practical pdf - Group c

Dermatology sessions

Description of any skin lesion:

 Site of the lesion (part of the body)



hand, face, leg, scalp, etc.

 Number of lesion



single, multiple, and write the exact number if you can.

 Arrangement of the multiple lesions



discrete, coalesce, grouped, linear, circular.

 Distribution of the lesions:

o  On extensor surface: elbow, knee, sacral region.
o  On flexor surface: axilla, groin, sub-mammary, umbilicus.
o  On distal site: on fingers called acral.
o  Central site: like chickenpox.
o  Sun exposed area: face, hand, neck, upper chest.
o  Localized: unilateral or follow dermatome.
o  Generalized: or called universal.

  Type of lesion primary or secondary lesion.
  Size of the lesion  from mm to cm.
  Color of the lesion  silvery, erythematous, pink.
  Shape of the lesion  irregular, circular, flat, elevated.
  Border of lesion  like active border in some lesion.
  Margin of the lesion  well defined (psoriasis), ill defined (dermatitis).

Types of lesion:

Primary skin lesions:

 Macule



A localized area of color or textural change in the skin.

 Papule



A solid elevation of skin <5 mm in diameter.

 Plaque



A palpable elevation of skin >2 cm diameter and <5 mm in height.

 Vesicle



A clear, fluid-filled blister <5 mm in diameter.

 Bulla



A fluid-filled blister >5 mm in diameter.

 Pustule



A visible collection of pus in a blister.

 Abscess



A localized collection of pus.

 Wheal



A transitory, compressible papule or plaque of dermal edema, red or white,

indicating urticarial.

 Angioedema  a diffuse swelling of edema that extend to the subcutaneous tissue.
 Nodule



A solid elevation of skin >5 mm in diameter.

 Papilloma



A nipple-like projection from the surface of the skin.

 Purpura



Extravasation of blood resulting in redness of skin or mucous membranes.

 Ecchymosis



A macular red or purple haemorrhage, >2 mm in diameter, in skin or

mucous membrane.

 Hematoma: a swelling form gross bleeding.
 Burrow



A tunnel in epidermis caused by a parasite, e.g. Acarus in scabies.

 Comedo



A plug of sebum and keratin wedged in a dilated pilosebaceous orifice on

the face.

 Telangiectasia



Dilated dermal blood vessels resulting in a visible lesion.

Secondary skin lesions:

 Scale



Accumulation of easily detached fragments of thickened keratin.

 Crust



Dried exudate, e.g. serum, blood or pus, on the skin surface.

 Ulcer



A circumscribed area of skin loss extending into the dermis.

 Excoriation



A superficial abrasion, often linear, due to scratching.

 Erosion



A superficial break in the epidermis, not extending into dermis, heals

without scarring.

 Fissure



A linear split in epidermis, often just extending into dermis.

 Sinus



a cavity or channel that permit the escape of pus or fluid.

 Scar



Replacement of normal tissue by fibrous connective tissue at the site of an

injury.

 Atrophy



Loss of epidermis, dermis or both, thin, translucent and wrinkled skin,

visible blood vessels.

 Stria



Atrophic linear band in skin, white, pink or purple, from connective tissue

changes.

Other skin lesions:

 Callus



Local hyperplasia of horny layer on palm or sole, due to pressure.

 Cyst



A nodule consisting of an epithelial-lined cavity filled with fluid or semisolid

material.

 Erythema



Redness of the skin due to vascular dilatation.

 Freckle



A macular area showing increased pigment formation by melanocytes.

 Lichenification



Chronic thickening of skin with increased skin markings, from rubbing

or scratching.

 Milium



A small white cyst that contains keratin.

 Petechia



A haemorrhagic punctate spot 1–2 mm in diameter.

See photos @ WWW.muhadharaty.com/lecture/3472

Hair loss:
 Localized:

o Scarring  Lichen planus, discoid lupus.
o Non scarring  trachiotillamonia,

alopecia areata.

 Diffuse:

o Scarring  radiotherapy, burn, trauma.
o Non scarring  cytotoxic drugs.

