Dermatology: Dr. N. Shear Blaise Clarkson and Elana Lavine, Chapter Editors Harriette Van Spall, Associate Editor

DERMATOLOGY
Dr. N. Shear
Blaise Clarkson and Elana Lavine, chapter editors
Harriette Van Spall, associate editor
APPROACH TO THE DERMATOLOGY . . . . . . . 2 DRUG ERUPTIONS . . . . . . . . . . . . . . . . . . . . . . . . 30

PATIENT Exanthematous Eruptions
History Urticaria
Physical Exam Fixed Drug Eruption
Delayed Hypersensitivity Syndrome
DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Photosensitivity Eruptions
Primary Morphological Lesions Serum Sickness - Like Reaction
Secondary Morphological Lesions
Other Morphological Lesions ERYTHEMA MULTIFORME (EM), . . . . . . . . . . . 32
STEVENS-JOHNSON SYNDROME (SJS) AND
USEFUL DIFFERENTIAL DIAGNOSES . . . . . . . 3 TOXIC EPIDERMAL NECROLYSIS (TEN)
Differential Diagnosis by Morphology
Differential Diagnosis by Location ERYTHEMA NODOSUM . . . . . . . . . . . . . . . . . . . . 33
COMMON SKIN LESIONS . . . . . . . . . . . . . . . . . . 5 MALIGNANT SKIN TUMOURS . . . . . . . . . . . . . . 33
Hyperkeratotic Basal Cell Carcinoma (BCC)
Fibrous Squamous Cell Carcinoma (SCC)
Cysts Malignant Melanoma
Vascular Others
Melanocytic Nevi
Miscellaneous HERITABLE DISORDERS . . . . . . . . . . . . . . . . . . 36
Ichthyosis Vulgaris
ACNEIFORM ERUPTIONS . . . . . . . . . . . . . . . . . . 11 Neurofibromatosis (NF)
Acne Vulgaris/Common Acne Vitiligo
Rosacea
Perioral Dermatitis SKIN MANIFESTATIONS OF INTERNAL. . . . . 37
CONDITIONS
DERMATITIS (ECZEMA) . . . . . . . . . . . . . . . . . . . 13 Autoimmune Disorders
Contact Dermatitis Endocrine Disorders
Atopic Dermatitis HIV
Seborrheic Dermatitis Malignancy
Stasis Dermatitis Others
Nummular Dermatitis Pruritus
Dyshydrotic Dermatitis
Diaper Dermatitis WOUNDS AND ULCERS . . . . . . . . . . . . . . . . . . . 39
INFECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 ALOPECIA (HAIR LOSS) . . . . . . . . . . . . . . . . . . . 39
Bacterial Non-Scarring (Non-Cicatricial) Alopecia
Superficial Skin (Epidermal) Scarring (Cicatricial) Alopecia
Deeper Skin (Dermal)
Hair Follicles NAILS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Periungual Region
Sexually Transmitted Infections TOPICAL THERAPY . . . . . . . . . . . . . . . . . . . . . . . .41
Viral Infections Vehicles
Dermatophytosis Topical Steroids
Yeast Dry Skin Therapy
Parasitic
COSMETIC DERMATOLOGY . . . . . . . . . . . . . . .43
PAPULOSQUAMOUS DISEASES . . . . . . . . . . . . 25 Chemical Peel
Psoriasis Laser Therapy
Psoriasis Arthritis
Lichen Planus SUNSCREENS AND PREVENTIVE . . . . . . . . . . .43
Pityriasis Rosea THERAPY
VESICULOBULLOUS DISEASES . . . . . . . . . . . . . 28 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
Pemphigus Vulgaris
Bullous Pemphigoid
Dermatitis Herpetiformis (DH)
Porphyria Cutanea Tarda
Differential of Primary Bullous Disorder
MCCQE 2002 Review Notes Dermatology – D1
APPROACH TO THE DERMATOLOGY PATIENT
HISTORY
❏ age, race, occupation (especially exposures), hobbies
❏ details of skin eruption should include:
• location, onset, duration (persistent versus intermittent eruption)
• alleviating and aggravating factors (plant contact, cosmetic/jewellery use,
exposure to heat/cold/sunlight, relationship to foods/spices)
• associated skin symptoms
• changes in sensation (itchiness, burning, pain)
• changes in surface (dryness versus discharge)
• past history including investigations and therapy
❏ associated systemic symptoms (weight loss, malaise, fever, diarrhea, arthralgias, muscle weakness)
❏ medications and allergies
❏ past dermatological history
❏ family history of atopy, skin cancer, psoriasis
PHYSICAL EXAM (How to describe a Lesion)
❏ S ize
❏ C olour (e.g. hyperpigmented, hypopigmented, erythematous)
❏ A rrangement (e.g. solitary, linear, reticulated, grouped, herpetiform)
❏ L esion morphology (see Table 2)
❏ D istribution (e.g. dermatomal, intertriginous, symmetrical/asymmetrical, follicular)
❏ Always check hair, nails, mucous membranes and intertriginous areas
Table 1. Skin Phototypes

Phototypes Colour of Skin Without Skin’s Response to Sun Exposure
Sun Exposure
I White Always burns, never tans
II White Always burns, little tan
III White Slight burn, slow tan
IV Pale Brown Slight burn, faster tan
V Brown Rarely burns, dark tan
VI Dark brown/black Never burns, dark tan
DEFINITIONS
PRIMARY MORPHOLOGICAL LESIONS
Table 2. Types of Lesions
< 1 cm Diameter ≥ 1 cm Diameter
Raised Superficial Lesion Papule (e.g. wart) Plaque (e.g. psoriasis)
Palpable Deep (dermal) Nodule (e.g. dermatofibroma) Tumour (e.g. lipoma)

Lesion (not necessarily raised)
Flat Lesion Macule (e.g. freckle) Patch (e.g. vitiligo)
Elevated Fluid-filled Lesions Vesicle (e.g. herpes simplex virus (HSV)) Bulla (e.g. bullous pemphigoid)
❏ primary lesion: an initial lesion that has not been altered by trauma or manipulation, and has
not regressed
❏ pustule: a vesicle containing purulent exudate (white, yellow, green)
❏ cyst: a nodule containing semisolid or fluid material
❏ erosion: a disruption of the skin involving the epidermis alone
❏ ulcer: a disruption of the skin that extends into the dermis or deeper
❏ wheal: a special form of papule or plaque that is blanchable and
transient, formed by edema in the dermis (e.g. urticaria)
❏ scar: replacement fibrosis of dermis and subcutaneous tissue
SECONDARY MORPHOLOGICAL LESIONS
❏ develop during the evolutionary process of skin disease, or are created by manipulation
or complication of primary lesion lesion (e.g. rubbing, scratching, infection)
❏ crust: dried serum, blood, or purulent exudate originating from a lesion (e.g. impetigo)
❏ scale: excess keratin (e.g. seborrheic dermatitis)
D2 – Dermatology MCCQE 2002 Review Notes
DEFINITIONS . . . CONT.
❏ fissure: a linear slit-like cleavage of the skin
❏ excoriation: a scratch mark
❏ lichenification: thickening of the skin and accentuation of normal
skin markings (e.g. chronic atopic dermatitis)
❏ xerosis: dryness of skin, eyes and mouth
❏ atrophy: histological decrease in size and number of cells or tissues
resulting in thinning or depression of the skin
OTHER MORPHOLOGICAL LESIONS
❏ comedones: collection of sebum and keratin
• open comedone (blackhead)
• closed comedone (whitehead)
❏ purpura: extravasation of blood into dermis resulting in
hemorrhagic lesions
• petechiae: small pinpoint purpura
• ecchymoses: large flat purpura
❏ telangiectasia: dilated superficial blood vessels; blanchable
USEFUL DIFFERENTIAL DIAGNOSES

