Dermatology

Dr Alan Shortt

44 Dermatology sites and resources

Dermatology emergencies

@@@ Dermatology history and examination

Pattern recognition inevitably forms a large part of dermatology diagnosis but systematic use of correct terminology / descriptors makes correct diagnosis easier, more accurate, and more consistant. Referrals are easier and more helpful, engendering personal satisfaction and professional respect

Listen to the patient blah blah – describe what you find – the description will give you the diagnosis or failing that wont make you look or feel like a schmuck

History of lesion/rash

Patients description distribution, shape, size, previous variation

When and when did it start

Spread

Course – episodic, previous rashes, continuous

Symptoms of the lesion

Itch – scabies, lice, eczema, urticaria, exanthemata, psoriasis, dermatitis herpetiformis

Pain

Weeping / bleeding

Provoking factors environment, sunlight, temporal, drugs, temperature, occupation, hobbies.

Relieving factors as above, treatment, including OTC.

Symptoms of associated structures

Mucous membranes

Scalp

Nails

General history

Family history

Contact history

Occupation

Associated complaints atopy, joints, bowels

Past medical history

Drug history

Examination

Distribution

Symmetry

Area affected exposed, seborrhoeic, gravitational, napkin, dermatomal

Pattern linear, clustered

Morphology

Primary lesion Macule, papule, nodule, pustule, vesicle, bulla, weal, plaque

Size

Colour / shine

Surface scale, lichenification, exudate, ulceration.

Edge regularity, distinctiveness

Associated features Telangiectasis, vascularity, purpura, excoriation, scarring, involvement of hair follicles

Related structures

Hair / scalp

Nails

Mucous membranes

Other structures as relevant eg lymph glands, joints etc

Papules are Palpable (macules are flat)

Dermatosis/Dermatoses

Any cutaneous lesion or group of lesions. A nonspecific term used to include any type of skin disease.

Dermatitis (pl. Dermatitides)

Inflammation of the skin. The term eczema also refers to an inflammation of the skin. The term eczema is often colloquially used to define the disease atopic dermatitis.

Dermatology descriptors

http://hacking-medschool.com/dermatology-history

ermatology Descriptors

1 Macule

flat circumscribed alteration in skin color. From pinpoint to any size (>2cm = patch)

2 Papule

a solid, elevated lesion with no visible fluid up to ½ cm. in diameter.

A papulosquamous lesion is a papule with desquamation (scaling).

3 Nodules

larger and deeper papules They may be located in the dermis or subcutaneous tissue, or in the epidermis. Nodules are usually ½ cm. or more in diameter. Ex: Metastatic neoplasm; xanthoma

4 Plaque

An elevated area of skin 2 cm. or more in diameter. It may be formed by a coalescence of papules or nodules. The surface area is greater than its height. It is a plate-like lesion.

5 Wheal

A wheal is an evanescent rounded or flat-topped elevation in the skin that is edematous, and often erythematous. They may vary in size from a few mm. to many cm. The shape may change and these lesions are usually pruritic (itchy). These are really variations of papules, nodules or plaques that are evanescent.

6 Vesicles and Bullae (Blisters)

Vesicles are circumscribed epidermal elevations in the skin containing clear fluid and less than ½ cm. in diameter. If the lesion has a diameter of greater than ½ cm, it is called a bulla. Vesicles and bullae arise from a cleavage at various levels of the skin. The more superficial the location, the more flaccid the bullous lesion. Vesicles and bullae are commonly called blisters. It is the diameter, not the cleavage plane that differentiates vesicles and bullae.

7 Pustule

A pustule is a circumscribed elevation of the skin that contains a purulent exudate that may be white, yellow, or greenish-yellow in color.

8 Abscess

A localized collection of pus in a cavity formed by disintegration or necrosis of tissue.

9 Cyst

A cyst is a closed sac that contains liquid or semisolid material. On palpation a cyst is usually resilient.

10 Atrophy

Atrophy of the skin may involve the epidermis, or the dermis, or both. It is the thinning process associated with decreased number of cutaneous cells. Sometimes the normal skin markings may be lost. Dermal atrophy may give rise to a depression in the skin.

Stria (plural striae) are linear, atrophic, pink, purple, or white lesions of the skin and are sometimes called “stretch marks”.

11 Sclerosis

Sclerosis refers to a circumscribed, diffuse hardening or induration in the skin. It is usually produced by induration of the dermis and/or subcutaneous tissue. Palpation is often necessary in diagnosing sclerosis.

12 Erosion

A loss of epidermis.

13 Ulcer

A loss of epidermis and dermis (and sometimes deeper tissue). If erosions and/or ulcers are produced by scratching, the term excoriation is used.

14 Fissure

Fissures are linear cleavages or gaps in the skin surface. (a variation really of an erosion or ulcer)

15 Desquamation

(scaling/exfoliation) Shedding of epidermal cells.

Secondary skin lesions

16. Scars

occur whenever ulceration has taken place and they reflect the pattern of healing. They may be hypertrophic, atrophic, or cribriform (perforated with multiple small pits).

17 Crusts (“scabs”)

Crusts result when serum, blood, or purulent exudate dries and it is a hallmark of pyogenic infection. Crusts are yellow when they have arisen from dried serum; green or yellow-green when formed from purulent exudate; and brown or dark red when formed from blood.

18 Lichenification

A chronic thickening of the epidermis with exaggeration of its normal markings, often as a result of scratching or rubbing.

19 pruritus /pruritic

= itching/itchy

20 erythema

Redness of the skin produced by vascular congestion or increased perfusion.

Reference on glossary of basic dermatologic lesions may be found in Acta Derm Venereol. Supplement 130, 1987.

Dermatology Descriptors	shape or arrangement of skin lesions in relation to each other	distribution of skin lesions over the body
Shape	linearannular polycyclic serpiginous reticular (netlike)	generalizedunilateral bliateral symmetrical asymmetrical localized grouped (herpetiform and zosteriform) sun-exposed agminate (collected together into clusters or masses); intertriginous
Size
Colour
Texture
Associated Symptoms

Macule (Latin = a stain) Any change in colour or consistency, without elevation above the surface of surrounding skin. Does not blanche.

Papule Circumscribed raised lesion less than 1cm in diameter.

Nodule Circumscribed raised lesion more than 1cm in diameter.

Rash may be a mixture, hence “macular papular rash” etc.

Plaque Area of skin raised slightly above the surrounding skin which is extensive, usually greater than 3cm across – stuck on like a wall-plaque eg psoriasis

Vesicles small blisters Circumscribed raised lesions containing clear fluid less than 0.5cm in diameter.

Pustules Circumscribed raised lesions containing cloudy fluid less than 0.5cm in diameter. Not necessarily infected.

Bullae large blisters Circumscribed raised lesions containing clear fluid more than 0.5cm in diameter.

CF “pustular bullae”

Cyst A fluid filled cavity below the dermis.