Causes:

 Normal hair + abnormal skin  Psoriasis,

seborrheic dermatitis.

 Normal skin + abnormal hair (loss) 

trachiotillomonia, alopecia areata, traction
alopecia.

 Skin and hair are abnormal  tenia capitis.

Photos form doctor:

Description

Photo

Psoriasis:

o  Site: extensor part of elbow.
o  Number: single.
o  Type: primary (plaque) and secondary

(scale).

o  Shape: oval and flat elevation.
o  Size: few cm in diameter.
o  Color: erythematous (red) plaques and

silvery and heavy scales.

o Margin: well defined.

Nail changes in psoriasis:

o  All nails are affected.
o  Nail pitting.
o  "End on" view  Separation of nail

from nail bed called onycholysis,
thickening of nail, subangular
hyperkeratosis.

o "Above" view  yellow color.
o "Lateral" view  see the shape,

convexity, concavity of nail.

Note:
Nail changes in psoriasis occur before or
during or after the psoriasis, but it not
occur in all patients.
It may lead to psoriatic arthritis:
seronegative and DIPs affected.

Psoriatic arthritis:

o  The DIPs are affected.
o  This is the typical picture.
o  Sometimes the DIPs are not affected.
o  Patterns of psoriatic arthritis:

1.  Oligoarticular assymmetric arthritis.
2.  Polyarticular symmetric arthritis (RA-like).
3.  DIP joint predominant.
4.  Destructive polyarthritis (arthiritis

mutilans).

5. Ankylosing spodylitis and sacroiliitis.

Psoriasis:

o Number: single.
o Type: primary lesion then the patient

scratch it lead to bleeding (Auspitz sign)

o  Shape: oval.
o  Size: few cm in diameter.
o  Color: pink primary lesion, and white

scales.

o Margin: well defined.
o There are pin-point bleeding  Auspitz

sign.

o This not occur in eczema.

Koebner phenomenon:

o  Lines of scratching.
o  Occur in psoriasis, warts, vitiligo.
o  koebner phenomenon  spread of a

disease in uninvolved skin by trauma.

Prosiasis:

o  Site: scalp.
o  Color: Silvery.
o  Lesion: heavy scaly scalp.
o  Occur in: psoriasis and seborrheic

dermatitis.

o Differences:

  Seborrheic: yellowish greasy scales.
  Psoriasis: powdery dry silvery scales.
  Seborrheic: Stop at hair line.
  Psoriasis: extend beyond hair line.

Chronic plaque psoriasis:

o Distribution: on extensor surface 

elbow, knee, sacral region.

o Lesion: plaques.
o Covered by scales  thick, white,

powdery.

o  Color: erythematous.
o  Margin: well defined.
o  Scratching lead to Auspitz sign.

Flexor psoriasis:

o In axilla, groin, sub-mammary,

umbilicus.

o No scales  because it is wet area.

Guttate psoriasis:

Tear drop lesions.
Occur in young children.

Pustular psoriasis:

Localized or generalized.

Erythrodermal psoriasis:

Red or erythematous exfoliation.

Psoriasis of nail:

o  Pitting.
o  Nail separation.
o  Yellow discoloration.

Stages of eczema (dermatitis):

Acute stage:
o  Ill defined.
o  Small multiple vesicles.
o  Oozing serious fluid.

Subacute stage:
o  Erythematous plaque with ill-defined

border

Chronic stage:
o  Ill defined.
o  Lignification: thickening of skin +

exaggeration of skin marks.

Types of dermatitis  Atopic dermatitis,
Seborrheic dermatitis, Stasis dermatitis, Contact
dermatitis.

Atopic dermatitis:

o Major criteria of atopic dermatitis:

1- Severe itching.
2- Typical lesion + predilection
according to age.
3- Positive personal or family history of
other atopic diseases like asthma.
4- Chronic relapsing.

o Predilection:

Infant: in cheek.
Little older: cheek, elbow, knee.
Adult: generalized.

o Prognosis: 2/3 improve – 1/3 persist.

