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Dermatology Approach
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Dermatology ApproachFayza Rayes
MBBCh. Msc. MRCGP (UK)Consultant Family PhysicianJoint Program of Family & Community Medicine Jeddah
www.fayzarayes.com
Dermatology Approach:Skin RashSkin pruritusMouth Condition Palm & Sole LesionsNail DiseasesNappy rashAcneSkin PigmentationsPrepared by dr. Fayza Rayes
Generalized-- Viral exanthema & drugs Extensor-- Psoriasis, SLE,-- Soles keratosis, ichthyosisFlexor-- Atopic dermatitisLower extremities-- Erythema nodosum-- Stasis dermatitisSites of pressure-- UrticariaSite of trauma-- Psoriasis-- Lichen planus, -- Molluscum, Warts.Site and/or Distribution of The Lesions
DD. Of Generalized Skin RashDrug eruptionAmpicillin rashViral exanthemaMeasles
Molluscum contaguasumLichenplanusPsoriasis
DD. Of Rash at Site of Trauma
Tinea versicolorPityreasis roseaDD. Of Truncal Lesions Rash
Secondary syphilisPalms & Soles Conditions
Dermatology Arrangement of lesionsArrangementIsolatedScatteredGroupedGrouped of vesiclesAnnular (ring)
LinearExamplesMelanoma, KeratoacanthomaMolluscam contagiosum, common wartsLichen planer, insect bitesHerpes simplex, herpes zoster (Dermatomal )Tinea corporis, erythema multiform, drug eruptions. Lupus erythomatosus, 2ry syphilis, pityriasis rosea.Contact dermatitis, linear scleroderma, keposi sarcoma
Approach to Patient with skin Rash1
Diffuse Erythema Differential DiagnosisInfectious :Streptococcal infection (Scarlet fever)Staphylococcal infection (Toxic syndrome)Enteroviral infection
Non-infectious Causes:Allergy-- VasodilatationEczema-- PsoriasisPityrosis rubra-- Lymphoma
Maculo-papular Rash with FeverDifferential DiagnosisInfection :--Measles-- Interoviral infection-- Chickenpox-- Mononucleosis-- Rubella-- Typhoid fever-- Rubeola (Red measles)-- Secondary syphilis-- Erythema infectious (5th)-- HIV (Primary)-- Adenoviral exanthema-- Early meningitisNon-infectious Causes :-- Allergy-- Erythema multiform-- SLE-- Erythema margenatum-- Dermatomyositis-- Serum sickness -- Drug rash
Chickenpox
MononucleosisMeaslesDD of Maculo-papular Rash with Fever
Common Exanthematous DiseasesMeasles IP (10-14 days)
Rubella IP (14-21 days)
Chickenpox IP (1-14 days)Maculopapular (5 days)Kopliks spots, Prodromal illness, complications are common.Macular --> maculopapular (3 ds)Malaise, little or no fever
Maculer --> Papules --> Viscles --> Crust (7ds)No other symptoms apart from rash & low grade fever
Measles
Complications: Secondary infectionRare: EncephalomyelitisIncubation period: 1-14 daysChickenpox
DD. Of Generalized Skin Rash
DD of Maculo-papular Rash with Fever
Typhoid feverDistribution of rose-spot rash: The typical rash of typhoid fever may appear towards the end of the first week but it has been recorded as late as the 20th day. It is present in about half the adults with typhoid but is less common in children. Rose spots are difficult to detect on dark skins.
Secondary syphilis Erythema infectious (5th)Early meningitisDD of Maculo-papular Rash with Fever
Early rash of meningitis:Fleeting macular or papular rash. This may occur alone or proceeding hemorrhagic eruption by few hours
Suspected Meningococcal InfectionImmediate TreatmentAdult and children older that 10 years 1200 mg Benzyl penicillin. IM
Children aged 1-9 years 600 mg Benzyl penicillin. IM
Infants aged less than 1 year 300 mg Benzyl penicillin. IM
The rash may be papules or pustules and crustsSecondary Syphilis-rash
Secondary syphilisDD of Papulosquamous Exanthems
* Figure 5. Drug eruption * Figure 6. Erythrodermic drug eruption
* Figure 7. Psoriasis * Figure 8. Lichen planus
DD of Papulosquamous Exanthems
SLE Erythema margenatum DD of Non-infectious Causes of Maculo-papular Rash
DD of Non-infectious Causes of Maculo-papular Rash
Erythema Multiforme with bulls eyes target lesions
Classification of Pustular LesionsLocal Infections :Bacterial :impetigo, folliculitisViral :herpes simplex, herpes zoster, Fungal :dermatophyte infection, candida
Systemic Infections :BacterialMeningococcaemia, Gonococcaemia & StaphylococcaemiaViral : varicella, enteroviral infection, HIV
Non-infective conditions :Generalized pustular psoriasis or localized pustular psoriasis. Acne vulgaris and rosacea, Eczema, Pemphigus, Porphyria, Erythema multiform, Erythema bullosum.
