2011

‫بسم اهلل الرحمن الرحيم‬

Slide Interpretations for Common Clinical

Problems in Ophthalmology, ENT and Dermatology

Dermatology Slides

Dr. Nada A. AL-Yousefi, MBBS, SBFM, ABFM

Lecturer and Senior Registrar
Family and Community Medicine Department
College of Medicine and King Khalid University Hospital
King Saud University
[email protected]
Dermatology Slides 2011

Common Slides in Dermatology FM Board Exam

1. Roseola (sixth disease, exanthem 31. Paronychia
subitum, and roseola infantum) 32. Alopecia Areata
2. Erythema infectiosum [fifth 33. Trichotillomania
disease] 34. Telogen effluvium
3. Hand-Foot-and-Mouth 35. Androgenetic alopecia
Disease(HFMD) 36. Psoriasis
4. Erythema Toxicum Neonatorum 37. Lichen Planus
5. Stevens-Johnson Syndrome 38. Guttate Psoriasis
6. Aphthous Ulcer (Aphthous 39. Pediculosis Corporis (body
stomatitis) louse)
7. Acanthosis Nigricans 40. Pediculosis Capitis
8. Melasma 41. Oral Candidiasis
9. Vitiligo 42. Hairy tongue
10. Pityriasis Alba 43. Common warts (verruca
11. Acne Rosacea vulgaris)
12. Acne Vulgaris 44. Plantar Wart
13. Acne, Infantile 45. Leukoplakia
14. Varicella-zoster 46. Scabies
15. Herpes zoster infection 47. Dermatitis (Atopic,
16. Erythema nodosum lichenification, Impetiginization,
17. Leukonychia (white nails) eczema herpeticum,
18. Orf irritant/Allergic contact dermatitis)
19. Erythema Marginatum 48. Seborrheic dermatitis
20. Erythrasma 49. Diaper Irritant Dermatitis
21. Necrobiosis Lipoidica 50. Candida-induced diaper
22. Pityriasis Rubra Pilaris dermatitis
23. Pyogenic Granuloma 51. Syphilis, Primary (chancre)
24. Molluscum Contagiosum 52. Chancroid
25. Tinea Versicolor (pityriasis 53. Herpetic Whitlow
versicolor) 54. Leishmaniasis
26. Tinea Capitis 55. Keratoacanthoma
27. Kerion 56. Squamous Cell Carcinoma
28. Tinea Corporis (Ringworm of 57. Basal Cell Carcinoma
body) 58. Melanoma
29. Tinea Pedis (athlete's foot) 59. Kaposi Sarcoma
30. Erysipelas 60. Hairsutism

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61. Sole keratosis 79. Discoid lupus erythematosus

62. Insect bite 80. Cellulites
63. Anthrax 81. Necrotizing Fasciitis
64. Infectious mononucleosis 82. Kawasaki Disease
65. Folliculitis 83. Toxic epidermal necrolysis
66. Bullous Pemphigoid (TEN)
67. Kobner's phenomina 84. Toxic shock syndrome
68. Lipodystrophy (insulin 85. Staphylococcal scalded skin
induced) syndrome SSSS
69. Neurofibromatosis 86. Leprosy
70. Fissured tongue 87. Tuberous Sclerosis
71. Geographic tongue 88. Pretibial myxedema
72. Kolonychia 89. Diabetic dermopathy
73. Port wine stain 90. Systemic Lupus
74. Congenital Nevomelanocytic Erythematosus
Nevus 91. Dermatomyositis
75. Mongolian Spot 92. Nikolsky's sign
76. Keloid Scar 93. Henoch-Schönlein Purpura
77. Skin tag 94. Milia
78. Telangiectasia

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Roseola (sixth disease, exanthem subitum, and roseola infantum)

(A summary of an Article Written by: Craig N. Burkhart MD, Dean Morrell MD, Lowell A. Goldsmith MD,
MPH, Nancy Esterly MD)

o Mild self-limited illness. caused by HHV-6 and HHV-7.

o Dx:
o Infants with roseola are typically between the age of 6 months and 1
year.
o high fever typically > 38.9 C (The infant is otherwise well and the fever
usually subsides on the 4th day).The fever is followed immediately by
the onset of asymptomatic rose-pink blanchable macules and papules 2-
3 mm in diameter that begin on the trunk and may spread to the neck,
upper and lower extremities. The rash typically lasts 1-2 days but can
resolve more quickly.
o May progress to involve the neck and extremities.
o DDx: Measles, Rubella, Scarlet fever, Viral exanthem, Exanthematous drug
eruption
o Rx: symptomatic treatment and supportive therapy.

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Erythema infectiosum [fifth disease]

(A summary of an Article Written by: Sarah Stein MD, Karen Wiss MD, Sheila Galbraith MD, Craig N.
Burkhart MD, Dean Morrell MD, Lynn Garfunkel MD, Nancy Esterly MD)

o Affect young children due to infection with parvovirus B19.

o Dx:
o Infection can result in a mild exanthem, no exanthem, or the typical
Erythema of the cheeks "slapped cheeks" rash.
o Prodromal headache with associated low-grade fever and rhinorrhea
beginning 2 days before the onset of the rash.

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o Children recover spontaneously without therapy.

o Classically, the rash in children with erythema infectiosum goes through
3 phases:
 After several days of a non-specific flu-like illness, an exanthem
abruptly begins with the appearance of asymptomatic, macular,
diffuse erythema involving the bilateral cheeks (slapped cheek
appearance).
 1-4 days later, a lacy reticulated eruption consisting of discrete
erythematous macules and papules appears on the proximal
extremities. The trunk later becomes involved.
 Recurrence of a milder form of the eruption after exposure to
heat, friction, or sunlight, or in response to crying or exercise.
Roughly 7% of children with erythema infectiosum develop mild
arthralgias that resolve within several weeks.
o DDX:
o Scarlet fever – Typically begins on the neck and trunk, then later involves
the extremities. Patients also display signs and symptoms of streptococcal
pharyngitis.
o Erysipelas of the face – An acute beta-hemolytic group A streptococcal
infection of the skin involving the superficial dermal lymphatics. Skin
lesions have a distinctive raised, sharply demarcated advancing edge.
o Cellulites– Almost always unilateral.
o Contact dermatitis – Usually is pruritic and asymmetric
o Kawasaki's disease – Fever, foot and hand edema, conjunctival injection,
lymphadenopathy and genital area erythema
o Rubella – Starts on the face and progresses caudad, covering the entire
body in one day and resolving by the third day. Red macules or petechiae
may be seen on the soft palate and uvula (Forchheimer's sign).
o Roseola infantum – Three days of high fever followed by the appearance of
a morbilliform erythema upon defervescence consisting of rose-colored
macules on the neck, trunk, and buttocks. Mucous membranes are spared.
o Rubeola(measles) – Is marked by the appearance of morbilliform lesions on
the scalp and behind the ears that spreads to involve the trunk and
extremities over 2–3 days. Koplik spots are pathognomonic and appear
during the prodromal phase.

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o Drug eruption.

o Rx:
o Reassure the parents that the eruption can persist and be exacerbated by
warmth and sunlight over a period of weeks to months.
o Patients are infectious from 7 days before the onset of the rash and not
infectious once the exanthem appears.
o Pregnant women up to 21 weeks pregnant, immunocompromised patients, and
patients with hemoglobinopathies are at elevated risk for complications.
Those with elevated risk who have shared a room for greater than 15 minutes
or had face-to-face contact with a laboratory-confirmed case should be
evaluated by their physician, and laboratory evaluation (serologies or viral
titers) should be considered to rule out infection.
o No therapy is necessary, as the condition is self-limited.

Hand-Foot-and-Mouth Disease(HFMD)
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

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o Acute, self-limited viral illness caused most commonly by Coxsackie virus A16
but can be complicated by encephalitis, interstitial pneumonia, myocarditis,
meningoencephalitis, and spontaneous abortion.
o It predominantly affects children, but adults can also develop the disease.
o Dx:
o The incubation period is short, ranging from 3–6 days.
o The illness begins with a mild fever, sore throat and mouth, cough,
headache, malaise, diarrhea, and occasionally arthralgias.
o One or two days after the onset of fever, small oral vesicles develop.
o Later, vesicles appear on the hands, feet, and, occasionally, the
buttocks.
o The disease is highly contagious and often spreads via aerosolized
droplets, nasal or oral secretions, or fecal material.
o Epidemic outbreaks usually occur from June to October.
o Ex:
o Small erythematous macules appear on the oropharynx, later developing
into 1–3 mm vesicles, which ulcerate easily. Shallow ulcerations may
involve the palate, tongue, gingiva, or buccal mucosa, and they are
often painful. On average, approximately 5–10 ulcers may be present.
o Lesions on the extremities begin as erythematous macules and then
develop a central, yellow-gray, oval or football-shaped vesicle on an
erythematous base. Lesions are most prevalent on the palms and soles,
but they can also be seen on the lateral and dorsal surfaces of fingers

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and toes as well as on the buttocks. Another helpful finding is that

lesions tend to be oriented parallel to skin lines.
o Patients may have cervical or submandibular lymphadenopathy.
o DDx:
o varicella, Erythema multiforme minor.
o For oral lesions, consider: Herpes stomatitis, Aphthous ulcers ,
Streptococcal infection, Candidal infection .
o For lesions on the hands, consider: Disseminated herpes simplex virus /
herpes zoster, Meningococcemia – Purpura and pustules, Subacute
bacterial endocarditis – Purpura
o Rx:
o This is a self-limited viral infection that needs to be treated only
symptomatically.
o Oral pain may interfere with alimentation, and topical oral anesthetics
(combination mouth rinses with diphenhydramine elixir, viscous
lidocaine, and over-the-counter liquid antacids [all mixed 1:1:1]) are
often needed.
o Encourage adequate hydration.

Erythema Toxicum Neonatorum

(A summary of an Article Written by: Craig N. Burkhart MD, Dean Morrell MD, Lowell A. Goldsmith MD,
MPH, Nancy Esterly MD)

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o Skin eruption of the newborn of uncertain cause.

o The rash develops in most infants between the second and fourth day of life
and resolves within hours to days.
o Dx: The characteristic lesion is a 1–2 mm pale-to-yellow papule or pustule
within a large (over 1 cm) inflammatory wheal. Early on, however, the rash
may only consist of blotchy, irregular erythematous macules. Any skin surface
may be involved, usually sparing the palms and soles.
o Rx: The condition is self-limiting. Reassure the parent that this is a transient
and benign common rash.

Stevens-Johnson Syndrome(previously named erythema multiforme

major)
(A summary of an Article Written by: Michael D. Tharp MD, Neil Shear MD)

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o Acute, severe hypersensitivity reaction usually triggered by drugs or infection

(sulfonamides, gold, phenytoin and other anticonvulsants, allopurinol,
penicillins, and non-steroidal anti-inflammatory drugs and mycoplasma
pneumonia. Herpes simplex virus (HSV) infection, influenza, orf, Coxsackie,
ECHO, and Epstein-Barr virus.
o Dx:
o Large, erythematous areas with bullae formation, purpura and
epidermal necrosis, widespread with the predominance of lesions on the
trunk with less involvement of the acral surface. Skin surrounding the
bullae may be red and tender, and the blisters may be hemorrhagic.
o Mouth is affected in virtually all cases. The lips can appear blackened
and crusted and are often held slightly open. Buccal and labial bullae,
erosions, and hemorrhagic crusting may be painful, making eating,
talking, and swallowing difficult and leading to dehydration. Severe oral
pain, hypersalivation, and trismus may be observed.
o Cervical lymphadenopathy correlates with the degree of oral
involvement.
o Conjunctivitis is the most common eye finding.
o Blisters and erosions characterize genital involvement.
o Swelling of the hands, feet, and lips may be seen. Urethral or vaginal
bleeding may occur.
o A positive Nikolsky's sign (pressure extending the blister in apparently
normal skin) may be present.
o DDx:

o Toxic epidermal necrolysis (TEN)

o Erythema multiforme (target lesions: 3 concentric colors that are round
and well demarcated that occur on the extremities more often than the
trunk. Precipitating factors are usually infectious (HSV, mycoplasma,
etc) and not medications. Lesions may be papular. Nikolsky sign
negative.)

o Staphylococcal scalded skin syndrome (Usually occurs in newborns,

infants, and young children; mucous membranes and palms/soles are
spared.), Bullous pemphigoid, Pemphigus vulgaris.
o Rx:

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o Hospitalization, often in the ICU or a burn unit depending on severity of

bullae and erosions. The primary goals are to provide fluid/nutritional
support, monitor for infection and pain control. Systemic steroids offer
no clinical benefit and may increase the rate of complications.
o Withdraw the triggering medication if it is known or suspected.
o If HSV is suspected as the trigger, treat with acyclovir, famciclovir, or
valacyclovir.