Atopic dermatitis:

o  Severe itching.
o  Childhood stage.
o  In popliteal fossa and antecubital fossa.
o  Lignification

Dermatitis:

o Severe itching.
o Infant age.

Occur in ankle, elbow, wrist.

Ichthyosis vulgaris:

Dry polygonal scales.

Keratosis pilaris:

o  Keratosis = thickening.
o  Pilaris = related to hair.
o  Tiny thickening (keratosis) at hair

follicles.

Occur in shoulder, upper thigh, buttock.

Name the condition? Atopic patient.

Tinea manuum:

o  Unilateral (right hand).
o  Scales concentrating in hand creases.
o  Investigation: KOH.
o  The cause is outside the body like fungal

infection,, because it is unilateral.

Tinea fasciae or corporis:

o  Unilateral lesion (affecting the left eye).
o  Erythematous plaque – well demarcated
o  Active border with relatively central

healing.

o Due to localized problem from outside

like infection (fungal).

Active border in tenia:

o Round plaque.
o The border is more red and more scaly

and more elevated than the center.

o There is active border and relatively

healed center.

o The cause is dermatophyte  it will eat

the keratin around it then eat the
surrounding keratin then extend and
eat more keratin so the lesion increase
in size.

o This is called tenia or ring worm.
o The tenia is named according to the site

of the lesion.

Tinea corporis:

o  Has active border.
o  Large size.
o  Hand  polycyclic lesion  called

Tinea circinata

Tenia incognito:

o Due to steroid therapy (because it looks

like eczema).

o  Unclear picture.
o  The disease not treated by the steroids.
o  Action of steroids  anti-inflammatory,

vasoconstriction, anti-proliferative.

o Steroid facies



bright red, atrophy of

skin, appearance of hair, acne, very thin
skin.

Tenia capitis:

o  School age child.
o  There is localized area of hair loss.
o  No complete devoid of hair and there is

scanty hair in the area.

o  Broken hair.
o  Early destructible hair.
o  Lusterless hair.
o  Scalp  scaly, inflammatory.

Alopecia areata:
o  Round patch.
o  Completely devoid of hair.
o  Normal skin of scalp.
o  School age child and other ages.

Causes of hair loss:
o  Generalized.
o  Localized:

  Tenia capitis.
  Alopecia areata.
  Male pattern.
  Burn of hair.
  Trichotellomania (psychological).

Athletes foot (tinea pedis):

o  Erythematous, eroded.
o  Exfoliation.
o  Affect webspace.
o  Mall odor due to superadded bacteria.

Tinea pedis:

o Vesico bullous.
o DDx: pustular psoriasis.

Tenia pedis:

o Scaly type.
o Affect whole sole then dorsum then

nails.

Tinea cruris:

o  Old name: eczema marginatium.
o  In upper inner thigh.
o  Genitalia is free.

o  Active border.
o  Not symmetrical.
o  Red brown color.
o  Dry area.

Candidiasis:

o  Folded area.
o  Bright red.
o  Macerated skin.
o  Genitalia affected.
o  Stellate lesion (lesions away from the

main lesion).

o Obese patient, Diabetic, Extreme age.

o Other endocrine diseases.

Tinea cruris:

o  Dry.
o  Red brown.
o  Upper inner thigh.
o  Active border.
o  Genitalia free.

Erythrasma:

o  It is bacterial infection.
o  Brown color.
o  Pink color under wood light.

DDx of lesion in thigh:
o  Psoriasis.
o  Eczema.
o  Candidiasis.
o  Erythrasma.
o  Tenia cruris.

Chicken pox:

o Multiple and discrete.
o Pleomorphic (papule, vesicles, crust) 

different stages at same time.

o Vesicles  erythematous ground.

Herpes simplex:

o  Multiple grouped vesicles.
o  Erythematous base.
o  At angle of mouth.
o  History: only few days.
o  Associated with tingling sensation.

Varicella zoster:

o  One dermatome.
o  Middle age or elderly.
o  Pain  could be post herpetic

neuralgia.

Warts

Plane warts:

o Strict to the surface.