Impetigo Herpes simplex
herpes zosterDD of Pustular Lesions - Local Infections
Generalized pustular psoriasis Erythema multiformeDD of Pustular Lesions Non-infective Conditions
Large, tense blisters in bullous pemphigoid DD of Pustular Lesions Non-infective Conditions
DD of Pustular Lesions Non-infective Conditions
Blisters
Septicemia, probably gonococcal.DD of Pustular Lesions Infective Conditions
Purpuric or Petechial Rash Differential DiagnosisInfections :Bacteremia (with or without DIC)Infectious endocarditisMeningococcemiaGonococcemia or other pathogenic bacteriaEnteroviral infectionDengue feverHepatitisRubellaInfectious Mononucleosis
Rash of meningitisDD of Purpuric or Petechial Rash
Non-infectious causes :AllergyLow platelets of any causeScurvyHenoch-Schonlain purpuraVasculitisAcute rheumatic feverHyperglobulinemiaPurpuric or Petechial Rash Differential Diagnosis
Vasculitis. Palpable purpuric papules on the lower legs are seen in this patient with coetaneous small vessel vasculitis. Purpuric Rash
Patient with rash Warning PresentationAssociated symptoms suggestive of serious illness.Purpuric or petechial rashGeneralized pustular rashInfection in dangerous area E.g.. eyes, dangerous area of the face.Very toxic patient
Approach to Patient with skin Pruritus 2
Pruritus HistoryDuration, localization & character of the itch.Provocating factorsDiurnal variationSleep disturbanceOccupational historyItchy contact
Pruritus Examination & warning presentationExamination :Patient general conditionCharacteristic of the skin lesion e.g.Burrows of scabiesLichenification of eczemaSkin discolorationScaly lesionWarning presentation :No overt skin diseaseIll elderly patient (cancer)
Systemic Causes of Pruritus1.Cholestasis :--Primarily biliary cirrhosis-- Pregnancy--Extrahepatic obstruction-- Drugs e.g. Contracep.2.Endocrine :--Thyrotoxiosis-- Myxoedema--Hyperparathyroidism-- DM3.Hematological / Myeloproliferative :-- Iron deficiency-- Polycythemia-- Hodgkins disease-- Multiple myeloma4.Chronic Renal Failure :5.Malignancy / Miscellaneous : -- Gout -- Psychological-- Old age.
Some common dermatological conditions associated with itchingSevereInfestation : Scabies, liceInsect bitesEczemaArticariaDermatitis herpetiformisLichen planusLichen simplexDrug reactionsModeratePsoriasisFungal infectionsPityriasis roseaPemphigiodXerosis (dry skin)Localized ItchingPruritus aniPruritus vulvae
Some common dermatological conditions associated with itchingSevereInfestation : Scabies, liceInsect bitesEczemaUrticariaDermatitis herpetiformisLichen planusLichen simplexDrug reactions
Childhood atopic eczema. Facial atopic eczema. Dermatological conditions associated with severe itching
Dermatological conditions associated with severe itching
Dermatological conditions associated with severe itching
Urticaria showing charac- teristic discrete and confluent, edematous, erythematous papules and plaques. Dermatological conditions associated with severe itching
Dermatological conditions associated with severe itching
Dermatitis herpetiformisDermatological conditions associated with severe itching
lichen planusDermatological conditions associated with severe itching
Dermatological conditions associated with severe itching
Dermatological conditions associated with severe itching
Dermatological conditions associated with severe itching
Dermatological conditions associated with severe itching
Some common dermatological conditions associated with itchingModerate:PsoriasisFungal infectionsPityriasis roseaPemphigiodXerosis (dry skin)
Pityriasis roseaSome common dermatological conditions associated with moderate itching
Pruritus ani - perianai dermatitis. Common Cause of Local Itching
Herpes simplex of the anus.