Can you “roll” it i.e. push it, if you can its superficial as in superficial scalds, or deep seated when you can’t move it.

The above lesions are in the dermis.

Nummular / Discoid (Latin = coins/discs) Flat disc like lesions of various sizes.

Erythema (redness) Dilatation of the superficial skin capillaries, causing redness. Always blanches.

Purpura Damage to superficial skin capillaries that have leaked blood. Does not blanch.

Angioma A tumour of blood vessels. Blanch, circumscribed.

Telangiectasia Small permanently dilated blood vessels in the skin. Blanch, linear.

Erosion Area of partial loss of the dermis or mucous membrane

Ulcer Area of full loss of the dermis or mucous membrane.

Fissure Crack or split in the dermis

Excoriation Scoring of the dermis from abrasion usually scratching.

Lichenification Hard thickening of the skin, with exaggerated skin markings, folds and creases.

Crust Dried serum

Scale Excessive accumulation of keratin on the skin

Xeroderma Dry skin

Icthyosis (latin = fish) Excessively dry scaly skin

Assessing Skin Characteristics
Colour	bruising discolouration erythema pallor duskiness jaundice or cyanosis
Texture	mobility thickness/thinnessrough/smothness fragility
Turgor	test at forearm or back oh hand
Moisture	excessive dryness moisture or sweating
Temperature	general or local heat or cold
Lesions	vascular changes haemangiomas telangiectasias purpura ecchymosis any other skin lesins(ERFF Lipincott 2007)

source?

Examples of dermatology formulations

Dermatology preparations and vehicles

Vehicles

Choice of vehicle can mean the difference between treatment success and failure. Patients will not use a topical therapy that irritates their skin, and will be loath to use one that does not ‘feel right’.

Ointments are greasy and generally insoluble in water, so can be difficult to wash off. They are most suitable for chronic dry conditions.

Creams contain oil and water, so are easier to apply and wash off, and are more cosmetically acceptable. They are better than ointments for acute conditions due to a cooling effect as they evaporate. However, their constituents are more likely to cause both irritant and allergic reactions.

Lotions also have a cooling effect, and may be preferable for treating hairy and large areas. They can be made up in either water or alcohol. The latter will sting if applied to broken skin.

Gels have a high water content, and are suitable for face and scalp.

Potency

see steroid ladder – this is maximum absolute effect not considering dilution or vehicle.

Vehicles

Occclusive Plastic or plastic backed dressings

Bandages

Pastes

Ointments

“Lipocreams”

Creams

Lotions

Excipients

Moisturisers, Emollients and bath additives

@@@ Emollients

· Emollients are an integral part of the treatment of all inflammatory dermatoses. They soothe inflamed skin and give the necessary lubrication to protect against further damage from external agents. They should continue to be applied even when the skin appears to return to normal, as it will still be unstable and easily irritated after the inflammation subsides.

· They are particularly important to use regularly in dry skin conditions such as occur in atopic dermatitis and elderly skin, both to reduce itching and protect against environmental irritants.

· There is no easy way to apply emollients, and they either have to be directly applied, or used in the bath/shower. It is helpful for patients to be shown how to do this properly by trained staff.

· Some emollients contain an antimicrobial agent. These may be useful where the inflammatory condition is at risk of secondary infection e.g. when the skin is broken by scratching.

· Emollients work, not by putting moisture into the skin, but by preventing water loss. For this reason, the more occlusive ointment preparations will tend to be more effective.

· Emollient effects are short-lived, particularly for cream formulations, so they need to be applied frequently for optimal effect. This is important to bear in mind when considering prescription quantities, as up to 500g per week may be required if treating large areas of skin.

· Emollients can be applied at any time of the day, particularly after a bath or shower, and can also be used as a soap substitute for cleansing.

· There are a wide variety of emollient preparations available. The cheaper ones are often as effective as the more expensive. It is helpful to give patients a range of emollients to find which suits their skin best, as choice of preparation will vary from person to person. Some patients like to use a cream or gel (non-sticky) during the daytime, and an ointment at night.

The best emollient is the one that the patient will use, so be prepared to give a selection to determine personal preference.

Role of Urea in Emollients

Retains water in skin being hygroscopic. It is also keratolytic and has regenerative and soothing effect as well as helping the penetration of other substances such as corticosteroids by increasing the skin hydration. Because of the above they are good for scaly conditions like Dry itchy eczema, Psoriasis & Icthyosis.

Important Points for Urea containing preparations:

Avoid contact with eyes, use in unbroken, non-infected and non-oozing skin only. Usually used for 3 years+ ages with lower strengths in younger children.

Emollients

Aqueous cream

Emulsifying ointment (can be held under warm to hot running water to give a foamy bath additive).

White Soft Paraffin / Liquid Paraffin 50/50

Dermol 200® shower emollient (contains antimicrobial agents)

Dermol 500® lotion* (contains antimicrobial agents)

Doublebase® gel*

Diprobase® cream*

E45® cream* (contains hypoallergenic lanolin)

Epaderm® ointment

Oilatum® cream, shower gel

*Available in pump dispensers which may be more suitable for long term use

Aqueous cream may cause skin irritation in some children when used as a leave-on moisturiser.

Bath Lotions

FIRST CHOICE: OILATUM® emollient

Oilatum® emollient (excipients include acetylated lanolin alcohols)

Oilatum Plus® emollient (contains antimicrobial agents)

Dermol 600® bath emollient (contains antimicrobial agents)

Balneum Plus® bath oil (has antipruritic action)

Barrier Preparations

See Skin Care Guidelines in the management of urinary and faecal incontinence

FIRST CHOICE: CONOTRANE® cream

Conotrane® cream

(contains dimethicone which is a useful barrier in the prevention and treatment of napkin rash, sores and in the management of incontinence).

Drapolene®

Sudocrem®

Zinc and Castor Oil ointment BP

(contains arachis (peanut) oil. Best avoided by families with a history of allergy or atopy as not yet clear whether can contribute to development of peanut allergy.)

Emollient Ladder Pennine VTS 2009

Very Greasy

50% Liquid soft Paraffin/White soft Paraffin

Greasy

Hydromol Ointment

Epaderm Ointment

Emulsifying Ointment

Rich Cream

Unguentum Cream

Doublebase Gel

Dermamist Spray

Neutrogena Dermatological Cream

Creamy

Diprobase cream

Cetraben Cream

Oilatum Cream

E45 Cream

Dermol 500 Cream (with Antimicrobial)

Aveeno Cream

Creamy with Urea

Aquadrate Cream

Calmurid Cream

Eucerin Cream

Balneum Plus Cream

E45 Itch relief Cream

Light

E45 Lotion

Aveeno Lotion

Kerl Lotion

Dermol 500 Lotion (with Antimicrobial)

Aqueous Cream (Not a good emollient)

Light with Urea

Eucerin Lotion

For Patients

1. Emollients moisturise and soften the skin.
2. Use regularly. (‘ Everyday regardless of how good eczema control is’.)
3. Choose one to suit you.
4. Avoid those with perfumes added.
5. Apply a thin film to your skin.
6. Any residue left on the skin is wasted and may be absorbed by clothing
7. Apply gently – do not rub vigorously.
8. Apply in the direction of hair growth – reduces the risk of blocked hair follicles which can become infected.
9. Allow at least 1 hour after moisturising before applying other treatment such as steroid creams
10. Bathe in warm, not hot water for about 10 to 15 minutes.
11. Remember: Never allow yourself to run out of emollients.
12. Emollients are very safe and cannot be over-used.