Verruca vulgaris:

o  Type of warts.
o  Pale or skin color.
o  Single papule.
o  Well defined.
o  Elevated.
o  Rough surface.

Warts

Filiform wart:

o Finger like, filiform.
o Condylomata lata



affect genitalia

Wart:

o  Painful in lateral site.
o  Rough surface.
o  With black dots.
o  Interruption of skin marks.
o  Multiple.
o  Scratching



lead to bleeding.

o Affect sole of foot.

Corn:

o  Painful in center.
o  Apex in center.
o  Smooth surface.
o  Continuation of skin marks.
o  Scratching lead to arrangement.
o  Few.
o  Over bone prominence.
o  Affect sole of foot.

Pityriasis alba:

o  Ill defined.
o  Hypo pigmented.
o  Scaly.
o  Mainly in face then extremities.

Vitiligo:

o  Well defined.
o  Hypo pigmented.
o  Not scaly.
o  Everywhere.

Tenia versicolor:

o  Well defined.
o  Hypo pigmented.
o  Scaly.
o  Mainly in the trunk and neck.
o  Wood light and KOH exam.

Generalized hair loss:

Hair:
o  Anagene (active growing)  black pulp.
o  Telogene (resting stage)  white pulp

of hair.

Telogene effluvium:   ---------------------->
o  Surgery derived infection.
o  Chronic problem.

Anagene effluvium:   -------------------------->
o  Cytotoxic drug.
o  Transient problem.

Scalp hair:
o  3 years anagene.
o  3 weeks transient.
o  3 months telogene.

Localized hair loss:

Both:
o  Alopecia areata.
o  Round, complete hair lose.
o  Normal scalp.

Upper:
o Bad prognosis because affect hair lines

and lead to generalized alopecia.

Lower:
o  Better prognosis.
o  Self-limited.

Cicatrical hair loss:

o Ill-defined bizarre shape of hair loss.
o Scalp: erythematous, crust, scar

formation.

Alopecia areata:

o  Multiple.
o  May lead to genralized alopecia
o  Bad prognostic sign include:

1.more than half of scalp affected
2.patient present from childhood
3.associatd with +family hx
4.associated with other autoimmune
disease or down syndrome
5.if patient present with hair loss
around scalp margin.

Splinter hemorrhage:

o Bacterial endocarditis.

Pterygium of nail:

o  Splitting of nail.
o  Growth of proximal nail fold.
o  It is lichen planus.

Koilonychia:

o Increased concavity.
o Occur due to IDA.

Clubbing of nail

o Lovibond angle.
o Causes of clubbing:

 Pulmonary diseases: lung cancer,

cystic fibrosis.

 Cardiac: cyanotic CHD.
 GIT: inflammatory bowel disease,

liver cirrhosis.

 Skin condition – malignancy –

acromegaly – thyroid acropachy –
pregnancy.

Nail matrix (form doctor) nail lunula
(from internet)

o Make the nail grow forward not

upward.

o It disappear in 4

and 5

nail in most

people.

Beau's line of nail:

o Groove of nails in same area.
o Nail growth arrest due to systemic

insult.

o Benefit: calculate the time of onset of

the disease.

Infection of nail and nail fold:

o A: candidiasis: for months or years.
o B: fungal (onychomosis): distal part of

the nail, nail separate from nail bed,
destruction, lower infection of nail.

o C: bacterial: severe pain, red, hot.

Melanonychia

o It is longitudinal Melanonychia.
o We should exclude malignant

melanoma.

Lichen planus:

o Multiple, purple, plateform, pruritus,

papule.

o Shiny color, fine scales.

Pityriasis rosea:

o Eruption.
o Affect trunk and upper thigh and upper

arm.

o Oval shape.
o DDx: psoriasis.

Cutaneous leishmaniasis:

o  Painless.
o  Chronic.
o  Large nodule.

Impetigo:

o  Erythema.
o  Golden yellow crust.
o  Young age.
o  Staphylococcus.

Folliculitis:

o Painful lesion.
o Affect hair follicles.

o Most common cause is staph. Aureus.

