Hospital Based Practice – Blistering skin conditions.

• Skin failure.
○ Dehydration
○ Poikilothermia.
 Loss of temperature control
○ Infection
○ Hypoalbuminaemia
○ High utput cardiac failure
○ Oedema

Erythroderma
• Defined as erythema covering > 90%
• Complication of.
○ Eczema
○ Psoriasis
○ Drug reactions
• Can cause.
○ Dehydration
○ Poikilothermia
○ Septicaemia
○ Hypoalbuminaemia
○ High output cardiac failure
○ Oedema
• Management.
○ Establish cause.
○ Rehydrate
○ Adquate nutrition
○ Temperature control
○ Monitor for septicaemia
○ Urgent dermotolgy referral.

Blistering
• Causes.
○ Epidermolysis bullosa
○ Pemphigus
○ Pemphigoid
○ Toxic epidermal necrolysis
○ Acute dependent oedema
• Complications.
○ Dehydration
○ Poor nutrition
○ Septicaemia
○ Pain
• Management.
○ Hydration & nutrition
○ Monitor for infection
○ Analgesia
○ Burst blisters
○ Urgent dermatology referral
Eczema Herpeticum.
• Diagnosis.
○ History of atopic eczema
○ Toxic
○ Pyrexial
○ Punctate erosions on face and upper trunk.
• Investigations.
○ Viral & Bacterial swabs.
○ FBC
○ CRP
• Management.
○ IV Aciclovir
○ NEVER topical steroids
• Complications.
○ Encephalitis.

Facial Cellulitis.
• Presentation.
○ Toxic
○ Pyrexial
○ Asymetrical facial swelling.
 Red
 Tender
○ Point of entry for infection.
• Investigations.
○ Temperature
○ Swabs
○ Blood cultures
○ FBC
○ CRP
• Differentials
○ Acute facial eczema
○ Rosacea
○ SLE
• Management.
○ IV antibiotics.
○ Eg. benzylpenicillin
• Complications.
○ Cavernous sinus thrombosis
Cellulitis.
• Presentation.
○ Toxic
○ Pyrexial
○ Swelling.
 Unilateral
 Painful
 Hot
○ Point of entry for infection.
• Investigations.
○ |Blood cultures
○ Swab
○ FBC
○ CRP
• Differentials.
○ Varicose eczema
○ Gravitational syndrome
○ DVT
○ Psoriasis
• Management.
○ IV antibiotics.
 Benzylpenicillin
 Flucloxacillin
○ Analgesia
○ Elevate leg
Acute Eczema.
• Classify.
○ Atopic
○ Infected
○ Phototoxic
○ Allergic
○ Exfoliative.
• Investigations.
○ Swab
○ Patch test.
 When settled
• Management
○ Emollient
○ Topical steroids
○ Antibiotics.

Acute Psoriasis
• Diagnosis.
○ Guttate
○ Pustular
○ Erythrodermic
• Triggers.
○ Strep. Pharyngitis
○ Drugs.
  Lithium
 Beta – blockers
 NSAIDs
• Management.
○ Emollient
○ Refer to dermatology.

Cutaneous vasculitis.
• Diagnosis.
○ Painful
○ Palpable
○ Purpura.
• Investigations.
○ Causes.
 Infection
 Drugs
 Endogenous
 Autoimmune disease
○ Systemic involvement.
 Urinalysis
 eGFR
 LFTs
 CXR
Pyoderma gangrenosa.
• Presentation.
○ Begins as pustules
○ Rapidly progress to ulcer.
○ Ulcer edge is
 Inflammed
 Bluish
 Undermined
• Associated conditions.
○ Inflammatory bowel disease
○ Rheumatoid disease
○ Monoclonal gammopathy
• Management.
○ Systemic steroids.

Skin ulcers.
• Ulcers are abnormal breaks in an epithelial surface.
• Leg ulcers affect 2% of the population in developed countries.
• Causes.
○ Venous disease
○ Arterial disease.
 Large vessel disease
 Small vessel disease
○ Neuropathy
○ Diabetes.
 Neuropathic
 Vascular
○ Lymphoedema
○ Vasculitis
 ○ Malignancy
○ Infection.
 TB
 Syphilis
○ Trauma
 Pressure
○ Pyoderma gangrenosum
○ Drugs.

○ May be multiple causes.