Table 3. Differential Diagnosis by Morphology
Dermatitis Nondermatitis
Red Scaling Lesions Atopic Dermatitis (flexural folds) Psoriasis (elbows/knees/scalp,
(epidermal cells produced Contact Dermatitis (history) nail pits, Koebner’s)
from excessive and Nummular Eczema (coin-like, isolated) Discoid Lupus (don’t see hair follicles)
abnormal keratinization Seborrheic Dermatitis (scalp/nasolabial folds/chest) Drug reaction (e.g. gold)
and shedding) Lichen Planus (flat surface, lacy lines
on surface)
Mycosis Fungoides (girdle area, leonine facies)
Pityriasis Rosea (Christmas-tree distribution)
Secondary Syphilis (palms + soles,
copper coloured)
Tinea (well demarcated, raised border)
Inflammatory Proliferative
Discrete Red Papules Acne (teenager, face/chest/back) Dermatofibroma (“dimple sign”)
(elevated/solid lesion < 1 cm) Bites/Stings (history of outdoors, central punctum) Hemangioma (blanching)
Folliculitis (in hair follicle) Psoriasis
Furuncle (very painful, central plug)
Hives (whitish border, pruritic)
Inflamed Epidermal Cyst (mobile under skin)
Inflamed Seborrheic Keratosis (stuck-on appearance)
Lichen Planus (purple, polygonal papules with flat surface)
Miliaria Rubra (heat/overbundling of child)
Pyogenic Granuloma (bleeds easily)
Scabies (burrow, interdigital/groin, family members)
Urticaria
Flat Brown Macule Actinic/Solar Lentigo (sun-damaged area)
(circumsrcibed flat and Congenital Nevus (contain hair)
discoloured area) Cafe-au-Lait (present in childhood, very light brown)
Hyper/hypopigmentation (e.g. posttraumatic, Addison’s)
Freckle (sun-exposed areas, disappears in winter)
Junctional Nevus (regular shape)
Lentigines associated with underlying disorders (LEOPARD, LAMB, Peutz-Jegher’s)
Lentigo Maligna (irregular, varied pigmentation)
Malignant Melanoma (characteristic atypia)
Pigmented Basal Cell Carcinoma
Simple Lentigo (non-sun exposed area, irregular)
Stasis Dermatitis
Viral Nonviral
Vesicles Viral Acute Contact Dermatitis (e.g. poison ivy)
(circumscribed collection • HSV (mouth, genitals) (exposure history)
of free fluid > 1 cm) • Zoster (dermatomal,painful) Cat-Scratch Disease
• Varicella (generalized, itchy) Dyshydrotic Eczema (sides of fingers/palms/soles)
• Molluscum (umbilicated) Dermatitis Herpetiformis (VERY itchy, gluten history)
• Coxsackie Impetigo
(painful, hand-foot-mouth, summer) Porphyria Cutanea Tarda
(hypertrichosis, heliotrope lesion around eyes,
alcohol ingestion)
Scabies
Bullae Bullous Impetigo (children, other family members)
(circumscribed collection Bullous Pemphigoid (tense, lower limb)
of free fluid > 1 cm) Drug eruption
EM/SJS/TEN (target lesions)
Lupus Erythematosus (American Rheumatology Association (ARA) criteria)
Pemphigus Vulgaris (flaccid, easy bleeding)
Poyphyria Cutanea Tarda (photodistribution, fragile skin, hyperpigmentation)
Dermatitis Herpetiforms (extensor surfaces, symmetrically grouped)
Acute dermatitis

USEFUL DIFFERENTIAL DIAGNOSES . . . CONT.
Table 3. Differential Diagnosis by Morphology (continued)
Pustules Acne (teenager, face/chest/back)
(elevated, contains Acne Rosacea (forties, telangiectatic, no comedones)
purulent fluid, Candida (satellite pustules, areas of skin folds)
varying in size) Dermatophyte infection
Dyshidrotic Eczema (sides of fingers/palms/soles)
Folliculitis (in hair follicle)
Hidradenitis suppurativa
Impetigo (honey-crust)
Sepsis (e.g. staph, gonococcal)
Pustular Psoriasis (psoriasis)
Rosacea
Varicella
Ulcer Common: Arterial, Venous, Neurotrophic, Pressure
(break in the skin that extends Uncommon: “CHIP IN” mnemonic
to the dermis, or deeper) Cancer (e.g. SCC), Chromosomal (e.g. XXY)
Hemoglobinopathy (e.g. Sickle Cell)
Inflammatory (e.g. RA, SLE, Vasculitis, Raynaud’s)
Pyoderma Gangrenosum (e.g. ulcerative colitis, RA)
Infectious (syphilis, TB, tularemia, plague)
Necrobiosis Lipoidica Diabeticorum (DM)
Oral Ulcers Aphthous
Cancer (SCC/BCC)
Dermatologic Diseases (Lichen Planus, Pemphigus vulgaris)
Iatrogenic (Chemo, Radiation)
Infectious (HSV/HZ, Coxsackie, HIV, CMV, TB, Syphilis, Aspergillosis, Cryptococcosis)
Inflammatory (SLE, Seronegatives, EM/SJS/TEN, allergic stomatitis)
Traumatic
Table 4. Differential Diagnosis by Location

Location Common Less Common and Rare
Scalp Seborrheic dermatitis, contact dermatitis, Pemphigus, DH
psoriasis, folliculitis, pediculosis, tinea, SCC
Ears Seborrheic dermatitis, psoriasis, infectious Fungal infection
eczematoid dermatitis, actinic keratoses
Face Acne, rosacea, impetigo, contact dermatitis, Lupus, actinic dermatitis, dermatomyositis,
seborrheic dermatitis, folliculitis, lentigo maligna melanoma
herpes simplex, BCC, SCC, actinic keratoses,
sebaceous hyperplasia
Eyelids Contact dermatitis (fingernail polish, hairspray),
seborrheic dermatitis, atopic eczema,
xanthelasma
Posterior Neck Neurodermatitis (LSC), seborrheic dermatitis, Acne keloidalis in black patients, acanthosis
psoriasis, contact dermatitis nigricans
Mouth Aphthae, herpes simplex, geographic tongue, Syphilis, lichen planus, pemphigus
contact dermatitis
Axillae Contact dermatitis, seborrheic dermatitis, Erythrasma, acanthosis nigricans,
hidradenitis suppurtiva inverse psoriasis, Fox-Fordyce disease
Chest and Back Seborrheic keratosis, dysplastic nevi, Secondary syphilis, Grover’s disease,
tinea versicolour, pityriasis rosea, acne, inverse psoriasis
seborrheic dermatitis, psoriasis, Herpes Zoster
cherry angioma, BCC, melanoma
Groin and Tinea, Candida, bacterial intertrigo, scabies,
Crural Areas psoriasis, pediculosis, granuloma inguinale,
lichen simplex
Penis Contact dermatitis, fusospirochetal and Primary and secondary syphilis,
candidal balanitis, chancroid, herpes simplex, balanitis xerotica obliterans, lichen planus
Condylomata (HPV), scabies
Hands Contact dermatitis, dyshydrotic eczema, Pustular psoriasis, granuloma annulare,
Tinea manis, (one-hand two feet), warts, erythema multiforme, secondary syphilis (palms)
atopic eczema, psoriasis, actinic and fungal infection
keratosis, solar lentigo
Cubital Fossae and Atopic eczema, contact dermatitis
Popliteal Fossae and prickly heat
Elbows and Knees Psoriasis, xanthomas Atopic ezcema, DH
Legs Contact dermatitis, stasis dermatitis, ulcers, Pyoderma gangrenosum, erythema nodosum,
nummular eczema, melanoma, ichthyosis leukocytoclastic vasculitis, HSP and other
vasculitidies
Feet Fungal infection, primary or secondary Psoriasis, erythema multiforme,
bacterial infection, contact dermatitis, secondary syphilis (soles),
atopic eczema, warts acral lentiginous melanoma (soles)