Cystic acne:

o Complications: Psychological and social

morbidity, permanent scarring, post
inflammatory hyperpigmentation, gram
negative folliculitis.

Urticaria

Seborrheic dermatitis:

o Area of predilection (center of body) 

ear, glabella, napkin area, eye brows.

Napkin dermatitis:

o  Use zinc oxide ointment.
o  Education of parents.
o  Cleaning and changing diaper.
o  Keep the area dry.

Contact dermatitis:

o Not touch the cause of rash.
o Wash skin with mild cool water and

soap.

o Use hydrocortisone cream.

Secondary Syphilis:

o Deeply seated vesiculation in palm.

Stasis dermatitis:

o Management: use compression stocking

to improve the edema and venous
insufficiency.

Photosensitivity:

o Sunburn.
o Destitution: sun exposed areas.

Juvenile planter dermatitis:

o Eczematous lesion in forefoot of baby.
o Main cause is friction with stocking.

Discoid lesion

Aphthous ulcer

Erythema multiform

Dermatitis crculi:

o Patient advised to use lubricant

ointment with corticosteroids.

Pedunculated skin tag:

o Smooth appearance raised from skin

surface on a fleshy stalk.

Molluscum contagiosum:

o Multiple small pearly dome shaped

papules with central umbilication.

Unilateral dermatomal:

o Picture on left  unilateral destitution.
o Picture on right  dermatomal

distribution.

Questions from lectures:

Q: Define psoriasis?

Psoriasis is a genetic, immune-mediated skin and/or joint inflammatory disease in which
intralesional inflammation stimulates basal keratinocytes to hyperproliferate.

Q: Which drugs are contraindicated in psoriasis?

  Lithium
  Antimalarial agents
  Beta blocking agents
  Systemic steroids
  Interferon

Q: What are the comorbidities associated with psoriasis?

Patients with psoriasis are at a higher risk for the following comorbidities than is the
general population:

1. Crohn’s dis. and UC (3.8 to 7.5 times); families with MS.

2. Cardiovascular disease

3. Metabolic syndrome???

4. Lymphoma (1.5 to 3 fold); non-melanoma skin cancer (250 PUVAs – 14 fold SCC)

5. Depression/suicide

6. Psychological/sexual dysfunction

7. Smoking

8. Alcohol

9. Obesity

10. Quality of life

Q: What are the clinical patterns of psoriasis?

A. Variations in the morphology of psoriasis:

 Chronic plaque psoriasis ((commonest type))
 Guttate psoriasis

  Pustular psoriasis
  Erythrodermic psoriasis
  Light-sensitive psoriasis
  HIV-induced psoriasis
  Keratoderma blennorrhagicum (Reiter syndrome)

B. Variations in the location of psoriasis:

  Scalp psoriasis
  Psoriasis of the palms and soles
  Pustular psoriasis of the palms and soles
  Pustular psoriasis of the digits
  Psoriasis inversus
  Psoriasis of the penis and Reiter syndrome
  Nail psoriasis
  Psoriatic arthritis

Q: What is the primary lesion in psoriasis?

Well demarcated, bright red, scaly, plaques.

Q: What are the precipitating factors of Erythrodermic psoriasis?

  The administration of systemic corticosteroids.
  The excessive use of topical steroids.
  Use of tar and anthralin on acutely inflamed plaques.
  Abrupt discontinuation of systemic therapy.
  Phototherapy complications.
  Severe emotional stress.
  Infection.

Q: What are the nail changes in psoriasis?

  Onycholysis  separation of the nail plate from the nail bed.
  Subungual hyperkeratosis
  Pitting
  Oil spot sign
  Nail dystrophy

Q: Write short notes about treatment of psoriasis:

 If the affected body surface area below 20% use topical treatment  like topical

steroids, pentocam, topical vitamin D3 analogue (Calcipotriene), Lubricants or lotions.

 If the affected body surface area above 20% use systemic treatment  like

Methotrexate, Acitretin, Cyclosporine, light therapy (lead to immunosuppression) 
PUVA, UVB, UVA1.