Aphthous Ulcer (Aphthous stomatitis)

(A summary of an Article Written by: Carl Allen DDS, MSD, Sook-Bin Woo MS, DMD, MMSc)

o Chronic, painful, non-infectious, ulcerative condition of the mouth of

unknown etiology.
o Predisposing medical conditions include hematinic deficiencies (iron, vitamin
B12, folate), Behçet's disease, inflammatory bowel disease, food and
medication hypersensitivities, gluten-sensitive enteropathy, neutropenia
(cyclic or otherwise), IgA deficiency, HIV disease, Sweet's syndrome and
reactive arthritis (Reiter disease). Stress and trauma can exacerbate the
condition.
o Systemic diseases with aphthous-like ulcerations: Behçet's disease,
Inflammatory bowel disease (ulcerative colitis, Crohn's disease, celiac
disease), Systemic lupus erythematosus, Hematinic deficiencies – iron, zinc,
folate, vitamins B1, B2, B6, B12.
o Rx:

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o Repletion of the deficient hematinic element will usually significantly

reduce the severity and incidence of ulcers but not completely
eliminate them.
o Fluocinonide 0.05% gel, apply 3 times daily.
o For severe cases: 40–60 mg prednisone daily for 7–14 days with a rapid
taper then maintaining on topical steroid therapy as above
o For pain relief: Topical benzocaine, 2% viscous lidocaine

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Acanthosis nigricans

Acanthosis nigricans involving the back and arms

of an obese black woman. From the collection of
Miguel Gutierrez, MD

Acanthosis nigricans involving the axilla of an

obese white woman From the collection of Melvin
Chiu, MD

o Dx:

o Fasting blood glucose ?DM ?Cushing

o Abdominal CT? Malignancy? gastric adenocarcinoma
o Rx:
o treatment of underlying disorders: such as obesity, hyperinsulinemia or
malignancy.
o unresolved despite treatment of underlying cause, or hereditary or
idiopathic
o topical therapy:
 ammonium lactate topical : (12% cream or lotion), apply sparingly
to the affected area(s) twice daily
 tretinoin topical : adults, (0.01 to 0.1% cream or gel), apply
sparingly to the affected area(s) once daily at bedtime
 calcipotriol topical : adults, (0.005% cream), apply sparingly to the
affected area(s) twice daily
o oral therapy: if no response to topical
 isotretinoin : oral, adults, 0.5 to 1 mg/kg/day given in 2 divided
doses
 metformin : oral, adults, 500-1000 mg twice daily
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Melasma
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Melasma is a disorder of hyperpigmentation affecting sun-exposed areas,

especially the face.
o The condition is much more common in women and is marked by brown
patches that worsen in response to estrogen, such as with pregnancy (termed
"chloasma") or the use of birth control pills.
o Rx:
o Sun avoidance and protection.
o If the patient is on oral contraceptive pills (OCPs) and needs to remain
on the OCPs, improvement may be difficult.
o Reassure pregnant patients with melasma (chloasma) that the
pigmentation will usually fade postpartum.
o A combination formula of 4% hydroquinone, fluocinolone acetonide
0.01%, and 0.05% tretinoin in a cream formulation (Tri-Luma®) has been
used with good results.

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Vitiligo
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Depigmented macules or patches. The lesions are usually chalk-white in color

and are surrounded by normal skin, creating well-demarcated margins
"symmetric involvement of the face, upper chest, hands, ankles, axillae,
groin, and around orifices (eyes, nose, mouth, urethra, and anus)".
o Dx:
o Use a Wood's lamp to demonstrate depigmentation as opposed to
hypopigmentation, which will not be as pronounced under illumination.
Under Wood's lamp, vitiligo lesions give a yellow-green or blue
fluorescence.
o Diagnosis can usually be made clinically, particularly when areas
elsewhere on the body are affected. Skin biopsy specimens will reveal
absence of melanocytes.
o Consider the following tests to screen for autoimmune disorders:
o Anti-nuclear antibodies
o CBC with red blood cell indices
o Thyroid-stimulating hormone level
o Fasting blood glucose
o DDx:

Tinea versicolor – KOH positive.

Pityriasis alba – Typically affects the cheeks of atopic individuals; presents with
hypopigmented, not depigmented, macules with ill-defined borders.

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Discoid lupus erythematosus

o Presents with atrophy, telangiectasia, and follicular plugging, which are
absent in vitiligo.

Sarcoidosis – Look for indurated papules and plaques that are hypopigmented,
not depigmented; visual changes and shortness of breath on review of systems.
Biopsy if needed.

Leprosy
 Lesions are usually hypopigmented, not depigmented. Some can have an
erythematous border. Lesions are anesthetic. Patient must have recently lived
in an endemic area.

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o Rx:
o Sun avoidance and use of sunscreens are recommended so as not to
enhance the contrast between pigmented and nonpigmented areas.
o Spontaneous repigmentation occurs in a few patients but is usually
incomplete.
o The goals of treatment include halting progression of disease and
inducing repigmentation. There are many treatment options:
o Steroid Therapy
 Systemic steroids have been anecdotally reported to be efficacious
in rapidly progressive vitiligo. A relatively short course may be
useful in the setting of rapidly progressive vitiligo.
o Phototherapy
o Topical Calcipotriene
o Immunomodulators
 Tacrolimus ointment 0.03% or 0.1% – Apply to the affected area
twice daily; can continue for 1 week after lesions repigment.
o Depigmentation Therapy
o Surgical Therapy: Superficial autologous skin grafts.

Pityriasis Alba
(A summary of an Article Written by: Sarah Stein MD, Karen Wiss MD, Sheila Galbraith MD, Craig N.
Burkhart MD, Dean Morrell MD, Lynn Garfunkel MD, Nancy Esterly MD)

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o Hypopigmented patches with subtle scaling and a defined but irregular

border, typically involving the cheeks.
o Lesions may also appear on the forehead, neck, and upper body and tend to
be symmetrical.
o There may be several or multiple lesions.
o DDx:
o Tinea versicolor: especially if hypopigmentation involves the face.
o Vitiligo: the patches are completely depigmented and very well
demarcated.
o Tinea corporis usually has raised borders.
o Topical medication such as retinoic acid, benzoyl peroxide, and potent
topical steroids.
o Psoriasis usually has a thicker scale and more well-defined border than
pityriasis alba.
o Atopic dermatitis – Pityriasis alba may be a manifestation of
postinflammatory hypopigmentation.
o Tuberous sclerosis usually includes hypopigmented patches on the
trunk and presents at birth with associated seizure, mental retardation,
and other skin lesions; shagreen patches and angiofibromas.
 k
o Leprosy can cause hypopigmented patches.
o Dx: This is a clinical diagnosis. However, a negative KOH prep will rule out
tinea versicolor.
o Rx:
o Emollients and moisturizing skin care routines are essential.
o Recommend nonsoap cleansers.
o Have the patient apply emollients, such as petroleum jelly.
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o Topical 1% hydrocortisone (or other low-potency glucocorticosteroid

cream or ointment) may be used sparingly for 3–7 days to abate any
ongoing inflammation.

Acne Rosacea

Acne rosacea: Courtesy of Dr.

Richard Allen Johnson (MD,
CM. Harvard Medical School).
Used with permission

Rhinophyma. Courtesy of Dr.

Richard Allen Johnson (MD, Rosacea fulminans. Courtesy
CM. Harvard Medical School). of Dr. Richard Allen Johnson
Used with permission (MD, CM. Harvard Medical
School). Used with permission

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o Most common manifestations:

o flushing, dilated prominent telangiectases (primarily on the face),
persistent facial erythema, inflammatory papules, and pustules on the
peri-orificial face.
o Prominence of sebaceous glands on the nose may result in fibrosis and
rhinophyma.
o It primarily affects the convexities of the central face, including the
cheeks, chin, nose, and central forehead, but it may extend to other
parts of the body (usually the upper trunk).
o Rx
o Avoidance of triggers is key to the management of the disease such as
spicy foods, hot drinks, and alcohol.
o Daily application of a sunscreen protective against UV-A and UV-B
radiation should be encouraged.
o Mild disease is initially treated with topical metronidazole or oral
tetracyclines.
o Other antibiotics and anti-inflammatory agents can be used as adjuncts.
 metronidazole topical : (0.75 or 1%) apply to the affected area(s)
once or twice daily
 OR benzoyl peroxide topical : (5-10%) apply to the affected area(s)
once or twice daily.
 OR tretinoin topical : (0.025%) apply to the affected area(s) once
or twice daily for 6-12 months
 OR metronidazole : 200 mg orally twice daily
 OR doxycycline : 100 mg orally once or twice daily

Acne Vulgaris
Typical appearance of Comedonal acne
acne
University of Michigan
University of Michigan Department of
Department of Dermatology
Dermatology

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Nodulocystic acne Scarring acne

University of Michigan University of Michigan

Department of Department of
Dermatology Dermatology

Most common manifestations:

o comedones, papules, pustules, nodules, cysts, and/or scarring, primarily on
the face and trunk. range from mild to severe with systemic symptoms.
o Acne is most common in adolescents, but may occur at any age. In addition
to the physical lesions, acne can have profound psychological and social
impact on patients.
o Rx
o Mild-to-moderate acne:
 Non-inflamatory:
 tretinoin topical : (0.01 to 0.1%) children >12 years of age
and adults: apply to the affected area(s) once daily before
bedtime or on alternate days
 Inflammatory acne:
 Combination therapy is the mainstay of treatment.
 Topical retinoids (tretinoin, a dapalene, and tazarotene)
are prescribed in combination with benzoyl peroxide and/or
topical antibiotics (clindamycin, erythromycin, or dapsone).
o Moderate-to-severe acne:
 Best treated by a combination of an oral antibiotic and a topical
retinoid.
 These drugs should not be used alone, due to potential for
developing antibiotic resistance.
 If oral antibiotics are used for more than 2 months without
significant improvement, then the addition of benzoyl peroxide to

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the treatment regimen should be considered to reduce the chance

of resistance and to increase efficacy of the antibacterial
treatment.
 Oral antibiotics are typically administered for at least 6 to 8
weeks and up to several months, although some patients require
indefinite antibiotic therapy.
 If 2 antibiotics from different classes are ineffective, a culture
could be performed to help guide antibiotic selection. It is
generally agreed that topical and oral antibiotics should not be
used as monotherapy.
 Tetracycline : adolescents and adults: 250-500 mg orally
twice daily for 2-3 months, followed by 250-500 mg once
daily for 1-2 months
 Minocycline : adolescents and adults: 50-100 mg orally
(regular release) twice daily for 2-3 months, followed by 50-
100 mg once daily for 1- 2 months
 Doxycycline : 50-100 mg orally twice daily for 2-3 months, followed by
50-100 mg once daily for 1-2 months
o Severe nodulocystic acne or resistant to standard treatment:
 Course of oral isotretinoin for 5 to 6 months is the treatment of
choice.
 FBC, lipid panel, and LFTs are monitored regularly.
 Before treatment with oral isotretinoin, patients require
counselling about the potential adverse effects i.e. Severe
headaches, decreased night vision, or signs of adverse psychiatric
events are signs for prompt discontinuation.
 Isotretinoin is teratogenic; therefore, women undergo
pregnancy tests before starting isotretinoin, and monthly
while taking the drug.
 isotretinoin : children >12 years of age and adults: 0.5 to 1 mg/kg/day orally
for a total of 5-6 months
o Acne in females with hormonal involvement:
 ovarian or adrenal hyperandrogenism and in patients with
polycystic ovary syndrome.
 Treatment options include:

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 Combined oral contraceptives containing cyproterone plus

ethinyloestradiol, or anti-androgenic drugs including
spironolactone.
 May require specialist endocrinologist involvement.

Infantile Acne

Varicella-Zoster
primary varicella; note lesions
are in different stages Images provided by the CDC
and the Public Health Image
Library

African patient with varicella

Varicella lesions in different

stages of healing

Typical vesicular rash of

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Varicella lesions in young boy

o Varicella (chickenpox), one of the childhood exanthemas, is caused by the

human alpha herpes virus.
o Varicella zoster: Varicella-zoster virus (VZV) is an exclusively human
virus.
o Incubation period: about 14 days (range 9 to 21 days).
o Characterised by fever, malaise, and a generalised pruritic, vesicular rash.
o The disease normally presents in childhood and is usually self-limiting.
o Adverse outcomes are more common in adults, pregnant women, and
the immunocompromised.
o Rx
o Symptomatic treatment may be all that is required by children with low
risk of developing severe disease.
o Hydration is important, particularly in toddlers and children with fever.
o Aspirin is contraindicated due to its association with Reye's syndrome.
o Antihistamine treatment for varicella in children has been associated
with ataxia, urinary retention, and other adverse effects.
 paracetamol : children <12 years of age: 15 mg/kg orally/rectally
every 4-6 hours PRN
 diphenhydramine : children 2-5 years of age: 6.25 mg orally every
4-6 hours PRN
 calamine lotion : apply to the affected area(s) PRN
o Moderate risk of severe disease Acute: patients 13 years of age and over;
those with concurrent chronic skin disease (e.g., atopic dermatitis); those
with concurrent underlying pulmonary disease; those receiving salicylate
therapy; those receiving short course or intermittent oral corticosteroids or
inhaled corticosteroids.
o Oral antiviral therapy within the first 72 hours improves the time to
healing of cutaneous lesions and decreases duration of fever in
adolescents and adults.
 Aciclovir : children >2 years of age: 20 mg/kg orally four times
daily for 5 days; children >40 kg body weight and adults: 800 mg
orally five times daily for 5 days.
o Patient Instructions:

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o It is preferable to keep the skin cool. Wearing light clothing can do this
as well as avoiding hot baths or showers.
o Secondary infection of the sores can be avoided by keeping the open
skin sores clean and avoiding scratching.
o For younger children, who have difficulty controlling their urge to
scratch, it is useful to cut their fingernails short. Another option is to
wear gloves or mitts.
o Complications:
o Secondary bacterial infection, varicella pneumonitis or pneumonia,
varicella encephalitis, varicella-associated cerebellar ataxia, varicella-
associated meningitis, varicella-associated intracranial vasculitis and
herpes zoster.