COMMON SKIN LESIONS
HYPERKERATOTIC
Seborrheic Keratosis (Senile Keratosis) (see Colour Atlas D8)
❏ definition: benign neoplasm of epidermal cells
❏ epidemiology
• > 30 years, M>F
• autosomal dominant inheritance
• more common with increasing age
❏ differential diagnosis
• solar lentigo
• spreading pigmented actinic keratosis
• pigmented basal cell carcinoma
• malignant melanoma (lentigo maligna, nodular melanoma)
• melanocytic nevi
❏ signs and symptoms
• round/oval, well demarcated discrete waxy papule/plaque, +/– pigment, warty surface,
“stuck on” appearance
• sites: face, trunk, upper extremities
• usually asymptomatic
❏ clinical course
• over time, increase in pigmentation, “stuck on” plaque appears warty, “horny cysts”
❏ investigations
• biopsy only if diagnosis uncertain
❏ management
• no treatment usually needed
• liquid nitrogen for cosmetic reasons
Actinic Keratosis (Solar Keratosis) (see Colour Atlas D19)
❏ definition: premalignant epithalial neoplasm
❏ epidemiology
• middle age and elderly (except in sunny climates)
• M>F, skin phototypes I-III (see Table 1)
• melanin is protective
❏ pathophysiology
• UV radiation damage to keratinocytes (especially UVB)
• pleomorphic keratinocytes, parakeratosis and atypical keratinocytes
• chronic cutaneous lupus erythematosus
• Bowen’s Disease
• SCC in situ
• superficial BCC
• discrete yellow-brown, scaly patches on a background of sun damaged skin (sand-like on palpation)
• < 1 cm, round/oval
• sites: areas of sun exposure - face (forehead, nose, cheeks,
lips, temples), ears, scalp if bald, neck, forearms, hands, shins
❏ clinical course
• may transform into SCC
❏ management
• 5-FU (fluorouracil) cream applied for 2-3 wks
• liquid nitrogen
• biopsy lesions that are refractory to treatment
Keratoacanthoma (see Colour Atlas D18)
❏ definition
• benign epithelial neoplasm with atypical keratinocytes
❏ epidemiology
• > 50 years, rare under 20 years
• skin phototypes I-III
❏ etiology
• associated with human papilloma virus (HPV)
• associated with UV radiation and chemical carcinogens (tar, pitch, mineral oil)
❏ pathophysiology
• proliferation of atypical keratinocytes in epidermis
• squamous cell carcinoma (SCC) (grows slower – months)
• red/skin coloured, firm, dome-shaped nodule with central keratin-filled crater
• sites: sun-exposed skin
❏ clinical course
• rapidly grow to ~2.5 cm in 6 weeks, with keratotic plug in centre of nodule by 6 weeks
• attains full size in < 4 months,spontaneously regresses in < 10 months
• disfiguring scar after regression
❏ management
• surgical excision
• curettage and electrocautery
• if on lip treat as SCC
COMMON SKIN LESIONS . . . CONT.
FIBROUS
Dermatofibroma
❏ definition
• button-like benign dermal tumour
❏ epidemiology
• adults, F>M
❏ etiology
• unknown
• often associated with history of trauma or insect bites
❏ pathophysiology
• fibroblast proliferation in dermis
• malignant melanoma, blue nevus, Kaposi’s sarcoma, dermatofibrosarcoma protruberans
• firm, red-brown, solitary, well demarcated dermal papules or nodules with central dimpling and
hyperpigmentation at centre
• site: legs > arms > trunk
• Fitzpatrick’s sign: pressure causes skin retraction (dimple)
❏ management
• no treatment usually needed (excise if bothersome or diagnosis uncertain)
Skin Type Tags (papilloma, acrochordon, fibroepithelial polyp)
❏ definition
• benign outgrowth of skin
❏ epidemiology
• middle-aged and elderly, F>M, obese
• small, soft, skin-coloured or tan, pedunculated papule or papilloma, 1-10 mm
• sites: neck, axillae, and trunk
❏ management
• clipping, cautery
CYSTS
Epidermal Cysts (see Colour Atlas D11)
❏ definition
• keratin-containing cyst lined by epidermis
❏ epidemiology
• most common cutaneous cyst
• youth to middle age adult
• round, yellow/flesh coloured, slow growing, mobile, firm, fluctuant nodule/tumour
• mobile over deeper structures
• sites: scalp, face, upper trunk, buttocks
❏ clinical course
• central punctum may rupture (foul, cheesy odour, creamy colour) and produce inflammatory reaction
• increase in size and number over time, especially in pregnancy
❏ management
• excise completely before becomes infected
Pilar Cysts
❏ definition
• thick-walled cyst lined with stratified squamous epithelium and filled with dense keratin
❏ epidemiology
• secnd most common cutaneous cyst
• F>M
❏ etiology
• idiopathic, post-trauma (e.g. EEG)
• hard, pea to grape-sized nodules under scalp
• multiple lesions often present
❏ clinical course
• may rupture and produce inflammatory reaction
❏ management
• excision
Dermoid Cysts
❏ definition
• rare, congenital hamartomas
• thick-walled cyst filled with dense keratin
❏ pathophysiology
• arise from inclusion of epidermis along embryonal cleft closure lines
• most common at lateral third of eyebrow and midline under nose
❏ management
• excision
Ganglion
❏ definition
• cystic lesion originating from joint or tendon sheath
❏ management
• drainage +/– steroid injection if painful
• excise if bothersome
VASCULAR
Hemangiomas
❏ benign proliferation of vessels in the dermis
❏ red or blue nodules that blanch with pressure
❏ management options: argon laser, tattooing, cosmetics, excision with skin expansion
Nevus Flammeus (Port-Wine Stain)
❏ definition
• vascular malformation of dermal capillaries
❏ epidemiology
• 0.3% incidence
❏ etiology
• congenital
• associated with Sturge Weber syndrome (V1, V2 distribution)
• red to blue macule present at birth
• dermatomal distribution, rarely crosses midline
• most common site: nape of neck
❏ clinical course
• papules/nodules may develop in adulthood, no involution
❏ management
• laser or make-up
Cavernous Hemangioma
❏ definition
• deeply situated proliferation of thick-walled blood vessels
• soft, compressible bluish subcutaneous mass
• feels like a “bag of worms”
• site: anywhere (distribution may indicate underlying cranial abnormality)
❏ clinical course
• can ulcerate
• 80% without scarring or discoloration
❏ management
• may require surgical removal
Angiomatous Nevus (Strawberry Nevus)
❏ congenital
❏ appears by age 9 months, increases in size over months, then regresses
❏ resolves spontaneously by age 6 years
❏ benign vascular proliferation of endothelial lining
❏ can excise if not gone by school age
Spider Angioma
❏ definition
• central arteriole with slender branches resembling legs of a spider
❏ epidemiology
• associated with hepatocellular disease, pregnancy, oral contraceptives (OCP)
• hereditary hemorrhagic telangiectacia, ataxia telangiectasia, telangiectasia in systemic scleroderma
• faintly pulsatile, blanchable, red macule
• sites: face, forearms and hands
❏ management
• electro or laser surgery
Cherry Hemangioma (Senile Hemangioma, Campbell Demorgan Spot)
❏ definition
• bright red, dome-shaped vascular papules, 1-5 mm
• site: trunk
❏ epidemiology
• > 30 years
• more common with increasing age
❏ clinical course
• increase in number over time
❏ management
• no treatment usually needed
• laser or electrocautery for small lesions
• excisions of large lesions if necessary

PIGMENTED LESIONS
Melanocytic Nevi (Moles) (see Table 5)
❏ be suspicious of new pigmented lesions in individuals over age 40
❏ average number of moles per person:18-40
Solar Lentigo (Aging Spots, Liver Spots)
❏ definition
• benign melanocytic proliferation in an area of previous sun damage
❏ epidemiology
• most common in Caucasians
• along dermal-epidermal junction
• > 40 years old
• skin phototype I-III
❏ pathophysiology
• increased number of melanocytes in dermal-epidermal junction due to chronic sun exposure
• well demarcated brown/black macules with an irregular outline
• sites: sun-exposed skin especially dorsum of hands and face
❏ management
• laser therapy
• shave excisions
• cryotherapy
❏ differential
• lentigo maligna
• seborrheic keratosis
• pigmented solar keratosis
Seborrheic Keratosis
Mongolian Spot
❏ definition
• congenital hyperpigmented macule
❏ epidemiology
• 99% occurs in Asian and aboriginal infants
❏ pathophysiology
• ectopic melanocytes in dermis
• gray-blue macule
• commonly on lumbosacral area, usually a single lesion
❏ clinical course
• disappears in early childhood
Freckles (Ephelides)
❏ definition
• commonly acquired hyperpigmented macules secondary to sun exposure
❏ epidemiology
• skin phototypes I and II
• most common in blonde and red haired individuals
• sharply demarcated light brown-ginger macules
• usually < 5 mm
• lesions multiply and grow darker with sun exposure
Becher’s Nevus
❏ definition
• asymptomatic pigmented hamartoma
❏ epidemiology
• M>F
• often becomes noticeable at puberty
❏ pathophysiology
• increased melanin in basal cells
• light brown macule with a papular verrucous surface and sharply demarcated borders
• sites: trunk and shoulders
• hair growth follows onset of pigmentation and is localized to areas of pigmentation
❏ clinical course
• lesion extends for 1-2 years and then remains stable, only rarely fading
• no malignant potential
❏ management
• cosmetic management as desired
• no treatment required

MISCELLANEOUS
Keloid
❏ definition
• excessive proliferation of collagen following trauma to skin
❏ epidemiology
• predilection for Blacks and Orientals
• M=F
• skin coloured or red or bluish papules or nodules
with clawlike extensions
• firm and smooth
• different from a hypertrophic scar
• may continue to expand in size for years
• sites: earlobes, shoulders, sternum, scapular area
❏ management
• intralesional steroid injections
• cryotherapy
• silicone compression
Pyogenic Granuloma
❏ definition
• rapidly developing hemangioma
❏ epidemiology
• < 30 years
❏ pathophysiology
• proliferation of capillaries with erosion of epidermis and neutrophilia
• nodular malignant melanoma
• SCC, nodular BCC
• glomus tumour
• bright red dome shaped sessile or pedunculated nodule
• sites: fingers, lips, mouth, trunk, toes
❏ clinical course
• lesions bleed frequently and persist for months
❏ management
• surgical excision with histologic examination
• electrocautery
• laser
• cryotherapy

