MOSSLUSCUM CONTAGIOSUM

Description of lesion
- pearly, umbilicated papules with a central keratinised core

Aetiology
- pox virus

Associated underlying conditions

- atopy
- immunocompromised patients (HIV, malignancy, DM, steroids)
- also in healthy children and atopic patients

Treatment
- electrotherapy
- electrocautery
- cryotherapy
- duofilm
PSORIASIS
- chronic inflammatory skin condition (psoriasis vulgaris)
- most common inflammatory dermatosis
- genetic predisposition

Description of lesion
- well-demarcated salmon pink plaques with Sites (symmetrical)
hyperkeratinisation and silvery scaling which - extensors
koebnerise and bleed if the scale is removed (Auspitz sign) elbows
knees
Exacerbating factors
lumbosacral
- hormones
- flexural surfaces (groin, sub mammary
- infections
HIT SSSD folds, axillae, umbilicus)
- trauma
- guttate (children, post streptococcal
- sunlight
throat infection, differentiate from
- stress
pityriasis rosea, resolve rapidly)
- smoking and alcohol
- scalp (beyond hairline, hairloss
- drugs
uncommon)
- nail
Associated underlying conditions
pitting
- arthritis (musculoskeletal system)
onycholysis
- metabolic syndrome
subungual hyperkeratinisation
- HIV and AIDS
also in IMM suppressed (DM)
Other forms of psoriasis
- erythrodermic: >90% body involved(associated with steroids and irritants)
- pustular: emergency, toxic, widespread erythema and pustules
- arthropathic: rheumatoid-like or large joints DDx of psoriasis
tinea corporis
Treatment herald patch of pityriasis rosea
1st line
- tar (antimitotic) and 2% salicylic acid (keratolytic)
Drugs that exacerbate psoriasis
- topical corticosteroids
NSAIDs
- emollients (soft white paraffin)
B-blockers
2nd line ACE inhibitors
- vitamin A (Tazarotene) & D (Calcipotriol) lithium
- UVB radiation
Types of psoriasis
Systemic classical plaque psoriasis
- IMM suppressants (methotrexate, azathioprine, cyclophosporine) flexural psoriasis
- retinoids (vitamin A preparations) guttate psoriasis
- PUVA (psoralens and UVA) erythrodermic and pustular
TINEA

Description of lesion
- pruritic, annular lesion with active raised or papular erythematous margin and central clearing

Aetiology
- dermatophyte infection (microsporin, trichophyton, epidermophyton)

Investigations
- take scraping of active margin and place on a slide prepared with KOH

Treatment
Localised
- topical antifungals (~azoles) terbinafine

Extensive
- systemic antifungals:
gruseofulvin 20mg/kg daily for 6 weeks (children)
gruseofulvin 1g/kg daily for 6 weeks (adults) tinea capitis scalp
atraconazole 200mg BD for 1 week tinea facei face
tinea corporis body
tinea unguium nails
tinea manum hands
tinea pedis feet
tinea cruris groin
SYPHILIS
- contagious, sexually transmitted disease

Description of lesion
- chancre: well demarcated painless punched out/ ulcerative lesions with erythematous base (usually solitary
but may be multiple in some patients)

Aetiology
- Treponema pallidum

Pathophysiology
Primary syphilis
- within 3 weeks of contact with infected person
- only affects glans penis and vulva or cervix chancre heals within 4- 8 weeks
- nontender lymphadenopathy

Secondary syphilis
- cutaneous eruption, patchy alopecia and condylomata lata
- constitutional symptoms
- neck stiffness, facial numbness or weakness and deafness
- latent syphilis may last many years and then.......

Tertiary syphilis
- may affect any organ mainly CNS and CVS
- CNS: neurosyphilis (altered mental state, dementia, sensorineural hearing and vision loss)

Cutaneous manifestations
Primary syphilis chancre
Secondary syphilis condylomata lata (flat, wart-like lesions around genitalia and anus)

Investigations
- VDRL (venereal disease research laboratory test)
- RPR (rapid plasma reagin)
- TPHA (t. pallidum haemagglutination test)

Treatment
- benzathine penicillin G 2.4 million
units IM stat dose
ACNE
- inflammation of pilosebaceous units of face and trunk

Pathophysiology
- androgens follicular hyperkeratinisation and seborrhoea altered follicular environment
colinisation with Propionibacterium acnes inflammation