Herpes zoster infection

Severe herpes zoster in an Severe herpes zoster in an

immunocompromised patient immunocompromised patient
Severe herpes zoster in an
involving dermatomes T1 and T2 showing multiple groupled
immunocompromised patient
vesicles, a few pustules, and
involving dermatomes T1 and T2 BMJ Case Reports 2009 Copyright extensive blackish adherent
© 2009 by the BMJ Publishing crusts with underlying erosions
Group Ltd. noted

o Caused by reactivation of a primary varicella-zoster virus (VZV) infection

because of a decline in the virus-specific cell-mediated immunity. Usually

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presents with pain described as burning or stabbing, followed by a vesicular

rash in the affected dermatome.
o The location of symptoms depends on the location of the affected nerve.
o Diagnosis is primarily based on the typical clinical symptoms, such as
dermatomal pain and eruption of grouped vesicles in the same dermatome.
Confirmation can be done using polymerase chain reaction (PCR) methods.
o Rx:
o Treatment is primarily to reduce pain using analgesics and viral
replication using antiviral medicine such as aciclovir.
o Treatment is usually with orally administered antiviral medicines such as
aciclovir, famciclovir, and valaciclovir, and is most effective when
started within 72 hours after rash onset.
o Intravenous aciclovir should be used in patients who cannot tolerate oral
medicines.
o Topical antivirals are not recommended.
o Postherpetic pain: The most common complication, suspected if pain
persists >30 days after rash onset or cutaneous healing. The pain usually
presents as a burning sensation or itching.
o Mild-to-moderate pain:
 Should be treated with non-steroidal anti-inflammatory drugs or
paracetamol, alone or in combination with a weak opioid
analgesic. Topical capsaicin has also been shown to provide pain
relief.
o Moderate-to-severe pain:
 Should be treated with a strong opioid analgesic.
 If the patient is not responding should be given either a tricyclic
antidepressant such as amitriptyline, or an anticonvulsant such as
gabapentin or pregabalin.
o Eye involvement:
o Treatment includes the use of antiviral drugs such as aciclovir,
famciclovir, or valaciclovir for 7 to 10 days, preferably started within 72
hours of rash onset.
o Intravenous aciclovir is given as needed for retinitis.
o Other treatment includes pain medicines, antibiotic ophthalmic
ointment to protect the ocular surface, and topical corticosteroids.

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o Referral to an ophthalmologist is required for all patients who have eye

manifestations.

Erythema nodosum
( A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

Table Source: Brodell RT, Mehrabi D. Underlying causes of erythema nodosum. Postgrad

Med 2000; 108: 147-9.

o Oral contraceptives are the most

common drug association.
o The eruption typically persists for 3–6
weeks and spontaneously regresses without
scarring or atrophy.
o Upper respiratory tract infection or
flu-like symptoms may precede or
accompany the development of the
eruption.
o Arthralgias are reported by a majority
of patients regardless of the etiology of
EN.
Examination:

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o The lesions are most commonly seen in a pretibial (anterior shin) distribution,
but they can also occur on the legs, thighs, buttocks, extensor arms, and
occasionally on the face and neck, predominantly in female patients.
o Erythematous, tender nodules and plaques, usually 2–5 cm in diameter.
o They are initially bright red and slightly elevated.
o After a week or two, the lesions become flatter and evolve into more
purple/livid color or red-brown, somewhat indurated plaques that might
appear to be bruised (contusiforme).
o Lesions never ulcerate (unlike nodular vasculitis).

Dx:
o Investigations to identify the underlying etiology may include ASO titers,
throat culture, tuberculin skin testing, and/or histoplasmin complement
fixation.
o It is recommended that all patients have a CBC and chest X-ray to rule out
associated pulmonary tuberculosis, coccidioidomycosis, or sarcoidosis.
o The need for further investigation will depend on the patient population
(children versus adults) and history.

Rx:

o Spontaneous resolution occurs in most cases.

o Bed rest and limb elevation are important alleviating measures.
o Identify and treat any underlying causes of the condition.
o Therapy NSAIDs (ibuprofen 400–800 mg p.o. every 6–8 hours, naproxen 275 mg
p.o. every 6–8 hours, or indomethacin ER 25–50 mg p.o. 3 times daily) may be
helpful.
o Applying topical corticosteroids with plastic cling wrap occlusion at night may
help to reduce inflammation.

Leukonychia (white nails)

(Authors: Bertrand Richert MD, Robert Baran MD)

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DDx:

o Inherited true leukonychia

o Acquired true leukonychia (total or partial) due to: Trauma (single or
repeated), Cryotherapy, Metabolic and endocrine disturbances, Malignancy,
Peripheral neuropathy, Renal disease,Psoriasis, Infectious diseases, Poisons/drugs
o Apparent leukonychia due to:Terry cirrhotic nail, Lindsay half-and-half nail
of renal failure, Muehrcke paired narrow white bands
o Pseudoleukonychia due to:
Onychomycosis, Keratin granulations (nail polish)

Dx:

o Careful history and physical exam.

o If onychomycosis is suspected, consider a KOH prep of nail scrapings or fungal
culture.
o If hereditary history, examine other affected family members.

Rx:

o Patients should be advised that manicures, pedicures, and ill-fitting shoes

may be contributing factors in traumatic causes of leukonychia.
o No treatment is necessary.
o Patients should be instructed to minimize trauma to the nails.

Orf
(A summary of an Article Written by: Art Papier MD, William Van Stoecker MD)

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o Caused by a parapox virus that infects sheep and goats.

o Transmitted to humans by direct contact, typically occurring in sheepherders,
farmers, butchers, and veterinarians.
o Mild fever (usually 3–4 days) and malaise are associated with infection.
o Spontaneous recovery usually occurs in 3–6 weeks.

Clinical picture:

o After a 5 day incubation period, a red to bluish papule develops at the

inoculation site.
o Quickly evolving to a flat-topped bulla or pustule.
o Multiple lesions can occur. Lesions can evolve to 2–4 cm in size.
o The lesion is often tender.
o A central umbilication with crusting can occur.

DDx:

o Milker's nodules (clinically indistinguishable from orf but is acquired from

contact with infected udders of cows), Cellulitis or erysipelas, Herpetic
whitlow, Molluscum contagiosum, Zoster, Paronychia, Felon, Insect bite,
Fixed drug eruption, Tinea, Urticaria, Angioedema, Cutaneous anthrax.

Dx:

o The clinical picture in association with a history of sheep or goat contact is

virtually diagnostic.
o Biopsy for electron microscopy is confirmatory.

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Rx:

o Treat secondary infection if it occurs.

Erythema Marginatum
(A summary of an Article Written by: Sarah Stein MD, Karen Wiss MD, Sheila Galbraith MD, Craig N.
Burkhart MD, Dean Morrell MD, Lynn Garfunkel MD, Nancy Esterly MD)

o Lesions are thin red lines that

spread centrifugally.
o The distinctive annular
erythemas present on the trunk and
proximal extremities but do not
occur on the face.
o Warming of the skin brings out
the rash.
o Erythema marginatum is often
associated with active carditis of
rheumatic fever 10%.

DDx:

o Rheumatic fever, Urticaria, Tinea corporis, Juvenile rheumatoid arthritis,

Erythema multiforme Mononucleosis, Erythema migrans (marker of Lyme
disease).

Dx:

o Skin biopsy: perivascular

neutrophilic infiltrate, which is
suggestive but not diagnostic.

Rx:

o self-limited, with the lesions

usually fading in 2–3 days.

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Erythrasma
( A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

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o Erythrasma is a common, chronic superficial bacterial infection of the skin

caused by Corynebacterium minutissimum.
Risk Factors:

o Regions of high humidity, especially in the tropics. Obesity, DM,

immunosuppression, a history of atopy, and hyperhydrosis are risk factors.
Lesions:

o Brown, almost flat, minimally scaly plaques with fine scale on the webs of the
toes, axillae, inframammary (beneath the breasts) folds, around the anus, and
in the groin. In the web spaces of the feet, macerated, white plaques can
have a surrounding yellowish color.
DDX:

o Psoriasis, Seborrheic dermatitis, Tinea corporis, Acanthosis nigricans, Contact

dermatitis, Tinea versicolor, Tinea pedis (differential of web space
erythrasma)
Dx:

o If a Wood's lamp (UVA lamp) is available, the diagnosis is confirmed by coral

red (pink-red) fluorescence due to the presence of coproporphyrin III
produced by the organism.
o KOH preparations of skin scrapings will often show chains of bacilli. Stain with
methylene blue to facilitate identification.

Rx:

o Washing with an antibacterial soap may both treat active infections and
prevent recurrences.
o Oral therapy (for recalcitrant cases) is with erythromycin (for 5 days).
o Topical imidazole creams – miconazole, clotrimazole, or econazole applied to
affected areas twice daily for 2 weeks.
o Topical antibiotics – topical erythromycin solution 2%, topical clindamycin
solution 2%, or topical fusidic acid cream 2% applied twice daily for 2 weeks.
o Benzoic acid 6%, salicylic acid 3% (Whitfield's ointment) – apply twice daily for
4 weeks. May be irritating.
o Severe cases: oral erythromycin, 250 mg 4 times daily for 2 weeks.
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Necrobiosis Lipoidica
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Necrobiosis lipoidica (NL) is a disorder of collagen degeneration with

granuloma formation and fat deposition.
o ?diabetic microangiopathy due to NL's strong association with diabetes
mellitus, more commonly type I diabetes.
o Red-brown papules or nodules that enlarge over time.
o Over time, these lesions coalesce into plaques and become yellow-brown,
waxy, and atrophic centrally. Telangiectasias are characteristic.
o Ulcers can occur at the sites of trauma and may be painful.
o Most commonly affects the pretibial area, but other common locations are the
ankles, calves, thighs, and feet.
o Lesions are usually bilateral. They have also been reported on the face, scalp,
trunk, and arms.

o DDX:
o Cellulitis or erysipelas, Abscess, Pretibial myxedema, Contact
dermatitis, Sarcoidosis, Diabetic dermopathy, Rheumatoid nodules,
Pyoderma gangrenosum, Vasculitis, erythema nodosum, Leprosy, Deep
fungal infections.

o Rx:

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o Intralesional triamcinolone and 0.1% betamethasone under occlusion have

demonstrated some success, as have the antiplatelet agents aspirin and
dipyridamole.
o Systemic corticosteroids tapered over 5 weeks were effective in a small case
series, though hyperglycemia was a reported side effect.
o Pulsed dye laser has been used to successfully treat prominent telangiectases.
o In diabetics, ulcer prevention with leg rest, support stockings, and glucose
control is important.

Pityriasis Rubra Pilaris

(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Classic cutaneous lesions include follicular papules on an erythematous base

coalescing to form large orange-red plaques but with characteristic islands of
sparing.
o The etiology of PRP has not been clearly defined.
o The onset of disease has been associated with myositis, myasthenia
gravis, hypothyroidism, HIV, infection, and malignancy
o DDx:
o Psoriasis: Several features facilitate the differentiation of PRP from
psoriasis, and they include the following:
 Islands of normal skin within larger plaques are characteristically
seen in PRP
 Orange-red, waxy-like keratoderma of the palms and soles are also
features seen in PRP

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 Nail oil-drop changes and nail pitting are characteristic of psoriasis

 A family history of psoriasis is often seen in psoriatic patients
 Biopsy
o Seborrheic dermatitis – Much more responsive to standard therapies.
o Drug eruption – Often present with urticarial.
o Atopic dermatitis – Patients are often aware of their atopic history
o Dx: Skin biopsy. Depending on the clinical situation, a search for HIV infection
or underlying malignancy may be indicated.
o Complications:
o Complications of erythroderma include volume shifts (ie, lower
extremity edema) secondary to loss of fluids and proteins, tachycardia-
induced high output cardiac failure, and thermoregulatory dysregulation
(hypo- and hyperthermia).
o Rx:
o Prednisone 40–60 mg/day is effective in controlling the disease and can
be tapered while instituting one of the following:
o Isotretinoin (20, 40 mg) 0.5–1.5 mg/kg daily with food.
o Methotrexate (10–30 mg weekly).
o Cyclosporin, Infliximab for refractory cases.
o Phototherapy can exacerbate PRP or induce remission.

