Features:
Lichen planus is a skin disorder of unknown aetiology, most probably being immune mediated.
Itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms.
Rash often polygonal in shape, 'white-lace' pattern on the surface (Wickham's striae).
Koebner phenomenon may be seen (new skin lesions appearing at the site of trauma).
Oral involvement in around 50% of patients.
Nails: thinning of nail plate, longitudinal ridging.
Dr Khaled Elmagraby
Pemphigoid gestationis
Shin lesions
The differential diagnosis of shin lesions includes the following
conditions:
1)
2)
3)
4)
Erythema nodosum
Pyoderma gangrenosum
Pretibial myxoedema
Necrobiosis lipoidica diabeticorum
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1) Erythema nodosum:
the commonest potentially serious causes (and therefore those that should be excluded first) include sarcoidosis
and tuberculosis.
A CXR is an important investigation to exclude both of these causes.
Dr Khaled Elmagraby
2) Pyoderma gangrenosum:
Pyoderma gangrenosum
Pyoderma gangrenosum typically is an expanding ulcer with a polycyclic or serpiginous outline and a characteristic
undermined bluish edge.
It can be associated with:
Inflammatory bowel disease
Rheumatoid arthritis
Monoclonal gammopathies, and
Leukaemia.
It usually responds to oral steroids.
The pathogenesis is unknown, and is presumed to be immunological.
Dr Khaled Elmagraby
3) Pretibial myxoedema:
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Cellulitis
It is an inflammation of the skin and subcutaneous tissues.
Typically due to infection by:
Streptococcus pyogenes or
Staphylococcus aureus.
Features:
Commonly occurs on the shins.
Erythema, pain, swelling.
There may be some associated systemic upset such as fever.
Management:
The BNF recommends flucloxacillin as first-line treatment for mild/moderate cellulitis.
Clarithromycin or clindamycin is recommend in patients allergic to penicillin.
Many local protocols now suggest the use of oral clindamycin in patients who have failed
to respond to flucloxacillin.
Severe cellulitis should be treated with intravenous benzylpenicillin + flucloxacillin.
Dr Khaled Elmagraby
Granuloma annulare
Papular lesions that are often slightly hyperpigmented and depressed centrally.
It is characterised by a raised annular configuration.
It is not clear from recent studies if there is actually a significant association between DM and granuloma
annulare, but it is often listed in major textbooks.
The treatment is 'masterful inactivity, The eruption
should disappear spontaneously.
Dr Khaled Elmagraby
Scabies
Crusted (Norwegian) scabies:
Crusted scabies is seen in pt. with suppressed immunity, especially
HIV.
The crusted skin will be teeming with hundreds of thousands of
organisms.
Ivermectin is the treatment of choice and isolation is essential.
Dr Khaled Elmagraby
Pityriasis versicolor
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Seborrhoeic
dermatitis
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Acne Rosacea
Mild papules and erythema Moderate papules and early pustules Severe erythema, papules and pustules
AdvancedDrRhinophyma
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Telangiectasia
Features:
Typically affects nose, cheeks and forehead
Flushing is often first symptom
Telangiectasia are common
Later develops into persistent erythema with papules and pustules
Rhinophyma
Ocular involvement: blepharitis
Management:
Topical metronidazole may be used for mild symptoms (i.e. Limited number of papules and pustules, no plaques).
More severe disease >> systemic antibiotics: oral Oxytetracycline.
Recommend daily application of a high-factor sunscreen.
Camouflage creams may help conceal redness.
Laser therapy may be for patients with prominent telangiectasia.
Dr Khaled Elmagraby
Pityriasis rosea
Pityriasis rosea
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Impetigo
Impetigo is a superficial bacterial skin infection usually caused by either Staphylococcus aureus or Streptococcus pyogenes.
'Golden', crusted skin lesions typically found around the mouth.
It is Very contagious.
Topical Fusidic acid is first-line ttt.
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Erythema ab igne
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Psoriasis
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This patient has psoriatic nail changes as evidenced by pitting, onycholysis and subungual debris.
It usually affects multiple nails.
The description of the rash is classical for psoriasis vulgaris which presents with well-demarcated, symmetrical, pink,
scaly papules and plaques on extensor surfaces.
Dr Khaled Elmagraby
This patient has Beau's lines, a benign nail condition that presents as a jagged transverse groove on the nail plate
corresponding to an episode of nail growth arrest, which can occur during an episode of severe medical illness. It
usually affects several nails.