Urea in Emollients

Retains water in skin being hygroscopic. It is also keratolytic and has regenerative and soothing effect as well as helping the penetration of other substances such as corticosteroids by increasing the skin hydration. Because of the above they are good for scaly conditions like Dry itchy eczema, Psoriasis & Icthyosis.

Avoid contact with eyes, use in unbroken, non-infected and non-oozing skin only. Usually used for 3 years+ ages with lower strengths in younger children.

Emollients and barrier preparations

Emollients

Aqueous cream

Emulsifying ointment (can be held under warm to hot running water to give a foamy bath additive).

White Soft Paraffin / Liquid Paraffin 50/50

Dermol 200® shower emollient (contains antimicrobial agents)

Dermol 500® lotion* (contains antimicrobial agents)

Doublebase® gel*

Diprobase® cream*

E45® cream* (contains hypoallergenic lanolin)

Epaderm® ointment

Oilatum® cream, shower gel

*Available in pump dispensers

Aqueous cream may cause skin irritation in some children when used as a leave-on moisturiser.

Emollient bath additives

FIRST CHOICE: OILATUM® emollient

Oilatum® emollient (excipients include acetylated lanolin alcohols)

Oilatum Plus® emollient (contains antimicrobial agents)

Dermol 600® bath emollient (contains antimicrobial agents)

Balneum Plus® bath oil (has antipruritic action)

Barrier Preparations

See Skin Care Guidelines in the management of urinary and faecal incontinence

FIRST CHOICE: CONOTRANE® cream

Conotrane® cream

(contains dimethicone which is a useful barrier in the prevention and treatment of napkin rash, sores and in the management of incontinence).

Drapolene®

Sudocrem®

Zinc and Castor Oil ointment BP

(contains arachis (peanut) oil. Best avoided by families with a history of allergy or atopy as not yet clear whether can contribute to development of peanut allergy.)

To use in conjunction with BNF and other local guidelines (Pennine VTS with thanks to Ashton,Wigan and Leigh NHS Trust & Dermnet.NZ)

Emollient Ladder

Very Greasy

. 50% Liquid soft Paraffin/ 50%White soft Paraffin

Greasy

. Hydromol Ointment

. Epaderm Ointment

. Emulsifying Ointment

Rich Cream

. Unguentum Cream

. Doublebase Gel

. Dermamist Spray

. Neutrogena Dermatological Cream

Creamy

. Diprobase cream

. Cetraben Cream

. Oilatum Cream

. E45 Cream

. Dermol 500 Cream (with Antimicrobial)

. Aveeno Cream

Light

. E45 Lotion

. Aveeno Lotion

. Kerl Lotion

. Dermol 500 Lotion (with Antimicrobial)

. Aqueous Cream (Not really a good emollient)

Fingertip units

One fingertip unit – approximately 0.5g – (enough to cover the distal pulp of the forefinger when squeezed out of the tube) – is sufficient to cover the area of both hands in an adult.

Shampoos and scalp applications

Betamethasone scalp application 0.1%

Apply thinly 1-2 times daily for short-term use in inflammatory dermatoses.

Betamethasone scalp lotion 0.1%

Apply thinly 1-2 times daily for short-term use in inflammatory dermatoses.

Lotion may cause less skin irritation as it does not contain alcohol.

Capasal® Shampoo

Ceanel concentrate® shampoo

Twice-weekly for dandruff and seborrhoeic dermatitis.

Ketoconazole shampoo

for seborrhoeic dermatitis and dandruff, apply twice weekly for 2-4 weeks,

for pityriasis versicolor, once daily for max. 5 days.

T/Gel® Shampoo

Topical steroids

* Topical corticosteroid preparations are used in the treatment of inflammatory conditions of the skin other than those due to an infection. They are not curative, and should be backed up with other measures, in particular irritant avoidance and regular emollients.

* Topical steroids should be applied thinly, once or twice daily. When applying along with an emollient, it doesn’t matter which agent is applied first, although ideally there should be a 15-30 minute gap between the two applications.

* They should not be used indiscriminately in pruritus, urticaria, or in undiagnosed rashes. They are contraindicated in rosacea, and care should be taken with regular review when treating any facial eruption where the diagnosis is unclear. Potent steroids should only be used in psoriasis (other than scalp) under specialist supervision due to the risk of provoking a severe pustular flare. Potent steroids can be used in recalcitrant conditions such as palmoplantar pustulosis, lichen simplex and nodular prurigo, as long as such patients are reviewed regularly to ensure treatment is appropriate.

* Choice of steroid strength will depend on the nature of the condition being treated, the age of the patient and the site of disease, the aim being to use the weakest preparation that will suppress the inflammation. Particular care should be taken when treating children (especially under wet wrap dressings), faces and flexures. It is reasonable to supply two strengths for patients with chronic conditions, one to be used for maintenance and a stronger one for short-term use during flare-ups.

* Compound preparations, which usually contain antimicrobial agents, are useful where there is overt secondary infection. Their use otherwise is debatable, although they are often used where there may be a microbial component present such as in flexures. Those that contain fusidic acid should only be used for short periods of time (up to 7 days) to reduce the likelihood of developing bacterial resistance.

* Prolonged use of potent steroids will lead to skin atrophy with easy bruising and striae formation and can suppress the pituitary-adrenal axis.

* Use on any strength of topical steroid on the face may cause a rosacea-like papular eruption (perioral dermatitis).

* Care should be taken with topical steroid use around the eyes because of the possibility of increased ocular pressure and cataract formation. In general, only mildly potent steroids should be used for as short a time as possible.