Pyogenic Granuloma
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

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o Pyogenic granulomas are rapidly growing, benign, vascular growths of

undetermined etiology.
o Pyogenic granulomas usually present as a solitary red papule or nodule that
grows rapidly and ulcerates or bleeds easily.
o Gingival lesions may arise during pregnancy (the so-called pregnancy tumor,
or granuloma gravidarum).
o DDx:
o Melanoma, Cherry hemangioma, Glomus tumor, Metastatic carcinoma,
Basal cell carcinoma, Squamous cell carcinoma, Granulation tissue.
o Dx: Skin biopsy is confirmatory.
o Rx:
o Attempt to eliminate any potential inciting factor(s), such as trauma
and offending medications, if possible.
o Recurrences are common regardless of the choice of treatment.
o Many lesions arising during pregnancy resolve after parturition.
o Shave excision with curettage and either electrodesiccation or
application of silver nitrate to the base is a common treatment
modality. Silver nitrate by itself may be used to treat smaller lesions.
o Removal indicated in cases of bleeding, emotional distress, discomfort,
or when the diagnosis is in doubt.
o Recurrences are common.

Molluscum Contagiosum
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

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o Contagious disease caused by infection with a DNA poxvirus.

o It manifests as smooth, firm papules with a central umbilication.
o DDx:
o Herpes simplex lesions can resemble molluscum with a central
umbilication, but lesions are fluid-filled rather than solid.
o Warts tend to have a verrucous or jagged surface, whereas molluscum
contagiosum lesions are smooth.
o Milia tend to be whiter in color and more concentrated on the face.
o Pyogenic granuloma is obviously vascular with frequent ulceration.
o Lichen planus lesions are purple, pruritic planar papules that can also
spread in a linear pattern.
o Basal cell carcinoma tends to be solitary.
o Keratoacanthomas have a central keratin core and grow rapidly.
o Rx:
o The condition is self-limited in immunocompetent patients.
o In cases of sexually transmitted molluscum contagiosum, consider the
possibility of other concomitant STDs.
o Instruct patients to avoid communal bathing, sharing of bath towels,
and shaving if lesions are present on the face of men or legs of women.
o Cryotherapy with liquid nitrogen.

Tinea Versicolor (pityriasis versicolor)

(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

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o Infection with yeast from the Malassezia genus – M. globosa, M. sympodialis,

M. furfur, and possibly others.
o Risk factors other than high heat and humidity include oily skin, excessive
sweating, pregnancy, poor nutrition, corticosteroid use, and some
immunodeficiency states.
o Clinically:
o Hyperpigmented or hypopigmented macules and patches or barely
elevated papules/plaques, usually on the chest, back, and upper arms.
o The macules may coalesce to form irregular patches.
o Most cases have a fine, dusty-appearing scale, but, in some cases, the
scale may be so fine that it is imperceptible.
o DDx:
o Seborrheic dermatitis may mimic tinea versicolor, especially if there is
involvement of the face.
o Tinea corporis
o Atopic dermatitis
o Pityriasis rosea
39 Preparatory Course of FM Saudi Board- Common Dermatology Slides
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o Pityriasis alba
o Guttate psoriasis
o Vitiligo
o Dx:
o Examination with a Wood's lamp accentuates the pigmentary findings.
o Rx:
o Inform patients that skin color changes will typically resolve within 1–2
months of treatment (and sometimes much longer).
o Recurrence of tinea versicolor is very common.
o Tinea versicolor is not contagious and is not due to poor hygiene.
 Systemic treatment:
 Ketoconazole 200 mg p.o. daily for 10 days or a single 400
mg dose
 Fluconazole 150–300 mg p.o. once weekly for 2–4 weeks or
300 mg p.o. repeated after 2 weeks
 Itraconazole 200 mg p.o. daily for 5–7 days
 Oral ketoconazole and fluconazole have similar efficacy.
 Topically, for large skin areas:
 Ketoconazole 2% shampoo – apply daily to scalp and body for
5–10 minutes for 1–14 days
 Topically, more limited areas:
 Clotrimazole 1% cream – apply twice daily for 2–6 weeks

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Tinea Capitis
(A summary of an Article Written by: Sarah Stein MD, Karen Wiss MD, Sheila Galbraith MD, Craig N.
Burkhart MD, Dean Morrell MD, Lynn Garfunkel MD, Nancy Esterly MD)

o fungal infection of the scalp caused by different species of dermatophytes,

the most common causative agent worldwide is Microsporum canis.
o Clinically: It presents as numerous scaly macules and patches of broken hairs
and alopecia on the scalp. More severe forms are associated with
inflammatory papules, pustules, and plaques as well as systemic symptoms
(ie, fever and malaise).
o DDx (all DDx of alopecia): Seborrheic dermatitis, Impetigo, Folliculitis,
Discoid lupus erythematosus, Lichen planus, Psoriasis, Alopecia areata,
Secondary syphilis, Trichotillomania, Kerion
o Dx: Fungal culture allows for the determination of the causative organism.
o Rx:
o Must be treated with systemic antifungal agents because the organisms
invade the hair follicle and cannot be reached by topical therapies.
 Pruritus is the first symptom to improve with therapy.
o Griseofulvin is the treatment of choice.
 dosed at 20–25 mg/kg/day for a minimum 8-week course.
o Other options include terbinafine, itraconazole, and fluconazole.
o Topical antifungal shampoos may be used in conjunction with systemic
therapy to decrease scale and contagiousness.
o Secondary bacterial infection should be treated with oral antibiotics.

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Kerion
(A summary of an Article Written by: Sarah Stein MD, Karen Wiss MD, Sheila Galbraith MD, Craig N.
Burkhart MD, Dean Morrell MD, Lynn Garfunkel MD, Nancy Esterly MD)

o Acute inflammatory reaction that accompanies severe cases of tinea capitis.

o It is almost exclusively seen in children, but on rare occasions it may be
seen in adolescents and young adults.
o It is often caused by trichophytin fungal organisms.
o Fever, pain, and lymphadenopathy may be associated.
o Clinically:
o Boggy, thick plaques of the scalp, often studded with pustules.
o These lesions can eventually rupture and drain pus.
o Scarring and permanent alopecia (hair loss) can result.
o Rx:
o Patient and family should be advised that scarring and permanent hair
loss might occur.
o Kerions must be treated with oral antifungal agents.
 e.g. Griseofulvin microsize 20–25 mg/kg/day (maximum 1 g/day)
for 6–12 weeks, Itraconazole 3–6 mg/kg/day, Fluconazole 3–6
mg/kg/day
o Selenium sulfide or ketoconazole shampoo can decrease fungal spores
and decrease infectivity
o For severe, painful inflammatory lesions, prednisone may be considered,
starting at 0.5 mg/kg/day and tapering off for 7–10 days

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Tinea Corporis (Ringworm of body)

(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Infection of the glabrous skin with dermatophyte species of fungus; namely of

the genera Trichophyton, Microsporum, or Epidermophyto.
o Tinea capitis (scalp), tinea faciei (face), tinea pedis (foot), and tinea cruris
(groin).
o Clinically:
o Annular, red, scaly patches anywhere on the body.
o Plaques often have an active border, meaning that the advancing edge
of the plaque has prominent scale with associated fungal hyphae.
o The central clearing of the elevated lesions leads to the appearance of
the annular shape, thus the description "ringworm".
o Papules, vesicles, and crusting may develop in the active border.
o Dx:
o KOH (potassium hydroxide) and under the microscope, observe for branching
or curving fungal hyphae crossing cell borders.
o A fungal culture will allow species determination, but it will take several
weeks.
o Rx:
o Small, localized lesions can be treated topically.
o Extensive disease will require 3–4 weeks of oral anti-fungal agents.
Topical agents should be applied at least 2 cm outside the border of the
lesions.
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o Limited: Use topical antifungals for 2–6 weeks, based on clinical response:
o Terbinafine 1% cream (Lamisil®) – apply once to twice daily (7.5, 15 gm
tubes)
o Clotrimazole 1% cream (Lotrimin®) – apply twice daily
o Extensive disease or disease unresponsive to topicals:
o Terbinafine – 250 mg daily for 2 weeks
o Itraconazole – 100–200 mg daily for 2–4 weeks or 200 mg twice daily for
1 week
o Fluconazole – 150 mg weekly for 2–4 weeks

Tinea Pedis (athlete's foot)

(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o The most common species of dermatophyte responsible are Trichophyton

rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum.
o Clinically:
o The condition causes dry scale on the feet, maceration between the
toes and, in some cases, leads to destruction of the nail plate
(onychomycosis)
o Web space involvement (the fourth web space is the most
common) usually consists of white and macerated skin and may
represent a mixed infection with bacteria. Fissuring may occur.
o Factors: high levels of humidity, occlusive footwear, and the use of
communal pools or baths. Athletes. may lead to a secondary (gram-negative)
bacterial infection, especially in diabetic patients.
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o Rx:
o Encourage patients to wear protective footwear in communal
bathing/swimming areas and to limit the use of highly occlusive
footwear.
o Dry the feet and interdigital spaces completely before putting on clean
socks.
o Tinea pedis can often be treated with a topical antifungal cream. More
extensive or complicated infections (bullous tinea pedis, tinea pedis
with onychomycosis, infections in immunocompromised patients) may
require systemic treatment.
o Use topical antifungals for 1–6 weeks, based on clinical response:
 e.g. Terbinafine 1% cream – apply twice daily, Clotrimazole 1%
cream – apply twice daily, Ketoconazole 2% cream – apply twice
daily, Miconazole 2% cream – apply twice daily.
o To avoid recurrence, treatment should be continued for at least a week
past the point of clinical clearing.
o Extensive disease or disease unresponsive to topicals:
 Terbinafine – 250 mg daily for 2 weeks
 Itraconazole – 100–200 mg daily for 2–4 weeks or 200 mg twice
daily for 1 week
 Griseofulvin ultra-microsize 330–750 mg daily for 4–8 weeks
 Fluconazole – 150 mg weekly for 2–4 weeks

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Erysipelas
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Caused by beta-hemolytic group A streptococci (Streptococcus pyogenes).

o Clinically:
o it presents as strikingly red, well-demarcated plaques that are very
tender.
o Burning paresthesias may be present.
o Commonly involved areas are the face, extremities, and penis.
o Cutaneous findings are usually preceded by abrupt onset of fever, chills,
nausea, and malaise.
o Lymphadenopathy is almost always present.
o Trauma to the skin is thought to be an important factor.
o Additional predisposing factors for erysipelas include alcoholism, diabetes,
an immunocompromised state, and nephrotic syndrome.
o DDx:
o Cellulitis
o contact dermatitis is usually pruritic.
o Orbital cellulitis
o Erythema nodosum
o Burn
o Deep venous thrombosis
o Polyarteritis nodosa
o Inflammatory carcinoma of the breast

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o Necrotizing fasciitis
o Angioedema
o Rx:
o Hospitalization for intravenous antibiotics is recommended in severe
cases, in the immunocompromised, and in patients at the extremes of
age (infants and the elderly).
o Consider using a penicillinase-resistant antibiotic to cover for
Staphylococcus aureus in cases of erysipelas not responding
appropriately to penicillin.
o Penicillin is first-line therapy:
 Penicillin V 250–500 mg p.o. 4 times daily for 10–14 days; penicillin
G procaine 0.6–1.2 MU IM twice daily for 10 days
 Dicloxacillin 250–500 mg p.o. 4 times daily for 10 days
 Erythromycin (for penicillin-allergic patients) 250–500 mg p.o. 4
times daily for 10 days.

Paronychia
(A summary of an Article Written by: Bertrand Richert MD, Robert Baran MD)

(Acute)

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(Chronic)

o Acute paronychia is defined as inflammation of a nail fold for fewer than 6

weeks.
o Pain, swelling, and redness are the cardinal symptoms, sometimes
accompanied by abscess formation.
o Causes:
o Trauma by foreign bodies, such as splinters; manipulations, such as
manicures or pedicures; fingernail biting; finger-sucking in children; or
"hangnail" removal.
o Occasionally, acute paronychia arises as a painful exacerbation of
chronic paronychia, which is now understood to be a localized form of
chronic irritant/allergic dermatitis.
o Certain drugs – including retinoids (isotretinoin, acitretin),
methotrexate, antiretroviral ..etc.
o Specific bacteria predominate in trauma-related acute paronychia
(Staphylococcus aureus, Streptococcus pyogenes, and anaerobic bacteria
derived from the oral flora.
o Patients with diabetes mellitus may be at increased risk of acute paronychia.
o Chronic paronychia may affect more than one digit, is present for more than
6 weeks after onset of symptoms, and is associated with irritant/allergen
exposure, often of an occupational nature (eg, dishwashing).
o Clinically:
o Periungual erythema, tenderness, and swelling that may be fluctuant or
exude pus.

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o Dx:
o Culture for bacteria, including anaerobic bacterial culture.
o Culture for fungi.
o If lesion is vesicular and painful, consider viral culture.
o Rx:
o If no abscess is present, warm water soaks 4 times daily for 15 minutes
or soaks in aluminum acetate or diluted white vinegar may prove
sufficient.
o A topical antibacterial agent such as mupirocin, bacitracin / neomycin /
polymyxin b sulfate, or gentamicin 2 or 3 times daily may be added in
uncomplicated cases.
 Limited data support the concomitant use of a potent topical
steroid such as betamethasone.
o More extensive or recalcitrant cases may require oral antibiotics. Such
drugs should have antistaphylococcal coverage as well as activity against
anaerobes. e.g. Clindamycin, Doxycycline, Trimethoprim-
sulfamethoxazole
o Incision and drainage is indicated when abscess is present (ie, with
fluctuance or a positive digital pressure test).