Dr Khaled Elmagraby
First line treatment would involve topical corticosteroid preparations as well as medicated shampoos containing zinc, coal
tar, salicylic acid, corticosteroids or ciclopirox.
Dr Khaled Elmagraby
Guttate psoriasis
Dermatitis herpetiformis
Dermatitis herpetiformis is an autoimmune blistering skin disorder associated with coeliac disease.
It is caused by deposition of IgA in the dermis.
Features: Itchy, vesicular skin lesions on the extensor surfaces (e.g. elbows, knees, buttocks).
Diagnosis: Skin biopsy: direct immunofluorescence shows deposition of IgA in a granular pattern in
the upper dermis.
Management: Gluten-free diet and Dapsone.
Dr Khaled Elmagraby
Pap smear.
Multinucleated giant cells representing infection by the herpes simplex virus.
Note the 3 M's; Multinucleation, Margination of the chromatin, Molding of the nuclei.
The cytopathic effect of HSV (multi-nucleation,
ground glass & marginated chromatin).
Dr Khaled Elmagraby
Dr Khaled Elmagraby
Target lesions.
Initially seen on the back of the hands / feet before spreading to the
torso.
Upper limbs are more commonly affected than the lower limbs.
If symptoms are severe and involve blistering and mucosal involvement the
term Stevens-Johnson syndrome is used.
Causes:
Viruses: HSV (the most common cause), Orf (Orf is a skin disease of
sheep and goats caused by a parapox virus).
Idiopathic
Drugs:
Penicillin,
Sulphonamides,
Carbamazepine,
Sarcoidosis
Malignancy
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Allopurinol,
Causes:
Same like the causes of Erythema multiforme (EM).
The antibiotic which is most associated with the development of StevensJohnson syndrome is >>> Sulphonamides (Co-trimoxazole).
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Onycholysis
Onycholysis describes the separation of the nail plate from the nail bed.
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Vitiligo
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Sweet's syndrome >> Haematological malignancy e.g. Myelodysplasia, AML - tender, purple plaques
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Cont.
Cont.
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Cont.
Erythema gyratum repens >>> Solid organ malignancies such as Lung cancer & Breast cancer.
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It is a common premalignant skin lesion that develops as a consequence of chronic sun exposure.
Features:
Small, crusty or scaly, lesions. May be pink, red, brown or the same colour as the skin.
Typically on sun-exposed areas e.g. temples of head.
Multiple lesions may be present.
Dr Khaled Elmagraby
TTT: Fluorouracil cream.
TEN is a potentially life-threatening skin disorder that is most commonly seen secondary to a drug reaction.
Features:
Systemically unwell e.g. pyrexia, tachycardia
Positive Nikolsky's sign: the epidermis separates with mild lateral pressure.
Dr Khaled Elmagraby
Phenytoin
Sulphonamides
Penicillins
Allopurinol
Carbamazepine
NSAIDs
Management:
Dr Khaled Elmagraby
Lupus vulgaris
Lupus vulgaris is the most common form of cutaneous TB seen in the Indian subcontinent.
It generally occurs on the face and is common around the nose and mouth.
The initial lesion is an erythematous flat plaque which gradually becomes elevated and may ulcerate later.
Dr Khaled Elmagraby
Scrofuloderma
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Blisters/bullae:
No mucosal involvement >>> Bullous Pemphigoid
Mucosal involvement >>> Pemphigus vulgaris
Dr Khaled Elmagraby
Pemphigus vulgaris
Bullous Pemphigoid
Bullous Pemphigoid
Pemphigoid is a disease of the elderly (over 60 years) characterised by the development of large tense blisters that heal
without scarring. It is caused by immunoglobulin (IgG) autoantibodies against components of the basement membrane.
Blistering in pemphigoid occurs at the sub epidermal level - deeper than the blisters of pemphigus vulgaris (which occur at
the dermal-epidermal junction); hence the tense blisters seen in pemphigoid. Blisters are thin-walled and fragile in
pemphigus - few intact blisters are ever seen.
Skin biopsy will reveal a sub epidermal blister withDran
infiltrate
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reveal IgG and C3 in the basement membrane zone.
Pemphigus vulgaris
Pemphigus vulgaris is a blistering disease seen predominantly in elderly patients. It is characterised by the formation of
thin-walled blisters that rupture easily (intact blisters are rarely seen).
Large surface areas of the body can be affected and the mortality without treatment is high.
Mucosal involvement is common at presentation (unlike pemphigoid).