Table 5. Melanocytic Nevi Classification
Type Age of Onset Description Histology Treatment
Congenital Nevus • Birth • Sharply demarcated pigmented brown • Nevomelanocytes in epidermis (clusters) • Surgical excision if suspicious, due to
plaque with regular/irregular and dermis (strands) increased risk of developing plaque
contours +/– coarse hairs melanoma
• > 1.5 cm
D10 – Dermatology
• Rule out leptomeningeal involvement
if on head/neck
Acquired Melanocytic Nevus • Early childhood to age 40 • Benign neoplasm of pigment • Excisional biopsy required if
• Involute by age 60 forming nevus cells on scalp, soles, mucous membranes,
• Well circumscribed, round, uniformly anogenital area, or if variegated
pigmented macules/papules colours, irregular borders, pruritic,
• < 1.5 cm bleeding, exposed to trauma
• Can be classified according to site
of nevus cells (see below)
• Junctional Nevus • Flat, irregularly bordered, uniformly • Melanocytes at dermal-epidermal • Same as above
tan-dark brown, sharply demarcated unction above basement membrane
smooth macule
• Compound Nevus • Domed, regularly bordered, smooth, • Melanocytes at dermal-epidermal junction; • Same as above
(see Colour Atlas D22) round, tan-dark brown papule migration into dermis
• Face, trunk, extremeties, scalp
• NOT found on palms or soles
• Dermal Nevus • Soft, dome-shaped, skin-coloured to • Melanocytes exclusively in dermis • Same as above
tan/brown papules or nodules often
with telangiectasia
• Sites: face, neck
Dysplastic Nevus • Childhood • Variegated macule/papule with irregular • Hyperplasia and proliferationof • Follow q 2-6 months with colour
(Clark’s Melanocytic Nevus) indistinct borders and focal elevation melanocytes in the basal cell layer photographs
• > 6 mm • Excisional biopsy if lesion changing or
• Risk factors: postive family history highly atypical
100% lifetime risk of malignant melanoma
with 2 blood relatives with melanoma
(0.8% risk for general population)
Halo Nevus • First 3 decades • Brown papules surrounded by • Dermal or compound neocellular nevus • None required
hypomelanosis (NCN) surrounded byhypomelanosis, • Excision if colour variegated or irregular
• Oval or round lymphocytes, histocytes borders
• Same sites as neocellular nevus (NCN)
• Associated with vitiligo, metastatic
melanoma
• Spontaneous involution with regression
of centrally located pigmented nevus
Blue Nevus • Childhood and late adolesence • Uniformly blue to blue-black • Pigmented melanocytes and • Remove if suddenly appears or has
macule/papule with smooth border melanophages in dermis changed
MCCQE 2002 Review Notes

• < 6 mm
ACNEIFORM ERUPTIONS
ACNE VULGARIS/COMMON ACNE (see Colour Atlas D5)
Definition and Clinical Features
❏ a common inflammatory pilosebaceous disease categorized with respect to severity of acne
Type I – comedonal, sparse, no scarring
Type II – comedonal, papular, moderate +/- little scarring
Type III – comedonal, papular, and pustular, with scarring
Type IV – nodulocystic acne, risks of severe scarring
❏ predilection sites: face, neck, upper chest, back
❏ epidemiology
• common during teen years
• severe disease affects males 10x more frequently than females
• incidence decreases in adult life
Pathogenesis
❏ increased sebum production
❏ sebum is comedogenic, an irritant, and is converted to free fatty acids (FFA) by
microbial lipases made by anaerobic diphtheroid Propionibacterium acnes
❏ free fatty acids + bacteria ––> inflammation + delayed hypersensitivity reaction
––> hyperkeratinization of follicle lining with resultant plugging
Exacerbating Factors
❏ menstruation/hormonal factors
❏ oral contraceptives (OCP): specifically those containing progestins with significant androgenic effects
(norethindrone acetate, levo/norgestrel)
❏ topical acnegenic agents
• workplace - heavy oils, grease, tars
• topical drugs - steroids, tars, ointment vehicles
• cosmetics - especially those containing cocoa butter, fatty acids, isopropyl myristate
❏ systemic meds: lithium, phenytoin, steroids, halogens (chloracne), androgens, iodides, bromides, danazole
❏ NB: foods are not a major aggravating factor
Differential Diagnosis
❏ rosacea
❏ folliculitis
❏ perioral dermatitis
❏ keratosis pilaris (arms, face)
Table 6. Acne Types and Treatments

Acne Type Treatment Options
Type I - Comedonal Benzoyl Peroxide (2.5%, 5%, 10%) – apply qd/bid
Adapalene (Differin) gel/cream; apply qhs sparingly
Tretinoin (Retin-A); apply qhs
• start with 0.01% and increase to 0.025% after one month
Tazarotene (Tazorac) (0.5%; 0.1% gel), apply qhs sparingly
Type II - Pustular Topical Antibiotic (clindamycin, erythromycin); apply bid

Benzoyl Peroxide
Tretinoin/ Adapalene gel/cream
Benzamycin gel (kept in patient’s refrigerator)
Type III - Papular Topical Antibiotic

Benzoyl Peroxide
Tretinoin
Oral Antibiotic (tetracycline, minocycline, erythromycin)
Type IV - Nodulocystic Isotretinoin (Accutane)

• 0.5 to 1.0 mg/kg/day for duration required to give
cumulative dose of 120-150 mg/kg

ACNEIFORM ERUPTIONS . . . CONT.
Table 7. Acne Treatments and Mechanisms of Action

Medication Mechanism of Action and Comments
Benzoyl Peroxide Bactericidal - for mild inflammatory lesions

May bleach fabrics
Adapalene Comedolytic - for comedones

Less irritating than tretinoin
No interaction with sun
Expensive
Tretinoin/ Comedolytic - for comedones

Tazarotene Causes sun sensitivity and irritation
Topical Antibiotic Bacteriostatic and anti-inflammatory - for inflamed lesions

Well tolerated
Oral Antibiotic Decreased bacterial and fatty acid levels; anti-inflammatory; inhibits leukocytic chemotaxis
Beware interaction between tetracycline and dairy products and antacids
Tetracycline can cause photosensitivity
Isotretinoin Most effective treatment for acne, reserved for severe cases
Reduces sebum production and causes atrophy of sebaceous glands,
increases skin cell turnover (comedolytic), inhibits bacterial growth in skin
Baseline CBC, pregnancy test, LFTs, TG, and cholesterol prior to start of therapy
Repeat tests at 2/6/10/14 weeks
Side effects: teratogenic, skin and mucous membrane dryness, hyperlipidemia,
reversible alopecia, abnormal LFTs
Other Treatments
❏ cryotherapy (for cysts)
❏ intralesional steroids (for cysts)
❏ dermabrasion
❏ chemical peel
❏ CO2 laser
❏ spironolactone – antiandrogen
❏ Diane-35 OCP (cyproterone acetate + ethinyl estradiol)
❏ high-estrogen OCP
❏ autovaccine (benefits not fully understood)
ROSACEA (see Colour Atlas D6)

❏ definition
• capillary vasodilation, papules, and pustules
❏ epidemiology
• 30-50 years old
• F>M
❏ pathophysiology
• unknown
• vascular: intermittent than persistent erythema/flushing, telangiectasias
• acneiform: papules, pustules, cysts; no comedones; symmetrical distribution
on forehead, cheeks, nose, chin
• ocular: conjunctivitis, blepharitis, keratitis
• rhinophyma: progressive enlargement of nose with sebaceous hyperplasia
• differentiated from acne by its absence of comedones
❏ exacerbating factors
• heat, cold, wind, sun, stress, drinking hot liquids, alcohol, caffeine, spices
(triggers of vasodilatation)
❏ cllinical course
• prolonged course common, recurrences common, may
disappear spontaneously

ACNEIFORM ERUPTIONS . . . CONT.
❏ management
• avoid exacerbating factors
• topical
• antibiotics (metronidazole 0.75% gel or 0.75% - 10% cream, clindamycin or erythromycin
have anti-inflammatory mechanisms; apply all bid)
• systemic
• tetracycline or erythromycin 250 mg qid until flare controlled then as needed,
maintenance dose 250 mg qd or every other day
• alternatives: minocycline, doxycycline
• others
• lasers for telangiectasias
• surgical “shaving”, CO2 laser for rhinophyma
• camouflage makeup for erythema
• treatment of H.pylori in affected individuals has been shown to decrease rosacea severity
• Rosacea Awareness Program (RAP)
• educational resources for physicians and rosacea patients
• accessible through physician offices and by toll-free telephones (in Canada)
• systemic lupus erythematosus (SLE)
• carcinoid syndrome
• acne vulgaris
• perioral dermatitis
PERIORAL DERMATITIS
❏ definition
• distinctive pattern of discrete erythematous micropapules that often become confluent,
forming inflammatory plaques on perioral and periorbital skin
❏ epidemiology
• 15 to 40 years old
• predominantly females
• initial lesions usually in nasolabial folds
• symmetry common
• rim of sparing around vermilion border of lips
❏ exacerbating factors
• inappropriate use of potent topical corticosteroids
❏ management
• topical
• metronidazole 0.75% gel or 0.75% - 10% cream to area bid
• systemic
• tetracycline 500 mg bid until clear, then 500 mg daily for one month, then 250 mg daily
for one additional month
DERMATITIS (ECZEMA)
❏ definition
• inflammation of the skin
❏ pathophysiology
• spongiosis, aka intercellular epidermal edema, with lymphocytic and eosinophilic infiltrates
in epidermis and dermis
• symptoms include pruritus and pain
• acute dermatitis: papules, vesicles
• subacute dermatitis: scaling, crusting
• chronic dermatitis: after lots of scratching, lichenification, xerosis and fissuring
CONTACT DERMATITIS (see Colour Atlas D2)
❏ definition
• cutaneous inflammation from interaction between external agent(s) and skin
❏ classification
1. irritant contact dermatitis
• toxic injury to the skin
• majority of contact dermatitis
• will occur in anyone given a sufficient concentration of irritants
• non-immune
• may be acute - quick reaction, sharp margins (e.g. from acid/alkali exposure)
• may be from cumulative insult - slow to appear, poorly defined margins (e.g. from soap)
• palmar surface of hand usually involved
• irritants include: soaps, weak alkali, detergents organic solvents, alcohol, oils
• management
• avoidance of irritants, compresses, topical and oral steroids