Alopecia Areata
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

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o Alopecia areata is a T-lymphocyte mediated autoimmune disease of the hair

follicle resulting in nonscarring hair loss.
o Most cases are limited to 1 or 2 small patches of alopecia, but in severe cases
all the hair on the scalp is lost (alopecia totalis) or all body hair is lost
(alopecia universalis).
o Hair in most patients will spontaneously regrow, though recurrences are
common.
o There is an increased incidence of alopecia areata in patients with Down
syndrome, lichen planus, and other autoimmune diseases such
as vitiligo, lupus erythematosus, rheumatoid arthritis, pernicious
anemia, or thyroid disease.
o Clinically:
o Scalp burning with or without slight erythema (peach colored) can
accompany the lesions.
o Exclamation point hairs with a tapering base and a ragged proximal
portion are diagnostic of the disease.
o A positive pull test from the periphery of a patch of hair loss indicates
that the disease is active and additional hair loss can be expected.
o DDx:

Trichotillomania
from the twisting and pulling of hair, may mimic alopecia areata. Hairs are broken off at varying lengths.

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Telogen effluvium
from nutritional, hormonal, and drug etiologies can lead to large clumps of hair coming out in a similar
fashion to alopecia areata. The loss is diffuse, not localized.

 Pull on a group of about 50 hairs, holding firmly with your

fingers. Normally, just 1–2 hairs should come out from their "roots"
(hair bulb).
 In telogen effluvium, many hairs should come out easily, and their
roots will have an elongated hair bulb.
 The scalp should appear nonerythematous and be entirely
unremarkable.
 Give patients reassurance that hair will spontaneously regrow and
will not progress to baldness.

Tinea capitis
Androgenetic alopecia
male or female pattern

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o Dx:
o This diagnosis can usually be made clinically.
o Scalp biopsy is diagnostic in equivocal cases.
o If the clinical situation warrants, tests for associated conditions may be
fruitful:
 ANA, rheumatoid factor
 Thyroid function tests
 Serum vitamin B12
o Rx:
o Counsel carefully before attempting treatment, which is often
unsuccessful.
o Patients with limited areas of loss in regions of no cosmetic importance
are often best left untreated because spontaneous regrowth often
occurs within a year.
o Treatments may stimulate hair growth, but there is no evince that the
natural course of disease is altered.
 Mild to moderate alopecia areata (less than 25% involvement) can
be treated with intralesional corticosteroids. Repeat at 4–6 week
intervals.
 Topical steroids are other approved therapies..
 For extensive disease, consider PUVA or topical steroids plus
minoxidil (each applied twice daily). The efficacy of each is
debated.
 Systemic corticosteroids may offer short-term help, but they
have no long-term benefit and should be considered
cautiously.

Psoriasis
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Psoriasis is a polygenic disease where genetically susceptible individuals with

certain HLA types (HLA-Cw6, HLA-B13, HLA-B17, HLA-B37, HLA-Bw16) mount
aberrant immune responses after exposure to infection, drug ingestion,
hypocalcemia, psychogenic stress, and/or external injury to the skin.

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o Psoriatic arthritis: Up to 30% of psoriatic patients may have erosive psoriatic

arthritis requiring systemic therapies.
o Pregnancy: Approximately 50% of pregnant females with psoriasis report
improvement of disease burden.
o Clinically:
o Sharply demarcated, erythematous, silver-scaled plaques of the scalp,
elbows, and knees.
o Additional sites of involvement include the hands, feet, and trunk.

o Nails: Fingernails are affected more often than toenails. Nail pitting,
onycholysis ("oil spots"), splinter hemorrhages, subungual hyperkeratosis,
leukonychia.

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o Joints: In psoriatic arthritis, look for distal and proximal interphalangeal

arthritis; "sausage digits" can be monoarticular or asymmetric oligoarthritis.
o Axilla, groin, intergluteal cleft: Locations for inverse psoriasis. Look for shiny
erythematous, sharply demarcated plaques. Fissuring can be noted.

o Rx:
o Topical Treatments:
 High-potency topical corticosteroids (class 1–2)
 Fluocinonide cream, ointment – apply twice daily (15, 30, 60,
120 gm)
 Clobetasol cream, ointment – apply twice daily
 Mid-potency topical corticosteroids (class 3–4)
 Mometasone cream, ointment – apply twice daily (15, 45 gm)
 Fluocinolone cream, ointment – apply twice daily (15, 30, 60
gm)
 Vitamin D Analog: Calcipotriene cream, ointment – Apply
twice daily to affected areas (30, 60, 100 gm tubes) (60 mL
scalp solution). Therapy can be rotated with steroid
treatment.
o Tar-Based Therapy
o Systemic Therapy:
o Methotrexate 10–20 mg p.o. weekly
o Mycophenolate mofetil 1 g p.o. twice daily

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o Cyclosporine 2–3 mg/kg p.o. daily

o Tacrolimus 1–3 mg p.o. daily
o Systemic therapies and TNF-alpha inhibitors are generally prescribed by
dermatologists or rheumatologists for moderate to severe plaque
psoriasis and/or psoriatic arthritis. Be sure to check PPD prior to use.
 Etanercept – Subcutaneous 50 mg twice weekly for 3 months, then
a once weekly maintenance dosage of 50 mg.
 Infliximab – IV 5 mg/kg initial infusion followed by 5 mg/kg at 2
and 6 weeks after the first infusion, then every 6 to 8 weeks.
o Ultraviolet Light: Can be used alone or in combination with acitretin
systemically.
o Referral to dermatology is indicated for management with systemic
medications.

Lichen Planus
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o The classic description is given by the 5 Ps: purple, planar, polygonal,

pruritic, papules most commonly seen on the volar wrists and flexural
surfaces.
o Papules can also be widespread and involve the trunk, inner thighs, shins,
hands, and genitalia. As the lesions become older, their surfaces develop
adherent scales that form fine, grayish-white streaks called Wickham's striae.

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o Mucous membrane involvement may consist of lacy, net-like, white plaques

with a violaceous base on the tongue or buccal mucosa.
o Nail changes such as thickening, splitting, ridges, and grooves can accompany
the skin manifestations.
o DDx:
o Psoriasis, Sarcoidosis, Warts, Pityriasis rosea, Kaposi sarcoma, Tinea
corporis
o DDx for oral lesions:
o Oral candidiasis, Leukoplakia, Pemphigus vulgaris, Seborrheic dermatitis
(genital lesions), Lichen sclerosus (vulvar lesions)
o Dx:
o Skin biopsy will confirm the diagnosis, although it can often be made
clinically.
o Rx:
o Oral LP needs to be followed and managed carefully:
 Patients with persistent, severe oral LP are at higher risk for oral
squamous cell carcinoma (SCC).
 Consultation with a dermatologist is recommended.
o Withdraw any potential offending medication.
o Control of pruritus. Antihistamines.
o First-line therapy consists of topical or intralesional corticosteroids.
 Topical corticosteroids, in cream or ointment formulations, should
be applied twice daily to only the lesions. Initially, use a high-
potency topical steroid (class 2 or 3).
 For severe disease, a superpotent topical steroid can be tried for a
short 2-week course, but be sure to schedule a close follow-up.
 Systemic corticosteroids can be used as a second-line treatment or
in those with severe disease: prednisone 30–60 mg p.o. daily for 2–
6 weeks, followed by a slow taper over several weeks.
 Severe cases have also been treated with narrow-band UVB or
PUVA.

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Guttate Psoriasis
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Acute, generalized eruption of small, discrete rain drop-like (hence the

name, guttate) papules with fine scale that occurs 2–3 weeks after an upper
respiratory infection.
o It most commonly occurs in children and is associated with an elevated anti-
streptolysin O, anti-DNase B, or streptozyme titer.
o Systemic symptoms such as fever, malaise, lymphadenopathy, myalgias, and
arthralgias are usually absent.
o Dx:
o Diagnosis can be made clinically based on history and its characteristic
clinical appearance.
o Bacterial cultures of the throat or perianal area may help to isolate an
organism in certain cases.
o The presence of antibodies to streptolysin O, anti-DNase B, or
streptozyme can confirm previous infection.
o Perform a skin biopsy if the diagnosis is in doubt and a urinalysis if there
is concern for post-streptococcal glomerulonephritis.
o Rx:
o Topical Therapies: Limited skin disease can be treated with topical
(class 2–4) corticosteroids.

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o Ultraviolet Light
A suitable and popular modality for guttate psoriasis.
o Systemic Treatments: For severe or recalcitrant guttate psoriasis
flares, systemic therapy can be considered. e.g. Methotrexate (10–15 mg
p.o. weekly), Cyclosporine (2–3 mg/kg p.o. daily) or Tacrolimus (1–3 mg
p.o. daily).
o Patients with recurrent episodes of streptococcal pharyngitis and
guttate psoriasis may be helped by tonsillectomy.
o Guttate psoriasis may be self-limiting or may respond to treatment of
the underlying infection. There are controlled studies demonstrating NO
benefit of systemic antibiotics in patients with guttate psoriasis and
serologic evidence of a recent streptococcal infection. However, it is
prudent to treat active streptococcal infection with a penicillin,
cephalosporin, or erythromycin for 10 days:
 Amoxicillin 250–500 mg p.o. 3 times daily
 Penicillin VK 250 mg p.o. 3–4 times daily
 Cefuroxime 250–500 mg p.o. twice daily
 Erythromycin ethyl succinate 400–800 mg p.o. 4 times daily

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Pediculosis Corporis (body louse)

(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Associated with poor hygiene, poverty, and homelessness.

o Clinically:
o Multiple erythematous papules that correspond to the insect bites.
o They may be found anywhere on the body but are most concentrated in
areas covered by clothing: groin, axillae, trunk, and buttocks.
o There may be excoriations and/or impetiginization.
o Dx:
o Close examination of the patient's clothing for lice, nits, and feces.
o The finding of a live louse or a viable nit will confirm the diagnosis.
o A Wood's lamp may be helpful, as lice and nits will fluoresce yellow-
green.
o Rx:
o Also examine the patient for pubic and head lice.
o Educate the patient about the importance of proper hygiene.
o Treat clothing and fomites:
o All clothing and bed linens should be washed with hot water and dried
using high heat.

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o Discard or avoid using heavily infested items for 2 weeks (seal in plastic
bags), if feasible. Iron the seams of furniture with a hot iron.
o For heavy infestation or in situations where regular bathing and changing are
not feasible, 5% permethrin cream or lotion head-to-toe for 8–14 hours is
advisable.

Pediculosis Capitis
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Dx: Lice and nits in the scalp hair.

o Rx:
o There is evidence of increasing resistance of lice to treatment with
permethrin.
o Use a fine comb to remove the nits.
o Most herbal and home remedies are unproven in effectiveness and
safety.
o Over-the-Counter Pediculicides:
 Permethrin 1% Apply to dry hair and rinse after 10 minutes. Repeat
in 1–2 weeks.
o Prescription Products:

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 Permethrin 5% Apply to dry hair and rinse after 8–12 hours. Repeat
in 1–2 weeks.
 Lindane: Use of these products is rarely recommended due to
potential systemic toxicity and limited effectiveness.
o Family members and close contacts must be examined and treated at
the same time to prevent re-infestation.

Oral Candidiasis
(A summary of an Article Written by: Carl Allen DDS, MSD, Sook-Bin Woo MS, DMD, MMSc)

o Caused by Candida albicans .

o Oral candidiasis frequently affects immunocompromised individuals such as
those with leukemia or other malignancies, and those with AIDS.
o Patients with diabetes and those on antibiotics are also predisposed to oral
candidiasis.
o Clinically:
o Three main clinical forms exist:
1. Pseudomembranous candidiasis (thrush):
 Curdy white papules and plaques are seen that wipe off with
some difficulty, leaving a raw bleeding surface.
2. Atrophic/erythematous form.
3. Hyperplastic form:
 where white papules and plaques are present that do not
wipe off, are often indistinguishable from leukoplakia.
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o DDx:

Lichen planus– usually reticulated and erythematous rather than plaque-like

Geographic tongue
Aphthous ulcers
Leukoplakia
Squamous cell carcinoma
Hairy tongue

 Rx of Hairy tongue:
 Hydration and better fluid and food intake with crunchy
foods (fresh fruits and vegetables).
 Mechanical debridement with a toothbrush with hard bristles
or a tongue scraper.
 Some keratolytic agents (e.g., 40% urea or salicylates) have
been tried but they are of limited utility.
o Dx of Oral Candiasis:
o Scraping white plaques with a tongue blade, applying to glass slide and
staining with KOH.
o Rx:
o One dose of oral Fluconazole 200 mg may be curative.

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o If using nystatin (see below), make sure that the patient removes the
dentures before using the rinse to make sure that the nystatin contacts
the infected mucosa under the denture.
 Nystatin rinse (1:100,000 iu/ml), swish and spit out 5 ml tid or qid.
 Be careful about using this in patients with dry mouths.

