Dermatology Notes

Macule Flat lesion <1cm (freckle)

Papule Raised lesion <1cm (insect bites)
Plaque Raised lesion >1cm, can’t squeeze it between fingertips
Nodule Raised lesion >1cm, can squeeze it

Cream vs ointment:
Ointment (paraffin based, Epaderm) is much greasier than cream (emulsion,
diprobase) and therefore more moisturising (but less aesthetically acceptable)
Lotion: more watery eg. Dermol 500

Eczema Psoriasis
Itchy Not
Coalescing papules Plaques
No silver scale (hyperkeratosis) silver scale (hyperkeratosis)
Flexural Not just flexural
Sometimes vesicles None
Ill-defined borders Well demarcated borders
Lichenification NO

Eczema
Exogenous Exo and Endo Endogenous
Contact dermatitis Allergic contact Varicose eczema
Photocontact dermatitis dermatitis Asteatotic Eczema
Atopic Eczema Pomphylx eczema
Eczema:
secondary infection  impetigo:
- staph/strep yellow crusting
- treat with systemic fluclox or erythromycin
or herpes:
- eczema herpeticum

Cellulitis: Often streptococcus- treat with flucloxacillin 2g IV QDS

Necrotizing Fasciitis: debride, piperacillin-tazobactam + clindamycin
HPV:
- HPV 1,2,3,4,6,10,11,57 cause viral warts
- usually last 6 months without treatment
- treat with topical salicylic and lactic acids or topical glutaraldehyde
Vasculitis:
Clinical signs:
- palpable purpura
- painful
- lower legs and buttocks

Seborrhoeic eczema = Cradle cap = Malessezia yeast infection

Urticaria
- weals and plaques
 - never lasts more than 24hrs
- dermal oedema

Lichen Planus
- violaceous flat-topped, purple, polygomal papules
- post inflammatory hyperpigmentation
- wickhams striae in mouth

Erythroderma (rash covering >90% skin surface)

- Dermatological EMERGENCY
- Eczema
- Psoriasis
- Cutaneous T cell lymphoma, Leukaemia
- Sezary Syndrome

Lentigo maligna
- Malignant melamona in situ
- Long standing, v. slow growing, sun-exposed areas

Pityriasis Rosea
- annular ring lesions evolving in to multiple in a week

Acne Rosacea (not acne vulgaris)

- multiple red papules, patches
- open and closed comedones
- erythema
- NO treatment

Pompholyx Eczema
- multiple extremely itchy vesicles on palms and feet (frank blistering)

Dermatitis Herpetiformis
- Eruption of symmetrical painful, itchy, blistering dermatosis on extensor
surfaces
- Associated with coeliac disease (gluten enteropathy)
- Uncommon
- Treat with gluten free diet and dapsone (dapsone can  haemolytic
anaemia therefore check reticulocyte count)

Tinea Cruris
- fungal infection
- chronic
- asymptomatic rash in groins

Dermatomyositis
- autoimmune attack on skin and muscle
- purple rash on upper eyelids and forehead (heliotrope rash)
Molluscum
- Most of the time in children
- Has umbilication and doesn’t coalesce compared to HSV
- Treat by expressing ripe lesions, imiquimod cream
- Think of HIV in adults who have molluscum

Dermatofibroma
- forms nodules
- scarring following insect bite
- nothing is as hard in the skin. Do pinch test

Lupus pernio
- purple tip of nose

Toxic Epidermal Necrolysis (EMERGENCY) > Steven Johnsons Syndrome

(mucosal involvement) > Erythema Multiforme (not as bad)

Toxic Epidermal Staphylococcal Scalded

Necrolysis Skin Syndrome
Age Adults Infants
Cause Drug-induced S. aureus infection
Histological Level of Split Intradermal Subcorneal
Mortality 30% Low
1st line Treatment Stop drug, supportive Rx, Systemic flucloxacillin or
ICU erythromycin

Venous Ulcer
- more shallow than arterial
- haemosiderin deposition
- lateral aspect of leg