Mouth Conditions3
Month Ulcers Differential Diagnosis Trauma (dentures)Aphthous ulcersCandida infectionHerpes simplexErythema multiform (from drugs)PemphigusLichen planusCarcinoma
DD. Of Oral ConditionsLichen planusAphthous ulcers
Aphthous ulcers: Small ulcers, 1 4 mm in diameter may occur on healthy persons as a recurrent, painful, self-limiting problem lasting five to six days, aetiology unknown. An aphthous-like ulcer may occur on the pharynx in infectious mononucleosis
Aphthus UlcerPemphigusDD. Of Oral Conditions
Iron deficiency anemia
Differential Diagnosis of Mucous Membrane Lesions Figure 1. Secondary syphilis Figure 2. Lichen planus Figure 3. Scrotal tongue Figure 4. Geographic tongueFigure 5. Aphthus ulcer Figure 6. Black hairy tongue
Figure 7. Pyogenic granuloma Figure 8. Median rhomboid glossitis
Palm & Sole Lesions4
Tinea pedisplantar wartsdyshydrotic dermatitis
DD. Of Acral Lesions
DD. Of Palm & Sole Lesions
Pustular psoriasis on sole of foot
Psoriasis nail with ridging and pitting
DD. Of Palm & Sole Lesions
Nail Diseases5
Differential Diagnosis of Nail Diseases * Figure 1. Fungal infection* Figure 2. Paronychia. * Figure 3. Posttraumatic hematoma * Figure 4. Ingrown toenail * Figure 5. Onychogryposis * Figure 6. Lichen planus* Figure 7& 8. Psoriasis
Splinter hemorrhages of the nails
Longitudinal section of distal phalanx to show nail.Brittle nails may be a sign of peripheral vascular insufficiency, anemia or hypothyroidism
Nappy Rash6
Nappy Rash Differential Diagnosis & Management Contact dermatitis -- Emollient, frequent changing & cleaning.-- Zincoxide paste + Topical steroidsAtopic dermatitis-- Emollient, Local steroids, Systemic antihistamine for pruritus antibiotics.Seborrhoeic dermatitis -- Local steroids / Antiseptic. Cleaning cream.Candiasis-- Topical antifungal e.g.. Nystatin & Unidazole or Hydrocortisone / Unidazole combination.
Napkin rash
Acne7
Acne - Lesions / StagesPrimary comedones
Mildly inflammatory : Comedones and papules
Moderate or severe Inflammatory : Many papules , pustules & some cysts
Conglobate abscesses (large cysts) & severe scarring
Rosacea is easily confused with acne, acne vulgaris tends to occur in a younger age group and comedones are usually present. Comedones are not seen in rosacea
Typical case of rosacea: small papules and pustules on an erythematous, telangiectatic background. The most common sites are the central cheeks, forehead, tip of the nose and chin
Acne Therapy GuidePrimary comedones
Mildly inflammatory : Comedones and papules
Moderate or severe Inflammatory : Many papules & pustules, some cysts
Conglobate abscesses, severe scarringRetinoic acid cream / gel
Topical antibiotic or benzoyl peroxide lotion or gel (sometimes retinoic acid)Benzoyl peroxide & oral or topical antibiotic (sometimes retinoic acid)Referral of treatment failures ReferralLesion / Stage Therapy
Skin Pigmentation8
* Figure 1. Pigmented basal cell carcinoma * Figure 2. Blue nevus * Figure 3. Lentigo maligna* Figure 4. Superficial spreading melanomaDifferential Diagnosis of Pigmented Skin Lesions
* Figure 5. Nodular melanoma * Figure 6. Seborrhoeic keratosis * Figure 7. Dermatofibroma* Figure 8. Angiokeratoma
Differential Diagnosis of Pigmented Skin Lesions
Figure 1. Pigmented basal cell carcinoma Figure 2. Blue nevus Figure 3. Lentigo malignaFigure 4. Superficial spreading melanoma* Figure 5. Nodular melanoma * Figure 6. Seborrhoeic keratosis * Figure 7. Dermatofibroma* Figure 8. Angiokeratoma
Differential Diagnosis of Pigmented Skin Lesions