Common warts (verruca vulgaris)

(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Benign skin proliferations caused by the human papillomavirus (HPV) types 2

and 4.
o They may be transmitted by direct or indirect contact.
o Autoinoculation is common.
o common warts are most often seen on the hands, feet, and knees.
o Clinically:
o Hyperkeratotic, skin-colored papules with a rough and irregular
(verrucous) surface. They may vary in size (1 mm to larger than 1
cm). There are usually several lesions scattered on the digits or
extremities.
o Tiny black or red dots within the lesion are characteristic of common
warts and represent thrombosed capillaries.

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Plantar Wart
o Rx:
o Warts are benign and usually self-limited. Therefore, it is reasonable to
not treat. Patients often request treatment, however, in which case
therapeutic options include the following:
o Destructive therapy: 40% salicylic acid plasters/ointments (OTC) with
strong adhesive tape as described above. Can leave on for 2–4 days,
followed by paring or pumice stone. Alternatives include silver nitrate
and glutaraldehyde solution.
o Cryotherapy using liquid nitrogen applied for 5 seconds.
o Topical medications: Tretinoin 0.1% cream or gel daily or twice daily as
tolerated.
o Intralesional immunotherapy.
o Intralesional chemotherapy.

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Leukoplakia
(A summary of an Article Written by: Carl Allen DDS, MSD, Sook-Bin Woo MS, DMD, MMSc)

o Leukoplakia refers to a mucosal white plaque.

o It is a common finding that can be a precursor of mucosal squamous cell
carcinoma.
o It is more common in smokers.
o DDx:
o Oral hairy leukoplakia is most frequently seen in HIV and AIDS patients.
o Lichen planus
o Candidiasis
o Squamous cell carcinoma
o Psoriasis
o Dx: Biopsy, which should rule out SCC.
o Rx: cessation of tobacco use is essential.

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Scabies
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Scabies is a parasitic infestation(Sarcoptes scabiei var. hominis).

o Transmitted most often via direct person-to-person contact and less
frequently by fomites.
o Factors that contribute to the persistence and spread of scabies are
overcrowding, delays in diagnosis, and poor public health awareness
o Dx:
o The tell-tale diagnostic sign is the burrow.

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o The burrow of the female scabies mite is a fine, thread-like, serpiginous

line with a terminal tiny (smaller than a pin head), black speck
representing the mite itself.
o The burrow, along with small erythematous papules and vesicles, is seen
mostly on the flexor wrists, elbows, and areolae, in the interdigital web
spaces, axillae, and umbilicus, along the lower abdomen, and in the
genital and buttocks regions.
o Scabies classically spares the head and neck areas.
o Pruritus tends to be more intense at night and when the patient is
warm.
o Rx:
o Treat the entire family and all close contacts.
o Patients should be instructed to launder bed linens, towels, and
clothing used in the last 72 hours prior to treatment in hot water and
dry on high heat.
o Items that cannot be laundered can be sealed in air-tight plastic bags
for 10–14 days.
o All carpets and upholstered furniture should be thoroughly vacuumed.
o Make sure to tell the patient that lesions can take a week or more to
clear, as the immune reaction will continue despite killing the mite with
the treatment.
 Itching may persist for up to 4 weeks despite complete eradication
of live mites.
o Lesions may become secondarily infected with Staphylococcus aureus.
o CDC-Recommended Regimens:
 Permethrin cream (5%) applied to all areas of the body from the
neck down and washed off after 8–14 hours OR Ivermectin 200
μg/kg orally, repeated in 2 weeks
 CDC-Recommended Alternative Regimen:
 Lindane (1%) 1 oz. of lotion (or 30 g of cream) applied in a
thin layer to all areas of the body from the neck down and
thoroughly washed off after 8 hours.
 Lindane is not recommended as first-line therapy because of
toxicity.

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 Lindane should not be used immediately after a bath or

shower, and it should not be used by persons who have
extensive dermatitis, women who are pregnant or lactating,
or children aged younger than 2 years.
 Pregnant or Lactating Women:
Per the CDC, pregnant or lactating women should not be treated
with lindane; however, they can be treated with permethrin.

Dermatitis
(A summary of an Article Written by: Sarah Stein MD, Karen Wiss MD, Sheila Galbraith MD, Craig N.
Burkhart MD, Dean Morrell MD, Lynn Garfunkel MD, Nancy Esterly MD)

o Scratching induces

lichenification

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Impetiginization:
o With Staphylococcus aureus or Group A streptococcus (Streptococcus
pyogenes).
o "Honey-crusted," or golden-yellow-crusted plaques, sometimes with small
inflammatory halos.
o Rx:
o Localized and Limited: Mupirocin ointment or cream for few lesions (3
times daily for 7–14 days).
o Widespread:
o e.g. Cephalexin 25–50 mg/kg/day p.o. divided 3–4 times daily (and this
can be twice daily).

eczema herpeticum
o Patients are at risk for generalized cutaneous infection with herpes simplex
virus (eczema herpeticum) treated with acyclovir.

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o Dx: Multiple lichenified papules on the elbows, knees, and dorsal hands
should elicit a search for nickel allergy (periumbilical or earlobe dermatitis)
as an exacerbating factor to the patient's atopic dermatitis.
o DDx:

Pityriasis rosea
Xerosis and atopy may be exacerbating factors in this condition
Contact Dermatitis Irritant/Allergic

Scabies
Scaly plaques in tinea corporis
Seborrheic dermatitis tends to involve the scalp and groin in infants
and has greasy scale as opposed to dry scale seen in atopic
dermatitis.
o Rx:
o Emphasizing good sensitive skin care is very important. Emollients and
moisturizing skin-care routines are essential. Recommend non-soap
cleansers.
o Intermittent use of topical corticosteroids to treat active, inflamed,
palpable plaques. Once areas are smooth, discontinue topical steroids.
o In general, use low- to mid-potency topical steroids on the face and
mid- to high-potency steroids on the trunk and extremities.

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o Extensive: Cyclosporin, azathioprine, tacrolimus, and mycophenolate

mofetil have all been used to treat extensive, resistant disease with
varying degrees of success. Phototherapy – including UVB, PUVA, and,
most recently, narrow band UVB.

Diaper Irritant Dermatitis

(A summary of an Article Written by: Craig N. Burkhart MD, Dean Morrell MD, Lowell A. Goldsmith MD,
MPH, Nancy Esterly MD)

o Irritant diaper dermatitis presents as confluent erythema covering areas in

greatest contact with the diaper (ie, the convexities of the buttocks, lower
abdomen, medial thighs, mons pubis, scrotum, and labia majora).
o Sparing of the skin folds is often seen.
DDx:

Candida-induced diaper dermatitis

o presents with pustules and discrete red papules, often found within the folds.

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Seborrheic dermatitis (look for rash at distant sites).

Allergic contact dermatitis
Psoriasis
Scabies
Physical abuse (child abuse)
Rx:

o Diapers should be changed immediately after urinating or defecating (usually

hourly for neonates and every 3–4 hours for infants).
o Improving the skin barrier:
o Thick ointments and pastes, such as petrolatum and zinc oxide
preparations, should be applied with every diaper change.
o Avoid harsh soaps and alcohol and instead use plain water or unscented
diaper wipes.
o Reducing inflammation:
o Apply low-potency topical steroids ointments, such as 1% hydrocortisone
twice daily for inflamed areas.
o Treat secondary candidiasis: If there is any suspicion of candidiasis (pustules
or rash longer than 3 days), apply nystatin, an azole antifungal (ie,
clotrimazole, miconazole, econazole, etc), or ciclopirox twice daily for 2–3
weeks or until 1 week after the rash has cleared.

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Syphilis, Primary (chancre)

(A summary of an Article Written by: Carl Allen DDS, MSD, Sook-Bin Woo MS, DMD, MMSc)

o Primary genital syphilis is a sexually transmitted bacterial disease caused by

Treponema pallidum.
o Initially, a dusky red macule appears at the site of inoculation.
o Then, a painless chancre (ulcer) appears 18–21 days after initial infection with
syphilis.
o Peri-oral extra-genital chancres are most common at the external lips or close
by.
o Chancres may also be seen within the oral cavity.
o If untreated, the chancre persists for 1–6 weeks. If treated, it resolves
without scarring in 1–2 weeks.
o DDx:
o Infectious:
o Oral HSV – Look for multiple small vesicles on an erythematous base;
usually painful; check DFA, Tzanck smear, PCR, and viral culture.
o Kaposi's sarcoma
o Cytomegalovirus infection
o Noninfectious:
o Aphthous ulcer
o Fixed drug eruption – Red-brown papules or annular plaques that are
commonly on the penis; can progress to bullae and erosions mimicking
syphilis.

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o Behçet's disease – Do tissue biopsy if suspecting this diagnosis, and look

for recurrent oral ulceration, recurrent genital ulceration, and ocular
abnormalities.
o Ulcerative squamous cell carcinoma – Do a tissue biopsy.
o Crohn's disease
o Dx:
o The diagnosis of syphilis is based on serologic findings or visual
examination of the organism.
o Serologic tests are not reactive until one week or more after the
chancre appears.
o The primary lesion exudate must be evaluated by darkfield examination
or direct immunofluorescent microscopy of the spirochete.
o The Venereal Disease Research Laboratory (VDRL) and the rapid plasma
reagin (RPR) are nontreponemal tests, and their titers correspond with
disease activity. False-positive results may occur with numerous
conditions.
o The microhemagglutination assay for T. pallidum (MTA-TP) and
fluorescent treponemal antibody absorption test (FTA-ABS) are more
precise treponemal tests used to confirm a positive nontreponemal test.
o Rx:
o Patients with neurological complaints should have an evaluation that
includes CSF analysis.
o CDC 2010 Treatment Guidelines:
 Penicillin G, IM or IV, for all stages of syphilis, remains the gold
standard.
 Penicillin allergy: doxycycline 100 mg orally twice daily for 14
days.
 Pregnancy: no alternative exists for penicillin.

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Chancroid

o A sexually transmitted acute ulcerative disease.

o Usually localized to the anogenital area and often associated with inguinal
adenitis.
o Haemophilus ducreyi, a Gram-negative, facultative anaerobic coccobacillus, is
the causative agent.
o Painful soft ulcers with ragged undermined margins develop 1 to 2 weeks
after inoculation.
o Chancroid facilitates the transmission of human immunodeficiency virus.
o Rx:
o Azithromycin and ceftriaxone are recommended as a single-dose
treatment
o Azithromycin 1 g orally in a single dose (CDC, WHO)
o Ceftriaxone 250 mg intramuscularly in a single dose Parenteral dosing
(CDC)
o Ciprofloxacin 500 mg orally bid for 3 days
o In about half of untreated patients, the course is that of spontaneous
resolution without complications.

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Herpetic Whitlow
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Herpetic whitlow, or distal digital herpes simplex virus (HSV).

o After an incubation period of 3–7 days, during which local tenderness,
erythema, and swelling may develop, a crop of vesicles appears at the portal
of entry into the skin. The vesicles are typically distributed around the
perionychium and on the volar digital skin. The lesions may progress to
erosions or may simulate a felon.
o Rx:
o Emphasize the importance of wearing gloves if the patient is a health
care professional.
o Acyclovir 200 mg 5 times per day for 7–10 days.

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Leishmaniasis
(A summary of an Article Written by: Art Papier MD, William Van Stoecker MD)

o Cutaneous leishmaniasis results from infection of the skin with obligate

intracellular parasites of the Leishmania genus.
o The primary lesions are noted several weeks to months after the sandfly
exposure and evolve thereafter, over weeks to months, from papular, to
nodular, to ulcerative.
o Pruritus, pain, and bacterial superinfection are also present at times.
o Dx: light-microscopic examination or Demonstration of parasite DNA by PCR or
other investigational molecular techniques.
o Rx:
o The lesions should be reexamined 4–6 weeks after the end of therapy
(earlier, if clinically indicated) and periodically thereafter to determine
whether they have resolved and to monitor for relapse (typically first
noted at the margins of the scar).
o Decisions about whether and how to treat should be made in
consultation with an expert.
 First-line parenteral:
 Sodium stibogluconate (available from CDC) or meglumine
antimonate (IV or IM)
 Alternative parenteral:
 Amphotericin B deoxycholate (IV) or Pentamidine (IV or IM)
 Oral:Consult an expert

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 Topical/local:
 Thermotherapy
 Cryotherapy

Keratoacanthoma
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Keratoacanthomas appear and grow rapidly over the course of a few weeks to a month.
o If left untreated, most keratoacanthomas spontaneously involute and resolve
within 6 months, leaving an atrophic scar.
o Clinically:
o A solitary dome-shaped, skin-colored nodule with a central keratin-filled
plug. It is sharply demarcated from the surrounding skin and may have
telangiectasias within the lesion.
o Lesions range in size from 1 to 2 cm.
o The most common locations include the central face, dorsal hands, and
arms. In women, the distal legs are also frequently involved.
o Dx: Biopsy.
o Rx:
o Keratoacanthomas may regress spontaneously if left untreated.
o It may induce significant local destruction and psychological distress to
the patient i.e. treatment is recommended in order to speed resolution,
prevent local destruction and metastasis, and improve cosmetic
outcome.
o Complete excision is the recommended treatment of choice.
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Squamous Cell Carcinoma

(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Risk factors for the development of SCC include chronic sun exposure, fair
skin and blue eyes, family history of skin cancer, scarring processes (chronic
ulcers, burns, hidradenitis), ionizing radiation, immunosuppression,
certain subtypes of human papillomavirus (HPV), and chemical carcinogens.
o Clinically:
o The majority of SCC lesions appear on chronically sun-damaged skin of
the head, neck, forearms, and dorsal hands.
o SCC often presents as an erythematous, hyperkeratotic papule or nodule
that may ulcerate, but it may also be skin colored and/or smooth.
o DDx:
o Basal cell carcinoma
o Verruca vulgaris
o Keratoacanthoma
o Pyogenic granuloma
o Amelanotic melanoma
o Hypertrophic discoid lupus erythematosus
o Hypertrophic lichen planus

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o Dx:
o A thorough history and physical exam is the most effective means of
detection. Biopsy of the lesion will demonstrate characteristic
histopathology.
o Depending on the clinical scenario, imaging such as a CT scan may prove
helpful in a staging workup.
o Rx:
o SCC of the head and neck, including the oral mucosa, has a higher
likelihood of metastasis. Refer these patients to a specialist.
o Mohs micrographic surgery and standard surgical excision with 3–4 mm
margins are first-line treatments.