Steroid ladder

Mildly Potent

Hydrocortisone 0.5%, 1% cream, ointment

(usually sufficient for childhood and facial eczema)

NB Hydrocortisone butyrate (Locoid®) is POTENT

Moderately Potent

Clobetasone butyrate 0.05% (Eumovate®) cream, ointment

Potent

Betamethasone valerate 0.1% (Betnovate®) cream, ointment, lotion

Mometasone furoate 0.1% (Elocon®) cream, ointment

Very Potent

Clobetasol propionate 0.05% (Dermovate®) cream, ointment (avoid in children)

Corticosteroids with antimicrobial agents

Mildly Potent

Canesten HC® cream (clotrimazole, hydrocortisone 1%)

Daktacort® cream, ointment (miconazole, hydrocortisone 1%)

Timodine® cream (nystatin, benzalkonium chloride, dimethicone, hydrocortisone 0.5%)

Fucidin H® cream, ointment (fusidic acid, hydrocortisone 1%)

Moderately Potent

Trimovate® cream (oxytetracycline, nystatin, clobetasone butyrate 0.05%)

Potent

Betnovate-C® cream, ointment (clioquinol 3%, betamethasone 0.1%)

FuciBET® cream (fusidic acid, betamethasone 0.1%)

Betnovate-C® may be preferred over FuciBET® where the combination of an antimicrobial and corticosteroid is required (inflammatory skin conditions associated with bacterial or fungal infection) due to concerns over resistance to FuciBET®. However, the antimicrobial agent should be selected according to the sensitivity of the infecting organism.

All preparations containing an antimicrobial agent should be applied regularly and for a short period (typically for no more than 7 days at a time) to reduce likelihood of bacterial resistance and sensitisation developing.

Steroid skin

Systemic Steroids @ Dermnet.nz

Acne

Mainly teenagers due to androgen induced follicular hyperlasia and plugging, overproduction of sebum and colonisation of blocked pores with propionobacter acnes causing inflammation.

Lesion

Comedodones (blackheads) – dilated pores with black keratin plug.

Whiteheads (cream colured domed papules

Pustules

Cysts

Mild – blackheads and whiteheads mainly over face

Moderate – as above pluse papules and pustules extendig to shoulders and back.

Severe – as above plus nodules and cysts.

Acne pathology

Acne lesions and classifications

Papulopustular acne

youtu.be/YuiblxDA5ek

Nodulocystic acne

@@@ Acne grades

Acne grading
Grade 1	Mild	open and closed comedones (whiteheads blackheads) with some superficial papules and pustules.
Grade 2	Moderate	more frequent deeper papules and pustules with mild scarring.
Grade 3	Severe	all of the above plus nodular abscesses and more extensive scarring.

Acne – approach to the patient

http://youtu.be/LU0N37wTRg8

Aims of Treatment

Prevent scarring
Limit duration
Reduce the psychological impact on the individual

Assessment

Duration, site, aggravating (stress, pre-menstrual, oral contraceptive) and relieving factors (sun), family history, past and present treatment and severity

* Performing a full examination of the skin in good light is essential to determine the type of acne lesion, extent of acne, and presence of or risk of scarring. However, there is no universal grading system or consensus on the best way to assess severity, nor do clinician and patient perceptions of acne severity always match

* Acne has a significant psychosocial impact which does not always correlate with disease severity. It also has a significant impact on relationships, confidence, and career aspirations. Therefore, assessment of psychosocial factors should become integral to patient management

* There are three validated Quality Of Life (QoL) scales for acne to aid psychosocial assessment:

Acne Disability Index (ADI)/Cardiff Acne Disability Index (CADI)
Acne Quality of Life Scale (AQOL)
Acne-Specific Quality of Life (Acne-QOL)

Patient information

Patients need to be reassured that acne is extremely common, it will improve and there are effective treatments. However, the impact of acne should not be trivialised

Patients need to be instructed on correct use of their treatment, for example, they should apply topical treatments sparingly to all areas of the skin where acne occurs, not just the lesions. It should also be explained that although topical treatments may improve the skin within 6 weeks, maximum benefit may not be seen for 3 to

Patient follow up should take place at 6–8 weeks, with treatment evaluated for efficacy, tolerance, and patient expectations. Treatment should be adjusted as necessary, either stepping up to a combination of two or three topical treatments prior to introduction of oral therapy, or if treatment is successful, establishing a maintenance regimen

Acne management

Acne management formulary

Tayside Algorithm

Grade 1

Benzoyl peroxide applied once or twice daily

Introduce gradually starting with the weakest preparation building up to the highest concentration tolerated. Emphasise there must be some skin peeling if treatment is going to work, if problematic reduce the frequency of application to alternate days.

or Tretinoin or isotretinoin applied once or twice daily. As with benzoyl peroxide, start with weakest preparation.

or Adapalene applied once daily, may be less irritant than retinoids.

Avoid retinoids and adapalene during pregnancy.

Exposure to sunlight of areas treated with topical retinoids or adapalene should be avoided or minimised.

When exposure cannot be avoided, a sunscreen product and protective clothing should be used.

Grade 2

First Choice

Erythromycin (topical) applied once daily or Erythromycin and zinc acetate applied once daily or Clindamycin 1% lotion applied once daily, is more suitable for dry skin.

These should be prescribed concomitantly with topical benzoyl peroxide, ie topical antibiotic to be applied in the morning and topical benzoyl peroxide at night.

or Adapalene – see above.

Grade 3

First Choice

Oxytetracycline 500mg twice daily for at least 3 months or Erythromycin 500mg twice daily for at least 3 months

Do not prescribe tetracyclines in pregnancy, breast-feeding or to children under 12.

Oxytetracycline can be given as a twice-daily dose to aid compliance and must be given for an adequate length of time (at least 3 months). Oxytetracycline tablets should be taken an hour before food and should not be taken with iron or antacid preparations which may reduce absorption.

If patients taking a combined oral contraceptive (COC) are commenced on an oral antibiotic treatment, then additional contraceptive precautions should be taken for three weeks

(still valid?)

If this falls into the pill free period then the next pack should be started without a break. Patients on every day pills should discard the inactive pills and continue immediately with the active pills (ie an active COC must be taken during this three-week period as well as other additional precautions).

If the antibiotic course exceeds three weeks, resistance to this interference develops and additional precautions become unnecessary after this initial three-week period.

If the patient has been receiving long-term oral antibiotic treatment then no precautions are necessary when the COC is introduced.

Effectiveness of oral progestogen-only contraceptives (including the emergency hormonal contraceptive Levonelle®) is not affected by broad spectrum antibiotics, but is reduced by enzyme inducing drugs.

Co-cyprindiol (Dianette® ) is in general no more effective than oral antibiotic therapy, but is useful in females who also wish to receive oral contraception. It is contra-indicated in pregnancy, so the need for careful compliance must be explained to patients before commencing.

It reduces sebum excretion, which is under androgen control, and so can also help in idiopathic hirsutism.

If not showing satisfactory response by 3 months, check compliance switch to alternative antibiotic such as doxycycline 100mg daily for at least 3 months or lymecycline 408mg daily for at least 8 weeks, then assess response.

Doxycycline and lymecycline may be taken with food, and this may help to reduce the incidence of nausea. Avoid excess sun exposure when taking doxycycline (dose-dependant, but idiosyncratic, phototoxic reaction).

Minocycline 100mg daily for 3 months is a third line option of oral antibiotic for acne (non-formulary), as if continued beyond this time, monitoring for hepatotoxicity (LFTs), pigmentation and for SLE (serum antinuclear antibodies) is required.