 You can use biological dugs  infliximab, rituximab.
 Also you can use immunosuppressive drugs (methotrexate).

Q: What are the drugs used in treatment of psoriatic arthritis?

  Non-steroidal anti-inflammatory drugs
  Intra-articular steroid injections
  Methotrexate
  Biologics
  Cyclosporine
  PUVA

Q: What is the active border of fungal infection?

 One very characteristic pattern of inflammation is the active border of infection.
 The highest numbers of hyphae are located in the active border, so samples are taken

from here.

  Typically the active border is scaly, red, and slightly elevated.
  Vesicles appear at the active border when inflammation is intense.
  This pattern is present in all locations except the palms and soles.

Q: Enumerate the types of tenia pedis and discus the most common one?

  The classic “ringworm” pattern
  Interdigital tinea pedis (toe web infection)
  Chronic scaly infection of the plantar surface
  Acute vesicular tinea pedis

The most common types  Interdigital tinea pedis (toe web infection)

  The web between the fourth and fifth toes is most commonly involved.
  Tight-fitting shoes are a predisposing factor.
  The toe web can become dry, scaly, and fissured or white, macerated, and wet.
  The bacterial flora is unchanged in the dry scaly pattern.

 The macerated pattern occurs from an interaction of bacteria and fungus.
 Extension out of the web space onto the sole or dorsum of the foot is common.

Q: Write short notes about treatment of tenia pedis?

  Terbinafine 1% cream twice daily for 1 week in the interdigital type.
  Econazole is excellent in the macerated interdigital TP.
  Recurrence is prevented by wearing wider shoes and expanding the web space with a

small strand of lamb’s wool. Powders(not necessarily medicated) absorb moisture.

 Oral terbinafine 250 mg daily for 2 weeks in the hyperkeratotic type and other types of

TP.

 Acute vesicular tinea pedis responds to wet compresses, oral antifungal and oral

antibiotics.

 Id reaction requires wet dressings, group V topical steroids, and occasionally systemic

steroids.

Q: Write about Tinea incognito?

 Fungal infections treated with topical steroids often lose some (or sometimes all) of

their characteristics.

 Tinea of the hand, body, face and groin are often misdiagnosed as eczema and treated

with topical steroids.

  Topical steroids reduce inflammation giving false impression of improvement.
  In the mean time, the fungus flourishes. Why?
  Treatment is stopped, the rash returns, but by this time it has changed. How?
  Intensity of itching is variable.
  Hyphae are easily seen with KOH exam. several days after stopping the use of steroids

when scaling reappears.

Q: What are the clinical infection patterns of tenia of the scalp?

  Noninflammatory grey patch pattern
  Noninflammatory black dot pattern
  Inflammatory tinea capitis (kerion)
  Seborrheic dermatitis type
  Pustular type

Q: Write about Tinea Versicolor?

 Lesions begin as multiple small, circular macules of various colors (pink, white, or

brown) that enlarge radially.

 A spectrum of clinical presentations and colors:

o  Red to fawn-colored macules, patches, or follicular papules
o  Hypopigmented lesions.
o  Tan to dark brown macules and patches.

 DDx: Vitiligo, pityriasis alba, seborrheic dermatitis, secondary syphilis, and pityriasis

rosea.

 Investigations

o Scraping & KOH.
o Wood’s light examination.

 Treatment

o  Topical treatment.
o  Ketoconazole shampoo.
o  Selenium sulfide suspension.
o  Terbinafine spray.
o  Other topical antifungals.
o  Oral itraconazole and fluconazole.

Q: Write about viral warts?

  Caused by human papilloma virus
  Main types, common, plane and plantar
  Very common
  Disappear spontaneously eventually
  If treatment is needed, options include:
  Salicylic acid topically – needs daily treatment and can take months
  Cryotherapy
  Imiquimod cream

Note  description = nodule, well circumscribed, round or oval shape, rough surface, dry,
cracked, black dots (thrombosed vessels).

Q: Write about shingles and post herpetic neuralgia?