Types of lesions
DDx of acne
- inflammatory:
eosinophilic folliculitis
papules
rosacea
nodules
steroid induced acne
cysts
acne keloidalis nuchae
pustules
psychosis barbae
- non-inflammatory:
comedones (hallmark of acne)
whiteheads

Types of acne
1. acne vulgaris
2. acne conglobata (severe acne with interconnecting abscesses and scarring)
3. pomade acne (forehead and temple involvement)
4. steroid induced acne
5. acne excoree (OCD, high AA personalities)

Treatment
mild (comedones) moderate or severe inflammatory

topicals: oral AB: topical:
tretinoin (retin A, aldopolin) tetracycline benzoyl peroxide (antimicrobial)
isotretinoin (give contraception too!) bactrim
zineryt (Zn + erythromycin) 2 tablets BD AB:
salicylin acid (keratolytic) doxycycline benzamycin
100mg BD
erythromycin

Drugs causing acne

- anti-epileptics : phenytoin, phenobarbital, carbamazepine
- anti-TB : INH, rifampicin
- antidepressants : Li
- steroids : testosterone
ITCHY FOLLICULITIS
- specific to HIV infected patients
- AKA popular pruritic eruption
-

Diseases encompassed
1. staphylococcal folliculitis
2. eosinophilic folliculitis
3. pityrosporum folliculitis
4. demodex mite folliculitis

Description of lesions
- pruritic papules centred on hair follicles on upper trunk and arms (face of black patients)

Treatment
- oral AB, potent topical steroids and emollients
- phototherapy or oral isotretinoin in resistant cases
HERPES VIRUS INFECTION

Types of herpes viruses

- HSV 1 : labialis
painful umbilicated vesicles on an erythematous base with central crusting

- HSV 2 : genitalis
painful umbilicated vesicles on an erythematous base with central crusting

- HSV 3 : zoster (varicella chickenpox; herpes shingles) Complications of varicella zoster

umbilicated vesicles on erythematous base (HSV 3 varicella zoster) encephalitis
if in dermatomal distribution then herpes zoster pneumonia
Complications of herpes zoster
- HSV 4 : EBV (Burkitts lymphoma, infectious mononucleosis) post-herpetic neuralgia
- HSV 5 : CMV ocular disease

- HSV 6 & 7 : pityriasis rosea

herald patch large, scaly, erythematous, oval on trunk or arm with papulosquamous lesions on the
trunk in Langers lines (Christmas tree distribution), :bathing trunk distribution, self-limiting Rx
symptomatic

- HSV 8 : Kaposis sarcoma

violaceous, fungating, well-demarkated plaques (KS)

Bedside investigations
- Tzanck smear of vesicle base

multinucleated giant cells (Tzanck cells)

Mechanism of infection with HSV
Treatment direct contact
HSV latent infection
- acyclovir 200mg 5x daily for 1 week
aerosol
- valacyclovir 500mg BD for 1 week

Varicella or herpes zoster Predisposing factors to HSV

- acyclovir 800mg 5x daily for 1 week stress
- valacyclovir 1g TDS for 1 week sunlight
- if pregnant and has pityriasis rosea, also use this treatment hormones
risk of intrauterine death, preterm delivery and neonatal hypoitonia pregnancy
trauma
infection
DISCOID LUPUS ERYTHEMATOSIS
- manifestation of SLE
- in the sun-exposed areas of the body

Description of lesion
- scaly, erythematous hyperkaeratotic plaques with follicular plugging, central atrophy and telangiectasia
- heal with scarring, atrophy and hypo/ depigmentation centrally

Treatment
- potent topical steroid
- sun avoidance/ sunscreen
- chloroquine

Criteria for SLE (4/11 is definitive)

1. malar rash
2. discoid rash
3. photosensitivity
4. painless oral ulcers
5. CNS psychosis and seizures
6. renal persistent proteinuria and red cell casts
7. haematologic pancytopenia, vasculitis
8. musculoskeletal non-erosive arthritis
9. serositis pleural and cardiac effusions
10. auto-immune anti-Sm, anti dsDNA, anti-CCP
11. ANA
ECZEMA
- AKA dermatitis
- inflammatory response of the skin to multiple
exogenous and endogenous agents

Exogenous Endogenous (contact)

atopic allergic
seborrhoeic irritant
asteatotic
discoid Common allergens: nickel,
hand eczema fragrance mix, neomycin,
gravitational formaldehyde, cobalt