If these develop, or if pre-existing SLE worsens, it must be discontinued.

Oral isotretinoin

side effects include teratogenicity, hyperlipidaemia, dryness and irritation of skin and mucous membranes.

Unless have Acne fulminans, have had 1 year of adequate treatment, psychologically distressed.

Expect: 10% improvement/ month of Tx; continue for at least 6/12 even if patient is better; after 6-12 months consider stopping oral antibiotics but continue topical keratolytics.

NB type VI skin hyperpigments, which fades very slowly? treat early

Acne vulgaris BMJ 2009

Management

Summary of principles:

Topical treatments are effective for mild/moderate acne. Advise patients to use treatment as a spot preventer not just spot remover.

Oral antibiotics (and antiandrogens for women) are necessary for moderate acne.

For severe acne use high dose antibiotics and at the same time instigate referral for isotretinoin which has a rapid effect and high rate of long term remission.

Early treatment and regular review to present scarring.

Clarify your expectations regarding speech of action and the suppressive and preventative nature of treatment.

Follow Up

This should be tailored to the need of the patient and the expected rate of change. In the early phase of treatment more frequent visits are required to review progress and encourage compliance. Maintain treatment for 8 to 12 weeks as the response with oral and topical preparations may be slow.

Topical Treatment for Mild Acne (see BNF section 13.6)

Benzoyl peroxide 2.5 10% once daily Can be used long term and with oral antibiotics

Tretinoin 0.1 0.25% once daily Avoid in pregnancy

Isotretinoin 0.05% once/twice daily Avoid in pregnancy

Clindamycin 1% twice daily Suitable for greasy skins

Erythromycin 2% & 4% + zinc acetate twice daily Suitable for greasy skins Less bacterial resistance

Treatment for Moderate Acne (see BNF section 13.6)

1st line treatments Oral antibiotics Use for a minimum of 3 months

Expect improvement in 2-8 weeks

Oxytetracycline 500 mg bd Over 14 years old, half hour before food, no milk or iron

Erythromycin 500 mg bd Frequent resistance of P. acnes and Staph

Trimethoprim 100 mg bd

2nd line treatments Doxycycline 100 mg daily P. acnes resistance occurs

Minocycline 100 mg daily Low incidence of pigmentation, arthralgia and hepatic damage; bacterial resistance unknown.

Cyproterone acetate + ethinyloestradiol (Dianette) Suitable for contraception in presence of acne.

Acne minocin

Don’t use minocycline as first line oral antibiotic in acne. BMJ Jan 2007

Acne – hospital referral

Indications for Hospital Referral

Severe acne

Cysts and scars

Psychological disorder due to acne

Late onset persistent acne (eg older than 25 years)

Failure of moderate acne to respond to adequate treatment after 6 months

Referral Letter

Treatment given name/dose/duration of medication

Expectation from referral ie diagnosis, reassurance, treatment, advice.

Acne rosacea

Erythematous rash with pustules and telangiectasia over cheeks and nose.

Rhinophyma – nose becomes enlarged red and bulbous in advanced stages

IPL in rosacea

Rosacea types

Sebacious hyperplasia

Acneiform rashes

Acneiform Eruptions

Perioral dermatitis

Erythematous papular eruption around the mouth particularly young females.

Acneiform eruption in typical distribution around the mouth with :

erythema (sparing the vermillion border),

sensitivity burning and itching around the mouth

small red sometimes flakey papules and sometimes pustules

also involves nasolabial folds and eyes

May be related to use of steroid creams

Mainly young women (M:F = 9:1)

Treatment

Avoid steroid creams.

Use lukewarm water, without soap, to clean the face +/- a neutral non-greasy cream

Advise the disorder may get worse before it gets better.

Oral tetracyclines (e.g. tetracycline 250 mg four times daily for 3 weeks) or topical metronidazole (less effective)

GPCSG

http://hacking-medschool.com/perioral-dermatitis-2

Eczema / dermatitis

Pityriasis rosea

Pityriasis Rosea: Herald patch and Typical colarette of scale; Christmas tree distribution on torso; 10% papular and very itchy.

Spontaneous resolution in 6-8 weeks; Eczematide in Type VI skin may persist months and need topical steroids. Tx: Nothing, or simple emollients; if very itchy ( mod potent) steroid eg Eumovate

an acute eruption of numerous, widespread, pink, scaly,val patches 1-4 cm in diameter, occurring over a period of days usually a larger initial ‘herald’ patch

the patches often follow the skin creases and mainly affect the trunk, face, scalp and upper limbs

there may be itching, usually mild but occasionally intense it occurs mainly in adolescents and young adults, and more often during autumn or spring

there may have been malaise, fever or lymphadenopathy before the rash appeared

the rash will last 6-10 weeks then disappear, leaving no trace

explain the condition and its course to the patient and reassure that it is not contagious, nor does it recur

Pityriasis versicolor

Scaly rash with areas of depigmentation due to Malasezzia furfur.

Larger oval herald patch followed few days later with scattered truncal christmas tree rash of annular scaly redbrown patches Pityriasis / Tinea Versicolor Pityriasis Versicolor: Unless uncertain diagnosis and negative microscopy.

Itchy orangey scaly macules on white skin or scaly pallor on pigmented skin particularly affecting upper chest and backmycology scarping will confirm ( take a scraping for Malassezia (pityrosporum) + send to St Thomas’ Mycology Dept for microscopy… unless you like do your own!)

More common in warm weather, in individuals who exercise heavily, and diabetics but patients may speak of having had a scaly itchy back for years. More noticeable when they acquire a sun tan so patients often come in the summer! Once treated effectively patches are no longer scaly, but skin may take months to repigment…and the condition often recurs!

Topical Tx: Ketoconazole shampoo lathered onto wet skin and left on for 5 minutes before washing off, repeated once daily for 5 days very effective, or daily Ketoconazole 2% cream (but Px large quantities)

Systemic Tx: Itraconazole 200mg once daily for 7 days (NB drug interactions) or Fluconazole – these are especially useful if there are small associated pustules and fine scale typical of pityrosporum folliculitis ( NB malassezia and pityrosporum orbiculare are the same organism)

hacking-medschool.com/scabies

Pityriasis rubra pilaris

Pityriasis Rubra Pilaris

Melanin

http://www.sankofa.ch/texts/Melanin.htm

Hyperpigmentation
Race
Addisons
Haematochromatosis
PBC
Renal failure

Albinism

Congenital complete failure of melanin production.

hacking-medschool.com/scabies

Vitiligo

http://www.vitiligosocietyweb.org.uk

Autoimmune hypopigmentation affecting exposed areas. May be associated with other autoimmune conditions – DM, hyperthyroidism, Addisons, pernicious anaemia.

hacking-medschool.com/scabies

Bacterial skin infections

hacking-medschool/abs-soft-tissue-infections

Recurrent Impetigo: unless the following has proved ineffective:

Swab the patient’s nose, axilla, groin, nose of siblings/ parents, +/nose/ axilla of partner;

Prescribe 2+/52 of oral antibiotics (Flucloxacillin or Erythromycin)+ Topical antibiotics + Dermol 600/ (bath additive)/ Dermol 200 shower gel; If nasal carriage is confirmed, prescribe 1/52 of topical nasal Bactroban ( = Mupirocin) tds or fucidin

If they have active eczema don’t stop their topical steroids; they may need Fucibet for a 3-5 days but do review them! Worsening eczema is often infected.