Blisters:
- Pemphigus
o Blisters rarely stay intact because intradermal split, friable
o IgG against desmoglein
o Mouth ulcers
o Uncommon
o Middle aged
o Trunk>limbs
o Possible mortality due to drugs
o Prednisolone + azathioprine
- Pemphigoid
o Blisters stay because subepidermal split  tense blisters with
urticated plaques
o IgG against basement membrane
o No mouth ulcers
o More common
 o Elderly
o Limbs> trunk
o Self-limiting
o Prednisolone (+ azathioprine)
- Acute contact dermatitis
- Porphyria (cutanea tarda)

Bowen’s Disease:
- SCC in situ, looks like superficial BCC, common in immunosuppression
(eg. Transplant patients)
- Chrnoic enlarging lesion in sun-exposed areas
- Manage with curretage, photodynamic therapy, cryotherapy, or topical
(imiquimod, 5-fu)
- Pre-malignant

Actinic keratosis
- related to age, sun exposure
- in the elderly
- treat with Aldara (imiquimod)
- feels rough, hyperpigmented macules
- pre-malignant, 10% can  SCC

Erythrema nodosum
- painful purpley nodules on lower limbs
- associated with strep infection, TB, COCP, sarcoid
- clinical diagnosis

BCC Subtypes:
- Superficial BCC
o Usually trunk and limbs, pearly edge, can become pigmented like
melanoma
- Nodular BCC
o Often on face, talangectasia, excision with 3-4mm margin
- Morpheic BCC
o UV, skin type, Gorlin’s syndrome (frontal bossing, cysts in jaw
bone)

BCC Differential Diagnosis

- Sebaceous Gland Hyperplasia:
o Can look like nodular BCC
o In oily area, often multiple with dimpled centre
- Intradermal Naevus

BCC management:
- Gold standard is excision
- Radiotherapy
- Topical Treatment: Aldara (imiquimod) or Efudix (5-FU)
- Photosensitizer and red wave length light for lesion
 - Cryotherapy to freeze

Sun exposure:
Melanoma associated with short-term, episodic UV (eg. Holiday)
BCC associated with chronic UV exposure (window cleaner)

SCC
2 wk wait referral from GP’s (like melanoma)
Gold standard is excision
Much more likely to kill patient than BCC
More rapid onset
Will ulcerate and won’t heal (Non-healing, ulcerated wound)
May occur on the edge of a wound
Indicateds background skin damage therefore do full skin check and follow up
for 5 yrs at least

SCC Differential Diagnosis:

- Actinic Keratosis  Bowen’s Disease  Keratoacanthoma (can self
resolve)  SCC
- Keratin Horn (but has no indurated base like SCC)
- Seborrhoeic Keratosis (benign)
o Most commonly seen pigmented lesion, looks keratotic
o Benign
o Genentically inherited
o Any skin type
o ‘stuck on’ apperance
o most of the time there are several
o Differential:
 Viral warts
 Actinic keratosis
 Benign melanocytic naevus
 Pigmented BCC
 Malignant melanoma

Melanocytic Lesions
Do ABCDE
(Assymmetry, Border, Colour, Diameter, Evolving?)
- Café au lait spots: macule common in neurofibromatosis type 1 and
tuberosclerosis
- Compound naevus: benign mole
- Halo naevus
- Atypical melanocytic naevus (funny looking benign mole)
- Morphoea: non-pigmented lesion, it is localised scleroderma, can be
progressive and burns itself out byt can impair growth of limb in children
- Seborrhoeic keratosis (stuck on appearance of multiple pigmented
papules with keratin cysts)
- Melanoma
- Lentigo maligna
Melanoma Risk factors
- Skin type (what happens when you go in to the sun? Type 1, 2, 3, 4, 5, 6)
- Burn  blisters?
- Family history of skin Ca
- Sun exposure (particularly episodic rather than cumulative)

Breslow Thickness (thickness or depth that melanoma grows in to skin) is

associated with prognosis

Melamona is much worse than  SCC which is much worse than  BCC