Dermatology Revision

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Dermatology Revision: 

Dermatology Revision Chris Harland


Aims To pass 4th year exam Hints towards 5th year Clinical


Objectives 5 year-Red Specialties handbook 2% of total exam mark: already done! 4 year/GEP-Linked Year 3 Objectives

GEP ‘Linked Year 3 Objectives: 

GEP ‘Linked Year 3 Objectives Skin Infection Eczema Psoriasis Skin manifestations of systemic disease Drug reactions Dermatological malignancies Leg ulcers Skin grafts & flaps/Burns management

GEP ‘Linked Year 3 Objectives: 

GEP ‘Linked Year 3 Objectives Skin Infection Eczema Psoriasis Skin manifestations of systemic disease Drug reactions Dermatological malignancies Leg ulcers Skin grafts & flaps/Burns management)

Skin Infection: 

Skin Infection


Herpes simplex infection around the mouth


Shingles affecting the maxillary division of the trigeminal nerve The diagnosis should be considered in any acute unilateral eruption, dermatomal distribution and especially if there are risk factors e.g. immunosuppressed, elderly patients


Shingles seen on the neck, affecting one of the cervical roots


An important complication of eczema is secondary infection by the herpes virus resulting in eczema herpeticum This is treated with systemic aciclovir


Eczema herpeticum affecting the face, trunk and limbs


Molluscum Contagiosum This is caused by the pox virus Classically a pearly pink and umbilicated papule They usually resolve spontaneously, which is preferable to mechanical destruction


Cellulitis A deep streptococcal infection of the subcutaneous tissue.Patients are usually systemically unwell with pyrexia and malaise. Classically, a poorly demarcated erythematous lesion which can be associated with streaking/red tracks due to spread of infection up the lymphatics, called acute lymphangitis. Treat with intravenous Flucoxacillin and Benzylpenicillin. Patients who are penicillin allergic should have Erythromycin instead.


Cellulitis affecting the leg and foot The portal of entry here may be athletes foot and one should check between the toes for evidence of this


Impetigo A contagious streptococcal or staphylococcal infection Typically produces a golden crusting Treat with topical Fucidin cream +/- oral Flucoxacillin in severe cases


Scalded Skin Syndrome. There is severe desquamation of the skin and systemic upset


Scabies of the hand The mite infection is caused by Sarcoptes Scabiei Female burrows into the epidermis and lays eggs. Individuals develop a hypersensitivity to mite excreta and become symptomatic with intense itch Burrows usually occur between fingers but they can be widespread


Scabies affecting the finger. Burrows (see arrows) are pathognomonic and are best seen on fingers and palms. The scattered papular lesions are a reaction to the infestation and wheals are common


Scabetic nodules in the axilla Scabies commonly affects the hands, feet, breasts and genitalia Extracting the scabies mite and positive identification down the microscope is useful


Scabies of the foot All family, sexual and household contacts are treated Treatment is with Permethrin. Malathion is used in pregnancy and in very small children




ECZEMA A type of inflammatory process affecting the skin and due to various factors, both internal and external Eczema = Dermatitis


FEATURES OF ECZEMA SYMPTOMS Itch Painful if fissures Weeping with infection SIGNS Acute erythema, oedema, papules and vesicles Chronic less oedema, lichenification, hyperkeratosis and fissuring


Severe acute eczema affecting both hands There is erythema, blistering, crusting (scabbing) and bleeding


Chronic eczematous patch, lichenification Lichenification = thickening of the epidermis due to scratching. Note the accentuation of the skin lines


Infantile eczema in an overtly miserable infant The skin looks weepy and infected


Complications Infection Bacterial (Staphylococcus) Viral (Herpes Simplex) in atopic eczema Erythroderma (see later in psoriasis) Side effects from treatments used e.g. allergic contact dermatitis and side effects of steroid abuse including telangiectasia, purpura and atrophy of the skin


Herpes infection around both eyes Classically, there are closely cropped vesicles or crusted erosions on an erythematous base Involvement of the eyes may lead to corneal scarring


Herpes infection of the hand with painful vesicles


Continued: Treat infections Flucoxacillin for Staphylococcal infections (or topical antibiotic/steroid) Aciclovir for Herpes infections




Clinical Patterns Skin Plaque Scalp Flexural Guttate Chronic Palmoplantar pustulosis Acute pustular Erythrodermic Nail psoriasis Joint/arthropathic psoriasis


Chronic plaque psoriasis, commonest form Well demarcated, red plaque with a scaly silvery surface


Scalp psoriasis. This classically affects the hairline and scale is shed leading to dandruff This can sometimes be difficult to distinguish from bad seborrhoeic dermatitis but psoriasis usually forms thicker scale


Nail changes in Psoriasis: Pitting Onycholysis Ridging Subungual hyperkeratosis Salmon patch


Nail psoriasis. Any nail (usually multiple) can be affected,This slide shows onycholysis which is “lifting off of the nail plate”


Marked psoriatic nail dystrophy. The presence of psoriasis does not preclude fungal infection and if there is any doubt, one should send samples for microscopy and mycology