DERMATITIS (ECZEMA) . . . CONT.
2. allergic contact dermatitis
• cell-mediated delayed (Type IV) hypersensitivity reaction
• minority of contact dermatitis
• often discrete area of skin involvement
• patient acquires susceptibility to allergen, and persists indefinitely
• many allergens are irritants, so may coincide with irritant dermatitis
• dorsum of hand usually involved
• management
• avoid allergen and its cross reactants
• wet compresses soaked in Burow’s solution (a drying agent)
• change q3h, steroid cream (hydrocortisone 1%, betamethasone valerate 0.05% or
0.1% cream applied bid)
• systemic corticosteroids for extensive cases (prednisone 1mg/kg and reduce over 2 weeks)
ATOPIC DERMATITIS (ECZEMA) (see Colour Atlas D3)

❏ definition
• subacute and chronic eczematous reaction caused by Type I (IgE-mediated)
hypersensitivity reaction (release of histamine) producing prolonged severe pruritus
❏ etiology
• associated with personal or family history of atopy (asthma, hay fever, anaphylaxis, eosinophilia)
• polygenic inheritance: one parent > 60% chance for child; two parents > 80% chance for child
• inflammation, lichenification, excoriations are secondary to relentless scratching
• atopic palms: prominent palmar creases
• associated with
• keratosis pilaris (hyperkeratosis of hair follicles, “chicken skin”)
• xerosis
• occupational hand dryness
Table 8. Phases of Atopic Dermatitis
Phase Distribution
Infant (onset at 2-6 months old) Face, scalp, extensor surfaces

Childhood (>18 months) Flexural surfaces
Adult Hands, feet, flexures, neck, eyelids, forehead, face, wrists
❏ management
• bath additive (Aveeno oatmeal) followed by application of
unscented emollients, or menthol (cooling agent)
• topical corticosteroids with oral antihistamines
• avoid prolonged potent dose; hydrocortisone cream for maintenance
• alternate with lubricants or tar solution
• avoid systemic corticosteroids
• antibiotic therapy if 2º infection by S. aureus e.g. fusidic acid cream
• Tacrolimus ointment for resistant atopic dermatitis in
children (0.03%) and adults (0.1%); main side effect is stinging for the first few applications
❏ prognosis
• 50% clear by age 13, few persist > 30 years of age
❏ complications
• may present as flares of dermatitis
• corticosteroid reaction
• bacterial superinfection (staph or strep)
• eczema herpeticum (HSV colonization of lesions)

DERMATITIS (ECZEMA) . . . CONT.
SEBORRHEIC DERMATITIS (see Colour Atlas D4)
❏ definition
• greasy, erythematous, yellow, non-pruritic scaling papules and plaques occurs in areas rich
in sebaceous glands
❏ epidemiology
• common in infants (“cradle cap”) and at puberty
• increased incidence in immunocompromised patients
• in adults, can cause dandruff (pityriasis sicca)
• sites: scalp, eyebrows, eyelashes, beard, face (flush areas,
behind ears, forehead), trunk, body folds, genitalia
❏ etiology
• possible etiologic association with the yeast Pityrosporum ovale
• possibly a pre-psoriatic state
• infants - one possible cause of “cradle cap”
• children - may be generalized with flexural and scalp involvement
• adults - scalp: diffuse in areas of scalp margin with yellow to white
flakes, pruritis, and underlying erythema
• face: eyebrows, sides of nose, posterior ears, globella
• chest: over sternum
❏ management
• face: Nizoral cream od + non-fluorinated steroid cream,
e.g. hydrocortisone 1%, tridesilon cream applied od – bid
• scalp: salicylic acid in olive oil or Derma-Smoothe FS lotion
(peanut oil, mineral oil, fluocinolone acetonide 0.01%)
to remove dense scales, 2% ketoconazole shampoo (Nizoral),
low potency steroid lotion e.g. betamethasone valerate 0.1% lotion bid
STASIS DERMATITIS (see Colour Atlas D1)

❏ definition and clinical features
• persistent skin inflammation of the lower legs with a tendency
toward brown pigmentation, erythema, and scaling
• associated with venous insufficiency
❏ management
• support stocking
• rest and elevate legs
• moisturizer to treat xerosis
• mild topical corticosteroids to control inflammation
• surgical vein stripping for cosmetic reasons only
❏ complications
• secondary bacterial infections, ulceration (common in medial malleolus)
NUMMULAR DERMATITIS
• annular coin-shaped pruritic plaques
• dry, scaly, lichenified
• often associated with atopy and dyshydrotic dermatitis
• secondary bacterial infection common
❏ treatment
• potent corticosteroid ointment e.g. Cyclocort ointment bid or
intralesional triamcinolone injection if severe
DYSHYDROTIC DERMATITIS
❏ definition
• “Tapioca pudding” papulovesicular dermatitis of hands and
feet, followed by painful fissuring
❏ pathophysiology
• NOT related to sweating
• acute vesicular lesions that coalesce into plaques
• plaques dry with local scale
• acute stage often very itchy
• secondary infection common
• lesions heal with desquamation and may lead to chronic lichenification
• sites: palms and soles +/– dorsal surfaces of hands and feet
❏ management
• topical
• high potency corticosteroid with saran wrap occlusion to increase penetration
• intralesional triamicinolone
• systemic
• prednisone in severe cases
• antibiotics for 2º S. aureus infection
DIAPER DERMATITIS (see Pediatrics Chapter)

INFECTIONS
BACTERIAL
❏ often involve the epidermis, dermis, hair follicles or periungual region
❏ may also be systemic
SUPERFICIAL SKIN (EPIDERMAL)
Impetigo Vulgaris (see Colour Atlas F5)
• acute purulent infection which appears vesicular and
progresses to a golden yellow crust surrounded by erythema
• sites: commonly involves the face, arms, legs and buttocks
❏ epidemiology
• preschool and young adults living in crowded conditions, poor hygiene,
neglected minor trauma
❏ etiology
• agent: Group A ß hemolytic Streptococcus, S. aureus, or both
• infected eczema, herpes simplex (HSV), varicella
❏ management
• remove crusts and use saline compresses, plus topical
antiseptic soaks bid
• topical antibacterials such as 2% mupirocin or fucidin tid,
continued for 7-10 days after resolution
• systemic antibiotics such as cloxacillin 250-500 mg qid or
cephalexin 250 mg qid for 7-10 days
❏ complication
• post-streptococcal glomerulonephritis
Bullous Impetigo
• scattered, thin walled bullae arising in normal skin and
containing clear yellow or slightly turbid fluid with no
surrounding erythema
• sites: trunk, intertriginous areas, face
❏ epidemiology
• neonates and older children, epidemic especially in day care
❏ etiology / pathophysiology
• S. aureus group II elaborating exfoliating toxin
• bullous drug eruption
• pemphigus
❏ investigations
• gram stain and culture of blister fluid or biopsy
❏ management
• cloxacillin 250-500 mg qid for 7-10 days
• topical antibacterials such as fucidin and mupirocin,
continued for 7-10 days
❏ complication
• high levels of toxin in immunocompromised or young children
may lead to generalized skin peeling or staphylococcal scalded skin syndrome (SSSS)
Erythrasma
• infection of the stratum corneum that manifests as a sharply demarcated,
irregularly shaped brown, scaling patch
• sites: intertriginous areas of groin, axillae, intergluteal folds,
submammary, toes
❏ epidemiology
• obese, middle-aged, blacks, diabetics, living in warm humid climate
❏ etiology
• Corynebacterium minutissimum
❏ diagnosis
• “coral-red” fluorescence under Wood’s light (365 nm) because of a water-soluble porphyrin
• tinea cruris (positive scraping for hyphae)
• seborrheic dermatitis (no fluorescence)
❏ management
• showers with providone-iodine soap
• topical econazole cream or 2% erythromycin solution applied bid for 7 days
• erythromycin (250 mg qid for 14 days) for refractory cases or recurrences
INFECTIONS . . . CONT.
DEEPER SKIN (DERMAL)
Table 9. Comparison of Erysipelas and Cellulitis
Erysipelas (see Colour Atlas ID8) Cellulitis
Lesion • Upper dermis • Lower dermis/Subcutaneous fat

