Dermatology ApproachFayza Rayes

MBBCh. Msc. MRCGP (UK)Consultant Family PhysicianJoint Program of Family & Community Medicine Jeddah

www.fayzarayes.com

fayzarayes@yahoo.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