Herpes Zoster (Shingles)

 Caused by reactivation of the chickenpox virus which has lain dormant in the dorsal

root or cranial nerve ganglia

 Rash is preceded by a prodromal phase of up to 5 days of tingling or pain
 Then develop painful grouped vesicles/pustules on a red base in a dermatomal

distribution.

 Most common in thoracic and trigeminal areas

 Lesions become purulent, then crusted
 Healing takes place in 3-4 weeks

Shingles treatment

 Aciclovir 800mg 5 times daily, for 7 days
 Rest, analgesia usually gabapentine.

Post-herpetic Neuralgia
Pain lasting longer than 3 months after the rash.
The followings are risk factors for developing post-herpetic neuralgia?
A: Older age
B: More severe pain during the eruption
C: Severely inflamed rash
D: Prodromal pain in dermatome

Q: Write about Herpes Simplex Virus?

  A highly contagious infection spread by direct contact
  Primary infection is usually asymptomatic.
  Recuurent infection presents as acute, painful gingivo-stomatitis with multiple small

intra/perioral ulcers (but any site could be affected).
Associated with fever, malaise and lymphadenopathy.

 Clinically: Grouped umbilicated vesicles/pustules on erythematous base.
 Treatment: Topical aciclovir 200mg 5 times daily for 5 days

Q: Write about Impetigo?

 A highly infectious skin disease, which commonly occurs in children.
 The causative organism is usually Staphylococcus Aureus (>90% cases1), but less often

can be strep pyogenes.

 Begins as a vesicle, which may enlarge into a bulla.
 Weeping, exudative area with characteristic honey coloured or golden, gummy crusts,

which leave denuded red areas when removed.

 May present as macules, vesicles, bullae or pustules
 Bullae are more prominent in staphylococcal infection and in infants

Impetigo

 Treatment:

Mild localised cases - use topical antibiotic Polyfax
Widespread or more severe infections – use systemic antibiotics, such as
flucloxacillin (or erythromycin if penicillin allergic)

Q: Write about Folliculitis?

  Inflammation of the hair follicle.
  Presents as itchy or tender papules and pustules at the follicular openings.
  Complications include abscess formation and cavernous sinus thrombosis if upper lip,

nose or eye affected.

  Most common cause is Staph Aureus.
  Other organisms to consider include:
  Gram negative bacteria – usually in patients with acne who are on broad spec

antibiotics

  Pseudomonas (“Hot tub folliculitis”)
  Yeasts (candida and pityrosporum)
  Folliculitis treatment:

 Topical antiseptics such as Chlorhexidine
 Topical antibiotics, such as Fusidic acid or Mupirocin
 More resistant cases may need oral antibioics such as Flucloxacillin
 Hot tub folliculitis – ciprofloxacin2
 Gram negative – trimethoprim

Q: What are the signs and symptoms of scabies in adults and infants?

In adults:

  Rash present for 4 to 8 weeks has suddenly become worse.
  Generalized, severe itching
  Nocturnal itching
  Pinpoint erosions and crusts on the buttocks
  Vesicles in the finger webs
  Diffuse eruption sparing the face
  Nodules on the penis and scrotum
  Patient becomes better, then worse, after treatment with topical steroids.
  Rash is present in several members of the same family.

In infants:

  Widespread involvement usually due to misdiagnosis and Rx.
  Sometimes the face and scalp are affected.
  Vesicles are common on the palms and soles (characteristic).
  Secondary eczematization and impetiginization are common.
  Burrows are difficult to find.
  Nodules may be seen in the axillae and diaper area.

Q: How you treat scabies?

1- Permethrin (cream)

 Is the drug of choice for the treatment of scabies in children and adults of all ages

including pregnant and lactating women.

 Two applications 1 week apart, apply from head/neck to toe and wash after 8-12 hours

(for permethrin and lindane).

2- Lindane (cream, shampoo, and lotion)

3- BENZYL BENZOATE

4- CROTAMITON

5- SULFUR

 The pharmacist mixes 5% to 10% precipitated sulfur in petrolatum.
 The compound is applied to the entire body below the neck once each day for 3 days

and the patient is instructed to bathe 24 hours after each application.