• May be confluent, erythematous, raised, warm plaque • Unilateral erythematous flat lesion poorly
often with vesicles demarcated, not uniformly raised
• Very painful (once called St. Anthony’s fire) • Tender
Distribution • Face and legs • Commonly legs
Etiology • GAS • GAS, S. aureus (large sized wounds),
H.fluenzae (periorbital),
Pasteurella multocida (dog/cat bite)
Systemic • Fever, chills, headache, weakness (more serious) • Fever, leukocytosis, lymphadenopathy
symptoms (less common)
Complications • Scarlet fever, streptococcal gangrene, fat necrosis, • Less likely

coagulopathy
• Spreads through lymphatics – if recurrent may cause
elephantiasis
Treatment • First line: Penicillin, Cloxacillin or Ancef • First line: Cloxacillan or Ancef/Keflex
• Second line: Clindamycin or Keflex • Second line: Erythromycin or Clindamycin
• If penicillin allergic use erythromycin • Children: Cefuroxime
• DM (foot infections): TMP/SMX and Flagyl
check for history of trauma, bites, saphenous vein graft, etc., but often no inciting cause identified
rarely skin/blood culture; clinical diagnosis. If suspecting necrotizing fasciitis, do immediate biopsy and
frozen section histopathology.
DDx: deep vein thrombosis (DVT) (less red, less hot, smoother), superficial phlebitis, RSD
Superficial Folliculitis
❏ definition
• superficial infection of the hair follicle
• pseudofolliculitis: inflammation of follicle due to friction, irritation or occlusion
❏ etiology
• normal non-pathogenic bacteria (Staphylococcus, Pseudomonas)
• acute lesion consists of a dome-shaped pustule at the mouth of hair follicle
• pustule ruptures to form a small crust
• sites: primarily scalp, shoulders, anterior chest, upper back, other hair-bearing areas
❏ management
• topical antibacterial (fucidin, mupirocin or erythromycin)
• oral cloxacillin for 7-10 days
• mupirocin bid for S. aureus in nostril and on involved hairy area
• keratosis pilaris
• HIV eosinophilic folliculitis
• pityrosporum yeast
Furuncles (Boils)
❏ definition
• red, hot, tender, inflammatory nodules involving subcutaneous
tissue that evolves from a folliculitis
❏ etiology
• S. aureus
• develops as a red, tender nodule that is tense for 2-4 days and then fluctuant
• yellowish point, which firms over summit, ruptures with discharge of tissue
• sites: hair follicles and areas of friction and sweat (nose, neck, face, axillae, buttocks)
❏ investigations
• if recurrent, rule out diabetes or hidradenitis suppurativa (if in groin or axillae)
❏ managemennt
• see ‘Carbuncles’

Carbuncles
❏ definition
• deep seated abscess formed by multiple coalescing furuncles
• lesions drain through multiple points to the surface
❏ etiology
• S. aureus
❏ management
• incise and drain large carbuncles to relieve pressure and pain
• if afebrile: hot wet packs, topical antibiotic
• if febrile/cellulitis: culture blood and aspirate pustules (Gram stain and C&S)
• cloxacillin 250-500 mg qid for 1 to 2 weeks
SEXUALLY TRANSMITTED INFECTIONS
Syphilis
• sexually transmitted infection caused by Treponema pallidum
characterized by a painless ulcer (chancre)
• transmitted sexually, congenitally, or rarely, by transfusion
• following inoculation, becomes a systemic infection with
secondary and tertiary stages
❏ primary syphilis (see Colour Atlas ID11)
• single red, indurated, PAINLESS, round / oval, indolent, chancre,
(Hunterian Chancre, [button-like papule]) that develops into
painless ulcer with raised border and scanty serous exudate
• chancre develops at site of inoculation after 3 weeks of incubation
and heals in 4-6 weeks; chancres may also develop on lips or anus
• regional non-tender lymphadenopathy appears < 1 week after onset of chancre
• M:F = 2:1
• diagnosis
• cannot be based on clinical presentation alone
• VDRL negative – repeat weekly for 1 month
• fluorescent treponemal antibody-absorption (FTA-ABS)
test has greater sensitivity and may detect disease earlier in course
• darkfield examination - spirochete in tissue fluid from
chancre or lymph node aspirate
• management
• benzathine penicillin G 2.4 million units IM, single dose
• if allergic to penicillin, alternatives include doxycyline,
tetracycline PO, or ceftriaxone IM
• differential diagnosis
• chancroid: painful
• HSV: multiple lesions
❏ secondary syphilis (see Colour Atlas ID13)
• appears 2-10 weeks after initial chancre, and 2-6 months after
primary infection (patient may not recall presence of primary chancre)
• associated with generalized lymphadenopathy, splenomegaly,
“acute illness” syndrome – headache, chills, fever,
arthralgia, myalgia, malaise and photophobia
• lesions heal in 1-5 weeks, and may recur for 1 year
• types of lesions
(1) macules and papules, round to oval, flat top, scaling,
non-pruritic, sharply defined, circular (annular) rash
• trunk, head, neck, palms, soles, mucous membranes
• DDx: pityriasis rosea, tinea corporis, drug eruptions, lichen planus
(2) condyloma lata: moist papules around genital/perianal region
• exudate filled with spirochetes
• DDx includes condyloma acuminata
(3) mucous patches: macerated patches mainly found in oral mucosa
• associated findings: pharyngitis, iritis, periostosis
• diagnosis
• VDRL positive
• FTA-ABS +ve; –ve after 1 year following appearance of chancre
• TPI +ve; darkfield +ve in all secondary syphilis except macular exanthem
• serologic test may be –ve if undiluted serum, or if HIV-infected
❏ management - as for primary syphilis
• tertiary syphilis
• extremely rare
• 3-7 years after secondary
• main skin lesion: ‘Gumma’ - a granulomatous non-tender nodule
• independent of other tertiary syphilis manifestations
• diagnosis
• VDRL: blood positive, CSF negative
• treatment: benzathine penicillin G 2.4 million units IM weekly

Gonococcemia
❏ definition
• disseminated gonococcal infection
❏ etiology
• gram negative diplococcus Neisseria gonorrheae
• pustules on a purpuric erythematous base, and pustules that
are hemorrhagic, tender, and necrotic (also known as “arthritis-dermatitis syndrome”)
• petechiae which may evolve into purpura and ecchymosis (see Colour Atlas ID1)
• associated with fever, asymmetric oligoarticular arthritis,
urethritis, proctitis, pharyngitis and tenosynovitis
• conjunctivitis if infected via birth canal
• site: distal aspects of extremities
• NB - do not confuse with skin lesion of meningococcemia
❏ management
• examine contacts and notify authorities
• look for syphilis and other STDs
• advise patient to avoid intercourse until cultures are negative
• ceftriaxone 125 mg IM or cefixime 400 mg po (drug of choice)
VIRAL INFECTIONS
Herpes Simplex
❏ clinical features
• grouped umbilicated vesicles (herpetiform arrangement) on
an erythematous base, caused by Herpes Simplex virus (HSV)
• transmitted via contact with erupted vesicles
• vesicles located on skin or mucous membranes
• primary
• children and young adults
• usually asymptomatic
• may have high fever, regional lymphadenopathy, malaise
• followed by antibody formation and latency of virus (in posterior root ganglion
[Gasserian ganglion of trigeminal nerve or sacral ganglion])
• secondary
• recurrent form seen in adults
• prodrome of tingling, pruritus, pain
• much more commonly diagnosed than primary
• triggers for recurrence: fever sunburn, physical trauma, menstruation,
emotional stress, upper respiratory tract viral infection
Classification
❏ 2 biologically and immunologically different subtypes: HSV-1 and HSV-2
❏ HSV-1
• most commonly “cold sores” (grouped vesicles which quickly
burst and commonly occur at the muco-cutaneous junction)
• recurrent on face, lips
• rarely on mucous membranes (rule out aphthous ulcer)
• impetigo
• eczema
❏ HSV-2
• incubation 2-20 days
• gingivostomatitis (entire buccal mucosa involved with erythema and edema of gingiva)
• vulvovaginitis (edematous, erythematous, extremely tender, profuse vaginal discharge)
• urethritis (watery discharge in males)
• recurrent on vulva, vagina, penis, lasting 5-7 days
• sexually transmitted
• 8% risk of transmission to neonate via birth canal if mother is asymptomatic
• diagnosis
• –ve darkfield, –ve serology for syphilis, –ve bacterial cultures
• Tzanck smear shows multinucleated giant epithelial cells with Giemsa stain
• tissue culture and electron microscopy on vesicular fluid
• skin biopsy (intraepidermal, ballooning degeneration, giant cells)
• antibody titres increase one week after primary infection
(NB - increase in titres are not diagnostic of recurrence)
❏ differential diagnosis of genital ulcerations
• multiple syphilitic chancres
• chancroid
• Candida balanitis
• lymphogranuloma inguinale