Treatment is with high-dose corticosteroids.
Immunofluorescent staining of a biopsy sample shows deposition of immunoglobulin (IgG) directed against intercellular
cement, resulting in a 'chicken wire' appearance.
In comparison, pemphigoid rarely involves the mucosa and presents with large tense intact blisters. Immunofluorescence
of pemphigoid shows deposition of IgG and complement
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the dermo-epidermal junction.
Dr Khaled
Dr Khaled Elmagraby
Keratoacanthoma (KA)
Keratoacanthoma is a benign epithelial tumour., low-grade malignancy that originates in the pilosebaceous glands.
It resembles squamous cell carcinoma (SCC) pathologically.
It is believed to develop from the hair follicle, and is said to be more common in males.
Some experts support classifying KA as a variant of invasive SCC.
Features - said to look like a volcano or crater:
Initially a smooth dome-shaped papule.
Rapidly grows to become a crater centrally-filled with keratin.
Spontaneous regression of Keratoacanthoma within
3 months is common, often resulting in a scar.
Dr Khaled Elmagraby
Such lesions should however be urgently excised as it is difficult clinically to exclude squamous cell carcinoma.
Keratoacanthomas are now considered as a well-differentiated variant of squamous cell carcinoma (SCC).
It presents as a rapidly enlarging nodule with a central keratinous crateriform scab.
There are reports of spontaneous regression but generally they should be treated with full excision.
NB: Basal cell carcinoma most commonly presents as an ulcerated nodule with pearly, rolled edges with telangiectasias.
Dr Khaled Elmagraby
This patient presents with a typical 'rodent ulcer' with rolled pearly edges and small telangiectasias.
It is the commonest malignant skin tumour and most commonly occurs in elderly patients with sun-damaged skin.
Dr Khaled Elmagraby
They are benign ganglion cysts usually found on the distal, dorsal aspect of the finger. It is firm dome-shaped
swelling. There is usually osteoarthritis in the surrounding joint. They are more common in middle-aged women.
Dr Khaled Elmagraby
Molluscum contagiosum
Such umbilicated, pearly papules 2-5 mm in diameter are seen in patients with advanced HIV/AIDS (CD4 count less
than 200 cells/mm3).
They are caused by a DNA pox virus called molluscum contagiosum virus (MCV).
They commonly occur on the face, especially near the eyelids; they also occur on genitals and trunk.
They should be treated with cryotherapy, liquid nitrogen or curettage.
Dr Khaled Elmagraby
Erythrasma
Erythrasma is a generally asymptomatic, flat, slightly scaly, pink or brown rash usually found in the groin or axillae.
It is caused by an overgrowth of the diphtheroid Corynebacterium minutissimum.
Examination with Wood's light fluorescence reveals a coral-red fluorescence.
Topical miconazole or antibacterial are usually effective.
Oral erythromycin may be used for more extensive infection.
Dr Khaled Elmagraby
Pompholyx
Pompholyx is a type of eczema which affects both the hands (cheiropompholyx) and the feet (pedopompholyx).
Features:
Small blisters on the palms and soles.
Pruritic, sometimes burning sensation.
Once blisters burst skin may become dry and crack.
Dr Khaled Elmagraby
Management: 1)Cool compresses. 2)Emollients.
3)Topical steroids
Pellagra
Pellagra is a caused by nicotinic acid (niacin) deficiency (Vit B3).
The classical features are the 3 D's - Dermatitis, Diarrhoea and Dementia.
Pellagra may occur as a consequence of isoniazid therapy (isoniazid inhibits
the conversion of tryptophan to niacin) and it is more common in alcoholics.
Features:
1) Dermatitis (red-brown, symmetrically scaly rash on sun-exposed sites termed Casal's necklace if around neck).
2) Diarrhoea.
3) Dementia, Depression.
4) Death if not treated.
Dr Khaled Elmagraby
Dr Khaled Elmagraby
Dermatomyositis (DM)
The characteristic heliotrope rash consists of a violaceous or erythematous rash (sometimes with oedema) in a
symmetrical distribution involving periorbital skin.
This is frequently subtle and may involve only a mild discolouration along the eyelid margin.
Dr Khaled Elmagraby
Dermatomyositis
Gottron's papules
Gottron's papules : roughened red papules over extensor surfaces of fingers at knuckles.
Gottron's papules are found over bony prominences, particularly the metacarpophalangeal joints, the proximal
interphalangeal joints, and/or the distal interphalangeal joints.