Advise parents to keep their children off nursery until the impetigo has healed or everyone else will get it, and their child may get it back! Impetigo

Antibacterial Skin Preparations

Silver sulfadiazine cream 1%

Dose: Apply with sterile applicator; burns, apply daily or more frequently if very exudative; leg ulcers or pressure sores apply daily or on alternate days (not recommended if ulcer is very exudative); finger tip injuries, apply every 2-3 days.

Antibacterials also used systemically

Fusidic acid cream, ointment, gel 2%

Dose: Apply 3 to 4 times daily for up to 7 days.

Metronidazole cream, gel 0.75%

Dose: Acute inflammatory exacerbation of acne rosacea, apply thinly twice-daily for 8-9 weeks; avoid contact with eyes.

BMJ Easily Missed Sep 2011 PVL positive Staphylococcus aureus skin infections

hacking-medschool.com/scabies

Pityriasis alba

hacking-medschool.com/scabies

Erythrasma

hacking-medschool.com/scabies

Erysipelas

youtu.be/RfNmUnl_Bxw

hacking-medschool.com/scabies

Fungal skin infections

Tinea Coles

Unilateral scaling and fissuring of palm feet groin or trunk

Terbinafine is fungicidal vs clotrimazole which is fungistatic

Tinea Capitis (trichpphyton) requires oral treatment with griseofulvin terbinafine or itraconazole syrup for 1 week (?) Tinea Capitis
tinea pedis
tinea manum
tinea incognit
Tinea cruris
Tinea Facialis
Tinea ingognita

Fungal Infection Rxed Steroids

Antifungal preparations

FIRST CHOICE: CLOTRIMAZOLE cream

Clotrimazole cream 1%

Dose: Apply 2-3 times daily, continuing for 14 days after lesions have healed.

Ketoconazole cream 2%

Dose: Apply 1-2 times daily

NB Only prescribable for seborrhoeic dermatitis and pityriasis versicolor. Endorse SLS.

Miconazole cream 2%

Dose: Apply twice-daily continuing for 10 days after lesions have healed.

Terbinafine cream 1%

Dose: Apply thinly 1-2 times daily for up to 1 week in tinea pedis, 1 to 2 weeks in tinea corporis and tinea cruris, 2 weeks in cutaneous candidiasis and pityriasis versicolor; review after 2 weeks. Not recommended for children.

Dermatophyte Infections (Ring Worm)

Skin infection

Treatment Samples for microscopy and culture can help to confirm the diagnosis but do not need to be taken from people with suspected uncomplicated athlete’s foot, mild infections of the groin area, or mild skin ringworm, when empirical treatment can be started immediately. Clotrimazole 1% or miconazole 2% cream, applied 2-3 times daily continuing for 10 days after lesions have healed. If ineffective, terbinafine 1% cream can be applied 1-2 times daily for up to one week. In some cases, the harder skin of the soles and palms may be affected. This sometimes requires oral therapy eg terbinafine 250mg daily for 2-6 weeks. Both topical and systemic terbinafine are not recommended for children.

Nail infection

Treatment Send nail scrapings or clippings for mycology. Treat with systemic therapy only if laboratory proof of dermatophytic infection. Oral terbinafine 250mg daily for 6-12 weeks in fingernail infection and for 3-6 months in toenail infection gives an approximately 80% cure rate. Not recommended for children.

Note: Self-adhesive packets for mycology samples can be obtained from microbiology.

Oral terbinafine should not be prescribed without laboratory proof of dermatophyte infection.

Molluscum contagiosum

Pox virus infection producing clusters of round, raised, pearly cream umbilicated lesions on the trunk and limbs of children.

Resolves completely, without scarring, after several months.

Common within atopic eczema OK to continue treatment for eczema

If necessary try Crystaside (off licence but used by Dr David Atherton and other local consultants)

Commonly become inflamed/ volcano like before resolution.

Don’t prick with orange stick/ traumatise, they do go more quickly but will scar.

Genital papules may occur in sexually active adults, but rarely elsewhere; consider immunosuppression if numerous and present elsewhere, or giant molluscum.

Warts and verrucae

http://prodigy.clarity.co.uk/warts_and_verrucae

No treatment has a very high success rate – average 60-70% at 3 months

Salicylic acid preparations slowly destroy the virus-infected epidermis. Excess keratin should be pared or filed prior to application.

Do not use on face due to risk of irritation/scarring.

Cryotherapy (liquid nitrogen) causes destruction of the epidermis

Optimal time between treatments is uncertain – probably 2-3 weeks.

Warn patient of pain and possible blistering.

Caution over tendons and if poor circulation.

It is not recommended to treat children under 7 years of age.

An immune reaction is usually necessary for clearance – so immunosuppressed patients may never clear.

Plantar warts must be distinguished from corns/callosities. This is easily done by paring away the keratin – warts have bleeding points, corns which have a central plug and callosities do not bleed.

Anogenital warts should be referred to the genito-urinary or paediatric department.

Unless facial ( filiform) for cryotherapy

Immunity occurs spontaneously ( in most); Follow wart guidelines – pare, topical Tx, duct tape all for 3-6/12 + then consider cryotherapy if nec

Mosaic wartsif recalcitrant refer to podiatrists

Impaired immunity/ Persistent hand warts in individuals with skin types 4/5KCH offer DCP

Most disappear by themselves with time, but may take 2-3 years

contagious

Action There is little evidence to prefer one treatment above another. Anecdotally, the application of a banana skin, withthe white inside part taped against the wart, each night for two weeks has often been reported to be effective virtually free, with no known side-effects.

Options:

leave alone

soak in warm water for 5 minutes twice daily, remove dead skin with an emery board, then apply salicylic acid. Persevere until completely disappeared; may take 3 months

liquid nitrogen not for children under the age of 10 years, as can be painful. Can also cause dramatic blood blistering, temporary numbness and a scar

A patient with a verruca should use a waterproof plaster or verruca sock for swimming and PE, and avoid sharing a towel.

EVerT: cryotherapy versus salicylic acid for the treatment of verrucae – a randomised controlled trial.NIHR HTA Sep 2011

Bullous diseases

Pemphigus

PemphiguS Superficial

PemphigoiD Deep

(Khan Mnemonics and Study Tips for Medical Students)

Pemphigus vulgaris

Rare and serious.