Basal Cell Carcinoma

(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

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o Basal cell carcinoma (BCC) the most common skin cancer.

o It is largely a non-metastasizing form of cancer. It is typically limited to areas
on the head, neck, face, and nose but can occur at any location.
o Clinically:
o Superficial BCCs typically appear as dry, scaly, flat papules or plaques
that enlarge slowly and sometimes develop a raised border. They are
typically well-defined and pink to red in color.
o Dx: Skin biopsy.
o Rx:
o Treatment must be individualized, but simple electrodesiccation and
curettage (ED&C) or cryosurgery is often effective for superficial BCC.
o Advise sun avoidance and sun protection measures such as sunscreens
and barrier clothing.
o Patients with skin cancer should be followed by a dermatologist at
regular intervals to assess for recurrence or the appearance of new
lesions.

Melanoma
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Malignant melanoma may arise from a previously existing pigmented lesion or

develop de novo.
o Early diagnosis and treatment can lead to complete cure and survival, while
advanced forms carry a poor prognosis.

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o The most frequent sites of melanoma metastasis are the lungs, liver, and
brain.
o Predisposing factors for melanoma include a family history or prior personal
history of melanoma, a history of severe sunburns, a changing mole, a giant
congenital nevus (greater than 20 cm), older age, fair skin, and multiple
atypical nevi.
o Clinically:
o An asymmetric macule with brown variegated pigmentation and notched
or ragged borders. May occasionally be somewhat elevated.
o Usually seen on the trunk in men and the lower extremities in women.
o Primary care physicians may play an important role in preventing
mortality from melanoma. By identifying risk factors for melanoma and
by applying ABCDE criteria to lesions brought to clinical attention by
patients or via a careful screening during physical exam, the generalist
will make the proper decision on the need to refer to a dermatologist.
 ABCDEs of melanoma:
 Asymmetry: One half of the lesion does not mirror the other
half.
 Border: The borders are irregular, shaggy, or indistinct.
 Color: The color is variegated; the pigment is not uniform,
and there may be varying shades and/or hues.
 Diameter: Classically, any pigmented lesion greater than 6
mm in diameter is concerning. Melanomas, however, are
often detected at smaller sizes.
 Evolving: Notable change in a lesion over time raises
suspicion for malignancy. Ulceration and bleeding are late
signs and should certainly prompt biopsy.
o DDx:
o Compound nevus
o Seborrheic keratosis – Presence of pseudo horn cysts is typical.
o Pigmented basal cell carcinoma – Pearly quality
o Atypical nevus
o Congenital nevus
o Pyogenic granuloma – Friable, glistening surface
o Metastatic carcinoma

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o Paget's disease
o Dx:
o Full-thickness skin biopsy.
o Chest radiograph
o Liver function tests and LDH
o PET scan
o MRI
o CT scan(s)
o Rx:
o Should be referred to and followed regularly by a dermatologist.
o Surgical excision is the treatment of choice.

Kaposi Sarcoma
(A summary of an Article Written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD,
MPH, Michael D. Tharp MD)

o Kaposi sarcoma (KS) is a malignant neoplasm of lymphatic endothelial cell

origin that occurs in several forms: AIDS-associated and non-AIDS-related,
including classic KS, endemic KS, and iatrogenically-induced KS. All 4 types
can be linked to coinfection with human herpesvirus type 8 (HHV-8).
o Clinically:
o Red, purple, or bluish black patches that slowly progress into rubbery
plaques.
o The disease is often limited to the lower extremities, especially
involving the ankles and feet.

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o Dx: Skin biopsy is diagnostic. Consider HIV testing if the patient's HIV status is
unknown.
o Rx:
o The treatment of advanced KS often necessitates a multidisciplinary
approach.
o Medical or radiation oncologists may be needed to administer systemic
chemotherapy or radiation therapy, respectively.

Systemic Lupus Erythematosus

(A summary of an article written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD, MPH,
Michael D. Tharp MD)

 Autoantibodies play significant roles in the diagnosis, management, and

prognosis of SLE. They are as follows:
o Anti-dsDNA – Highly specific for SLE. Rising levels correlate with increased SLE
activity and an increased risk for SLE nephritis. Seen in approximately 55–65% of SLE
patients.
o Anti-Sm – Highly specific for SLE. Seen in approximately 25–30% of SLE patients.
Considerable diagnostic value, but levels do not correlate with disease activity.
o Anti-RNP – Highly specific for SLE. Seen in approximately 5% of SLE patients.
o ANA – Highly sensitive for SLE. Seen in approximately 99% of SLE patients. In other
words, it is very rare for an SLE individual to have a negative ANA. Considerable
screening value, but levels do not correlate with disease activity.
o Anti-histones – Highly specific for drug induced SLE.
 The organ systems most commonly affected in SLE are the skin, renal,
pulmonary, CNS, hematologic, and joints. Fever, myalgias, weight loss, and
lymphadenopathy are very common nonspecific constitutional findings.
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 Clinically:
o the malar or "butterfly" blush. Erythema covering the nose and medial
cheeks can occur after sun exposure and precede the systemic
symptoms by weeks.
o A photodistributed cutaneous eruption can develop with prominence on
the dorsa of the hands, arms, and trunk.
o Nail fold erythema and even necrosis can occur.
o Small mucous membrane ulcers, especially on the palate, can develop.
o Livedo reticularis is common.
o Discoid LE lesions can also be seen.
 Dx: The American College of Rheumatology 1982 Revised Criteria for
Classification of Systemic Lupus Erythematosus. Any 4 or more of the 11
criteria are present at any time during a patient's history:
1) Malar rash
2) Discoid rash
3) Photosensitivity
4) Oral ulcers
5) Arthritis
6) Serositis
7) Renal disorder
8) Neurologic disorder
9) Hematologic disorder
10) Immune disorder
11) Presence of anti-nuclear antibodies
 DDx:

Dermatomyositis

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o Characteristic heliotrope rash (violaceous plaques surrounding eyes),

photodistributed cutaneous eruption, and nailfold changes. Look for
elevated serum CK levels and proximal symmetric extremity weakness.

Rosacea – ANA negative.

Stevens-Johnson syndrome
Antiphospholipid antibody syndrome / lupus anticoagulant
Seborrheic dermatitis – No systemic findings. Erythema and scale in
sebaceous distribution.
Contact dermatitis
Pityriasis rubra pilaris
Sarcoidosis
Scleroderma
 Rx
o Consultation with multiple specialists is mandatory for patients with
SLE.
o The patient should avoid sunlight (especially at noon and at high
altitudes), photosensitivity drugs (antihistone antibody), and exogenous
estrogens.
o Antimalarials: Hydroxychloroquine: 200–400 mg p.o. daily or
Chloroquine: 125–250 mg p.o. daily
o Glucocorticoids: Prednisone: 5–60 mg p.o. daily or divided 2–4 times
daily; taper over 2 weeks
o Immunosuppressives:
 Cyclophosphamide: 10–20 mg/kg IV every 3–4 weeks or 1.5–2.5 mg/kg p.o.
daily
 Azathioprine: 1.5–3 mg/kg p.o. daily, maintenance dose of 1–2 mg/kg/day
 Mycophenolate mofetil: 500 mg p.o. twice daily, increase over several weeks
to 1,500 mg p.o. twice daily
o Arthritis, arthralgias, and myalgias can be managed with nonacetylated
salicylates (choline magnesium trisalicylate 500 mg to 1.5 g p.o. 2–3
times daily) and NSAIDs (ibuprofen 400–600 mg p.o. every 4–6 hours, as
needed).

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Scarlet Fever
(A summary of an article written by: Sarah Stein MD, Karen Wiss MD, Sheila Galbraith MD, Craig N.
Burkhart MD, Dean Morrell MD, Lynn Garfunkel MD, Nancy Esterly MD)

 caused by the erythrogenic exotoxin of group A streptococcus,

Streptococcus pyogenes.

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 Clinically:
o A sandpaper-like exanthem, 1–2 mm in diameter, with minute, confluent
red papules, which begins on the neck, moves to the trunk, and finally
to the extremities.
o There is beefy red enlargement of the tonsils, tonsillar exudate, and
tender submandibular adenopathy when strep pharyngitis is the evoking
infection.
o The tongue initially has a white coating, giving a "white strawberry"
tongue appearance that then sheds to reveal a bright red strawberry
tongue.
o The palms and soles are spared initially, but in later phases of the
eruption they may shed thick masses of stratum corneum. The cheeks
are usually flushed, with no discrete papules.
o The rash typically lasts for 4–5 days, and as it subsides, desquamation
occurs beginning on the neck and face and eventually involving the
hands and feet.
 DDx:

Toxic shock syndrome

o Originates from Staphylococcus aureus infections arising in the setting of

super absorbent tampons, nasal packing, or surgical site infections.
Patients are systemically ill and eventually desquamate.
o Potentially life-threatening emergency

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Staphylococcal scalded skin syndrome (SSSS) or Ritter's disease

o Usually occurs in young children following an S. aureus infection –

Affected skin is notably tender.
o The natural history of SSSS is characterized by the following:
 Prodromal symptoms and/or purulent rhinorrhea and/or
conjunctivitis
 Facial erythema that generalizes to the body in less than 48 hours
 Bullae development, positive Nikolsky's sign, very tender skin
 Skin wrinkling and epidermal sloughing within 48 hours after bullae
develop
 Desquamation continues for up to 5 days
 Re-epithelialization, without scarring, completed over following 2
weeks
o Rx:
 Nafcillin or oxacillin (150 mg/kg/day IV in 4 divided doses) for 5–7
days
 A macrolide such as azithromycin (500 mg IV daily for 2 days, then
250–500 mg p.o. daily to complete a course of 7–10 days) is an
alternative

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Kawasaki disease

o Characterized by "strawberry tongue," conjunctival injection, cervical

lymphadenopathy, and rash – This is also more common in children.
o Potentially life-threatening emergency
o It is classically characterized by 6 criteria:
 Fever lasting at least 5 days (usually longer)
 Conjunctival injection without exudate
 Red lesions of the mouth or pharynx
 Acute hand and foot edema followed by peeling
 Polymorphous cutaneous eruption
 Lymphadenopathy
o The majority of individuals affected by Kawasaki disease follow a benign
course.
o Coronary artery aneurysms develop in 20–25% of untreated patients.
o Management:
 CBC with differential, ESR, C-reactive protein, urinalysis for blood
and protein, liver function tests, and an ECG.
 Echocardiography should be performed at diagnosis, at 2 weeks,
and at 6–8 weeks after onset.
 Treatment is with intravenous gamma globulin and aspirin.
 Treatment is best if initiated within the first 10 days of the
illness.

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Infectious mononucleosis (EBV)

o Caused by Epstein-Barr virus (EBV).

o The classic clinical triad consists of fever, pharyngitis, and cervical
adenopathy.
o The child appears generally ill with readily apparent cervical
adenopathy in most cases.
o Splenomegaly typically occurs during the second and third week.
o Hepatomegaly rarely develops.
o Complications:
 Upper airway obstruction, hemolytic anemia, thrombocytopenic
purpura, severe granulocytopenia, pneumonia,
meningoencephalitis, recurrent aseptic meningitis (Mollaret's
meningitis), Guillain-Barré syndrome, Fisher's syndrome (bilateral
ptosis, total ophthalmoplegia, cerebellar symptoms, and
hyporeflexia), psychosis, Bell's palsy, myocarditis, pericarditis,
coronary artery spasm, pancreatitis, nephritis, and fulminating
hepatic necrosis.
 Neurological complications, airway obstruction, and splenic
rupture are the most common causes of death in otherwise
healthy persons.
o Dx:
 The "Monospot" test, measuring heterophil antibody by a
commercial kit, may be slightly more sensitive than the classic
tube heterophil test.