Joint deformity in psoriasis seen here affecting mainly the distal interphalangeal joints


ERYTHRODERMA This is when the whole of the skin becomes red and there is little or no scaling Dangers include: poor thermoregulation protein and fluid loss high output cardiac failure secondary infection/septicaemia Some causes: psoriasis eczema drug eruptions pemphigus lymphoma Treatment is supportive and of the underlying cause


Erythrodermic Psoriasis Psoriasis covers virtually the whole body with widespread erythema and little or no scaling


Treatment: TOPICAL Emollients, Tar, Salicylic acid, Dithranol Vitamin D analogue (eg. Calcipotriol) Topical steroids PHYSICAL PUVA/UVB therapy SYSTEMIC Cyclosporin (need to monitor renal function and blood pressure) Methotrexate (monitor FBC, LFTs, teratogenic) Vitamin A analogue (Acitretin; teratogenic)

Cutaneous manifestations of systemic disease: 

Cutaneous manifestations of systemic disease


Neurofibromatosis Characterised by multiple skin neurofibromas, skin pigmentation (> 5 café au lait patches) and axillary freckling


Erythema Multiforme. Target lesions on the hands are typically concentric rings and the centre may be bullous or necrotic. They are fixed lesions unlike in urticaria


Stevens-Johnson Syndrome Eye changes include conjunctivitis, uveitis and corneal ulceration, so its important to ask for early ophthalmology review


Necrobiosis lipoidica diabeticorum Orange/yellow waxy, atrophic appearance with overlying telangiectasia, often seen over the shins and they may ulcerate Histologically there is partial necrosis of dermal collagen and a histocytic cell response


Granuloma Annulare. Flesh coloured, smooth, cobble-stoned, annular lesion with central sparing. They are of variable size and unlike fungal infections there is no flaking. Especially seen over extensor surface of hands They have a similar pathology to necrobiosis lipoidica diabeticorum


RHEUMATIC CAUSES Systemic sclerosis -Tight shiny facial skin -Telangiectasia -Sclerodactyly -Calcinosis +/- ulceration -Raynaud’s phenomenon Anti-centromere and antinucleolar antibodies +ve


Systemic sclerosis Classically there is beaking of the nose, furrowing of the lips and facial telangiectasia (they are mainly on the cheeks and nose) Most organs may be affected but most frequently the oesophagus and patients can present with dysphagia


Sclerodactyly. The skin of the fingers appear tightened and shiny due to fibrosis. There are telangiectasia also seen here affecting the hands


Vitiligo Areas of pigment loss are symmetrical and are often annular in outline, but can be various shapes Usually initially affect fingers, hands, face and genitalia Exhibits the Kobner reaction, with the development of lesions at traumatized sites


Graves disease and vitiligo Tests will include those for thyroid function and autoantibodies


Kaposi Sarcoma They are blue/black palpable and discrete lesions seen over the skin and in the mouth


Kaposi Sarcoma affecting the palate


Kaposi Sarcoma affecting the back in a young man


Lupus Pernio Classically, purplish/red palpable lesions, especially seen over the nose, cheeks and earlobes


MISCELLANEOUS Erythema Nodosum F>M, young adults Causes: -Sarcoidosis -Streptococcus (preceding URTI) -Tuberculosis, Leprosy -Drugs (Sulphonamides, OCP, Penicillin) -Inflammatory Bowel Disease -Behcets Syndrome (Orogenital ulcers, uveitis, arthritis, meningoencephalitis, colitis) -Idiopathic It presents with tender, erythematous nodules especially over the legs and is associated with fever, arthralgia and malaise Treatment is of the underlying cause


MISCELLANEOUS Urticaria (hives, “nettle-rash”) Common Pink, itchy or burning swellings (wheals) can occur anywhere on the body. Individual lesions last for less than 24hrs but new lesions can continue to appear elsewhere Classified as acute or chronic (urticaria persisting for >6 weeks) The majority are idiopathic but other causes include - physical (cold, heat) - autoimmune (hyperthyroidism) - drugs - SLE


Dermatitis Herpetiformis More common in Caucasians Any age, peak 20-30s Associated with Gluten sensitive enteropathy Histologically there are subepidermal blisters and immunofluorescence shows fixed IgA in dermal papillae. There is no circulating autoantibody Treatment is lifelong with a gluten free diet. Dapsone can also be given to these patients (side effects include methaemoglobinaemia and haemolytic anaemia)


Dermatitis Herpetiformis Intensely pruritic, symmetrically distributed, erythematous papules and vesicles over the extensor surfaces of elbows, knees, forearms, buttocks and face/scalp


Dermatitis Herpetiformis affecting the buttocks


Dermatitis Herpetiformis affecting the extensor surface of both knees




Blister is a circumscribed skin lesion containing fluid Vesicle <0.5cm blister Bulla >0.5cm blister


Bullous Pemphigoid Affects the older patient Histologically there are subepidermal blisters with the defect in the dermo-epidermal junction. Immunofluorescence shows IgG and C3 binding to the dermo-epidermal junction in a linear fashion. Circulating IgG is present in the serum Treatment is initially with moderate doses of systemic steroids and this can be stopped after several years (? role of steroid sparing agents)