Superficial flaccid easily ruptured ( strip on pressure – Nikolskis sign) epidermal/intradermal blisters affecting skin and mucous membranes in middle aged and elderly

Pemphigoid

Tense large sun-epidermal blisters. May be assoc with underlying malignancy.

Stevens-Johnson syndrome

Cutaneous erythema multiforme with ulceration of mucous membranes.

Causes – drugs (penicillin, sulphonamides) bacterial and viral infections)

http://www.merckmanuals.com/stevens-johnson_syndrome and_toxic_epidermal_necrolysis

Dermatitis herpetiformis

Small itchy blisters on large joints and lumbo sacral area.

May be asoc with coeliac diseases.

Toxic Epidermal Necrolysis

Staph infection with large blisters and crusting.

Erythema multiforme

Erythematous macules with clear centre (target lesion) due to drugs, bacterial or viral infections affecting usually the distal upper limb only.

Erythema Multiforme @ PubMed

Hyperhydrosis

hyperhidrosis uk

Scleroderma / systemic sclerosis

CTD characterised by diffuse fibrosis and vascular abnormalities of skin, joints, and viscera.

Clinical features

Thick taught puckered waxy skin with thin hairs on the face especially round the mouth with telangiectasia of lips tongue face and fingers.

Sausage fingers with thickened skin and loss of knuckle crease +/- arthralgic swelling , calcification, and vasculitic ulceration of fingertips.

CREST syndrome

Calcinosis of skin
Raynauds
Esophageal dysmobility
Sclerodactyly
Telangiectasia

CREST Medscape

Hereditary Haemorrhagic Telangiectasia Osler-Weber Rendu Syndrome

Hereditary Haemorrhagic Telangiectasia Medscape

Small flat telangectasic lesions on lips buccal and nasal mucosa tongue fingers tips and toes together with internal lesions and AV aneurysms in lungs liver and spleen which may bleed easily.

AD inherited condition.

Morphea

morphea.co.uk

Campbell de Morgan spots

Campbell de Morgan @ BBC Health

Squamous cell carcinoma SCC

Basal cell carcinoma BCC

Rodent ulcers. Rolled pearly edge with telangiectasia and destructive centre on sun exposed areas of the face.

Gorlins syndrome = BCC + palmar pits + mandibular cysts + CNS tumours

Improving Outcomes for People with Skin Tumours including Melanoma.” (May 2010) and “Revised Guidance and Competences for the Provision of Services using GP’s with Special Interests (GPwSI) Dermatology and Skin Surgery” (DOH April 2011).
These guidelines describe the circumstances where a low risk basal cell carcinoma might be removed by a GP as part of a DES or LES. You will note the extensive governance arrangements which need to be in place before this can occur.

Imiquimod

Imiquimod PUK

Skin metastases

Fixed drug reaction

dermnetnz fixed drug eruption

Erythema nodosum

Round red painful/tender nodules up to 5cm in diameter on anterior surface of lower legs =/- extensor surfaces of arms.

May occur 2-3 weeks following streptococcal throat infection, drugs (OCP, aspirin, sulphonamides), TB, RHF, Sarcoidosis

youtu.be/bTNxyVOVbgA

Erythema multiforme

Dermatofibroma

Lichen planus

Lichen sclerosis

Squamous carcinoma in situ – Bowens disease

Chloasma malasma

Patchy pigmentation over forehead and around eyes in pregnancy or OCP use.

Chloasma @ drugs.com

Kligman’s formula 4% hydroquinone, 0.1% tretinoin, 1% hydrocortisone

Peutz Jeghers

Peutz Jeghers.com unattractive

Black skins

AAD

Pseudofolliculitis barbae

Pseudofolliculitis @ AOCD

Acne keloides nuchae

dermnetnz keloid-acne

youtu.be/5F-iyIu2Wrg

youtu.be/lQL1khTYBf8

Dermatosis papulosa nigra

Dermatosis papulosa nigra Medscape

Lichen simplex chronicus

Lichen Simplex Chronicus @ Skinsight

Nodular prurigo

Nodular Prurigo UK website

Lichen nitidus

Lichen nitidus @ Wrong Diagnosis.com

Acanthosis nigrans

Acanthosis Nigrans @ rare diseaes.org

Dark brown thickened axillary pigmentation. May be congenital or if developing in adulthood associated with underlying malignancy (eg stomach, bowel, lung) or endocrine disorder such as DN, Cushings, hypothyroidism or acromegaly.

youtube.com/watch?v=rosQtcBEibk

Actinic keratosis solar keratosis

Small irregular scaly warty plaques in sun exposed areas (foreheads) of fair skinned people (Celts)

Solarize (topical dicofenac) or Efudix bd (Fluorouracil) 6 weeks

Cryotherapy

Photodynamic therapy

Keratacanthoma

Small fast growing warty lesions with a central horny plug seen on light expsed areas. Benign buy may be confused with SCC.

Seborrhoeic warts seborrhoeic keratoses

Well demarcated stuck-on lesions with greasy/ crusted papilliferous surface

Pale brown to very dark. Frequently itchy and often traumatised

if look angry may have been traumatised so treat with Fucibet (not face) for 2weeks and review.

Pompholyx

youtube.com/watch?v=BXcrS9Qmksw

Pretibial myxoedema

Mauve coloured swelling on shins in hyperthyroidism.Pretibial Myxoedema DermnetNz

Bacterial skin infections (dermatology)

Recurrent Impetigo: unless the following has proved ineffective:

Swab the patient’s nose, axilla, groin, nose of siblings/ parents, +/nose/ axilla of partner;

Prescribe 2+/52 of oral antibiotics (Flucloxacillin or Erythromycin)+ Topical antibiotics + Dermol 600/ (bath additive)/ Dermol 200 shower gel; If nasal carriage is confirmed, prescribe 1/52 of topical nasal Bactroban ( = Mupirocin) tds or fucidin

If they have active eczema don’t stop their topical steroids; they may need Fucibet for a 3-5 days but do review them! Worsening eczema is often infected.

Advise parents to keep their children off nursery until the impetigo has healed or everyone else will get it, and their child may get it back! Impetigo

Antibacterial Skin Preparations

Silver sulfadiazine cream 1%

Dose: Apply with sterile applicator; burns, apply daily or more frequently if very exudative; leg ulcers or pressure sores apply daily or on alternate days (not recommended if ulcer is very exudative); finger tip injuries, apply every 2-3 days.

Antibacterials also used systemically

Fusidic acid cream, ointment, gel 2%

Dose: Apply 3 to 4 times daily for up to 7 days.

Metronidazole cream, gel 0.75%

Dose: Acute inflammatory exacerbation of acne rosacea, apply thinly twice-daily for 8-9 weeks; avoid contact with eyes.