❏ management of HSV
• rupture vesicle with sterile needle
• tepid wet dressing with aluminum subacetate solution, Burow’s compression, or betadine solution
• acyclovir: 200 mg PO, 5 times a day for 10 days for 1st episode
• topical therapy is generally not as effective
• famciclovir and valacyclovir may be substituted
• in case of herpes genitalis, look for and treat any other sexually transmitted infections
❏ complications
• dendritic corneal ulcers
• stromal keratitis
• erythema multiforme (EM)
• herpes simplex encephalitis
• HSV infection on atopic dermatitis causing Kaposi’s varicelliform eruption (eczema herpeticum)
Herpes Zoster (Shingles)
❏ definition
• a localized infection caused by varicella zoster virus (VZV) in a person who
has already had the primary infection chicken pox
❏ etiology
• occurs when cellular and humoral immunity to VZV is compromised
• risk factors: old age, immunosuppression, occasionally associated
with hematologic malignancy
❏ distribution: thoracic (50%), trigeminal (10-20%), cervical (10-20%); disseminated in HIV patients
• unilateral and dermatomal eruption occurring day 3-5 after pain and
paresthesia of a dermatome
• vesicles, bullae and pustules on an erythematous, edematous base
• lesions may become eroded/ulcerated and last days-weeks
• pain is pre-herpetic, synchromas with rash, or post-herpetic
(may persist for months and years)
• severe post-herpetic neuralgia often occurs in elderly
• involvement of tip of nose indicates eye involvement (conjunctivitis, keratitis, scleritis, iritis)
❏ management
• compresses with normal saline, Burow’s, or betadine solution
• analgesics (NSAIDs, amitriptyline)
• for patients over 50 years old, with severe acute pain or ophthalmic involvement
• famciclovir 500 mg tid X 7 days or
• valacyclovir 1,000 mg tid X 7 days or
• acyclovir 800 mg 5x day for 7 days (if immunocompromised)
Clinical Pearl
❏ In Herpes Zoster, antiviral treatment must be started within
72 hours of the onset of rash unless there is ophthalmic involvement.
• myocardial infarction (MI), pleural disease, acute abdomen, vertebral disease
• contact dermatitis
• localized bacterial infection
• zosteriform herpes simplex virus (more pathogenic for the eyes than varicella zoster)
Hand-Foot-and-Mouth Disease
• highly contagious vesicular eruption in hands, feets and mouth caused by coxsackie A16
• grey vesicles in parallel alignment to palmar and plantar creases of hands, feet and diaper area
• a painful ulcerative exanthem over buccal mucosa and palate
• 3-6 day incubation, resolves in 7-10 days
❏ epidemiology
• commonly affects young children
❏ management
• xylocaine gel as analgesic

Molluscum Contagiosum (see Colour Atlas ID3)
• discrete dome-shaped and umbilicated pearly white papules
caused by DNA pox virus (molluscum contagiosum virus (MCV))
❏ epidemiology
• afflicts both children and adults; M>F, MCV-1
• seen in 8-18% of symptomatic HIV and AIDS patients
• sites: eyelids (may cause conjunctivitis), beard (likely spread by shaving),
neck, axillae, trunk, perineum, buttocks
• transmission: direct contact, auto-inoculation, sexual
❏ management
• topical cantharidin (painless application, blisters within days)
• liquid nitrogen cryotherapy (10-15 seconds)
• curettage
• fibromata, nevi, keratoacanthoma, basal cell carcinoma
Verruca Vulgaris (Common Warts) (see Colour Atlas ID4)
• hyperkeratotic, elevated discrete epithelial growths with papillated surface
• caused by human papilloma virus (HPV) – at least 80 types are known
• located at trauma sites: fingers, hands, knees of children and teens
• paring of surface reveals punctate red-brown specks (dilated capillaries)
❏ management
• 65-90% resolve spontaneously over several years
• 40% salicylic acid paste under occlusion (keratolytic)
• cryotherapy with liquid nitrogen (10-30 seconds); no scar but hypopigmentation
• light electrodesiccation, curettage with local anesthesia
• seborrheic keratosis, molluscum contagiosum
Verruca Plantaris (Plantar Warts) and Verruca Palmaris (Palmar Warts)
• hyperkeratotic, shiny, sharply marginated papule/plaque
• caused by HPV 1, 2, 4, 10
• located at pressure sites: heads of metatarsal, heels, toes
• paring of surface reveals red-brown specks (capillaries), interruption of epidermal ridges
❏ management
• none if asymptomatic, disappears in 6 months
• if tender on lateral pressure, 40% salicylic acid plaster for 1 week then cryotherapy
• need to scrape (“pare”) lesions to differentiate wart from callus and corn
• callus: paring reveals uniformly smooth surface with no interruption of epidermal ridges
• corn (caused by underlying bony protuberance):
paring reveals shiny keratinous core, painful to vertical pressure
Verruca Planae (Flat Wart)
• multiple discrete, skin coloured, flat topped papules occurring grouped or in linear configuration
• common in children
• sites: face, dorsa of hands, shins, knees
❏ management
• electrodesiccation
• cryotherapy
Condylomata Acuminata (Genital Warts)
• skin coloured pinhead papules to soft cauliflower like masses in clusters
• caused by HPV that is immunologically distinct from HPV of verruca vulgaris
• types 6 and 11 are the most common causes
• types 16, 18, 31, 33 cause cervical dysplasia, squamous cell cancer and invasive cancer
of vagina and penis
• asymptomatic, lasts months to years
• sites: genitalia and perianal areas
• female: from cervix to labia and perineum
• male: from meatus to scrotum
❏ epidemiology
• young adults, infants, children
• highly contagious, transmitted sexually and non-sexually
(e.g. Koebner phenomenon via scratching, shaving)
• can spread without clinically apparent lesions
• children delivered vaginally by infected mothers are at risk for anogenital condylomata
and respiratory papillomatosis
❏ investigations
• acetowhitening: subclinical lesions seen with 5% acetic acid x 5 minutes and hand lens
(tiny white papules)
• false positives due to psoriasis, lichen planus
❏ management
• podophyllin (contraindicated in pregnancy)
• imiquimod
• 5-FU
• salicylic acid
• liquid nitrogen, electrocautery
• trichloroacetic acid (80-90%), intralesional interferon
• surgery only needed for giant lesions
❏ complications
• fairy-ring warts, ie. satellite warts at periphery of treated area of original warts
• condylomata lata (secondary syphilitic lesion, darkfield strongly + ve)
• molluscum contagiosum
• lichen planus
• pearly penile papules
DERMATOPHYTOSIS
❏ definition
• infection of skin, hair and nails caused by a species of dermatophyte (fungi that live within the
epidermal keratin and do not penetrate deeper structures)
❏ etiology
• Trichophyton, Microsporum, Pityrosporum, Epidermophyton species
❏ pathophysiology
• digestion of keratin by dermatophytes results in scaly skin, broken hairs, crumbling nails
❏ investigations
• skin scrapings, hair, and nail clippings analyzed with potassium hydroxide (KOH) prep
(since these fungi live as molds, look for hyphae, and mycelia)
❏ management
• topicals may be used as first line agents for tinea corporis/cruris and tinea pedis (interdigital type),
e.g. clotrimazole or terbinafine cream applied bid, continued till one week after complete
resolution of lesions
• oral therapy is indicated for onychomycosis, tinea capitus, e.g. terbinafine (Lamisil) or
itraconazole (Sporanox)
• itraconazole is a P-450 inhibitor. It alters metabolism of non-sedating antihistamines, cisapride,
digoxin, and HMG CoA reductase inhibitors
Tinea Capitis (see Colour Atlas D10)
❏ definition
• non-scarring alopecia with scale
❏ etiology
• Trichophyton tonsurans and Microsporum species
❏ epidemiology
• affects children (mainly black), immunocompromised adults
• very contagious and may be transmitted from barber, hats, theatre seats, pets
• round, scaly patches of alopecia
• may see broken off hairs
• if tissue reaction is acute, a Kerion (boggy, elevated, purulent inflamed nodule/plaque)
may form - this may be secondarily infected by bacteria and result in scarring
❏ investigations
• Wood’s light examination of hair: green fluorescence only for microsporum infection
• culture of scales/hair shaft may be done on Sabourad’s agar
• microscopic examination of a KOH preparation of scales or
infected hair shafts reveal characteristic hyphae
❏ management
• griseofulvin 15-20 mg/kg/day x 8 weeks or terbinafine (Lamisil) 250 mg od x 2-4 weeks
(vary dose by weight)
• psoriasis, seborrheic dermatitis, alopecia areata, trichotillomania