 These preparations are messy, have an unpleasant odor, stain, and cause dryness.
 Sulfur in petrolatum is thought to be safe for infants <2 months old and pregnant and

nursing women.

6- Ivermectin

Q: Write short notes about Nits?

 The female lays approximately six eggs, or nits, each day for up to 1 month, and then

dies.

 Nits are 0.8 mm long and are firmly cemented to the bases of hair shafts close to the

skin to acquire adequate heat for incubation.

 Nits are very difficult to remove from the hair shafts.

Q: How you treat pediculosis?

Permethrin (1% and 5%) is the most effective treatment. It paralyzes the nerves that allow
the lice to breathe.

  Remains active for 2 weeks.
  Only apply to dry hair.
  It is insecticidal and ovicidal.
  Two applications (10 min. each) one week apart.
  Permethrin has a clinical efficacy of 95%.
  Lindane and pyrethrin have cure rates less than 90%.

Malathion

Ivermectin

Co-trimoxazole (480mg twice daily for 3 days), and repeated after 1 week.

Shaving the head

Nit removal (Combing)

Fomite control

Eye infestation: Baby shampoo or Vaseline; Ivermectin.

Q: Management of leishmaniasis?

History:

  History of travel (or living) to an endemic area in the previous weeks or months.
  History of insect (sandfly) bites in the previous weeks or months.
  History of high-risk activities such as sleeping outdoors.
  Non-healing chronic nodular, violaceous ulcer for 4–6 weeks or longer.

Examination:

 Chronic nodules – dusky red in color – ulcerated or crusted – non-healing – on exposed

body parts.

Investigations:

 Demonstration of amastigotes in Giemsa-stained smears from infected skin by direct

microscopy.

 Demonstration of intracellular amastigotes in the dermis of H & E skin sections.
 Growth of promastigotes in Nicolle–Novy–MacNeal (NNN) culture medium from

lesional specimens

 Demonstration of leishmanial DNA by PCR.

Treatment:

 Try topical treatment methods for simple sores.
 Reserve the systemic use of pentavalent antimonials for problematic sores: these

include:
1.Sores where scarring would be disabling or severely disfiguring.
2.Sores that will not heal easily (on shin or over a joint).
3.Sores involving mucosa or cartilage.

 Weekly intralesional sodium stibogluconate PLUS daily oral itraconazole 100 mg (or

allopurinol) for 6 to 8 weeks.

 IM sodium stibogluconate in a single daily dose of 20 mg/kg for 15–21 days.

 Severe scarring may require plastic repair.
 After healing, patients are normally immune to reinfection with the same species.

Q: Write about pathogenesis of acne?

  Increased sebum production (androgens)
   Abnormal keratosis (androgens)
   bacterial proliferation (Propionibacterium acnes)
   inflammation

Q: Enumerate the clinical manifestations of acne?

  Closed comedone (whitehead)
  Open comedone (blackhead)
  Papules
  Pustules (pimples)
  Cysts and nodules

Q: Write about classification of acne?

  Comedonal acne: Only comedons
  Mild acne:  Less than 20 pustules.
  Moderate to severe acne: More than 20 pustules

Q: Write about treatment of acne and side effects?

 Antibiotics: Topical (clindamycin and erythromycin) and systemic antibiotics used in

the treatment of acne vulgaris are directed at Propionibacterium acnes.
Minocycline, Doxycycline (50 t0 200 mg / day for 3 months), Tetracycline, Lymecycline

 Retinoids: These agents decrease the cohesiveness of abnormal hyperproliferative

keratinocytes.
Isotretinoin (systemic) 0.5 - 1 mg per kg over 4 to 6 months
Tretinoin (topical) cream (0.025%, 0.05%, 0.1%)

 Side effects:

Mucocutaneous: dry lips, facial dermatitis, dry nose, dry skin, pruritis, conjunctivitis,
hair loss, impetiginization.
Arthralgia and myalgia and headache.
Depression and mood swing.
Impaired night vision.