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 IgM viral capsid antigen (VCA) serology is 100% sensitive and

diagnostic of a primary EBV infection.
o Rx:
 Observe for complications.
 Supportive and symptomatic.
 Other DDx:
o Exanthematous drug eruptions will have a history of exposure.
o Sunburns occur after sun exposure and are photodistributed.
o Photosensitive and phototoxic drug eruptions are photodistributed.
Photocontact dermatitis is photodistributed.
o Rubeola has associated cough, coryza, conjunctivitis, and Koplik spots.
o Rubella has occipital and post-auricular lymphadenopathy.
o Primary HIV infection is characterized by lymphadenopathy and rash.
o Lupus erythematosus has associated photosensitivity.

o Dx: The diagnosis is usually made on clinical grounds and supported by a rising
ASO and positive cultures for Streptococcus.
o Rx:
o The patient usually appears ill and lethargic.
o The response to systemic antibiotics for the constitutional symptoms is
fairly rapid.
 Intravenous penicillin (penicillin G, 4 divided doses) or
erythromycin 1 gm IV every 6 hours is the therapy of choice.
o Follow-up urine exams should be done to exclude glomerulonephritis.

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Toxic epidermal necrolysis (TEN)

o Drug induced, high fevers, skin tenderness, mucosal erosions, and skin
detachment about 1–3 weeks after the inciting medication is started.

o Potentially life-threatening emergency

Nikolsky's sign

o Disrupting the epidermal barrier with firm rubbing.

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Diabetic Dermopathy
(A summary of an article written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD, MPH,
Michael D. Tharp MD)

o Diabetic dermopathy presents as few or many macules, patches, and papular

lesions that are dark brown to reddish-brown in color at the anterior lower
legs.
o They are usually oval, round, or linear in shape and smooth and well
demarcated, though some papules can have scale or hemorrhagic crusts.
o They vary in size from 0.5 cm in diameter up to large patches covering most
of the shin.
o Older lesions are covered with a thin scale and appear atrophic and
hyperpigmented.
o The presence of well-demarcated, hyperpigmented, atrophic scars on the
shins of a diabetic patient strongly point to a diagnosis of diabetic
dermopathy.

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Lipodystrophy, Drug Induced

o It is characterized by the loss of subcutaneous fat on the extremities and face

and accumulation of fat in the abdomen and posterior neck/upper back.

Bullous Pemphigoid
(A summary of an article written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD, MPH,
Michael D. Tharp MD)

o A chronic autoimmune subepidermal blistering disease most frequently seen

in the elderly.

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o The disease can occur on any body surface, but mucous membrane
involvement is rarely seen.
o Associated with:
o Autoimmune diseases such as diabetes mellitus, thyroiditis,
dermatomyositis, lupus erythematosus, rheumatoid arthritis, ulcerative
colitis, myasthenia gravis, and multiple sclerosis.
o Therapeutic radiation or drugs (furosemide, NSAIDs, captopril,
penicillamine, and some antibiotics).
o Follow certain nonbullous inflammatory skin diseases, such as psoriasis
and lichen planus, or vaccination (most often in children).
o Rx:
 Self-limiting, but it can become chronic over months to years.
There is a wide spectrum of clinical severity. The disease can be
generalized and severe, or patients may have only a few
asymptomatic, localized bullae.
 Secondary infection of lesions should be treated aggressively with
appropriate systemic antibiotics.
 Involve a dermatologist in the patient's care.

Pretibial Myxedema
(A summary of an article written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD, MPH,
Michael D. Tharp MD)

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o Pretibial myxedema is an uncommon dermopathy associated with Graves

disease.
o Rare cases have occurred with Hashimoto's thyroiditis and in euthyroid
patients.
o The precise pathogenesis is unknown.
o There is localized dermal accumulation of mucopolysaccharides
(hyaluronic acid), presenting clinically as diffuse nonpitting lesions or
sharply circumscribed lesion(s) of the anterior lower leg.
o Nonpitting edema with occasional raised, hyperpigmented, violaceous
papules or plaques, which may appear waxy or indurated on the anterior
shins but may appear anywhere on the skin, including the arms, head,
neck, and legs. It is often bilateral.
o Rx:
o Treatment is primarily undertaken for cosmetic reasons.
A significant portion of patients will experience complete spontaneous
remission.
o Topical steroids under occlusion (betamethasone, fluocinonide,
triamcinolone) are the mainstay of treatment.

Cellulitis
(A summary of an article written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD, MPH,
Michael D. Tharp MD)

o Cellulitis is a common bacterial infection of the dermis and subcutaneous

tissue characterized by erythema, pain, warmth, and swelling.

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o Immunocompetent adults: Staphylococcus aureus (methicillin sensitive

or methicillin resistant) and Streptococcus pyogenes
o Immunocompromised individuals, including those with diabetes, venous
insufficiency, or decubitus ulcers: mixture of gram-positive cocci and
gram-negative aerobes.
o Clinically:
 Unilateral erythematous, warm to hot, tender patches
 Unilateral extremity edema
 Lymphangitis and inflammation of regional lymph nodes
 Vesicles, bullae, ecchymoses, and petechiae in severe cases
 Distinguishing cellulitis from necrotizing fasciitis:

necrotizing fasciitis

 The following clinical features suggest a deep necrotizing

infection:
 Constant pain that is quite severe, and pain is out of
proportion to physical exam
 Presence of bullae
 Skin necrosis or ecchymosis that precedes necrosis
 Gas (crepitus, or crackling sounds) in the soft tissues
 Edema extending beyond areas of erythema
 Signs of systemic toxicity including fever, delirium, renal
failure, hypotension, and tachycardia
 Cutaneous anesthesia
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 Rapid progression despite antibiotic therapy

o Rx of Cellulites:
o Antibiotics should include S. aureus and S. pyogenes coverage.
o The majority of patients develop mild cellulitis, and oral antibiotics can
be administered.
o Antibiotics with MRSA coverage should be administered in patients with
recurrent infections, a history of MRSA, and in immunocompromised
individuals.
o Note that patients should be evaluated frequently to determine
appropriate response to therapy.
 Dicloxacillin Adults: 500 mg p.o. every 6 hours, Children: 50 mg/kg/day p.o.
divided every 6 hours
 Cephalexin Adults: 500 mg p.o. every 6 hours, Children: 50 mg/kg/day p.o.
divided every 6 hours
 Ceftriaxone Adults: 1–2 g IV/IM daily or divided twice daily, Children: 50–75
mg/kg/day IV/IM divided twice daily
 Nafcillin Adults: 2 g IV/IM every 4 hours, Children: 150 mg/kg/day IV/IM
divided every 6 hours

Folliculitis
(A summary of an article written by: Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD, MPH,
Michael D. Tharp MD)

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 There are many agents that can cause follicular inflammation:

o Infectious pathogens (directly invading follicles) "Staphylococcus"
o Physical irritation "perspiration, friction, occlusion, or shaving"
o Systemic drugs "Corticosteroids, ACTH, androgens, iodides, bromides,
lithium, isoniazid, and anticonvulsants"
o Underlying disease states
 Patients asymptomatic, or has painful, or pruritic Small erythematous papules
and pustules pierced by a central hair.
 Lesions often heal spontaneously without scarring.
 Rx:
o Treatment directed at staphylococcal infection.
 Mild cases of folliculitis may resolve spontaneously. Recommend the
patient use an antibacterial soap.
 Possible regimens include mupirocin ointment 3 times daily to
affected areas; alternatively, erythromycin solution
2%, clindamycin solution 2%, or Benzamycin® cream twice daily
to affected areas may be tried.
 If there is no response to topical therapy after
approximately one month or for widespread or deep-
seated cases, use an anti-staphylococcal oral antibiotic:
o Dicloxacillin or cephalexin 500 mg p.o. 4 times daily for
10–14 days
o Azithromycin (Z-Pak®) 500 mg the first day, then 250 mg
daily for 5 days is an alternative
o Avoidance of external irritants:
 Changing the patient's skin routine is often beneficial (Identify
etiologic habits such as shaving).

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Henoch-Schönlein Purpura
(A summary of an article written by: Sarah Stein MD, Karen Wiss MD, Sheila Galbraith MD, Craig N.
Burkhart MD, Dean Morrell MD, Lynn Garfunkel MD, Nancy Esterly MD)

 An idiopathic cutaneous small vessel vasculitis characterized by IgA deposition in

vessel walls.
 A history of preceding upper respiratory tract infection is frequently elicited.
 Patients may experience a 2–3 week history of fever, headache, myalgias,
arthralgias, and abdominal pain that precedes the skin eruption.
 Extracutaneous manifestations :
o Arthritis, gastrointestinal bleeding, pulmonary hemorrhage, and nephritis.
o Renal involvement is typically mild and self-limited with transient
microscopic hematuria and minimal proteinuria.
o Approximately 2% of patients progress to end stage renal disease.
 Consensus criteria for the diagnosis of HSP includes palpable purpura plus at
least one of:
o Diffuse abdominal pain
o Acute arthritis or arthralgias
o Renal involvement
o A skin biopsy showing IgA deposition
 On examination:
o Erythematous macules and papules or urticarial lesions that quickly evolve
into purpura within 24 hours.
o Lesions are symmetrically distributed over the buttocks, distal legs, and
extensor extremities.

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o Individual lesions resolve with hyperpigmentation over 5–7 days, but

recurrent crops tend to appear over a period of 6–16 weeks.
 DDx:
o Vasculitis, Kawasaki disease, Erythema multiforme, SLE, Meningococcemia,
disseminated intravascular coagulation (DIC), Thrombocytopenic purpura
The long-term prognosis in patients with HSP is associated with the
presence or absence of renal disease.
 Rx:
o HSP is generally benign and self-limited.
o Treatment is usually supportive.
o Corticosteroids may be effective in treating abdominal pain and arthritis,
although reliable data is lacking.

Koilonychia
(A summary of an article written by: Bertrand Richert MD, Robert Baran MD)

o Koilonychia refers to a nail being concave with the edges everted, often
nicknamed "spoon-nail."
o Categorized as acquired, idiopathic, and hereditary.
o Acquired koilonychia, the most common form, can be caused by trauma;
dermatologic diseases such as psoriasis, fungal infections, and Raynaud
phenomenon; or systemic disease such as iron deficiency anemia or Plummer-Vinson
syndrome.
o Dx: CBC with peripheral smear and serum iron, total iron-binding capacity
(TIBC), and serum ferritin to assess for iron deficiency anemia.
o Rx: Search for and treat any underlying disease.
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Tuberous Sclerosis
(A summary of an article written by: Sarah Stein MD, Karen Wiss MD, Sheila Galbraith MD, Craig N.
Burkhart MD, Dean Morrell MD, Lynn Garfunkel MD, Nancy Esterly MD)

 An autosomal dominant disorder caused by mutations in the genes for the

proteins hamartin and tuberin.
 It is characterized by tumor-like growths, or hamartomas, in almost every organ.
 It is often associated with epilepsy, mental retardation, and autism.
 Clinical Diagnostic Criteria for Tuberous Sclerosis:
o Definite tuberous sclerosis complex requires 2 major features or 1 major
and 2 minor features; may not be diagnosed until adulthood.
 Major Features
 Facial angiofibromas or forehead plaque
 Ungual fibroma
 Three or more hypomelanotic macules
 Shagreen patch
 Multiple retinal nodular hamartomas
 Cortical tuber
 Subependymal nodule
 Subependymal giant cell astrocytoma
 Cardiac rhabdomyoma (usually asymptomatic)
 Renal angiomyolipoma or pulmonary lymphangiomyomatosis
 Minor Features
 Multiple pits in dental enamel
 Hamartomatous rectal polyps
 Bone cysts
 Cerebral white-matter radial migration lines
 Gingival fibromas
 Nonrenal hamartoma
 Multiple renal cysts
 Retinal achromic patch
 "Confetti" skin lesions

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o On Examination:
o Hypomelanotic macules ("ash-leaf spots") are round, oval, linear, or
lance-ovate-shaped, well-defined macules of decreased pigmentation.
Although usually obvious under natural light, occasional fair-skinned
infants require Wood's lamp examination in a completely darkened room
to accentuate the macules.

o Angiofibromas are 1–4 mm flesh-colored, pink, or red papules with a

smooth surface located over the nasolabial folds, medial cheeks, and
chin. The upper lip and sides of the face are usually spared.

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o Forehead plaques are flesh-colored, pink, or red plaques with irregular

outlines and an uneven surface usually located on the forehead or scalp.
They may be soft, doughy, or hard.

o Shagreen patches are flesh-colored, pink, or brown plaques that range

in size from 1 to several centimeters.

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o Ungual or periungual fibromas are skin-colored to reddish nodules that

appear on top of nails and are often associated with deep grooves.

o Management:
o Tuberous Sclerosis Consensus Conference Guidelines for the Ongoing
Evaluation of Established Patients:
 Cranial imaging (CT or MRI) – every 1–3 years
 Neurodevelopmental testing – at time child enters school and
periodically if educational or behavioral concerns
 EEG – as indicated for seizure management
 Renal ultrasonography – every 1–3 years
 Chest CT – only women upon reaching adulthoo
 Dermatologic exam – yearly in patients who may benefit from laser
surgery

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Miscellaneous (Discussion within the text)

Insect bite

Anthrax

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Kobner's phenomina

Neurofibromatosis

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Fissured tongue

Geographic tongue

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Port wine stain

Congenital Nevomelanocytic Nevus

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Mongolian Spot

Keloid Scar

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Telangiectasia

Milia

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