BMJ Easily Missed Sep 2011 PVL positive Staphylococcus aureus skin infections

Infestations (dermatology)

250textbooks/infestations-infections

Scabies

Intensely itchy red excoriated lesions with burrows especially in the finger webs (adults).

youtu.be/UULVgJCsJMo

Treatment of lice and scabies

Dimeticone 4% lotion

Dose: Head lice, rub into dry hair and scalp, allow to dry naturally, shampoo after a minimum of 8 hours (or overnight); repeat application after 7 days.

Malathion 0.5% in aqueous basis

Dose: Head lice, rub into dry hair and scalp, allow to dry naturally, remove by washing after 12 hours and repeat treatment after 7 days. Crab/pubic lice, apply aqueous preparation to all parts of the body (not merely the groin and axillae) for 12 hours, or overnight; a second treatment needed after 7 days to kill lice emerging from surviving eggs.

Several products are available which require the use of a fine tooth plastic detection comb and hair conditioner; a head lice device (Bug Buster® Kit) is prescribable on the NHS. The methods typically involve meticulous combing with the detection comb over the whole scalp at 4 day intervals for at least 2 weeks.

Permethrin cream 5%

Dose: Scabies: apply over whole body including face, neck and ears and wash off after 8 to 12 hours. Those with sparse hair should also apply the cream to their scalp. If hands are washed with soap and water within 8 hours of application, cream should be re-applied. Repeat treatment after 7 days. All members of household/close contacts should be treated once only.

Management of Scabies

1. Consider as a possible diagnosis in anyone who is itchy.

2. Confirm diagnosis by identifying the burrows, which are linear scaly tracks ~ 1cm in length –

* almost always found on hands, especially web space, side of finger, palm

* look at soles of feet in infants

* lumps on male genitalia and female areola can be helpful confirmatory signs

3. Be confident and upbeat with the patient –

* can affect anyone (even Dermatologists) and is curable if instructions followed

* give scabies information leaflet explaining nature of condition and its treatment

4. Treat patient with Permethrin 5% cream on two occasions, 7 days apart –

* overnight application best (8 hours)

* cover all skin from head to feet, except hair-bearing scalp, eyelids and mouth

* make sure sufficient is prescribed —

– average adult 30g
– large adult 60g
– age 12 and over 30g
– 5–12 15g
– 2–5 7.5g

* children under 2 years of age should be treated under medical supervision

* use aqueous malathion (24 hours x 2 applications) if allergic to lanolin

5. Treat all household members and other close contacts simultaneously, whether they have symptoms or not. Scabies is highly infectious and contacts may be asymptomatic as the incubation period is 2 – 6 weeks. Encourage the family not to delay treatment. It is important that all contacts apply treatment on the same day to minimize the chances of reinfestation from an untreated contact.

6. Tell patient itch may persist for up to a month after treatment –

* treat symptomatically with Crotamiton 10% (Eurax® ) cream, moderate-strength topical steroid, emollient or oral antihistamine

Refer to NHS Tayside’s Guidelines for the Control of Scabies infection when available (due to be published shortly) and PRODIGY Guidance – scabies for further advice.

Sarcoptes Scabei Intensely itchy rash due to waste products of mites as they burrow into skin – particularly web spaces flexor surface of wrists also papules on buttucks and genitalia

Coles

Aqueous malathion 0.5% liquid 24 hrs

Permethrin 5% dermal cream 8-12 hours

Repeat 7 days

Do not have hot bath prior to Rx.

Apply below neck line plus scalp face and ears for Infants children elderly and immunocompromised

Treat all household members at same time

Ivermectin available on named patient basis for resistant Norwegian Scabies

Its normal to itch for up to 6 weeks after Tx and doesn’t mean that Tx has failed, especially if treatment advice was followed, including Tx of household contacts and sexual partner(s)

Norwegian scabies

BMJ lesson of the week 2000

Headlice (nits) and crabs

Headlice

Crablice
youtu.be/bHDr3R2Eatk

Head lice pediculosis humanis capitis

MIMS Lice and Scabies Treatments

Dimeticone 4% lotion

Dose: Head lice, rub into dry hair and scalp, allow to dry naturally, shampoo after a minimum of 8 hours (or overnight); repeat application after 7 days.

Malathion 0.5% in aqueous basis

Dose: Head lice, rub into dry hair and scalp, allow to dry naturally, remove by washing after 12 hours and repeat treatment after 7 days.

Crab/pubic lice, apply aqueous preparation to all parts of the body (not merely the groin and axillae) for 12 hours, or overnight; a second treatment needed after 7 days to kill lice emerging from surviving eggs.

Several products are available which require the use of a fine tooth plastic detection comb and hair conditioner; a head lice device (Bug Buster® Kit) is prescribable on the NHS. The methods typically involve meticulous combing with the detection comb over the whole scalp at 4 day intervals for at least 2 weeks.

Examination

may have enlarged lymph nodes at back of neck

nits (louse eggs adhere to hair tightly, whereas dandruff falls off easily)

Action follow current local recommendations if none, use aqueous malathion

check all of household and treat affected people only (repeat after 2 weeks)

apply conditioner liberally, then use fine metal comb to break the legs of the lice, so that they cannot reproduce.

Fleas

Ctenocephalides canis & felis

Carried by cats dogs hedgehogs. Bites can cause itchy papules.

youtube/eXX0W8HEJ7I

Threadworms pinworms

Enterobius vermicularis.

Mebendazole 100mg as a single dose. If reinfection occurs second dose may be needed after 2 to 3 weeks

or Pripsen®, one sachet, stirred into a small glass of milk or water and drunk immediately, repeated after 14 days.

http://www.youtube.com/watch?v=V7q2fypGgfQ

From dirt/soil to child then parents/others by hand mouth transmission

Spider Naevi @ Medscape

Liver disease RhA pregnancy

Telangiectasia

Systemic Sclerosis
Hereditary Haemorrhagic Telangiectasia

Granuloma annulare

Granuloma Annulare @ AAFP

Lentigines

Freckles

Peutz Jeghers syndrome

Lentigines Cleveland Clinic

Birthmarks

Vascular malformations and birthmarks

Nevus sebaceus

Discoid lupus erythematosis DLE

Chronic erythematous skin condition involving face neck scalp and arms with scaling, scarring, atrophy hypo and hyperpigmentation.

Some patients go on to develop SLE

SLE

(belongs in rheumatology)

Inflammatory CTD affecting young women causing facial rashpurpura photosensitivity arthropathy (mcp and PIP)pleurisy, pericarditis kidney disease and psychosis.

Typical scaly red rash with scarring and atrophy in butterfly/batswing appearance over cheek and bridge of nose.

SLE syndrome may be causaed by phenytoin, procaineamide , hydralazine isoniazid

or exacerbated by penicillins, sulphonamides and the COC.

Lupus Pernio

Disfiguring complication of sarcoid of the upper respiratory tract causing bluish discoloration of nose, plaques scars and keloids.

Albinism

Telangiectasia

Lupus Pernio

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