermatology in General Practice"— Presentation transcript:

1 Dermatology in General Practice
Dr Lynne Rees

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

9 vesicle Small fluid filled blister

10 Bulla A large fluid filled blister

11 ECZEMA Synonymous with dermatitis
Large proportion of skin disease in developed world 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 Exacerbating factors Detergents Infection Teething Stress
Cat and dog fur ???? House dust mite ???? Food allergens Theory of protection from parasite

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






22 complications Bacterial infection
Viral infections – warts, molluscum, herpes Keratoconjunctivitis Retarded growth

23 investigations Clinical ??IgE ??RAST

24 Prognosis Most grow out of it! 15% may come back – often very mildly

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 Bath oils – 2-3 capfuls per bath

32 Discoid eczema Variant of eczema Atopic and non atopic
Easily confused with psoriasis Well demarcated scaly patches Limbs Often infective component (staph aureus)



35 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


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

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

39 Clinical features Affects body sites rich in sebacceous glands
Infancy – cradle cap, widespread rash, child unbothered, little pruritus Young adults – erythematous scaling eyebrows, nasolabial folds, forehead scalp Elderly – more extensive

40 Treatment Suppressive Mild steroid and antifungal combination
Ketoconazole shampoo Emollients Soap substitutes




44 Venous eczema Lower legs Venous hypertension Endothelial hyperplasia
Extravasation of red and white cells Inflammation Purpura pigmentation

45 Clinical features Older women Past history DVT Haemosiderin deposition

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


48 Asteatotic eczema Dry skin Repeated soaping Worse in winter
Hypothyroidism Avoid soap Emollients Bath oils


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

51 irritant Can occur in any individual Repeated exposure to irritants
Common in housewives, hairdressers, nurses

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



55 Lichen simplex Cutaneous response to rubbing
Thickened scaly hyperpigmentation Emotional stress May need biopsy to diagnose


57 treatment Stop rubbing! Very potent steroids Occlusion



60 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

61 Chronic plaque Extensor surfaces Sacral area Scalp Koebners phenomenon





66 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



69 Guttate psoriasis

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



73 Treatment Calcipotriol too irritant Steroid

74 Erythrodermic and pustular psoriasis
More severe Need dermatologist! Usually need oral therapy






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



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

84 treatment Suit patient Control rather than cure Topical therapies
Light treatments Oral therapy

85 Topical therapy Emollients
Vit D analogues- calcipotriol, calcitriol, tacalcitol (dovonex, silkis, curatoderm) Tazarotene – (zorac) Coal tar – alphosyl, exorex, cocois, polytar Dithranol –dithrocream, dithranol 0.1% to 2% for short contact Steroids – eumovate Combinations – dovobet, alphosyl HC, etc

86 Light treatments Not the same as sun beds!!!! UVB UVA


88 Cause of acne Common facial rash Usually adolescents
May occur in early and mid adult life Blockage of pilosebacceaous unit with surrounding inflammation Androgens lead to increase sebum production Increased colonisation by propionibacterium acnes

89 Clinical features Increased seborrhoea Open comedones Closed comedones
Inflammatory papules Pustules Nodulocystic lesions





94 Acne distribution

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

96 Topical treatments Benzoylperoxidase – OTC, PanOxyl 5 to 10%,
Azelaic acid – skinoren ,avoid in pregnancy Antibiotics – clindamycin, erythromycin, steimycin Retinoids – adapalene, tretinoin, avoid in pregnancy, avoid uv light, differin, retin-A

97 Combination topical treatments
Antibiotics plus benzoyl peroxidase – benzamycin Retinoid plus antibiotic – isotrexin Antibiotic plus zinc - zineryt

98 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. Consider side effects and interactions when starting antibiotics 3 to 4 months before any improvement

99 Antibiotics Oxytetracycline 500mg bd Tetracycline 500mg bd
Doxycycline 100mg od Minocycline 100mg od Erythromycin 500mg bd

100 Hormone treatment for acne
Dianette - not if COCP contraindicated Withdraw when acne controlled VTE occurs more frequently in women taking dianette than other cocp.

101 Oral retinoids Hospital only Long list of side effects Teratogenic
Very effective


103 Clinical features rosacea
Onset middle age Facial flushing / erythema Inflammatory papules Pustules No comedones Telangectasia Blepharitis rhinophyma





108 Treatment Supressive rather than curative Topical metronidazole 0.075%
Tetracycline 500mg bd for 3 months Metronidazole 400mg bd Roaccutane Plastic surgery and some laser therapy for rhinophyma


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