Sites
- flexures
Description of lesion - groin (seborrhoeic dermatitis)
- pruritic, erythematous lesion with scaling and popular vesicles - hand eczema
- dry, leathery lesion with excoriation with lichenification - gravitational eczema
- periorbital and perioral
Pathogenesis
- T-cell mediated, autosomal dominant
- clinical response to common allergens causes raised IgE binds to mast cells, basophils and Langerhans
cells inflammation
Associated features
Complications
- sinusitis
- HSV infection
- conjunctivitis
- secondary infections (staph and strep)
- atopy
Treatment
General Side effects of steroids
- antihistamine - dermal atrophy
- avoid irritants: - change in skin colour
house dust mite - increased blood vessels
- hair growth
wool
- stunting of growth
dander
- cataracts
foods
- hypertension and DM
stress

Steroids
- topical steroids (CORNERSTONE OF THERAPY!)

Emollients (aqueous cream as a soap substitute)

- maintains barrier function
- prevents water loss
- soothing and prevents itch

Others
- PUVA (UVB if resistant), immunosuppressives (azathioprine, cyclosporine)
WARTS

Description of lesion
- verrucous papules and nodules (verruca vulgares and condyloma accuminata)
- flat-topped, hypopigmented papules (flat/ plane warts)

Aetiology
- Human Papilloma Virus infection

Risk factors
- immunosuppression (steroids, HIV, hemotherapy)

Types of warts
- verruca vulgares (common wart)
- condyloma accuminata (genital warts)
- verruca plana (plane warts/ flat warts)

Treatment
Medical
- podophyllin
- AgNO stick
- aldara
- interferon injection

Surgical
- electrocautery
- cryotherapy
LICHEN PLANUS

Description of lesion
- Pruritic, Purple, Polygonal Papules and Plaques with surface network of fine, lacy lines (Wickhams striae)

Drugs causing lichen planus

Sites
- ACE inhibitors
- common: ankles and flexor surface of wrists
- B-blockers
- mucosal: mouth
- antimalarials
- nails dystrophic
Treatment
- potent topical steroids
- oral steroids
Associated conditions
ulcerative colitis
alopecia areata
vitiligo
dermatomyositis
myasthenia gravis
hepatitis C infection
chronic active hepatitis
primary biliary cirrhosis
VITILIGO
- autoimmune disorder of depigmentation d/t areas of melanocyte loss

Description of lesion
- well demarcated macules of complete pigmentation loss
- often symmetrical and involve hands, face and genitalia

Complications
- serious sunburn

Treatment
- sunscreen
- referral to a cosmetic dermatologist for tattooing or to a camouflage specialist
PITYRIASIS VERSICOLOUR
- condition of young adults

Description of lesion
- whites : redish brown scaly macules on trunk
- blacks/ tanned people : macular areas of hypopigmentation

Causative agent
- infection with Pityrosporum

Investigations
- Woods light
- skin scrapings

Treatment
- selenium sulphide or ketokonazole shampoo or topical `azole cream
- oral antifungals if resistant
MELASMA *use Woods lamp to observe the
- AKA mask of pregnancy skin and check for excess melanin
- also seen in Addisons disease
- usually self-limiting after stopping hormonal therapy/ contraceptive

Description of lesion
- dark, irregular, well-demarcated hyperpigmented macules to patches found on upper cheek, nose, lips,
upper lip and forehead

Aetiology
- stimulation of melanocytes by oestrogen and progesterone when sun is exposed to sun
- genetic predisposition

Risk factors
- pregnancy
- oral contraceptive
- HRT
PORPHYRIA CUTANEA TARDA
- rare genetic disorder associated with liver disease usu. d/t hepatic damage from hepatitis C or alcohol

*clinical association with HCC!

Description of lesion
- blisters on sun-exposed skin
- skin fragility, scarring, milia and hypertrichosis

Treatment
- very low dose chloroquin
- repeated venesection
- avoidance of alcohol
SCABIES

Description of lesion
- itchy papules and burrows

Sites
- wrists
- web spaces of hands and feet
- axillae
- umbilicus
- nipples
- groin

Complications
- secondary impetigo
- other family members also infected

Treatment
- ascabiol
IMPETIGO

Description of lesion
- ruptured vesicles with honey-coloured crust

Causative agent
- Staphylococcus aureus or Streptococcus

Investigations
- pus swab

Can progress
- impetigo furuncle carbuncle ecthyma cellulitis

Treatment
Local
- topical antibiotic (mipirocin or fucidin)

Extensive
- KMnO4 baths

Serious
- oral AB (flucloxacillin)
DRUG REACTIONS
DERMATOLOGICAL MALIGNANCIES