This is the histology of a patient with Bullous Pemphigoid. The defect is in the dermo-epidermal junction and the blister space is filled with eosinophils (note the pink cytoplasm)


Bullous Pemphigoid Tense blisters on an erythematous pruritic base, usually affecting upper arms and thighs


Pemphigus Affects adults 40-60s Biopsy shows intraepidermal vesicles with keratinocytes floating free in the blister cavity (acantholysis) Immunofluorescence shows IgG fixed against intercellular desmosomes between keratinocytes. Circulating IgG is found in the serum Treatment is initially with high dose systemic steroids and in the long-term a steroid sparing agent e.g. Azathioprine


Bullous Pemphigus It usually begins in the oral mucosa and is characterised by flaccid vesicles which are fragile and burst readily producing eroded areas on the face, scalp, neck and chest Nikolsky sign positive is when a shearing stress on normal skin can cause new erosions to form


There are eroded areas on the chest wall and a positive Nikolsky sign due to fragility of the blisters


Pemphigus affecting the oral mucosa


Pemphigus Vulgaris

Drug reactions: 

Drug reactions

Dermatological malignancies: 

Dermatological malignancies


SKIN TUMOURS Melanoma Non-Melanoma (SCC, BCC, others)


MALIGNANT MELANOMA Relatively uncommon, but recent increase in incidence Usually occurs on sun-exposed sites vulnerable to episodic exposure and sunburn (backs in men and legs in women) More common: -fair/freckled skin -large number of moles -atypical, large moles -family/personal previous history


Mackie’s Guide for Malignant Melanoma: Major signs - change in shape - change in size - change in colour Minor signs - inflammation - crusting/bleeding - diameter >7mm - altered sensation e.g. itch ABCD: Asymmetry, Border, Colour, Diameter


Its important to pick up early as prognosis is directly related to tumour thickness (Breslow) Thin lesions <1.5mm Thick lesions > 3.5mm


Various forms of melanoma: Nodular melanoma Superficial spreading melanoma Acral melanoma Subungual melanoma (melanoma seen under the nail and spread to the skin produces Hutchinsons sign) Amelanotic melanoma (often there is a rim of pigment and can present late) Lentigo maligna (pre-malignant melanoma)


Superficial Spreading Melanoma. This is the most common variety, which initially grows horizontally before becoming raised. Note the irregular edge, non-uniform pigmentation and large size


Superficial spreading melanoma This is Clark’s level 1 (in situ i.e. no invasion) There are fuzzy edges and non-uniform colour


Nodular melanoma. There is a nodular component and they are more aggressive than the superficial variety as their growth is mainly vertical


Afro-Caribbean people rarely get melanomas but when they do it is usually on their hand or sole of their foot- Acral melanoma


Satellite lesions are indicative of cutaneous metastasis and advanced stages


Lentigo maligna This is a non-invasive form of melanoma and consists of proliferating malignant melanocytes Typically flat, brown, irregularly pigmented area on elderly, sun-damaged face It spreads along the skin insidiously and the presence of nodules indicate invasion


Treatment Wide excision of the malignant melanoma Prognosis 97% (Breslow <0.78mm) 90% (Breslow <1.5mm) 40% (Breslow >3mm)

Sentinel node biopsy: 

Sentinel node biopsy Staging procedure First draining lymph node Early treatment if lymph spread Prognosis?


Basal cell carcinoma at the nasolabial fold There is a pearly, translucent edge especially when the skin is stretched and also overlying telangiectasia


Nodular BCC on the nose Treatment options for BCCs include: excision radiotherapy curettage and cautery The treatment option depends on the location, size of the BCC and any previous treatments


Squamous cell carcinoma of the lip.


Marjolins Ulcer SCC arising from a venous ulcer Treatment options for squamous cell carcinoma include: excision radiotherapy


There are multiple pigmented naevi on this woman’s back. Can you spot the melanoma? Multiple dysplastic naevi and melanoma found in families (dysplastic naevus syndrome) represents a high risk of melanoma and they should be screened periodically for melanoma

Leg ulcers: 

Leg ulcers

Leg ulcers: 

Leg ulcers Venous Arterial Diabetic Sickle cell Pressure/decubitus Tumours Neuropathic (eg leprosy) Traumatic Infections (eg Buruli ulcer)


Erosion Ulcer


Venous ulcer -medial malleolus -pitting oedema -haemosiderin (brown) -eczema -varicose veins -lipodermatosclerosis


Sickle cell ulcer

Skin grafts/flaps Burns management: 

Skin grafts/flaps Burns management

GEP ‘Linked Year 3 Objectives: 

GEP ‘Linked Year 3 Objectives Skin Infection Eczema Psoriasis Skin manifestations of systemic disease Drug reactions Dermatological malignancies Leg ulcers Skin grafts & flaps/Burns management)


GOOD LUCK! To pass 4th year exam Hints towards 5th year Clinical

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