3. What are you describing?
Pruritus
Lesion – altered area of skin
Rash – eruption
Naevus – localised malformation of tissue
structure.
Comedone – plug in a sebaceous follicle
containing sebum – may be open (blackhead) or
closed (whitehead).
“The patient has a rash…”
4. Where is it?
Generalised – all over body
Widespread – extensive
Localised – one area of skin
Flexural – body fold eg groin, axilla
Extensor – eg knees, shins
Pressure areas – sacrum, buttocks, ankles, heels.
Dermatome – skin supplied by single nerve
Photosensitive areas – sun exposed.
“The patient has a widespread rash affecting their torso”
5. What colour is it?
Erythema – redness (due to inflammation and
vasodilation) blanches on pressure.
Purpura – red or purple colour (due to bleeding into
the skin or mucous membranes) does not blanch to
pressure. Petechiae (small pinpoint macules) and
ecchymoses (larger bruise like patches)
Hypopigmentation (pityriasis vesicolor)
De-pigmentation (vitiligo)
Hyperpigmentation (melasma)
10. Atopic Excema
Itchy papules and vesicles on an erythematous base.
Affects face and extensor in infants, flexor aspect
children and adults.
Occurs in early childhood, usually resolves.
Risk factors: fhx of atopy, assoc asthma, allergic rhinitis
etc)
Exacerbating factors: infections, allergens (chemical,
food, dust, pets), sweating, heat, stress.
Complications: secondary bacterial/viral infection
26. Urticaria, Angioedema, Anaphylaxis
Causes – food, drugs, insect bites, contact eg
latex, autoimmune, hereditary (angiodema), etc
Urticaria – swelling superficial dermis – raises
epidermis causing itch wheals.
Angiodema – deeper swelling involving dermis
and subcutaneous tissue – tongue and lips.
Anaphylaxis – bronchospasm, facial and
laryngeal oedema, hypotension, can start with
angiodema and urticaria.
27. Management
ABC approach – call for help if concerned.
Urticaria only – antihistamines
Angioedema and severe urticaria –
corticosteroids and antihistamines.
Anaphylaxis – get help!
Adrenaline 0.5 mg IM = 0.5 mL of 1:1000
Antihistamine – chlorphenamine
Corticosteroids
33. Necrotising fasiitis
•
Rapidly spreading infection of the deep fascia with secondary
tissue necrosis
•
Group A haemolytic strep or mixed anaerobic and aerobic
bacteria.
•
Risk factors – abdominal surgery, diabetes, immunosuppression,
age, malignancy
•
BUT 50% occur in previously healthy individuals
•
Pain disproportionate to signs, erythematous blistering necrotic
skin, systemically unwell with fever and tachycardia, subcutanceos
emphysema (crepitus).
•
Urgent surgical debridement and antibiotics
37. Impetigo
Streptococcus pyogenes and/or Staphylococcus aureus
Enlarging pustules and round, oozing patches +/- golden
yellow crusts.
Exposed areas such as the hands and face, or in skin folds
particularly the armpits.
Management:
Antiseptic or antibiotic ointment eg. Fusidic acid
Oral antibiotics
Avoid spread
Avoid close contact with others.
Affected children must stay away from school until crusts have dried
out.
Use separate towels and flannels.
Change and launder clothes and linen daily.
39. Scabies
Itchy rash on trunk and limbs, finger webspaces,
wrist, spares the scalp
Burrow tracts can be seen
Diagnosis on microscopic examination of tracts.
Treatment (all contacts simultaneously!)
25% Benzyl benzoate lotion, applied daily for 3 days
5% Permethrin cream, left on for 8-10 hours
0.5% Aqueous malathion lotion, left on for 24 hours
40. MCQs
Atopic Eczema True or False
A. a family history of atopy
B. If occurs early and defined has bad
prognosis
C. In children it is common on cheeks
D. In adults more common on flexor area
E. Pruritis is absent
41. MCQ 2
What skin condition
is this likely to be?
-
Atopic dermatitis
Tinea corporis
Psoriasis
Vitiligo
Scabies
What else should
you examine?
42. MCQ 3
True or False which of the following are known
risk factors for melanoma?
Sun bed use
Xeroderma pigmentosum
Smoking
Ciclosporin
Living in the South West
Obesity
43. MCQ4
How would you manage this
patient?
Imiquimod cream
Watch and wait
Punch biopsy of the lesion for
histology
Take a picture and review in
3months to see if it has grown
Surgically remove with a 2mm
margin for histology
WLE with a 2-3cm margin
44. MCQ 5
A 60 year old woman presents with raised, erythematous
lesions on the limbs and blistering in the mouth and
eyes. She had been taking a number of drugs prescribed
by her GP. Which may be responsible for her
presentation?
nifedipine
paracetamol
paroxetine
prednisolone
Sulphasalazine
What is the most important first management?
45. MCQ 6
A 22 year old male presents with generalised pruritus
of six weeks duration. Examination reveals little
except for erythematous papules between the fingers.
Which of the following therapies would be most
appropriate for this patient?
astemizole
calamine lotion
chlorpromazine
ciprofloxacin
permethrin cream
46. MCQ 7
Which of the following is a recognised
feature of psoriasis?
angular stomatitis
iridocyclitis
Koebner Phenomenon
loss of hair
response to chloroquine
Notes de l'éditeur
Primary genetic defect in skin barrier function (filaggrin).
Care of a patient with SJS/TEN requires:
Cessation of suspected causative drug(s) – the patient is less likely to die and complications are less if the culprit drug is stopped no later than the day that blisters/erosions appear
Hospital admission – preferably immediately to an intensive care and/or burns unit as this improves survival, reduces infection and shortens hospital stay
Nutritional and fluid replacement (crystalloid) by intravenous and nasogastric routes – reviewed and adjusted daily
Temperature maintenance – as body temperature regulation is impaired
Pain relief – as pain can be extreme
Sterile handling and reverse isolation procedures
Skin care:
topical antiseptics e.g. silver nitrate or chlorhexidine, (but not silver sulfadiazine as it is a sulfa drug)
dressings such as gauze with petrolatum or non-adherent nanocrystalline-containing gauze
biosynthetic skin substitutes can reduce pain
avoid using adhesive tapes
preferable not to remove the dead skin; leave the blister roof as a ‘biological dressing’
daily examination and skin culture to detect bacterial infection
Eye care:
daily assessment by ophthalmologist,
frequent eye drops/ointments (antiseptic, antibiotic, cortisone)
Mouth care:
mouthwashes
topical oral anaesthetic
Lung care:
may include aerosols, bronchial aspiration, physiotherapy
may require intubation and mechanical ventilation if trachea and bronchi are involved
Urinary catheter because of genital involvement and immobility
Psychiatric support for extreme anxiety and emotional lability
Physiotherapy to maintain joint movement and reduce risk of pneumonia
Regular assessment for infection including of skin, mucous membranes, catheter sites:
Staphylococcal infection is common; gram negative infection may also arise
appropriate antibiotic should be given if infection develops
prophylactic antibiotics are not recommended and may even increase the risk of sepsis