Papules may also be found overlying the elbows, knees, and/or feet.
The lesions consist of slightly elevated violaceous papules and plaques, and may be scaly.
Nailfold changes consist of periungual telangiectases and/or a characteristic cuticular change with hypertrophy of
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the cuticle and small haemorrhagic infarcts with this hypertrophic area.
Dermatomyositis
heliotrope
The classic purple (heliotrope) rash is seen on sun-exposed areas, especially the eyelids, nose, cheeks,
forehead, knees, knuckles and around the nail beds. The rash may be pruritic.
Dr Khaled Elmagraby
The condition is inherited as an autosomal dominant trait; sporadic cases also occur.
Patients typically present early in adult life with anaemia due to occult bleeding from gastrointestinal
telangiectasiae.
Lesions commonly occur in the mouth and on the face.
Dr Khaled Elmagraby
Complications of the disease include haemoptysis and pulmonary haemorrhage.
Necrobiosis Lipodica
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Dr Khaled Elmagraby
Acanthosis nigricans
Erysipelas
Streptococcus pyogenes infection of the deep dermis and subcutis
Cutaneous tuberculosis
(lupus vulgaris)
It is usually occurs due to spread from an endogenous source; more than 80% of cases occur on the face and neck.
Lesions begin as papules and coalesce to form a plaque. The centre of the lesion consists of scar tissue while the lesion
extends from the periphery.
Apple-jelly nodules are classically described at the margins
of the lesions.
Dr Khaled Elmagraby
Ancylostoma braziliense
cutaneous larva migrans (creeping eruption).
The infection is acquired by direct contact with dog or cat faeces - often acquired when sunbathing on contaminated
sand, etc. The larvae burrow in the dermo-epidermal junction.
Symptoms include pruritus and a raised, serpiginous erythematous rash that migrates at a rate of up to 1 cm/day.
Treatment: Oral ivermectin in a single dose of 200 g/kg body weight is the main treatment
Other ttt: with topical thiabendazole or oral albendazole.
Acute infection with the human nematodes Strongyloides
stercoralis, Necator americanus and Ancylostoma duodenale,
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may produce a similar appearance.
The picture shows characteristic purple lesions of Kaposi's sarcoma (KS) on the hard palate.
The disease was originally described by Kaposi as a rare tumour in elderly men of Mediterranean origin ('classical Kaposi's
sarcoma') in whom KS was usually found on the lower legs and feet.
Dr Khaled Elmagraby
TTT: Aciclovir
Dr Khaled Elmagraby
Dr Khaled Elmagraby
Classic EF, also known as Ofuji disease (eosinophilic pustular folliculitis), is more common in individuals of
Japanese descent, although anyone can be affected. The clinical presentations of EF vary slightly, but
histologically the forms are identical.
Immunosuppression-EF: it is The most common type of EF, it differs from the classical form in that the eruption
is exquisitely pruritic. It also tends to present with erythematous, almost oedematous, papules with few pustules
(whereas the classic form tends to have clusters of pustules). Because the eruption is so pruritic the lesions are
often excoriated on presentation, making identification of a primary lesion difficult. The lesions are found
primarily on the face and upper trunk (from the waist up). Histologic examination of a papule shows an acute
and chronic infiltrate of eosinophils and lymphocytes focused at the level of the follicular isthmus that can rarely
progress to complete follicular destruction.
Men seem to be more commonly affected than women. The patient's CD4+ cell count is often below 250/L and
patients may have a peripheral eosinophilia and lymphopenia.
Cases of immunosuppression-EF may worsen 3 to 6 months after the initiation of antiretroviral therapy as part of
the immune restoration syndrome and even after the CD4+ cell count rises above 200/L. The reason for this
development is unknown, but may represent a previously quiescent immune system now reacting to antigens.
Dr Khaled Elmagraby
Cutaneous anthrax
caused by Bacillus anthracis
Cutaneous disease is the commonest form of the infection in humans and is usually due to contact with infected animals
or animal products. Anthrax is endemic to herd animals in some parts of the world.
Following exposure, the skin lesion evolves over a period of ~2 weeks into a papule, pustule, vesicle and eventually forms
an ulcer with a central black eschar. The surrounding skin is usually boggy and oedematous. Lesions are usually painless
with tender regional lymph nodes.
Lesions heal spontaneously in 80-90% of cases; 10-20%
of patients progress and become bacteraemic associated with a
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high mortality. Penicillin is effective in treating the infection.