○ For leg ulcers.
 70% are venous
 15% are mixed venous and arterial
 2% are arterial.
• History.
○ Length of history
○ Number of ulcers.
○ Pain
○ History of trauma
○ Co – morbidities.
 Varicose veins
 Peripheral artery disease
 Diabetes
 Vasculitis
○ Is the patient particularly odd?
 Consider self – inflicted ulcers.
 Dermatitis artefacta

• Examination.
○ Note features such as.
 Site
 Number
 Surface area
 Depth
 Edge
 Base
 Discharge
 Lymphadenopathy.
 Sensation
 Healing.
○ If ulcer is in the legs, look for evidence of venous insufficiency.
 Check Ankle – Branchial pressure index.
○ Site.
  Gravitational ulcers.
• Tend to occur just superior to medial malleolus.
• Mostly related to superficial venous disease.
• May reflect venous hypertension
○ Via damage to deep vein valves
 eg. Secondary to DVT.
 Venous hypertension.
• Leads to development to superficial varicosities and skin changes.
○ Eg. Lipodermatosclerosis.
 Skin
• Induration
• Pigmentation
• Inflammation
• Minimal trauma to leg leads to ulceration.
○ May take many months to heal
○ Temperature.
 Ulcer and surrounding tissue is cold in ischemic ulcers
 Warm and well perfused ulcers tend to have local causes.
○ Surface area.
 Draw map of the area to quantify and time any healing.
 Wound > 4 weeks old is a chronic ulcer, compared with a acute ulcer.
○ Shape.
 Unusual morphology is often due to underlying mycobacterium infection.
• Cutaneous TB
• Tuberculosis colliquativa cutis.
○ AKA scrofuloderma.
○ Infected lymph node ulcerates to the skin.
○ Depth.
 If not uncomfortable for patient, a probe can be used to measure depth.
 Most commonly can be performed with neuropathic ulcers.
○ Discharge.
 Culture any discharge before staring antibiotics.
 Antibiotics rarely work anyway.
 Watery discharge is said to favour TB
 Bleeding discharge normally indicates malignancy.

○ Edge.
 Eroded edge
• Suggest active and spreading disease.
 Shelved or sloping edge.
• Suggests healing.
 Punched out edge.
• Syphilis
• Ischemic
 Rolled over/ everted edge.
• Malignancy
 Undermined edge.
• TB
○ Base.
  Any muscle, bone or tendon destruction.
• Malignancy
• Pressure sores.
• Ischemia
 May be a grey – yellow slough.
• Overlying pale pink base.
 Slough.
• Mixture of
○ Fibrin
○ Cell breakdown products
○ Serous exudates
○ Leucocytes
○ Bacteria
○ Doesn’t necessarily imply infection
○ Part of the normal healing process.
 Granulation tissue.
• Deep – pink gel – like matrix.
• Contained within fibrous collagen network.
• Part of normal wound healing process
○ Associated lymphadenopathy.
 Suggests.
• Infection
• Malignancy
○ Position in extension/ healing.
 Healing is heralded by.
• Granulation
• Scar formation
• Epithelialization
 Inflamed margins indicates extension.

• Investigations.
○ Skin and ulcer biopsy.
 Vasculitis
 Maligant changes
 Ward’s test.
• Doppler probe in centre of ulcer.
○ Look for underlying systemic disorders.

• Management.
○ Often difficult and expensive.
○ Treat cause.
○ Focus on prevention.
 Optimise nutrition
 Reduce risk factors.
• Drug addiction
• Smoking
 Expert nursing care
• Community nursing team
• Varicose leg ulcer clinic
• 4 – layer compression bandaging.
 ○ Systemic antibiotics rarely is effective.
○ Topical agents can help.
 Silver sulphadiazine
 Gentamicin.

Brown pigmented lesions.

• Causes include.
○ Melanoma
○ Sun – related freckles.
○ Lentigos.
 AKA moles.
 Persistent brown macules
 Often large than freckles.
○ Cafe – au – lait spots.
 Faint brown macules.
 If > 5, consider neurofibromatosis
○ Seborrhoeic keratoses/ warts.
 Benign greasy – brown warty lesions.
 Usually on the
• Back
• Chest
• Face
 Very commonly in the elderly.
○ Chloasma.
 AKA melasma
 Brown patches.
 Especially on the face.
 Related to pregnancy or pill use.
 May respond to topical azelaic acid.
○ Systemic disease.
 Addison’s disease.
• Palmar creases
• Oral mucosa
• Scars
 Haemochromotosis
 Porphyria cutanea tarda.
• Brown lesions
• Fragile skin
• Blisters.