Mycosis fungoides,
(Cutaneous T cell lymphoma)
The disease presents as a pruritic eczematous rash (the pre-malignant stage) and develops telangiectasias and
areas of 'cigarette paper' atrophy.
As malignancy develops, nodular lesions appear and proceed to become necrotic.
Dr Khaled Elmagraby
HZV
Herpes Zoster Virus
This patient has grouped vesicles and blisters over an erythematous base in a dermatomal distribution.
The lesions are also typically painful.
Herpes zoster is caused by varicella-zoster virus.
Dr Khaled Elmagraby
It occurs commonly in children and young adults, Although commonly idiopathic, it can occur after prior infections.
Patients present with signs and symptoms affecting:
The skin (vasculitis)
Joints (arthralgia and arthritis)
Gastrointestinal (GI) tract (intussusceptions, GI bleeding, perforation) and
Genito-urinary tract (haematuria, proteinuria).
Immunofluorescence studies will reveal IgA deposits within blood vessel walls.
The disease is usually self-limiting.
Dr Khaled Elmagraby
Eczema herpeticum
It is a cutaneous infection caused by herpes virus, seen in patients with pre-existing inflammatory skin disorders, for
example, eczema, Darier's disease.
Patients present with new onset of clustered blisters and erosions over an erythematous base. The eruption can be
widespread and patients may be ill. Lesions may be secondarily impetiginised with Staphylococcus infection.
Treatment requires systemic anti-virals e.g. oral aciclovir. Systemic antibiotics may be required if lesions are secondarily
impetiginised.
Topical aciclovir will not be useful in this setting, as the patient requires systemic anti-virals.
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The patient does not present with a fungal infection Dr
and
will not require treatment of topical or oral anti-fungals.
Lichenification
Lichenification of the skin is due to epidermal thickening characterised by visible and palpable thickening of the skin
with accentuation of skin markings.
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Dr Khaled Elmagraby
Alopecia areata
Alopecia areata is common in children as well as adults. It presents with localised patches of non-scarring hair loss.
Remaining hairs have a characteristic 'exclamation mark' appearance, and are tapered towards the base. More severe
involvement may present as alopecia totalis (total loss of scalp hair) or alopecia universalis (total loss of all body hair).
Androgenetic alopecia presents after puberty as a more diffuse slow hair loss with characteristic loss over the temporal
regions and vertex in males.
Discoid lupus erythematosus (DLE) presents as scarring alopecia. Areas of alopecia are usually atrophic with visible loss of
hair follicles. Patients may have DLE lesions elsewhere. If not treated early, hair loss is usually irreversible.
Telogen effluvium presents with diffuse hair loss and usually presents 1 to 3 months after a stressful episode, for
example, viral illness, surgery, childbirth, emotional stress. Hair loss is never complete and usually stops after 3 to 5
months. Subsequent hair regrowth is usually complete.
Trichotillomania is more commonly seen in children compared to adults. Patients also present with localised hair loss but
in a bizarre pattern. Hairs of differing lengths are usually seen within and at the edges of the patches. Patients may or may
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not volunteer a history of hair pulling.
This patient has severe chronic discoid lupus erythematosus of the scalp.
This is a form of scarring alopecia that usually presents as localised patches of hair loss.
Early treatment is necessary to prevent scarring.
Approximately 10% of patients may have signs of systemic lupus erythematosus.
Dr Khaled Elmagraby
Neonatal lupus
This infant has neonatal lupus. He presents with a characteristic peri-orbital 'raccoon-eyes' rash.
Other similar pink to red macules, which may have an annular configuration, may be seen on the scalp, face and
extremities.
The mother is usually positive for anti-Ro or anti-La antibodies but may not have overt lupus erythematosus.
Congenital heart block is sequela that may occur in some infants with neonatal lupus, sometimes requiring pace-maker
insertion.
Dr Khaled Elmagraby
Angiosarcoma
Angiosarcomas are malignant vascular tumours most commonly seen in elderly men.
They most commonly occur on the scalp and forehead.
They present an infiltrative vascular patch or plaque with super-imposed nodules which may bleed with minor trauma.
They have a poor prognosis.
Angiosarcomas can also occur in areas of chronic lymphoedema.
Dr Khaled Elmagraby
Fish-tank granuloma
Mycobacterium marinum
This patient has a fish-tank granuloma, caused by the atypical mycobacterium, Mycobacterium marinum.
It is found in ornamental fish and is commonly seen in individuals who rear fish as a hobby.
Dr Khaled Elmagraby