Tinea Corporis (Ringworm)
• pruritic, scaly, round/oval plaque with erythematous margin and central clearing
• single or multiple lesions
• peripheral enlargement of lesions
• site: trunk, limbs, face
❏ etiology
• T. rubrum, E. floccosum, M. cannis, T. cruris
❏ epidemiology
• most common in farm children and those with infected pets
❏ investigations
• microscopic examinations of KOH prep of scales scraped from active margin shows hyphae
• scales may be cultured on sabourad’s agar
• psoriasis
• seborrheic dermatitis
• nummular dermatitis
• pityriasis rosea
Tinea Cruris (“Jock Itch”)
• scaly patch/plaque with a well-defined, curved border and central clearing on medial thigh
• does not involve scrotum
• pruritic, erythematous, dry/macerated
❏ etiology
• T. rubrum, T. mentagrophytes, E. floccosum
❏ epidemiology
• most common in adult males
❏ investigations
• same as for Tinea corporis
• candidiasis (involvement of scrotum and has satellite lesions)
• erythrasma (coral-red fluorescence with Wood’s lamp)
• contact dermatitis
Tinea Pedis (Athlete’s Foot)
❏ definition
• pruritic scaling and/or maceration of the webspaces and powdery scaling of soles
• white vesicles, bullae, scale maceration
• interdigital
❏ etiology
• T. rubrum, T. mentagrophytes, E. floccosum
❏ epidemiology
• chronic infections are common in atopics
• heat, humidity, occlusive footwear are predisposing factors
• aute infection - red/white scales, vesicles, bullae, often with maceration
• may present as flare-up of chronic tinea pedis
• frequently become secondarily infected by bacteria
• chronic: non-pruritic, pink, scaling keratosis on soles, and sides of foot, often in a
“moccasin” distribution
• sites: interdigital, especially in 4th webspace
❏ investigations
• microscopic examination of a KOH prep of scales from roof of a vesicle or powdery scaling area
• culture of scales on sabourad’s agar
• dyshydrotic dermatitis
• allergic contact dermatitis (dorsum/heel)
• atopic dermatitis
• erythrasma, intertrigo (interdigital)
• psoriasis (soles or interdigital)
Tinea Manuum
• acute: blisters at edge of red areas on hands
• chronic: single dry scaly patch
• primary fungal infection of the hand is actually quite rare; usually associated with tinea pedis
with one hand and two feet affected = “1 hand 2 feet” syndrome
❏ etiology
• same as in tinea pedis
• contact dermatitis, atopic dermatitis, psoriasis (all three commonly mistaken for fungal infections)
• granuloma annulare (annular)
Tinea Unguium (Onychomycosis) (see Colour Atlas D9)
• crumbling, distally dystrophic nails; yellowish, opaque with subungual herperkeratotic debris
• toenail infections usually precede fingernail infections
❏ etiology
• T. rubrum (90% of all toenail infections)
❏ investigation
• KOH prep of scales from subungual scraping shows hyphae on microscopic exam
• subungal scraping may be cultured on Sabourad’s agar
❏ management
• terbinafine (Lamisil) 250 mg od (6 weeks for fingernails, 12 weeks for toenails) or pulse itraconazole
(Sporanox) at 200mg bid x 7d, then 3 weeks off (2 pulses for fingernails, 3 pulses for toenails)
• psoriasis (pitting, may have psoriasis elsewhere)
• trauma
• lichen planus
Pityriasis (tinea) Versicolour (see Colour Atlas ID7)
❏ definition
• chronic asymptomatic superficial fungal infection with brown/white scaling macules
❏ etiology
• P. ovale
❏ pathophysiology
• Malassezia furfur (Pityrosporum orbiculare) that produces cicarboxylic acid ––>
inflammatory reaction and inhibited melanin production, yielding variable pigmentation
❏ epidemiology
• P. ovale also associated with folliculitis and seborrheic dermititis
• young adults, M=F
• predisposing factors: summer, tropical climates, Cushing’s syndrome, prolonged corticosteroid use
• affected skin darker than surrounding skin in winter, lighter in summer (doesn’t tan)
• sites: upper trunk most common seen on face in dark skinned individuals
❏ investigations
• direct microscopic exam of scales for hyphae and spores (“spaghetti and meatballs”)
prepared in KOH
• Wood’s lamp (faint yellow-green fluorescence)
❏ management
• scrub off scales with soap and water
• selenium sulfide
• ketoconazole cream or 200mg PO daily for 10 days
YEAST
Candidiasis (see Colour Atlas ID10)
❏ Candidal paronychia: painful red swellings of periungual skin
❏ Candidal intertrigo
• macerated/eroded erythematous patches that may be covered with papules and pustules,
located in intertriginous areas
• peripheral “satellite” pustules
• often under breast, groin, interdigital
• predisposing factors - obesity, diabetes, systemic antibiotics, immunosuppression, malignancy
• intertrigo starts as non-infectious maceration from heat, moisture and friction;
evidence that it has been infected by Candida is a pustular border
• management
• keep area dry, miconazole cream bid until rash clears
❏ mucous membranes - glossitis (thrush), balanitis, vulvo-vaginitis
PARASITIC
Scabies (see Colour Atlas ID2)
❏ definition
• a transmissible parasitic skin infection (Sarcoptes scabiei, a mite),
characterized by superficial burrows, intense pruritus and secondary infection
• secondary lesions: small urticarial crusted papules, eczematous plaques, excoriations
• intractable pruritus worse at night (mite more active; pruritus is also worse at night)
• sites: axillae, cubitus, wrist, side of palm, web spaces, groin, buttocks, back of ankle, toes, penis;
sparing of head and neck, except in infants
• dermatitis herpetiformis: see vesicles, urticaria, eosinophilia, no burrows
• asteatotic eczema (“winter itch”)
• neurotic excoriation
Clinical Pearl
❏ Intractable pruritus worse at night.
❏ epidemiology
• risk factors: sexual promiscuity, crowding, poverty, nosocomial
• immunocompromised: Norwegian Scabies = Crusted Scabies; all over body
• scabies mite remains alive 2-3 days on clothing/sheets
• incubation = 1 month, then begin to itch
• re-infection followed by hypersensitivity in 24 hours
❏ investigations
• microscopic examination of root and content of burrow with KOH for mite, eggs, feces
❏ management
• bathe then apply Permethrin 5% cream (i.e. Nix) or Kwellada P from head (not neck)
down to soles of feet (must be left on for 8 hours)
• Nix and Kwellada P preferred in children (seizures reported with Kwellada’s old formulation)
• may require second treatment 7 days after first treatment
• change underwear and linens; wash with detergent in hot water cycle then dry with machine
• +/– antihistamine
• treat family and contacts
• pruritus may persist for 2-3 weeks due to prolonged hypersensitivity reaction
Lice (Pediculosis)
• intensely pruritic red excoriations, morbilliform rash, caused by louse which is a parasite
• scalp lice: nits on hairs; caused by Pediculus capitus
• red excoriated skin with secondary bacterial infection, lymphadenopathy
• pubic lice: nits on hairs; caused by Phthirus pubis
• excoriations
• rarely in chronic cases: “maculae ceruleae”= bluish grey, pea-sized macules
• NB: large portion of patients with pubic hair lice also have other STDs
• body lice: nits and lice in seams of clothing; caused by Pediculus corporis
• excoriations and secondary infection
• mainly on shoulders, belt-line and buttocks
• bacterial infection of scalp: responds rapidly to antibiotic
• seborrheic dermatitis: flakes of dandruff readily detached
• hair casts: pulled off more easily than nits, no eggs on microscopy
❏ management
• oral ivermectin 200 mg/kg very effective
• Permethrin 1% (Nix) cream rinse (ovicidal)
• Kwellada shampoo (kills newly hatched nits)
• comb hair with fine-toothed comb using dilute vinegar solution to remove nits
• repeat in 7 days
• bedding, clothing and towels should be changed and washed with detergent
in hot water cycle then dried in dryer
• in body lice, clothing must be washed
PAPULOSQUAMOUS DISEASES
PSORIASIS (see Colour Atlas D7 and RH23))
❏ types
• plaque psoriasis
• guttate psoriasis
• erythrodermic psoriasis
• pustular psoriasis
• psoriatic arthritis
❏ differential
• seborrheic dermatitis
• chronic dermatitis
• mycosis fungoides (cutaneous T-cell lymphoma)
Plaque Psoriasis
❏ definition
• a common chronic and recurrent disease characterized by well circumscribed erythematous
papules/plaques with silvery white scales, mostly at sites of repeated trauma
❏ epidemiology
• multifactorial inheritance: 30% with family history and HLA markers
❏ pathophysiology
• decreased epidermal transit time from basal to horny layers and shortened cell cycle of
psoriatic and normal skin
• exacerbating factors: drugs (lithium, ethanol, chloroquine, beta-blockers), sunlight, stress, obesity
• worse in winter (lack of sun and humidity)
• Koebner phenomenon (isomorphic response): induction of new lesion by injury
(e.g. in surgical wounds)
• Auspitz’s sign: bleeds from minute points when scale is removed
• sites: scalp, extensor surfaces of elbows and knees, trunk, nails, pressure areas

PAPULOSQUAMOUS DISEASES . . . CONT
❏ management
• topical treatment for mild to moderate cases
• topical plus systemic treatment is indicated in treatment of resistant or severe cases
• lubricants and avoidance of rubbing/friction are recommended in all cases
Table 10. Topical Treatment of Psoriasis
Treatment Mechanism Comments
Lubricants Reduce fissure formation Petroleum is effective
Salicylic acid 1-12% Remove scales
Anthralin .1%, .2%, .4% Increase cell turnover Stains and irritates normal skin
Tar (Liquor carbonis detergent) Inhibits DNA synthesis, Poor longterm compliance
increase cell turnover
Calcipotriol Binds to skin Not to be used on face or skin folds
(vit. D derivative; Dovenex) 1, 25-dihydroxyvitamin D3
to inhibit keratinocyte
proliferation
Corticosteroid ointment Reduce scaling and Use appropriate potency steroid
thickness in different areas and degree of psoriasis
Tazarotene Retinoid derivative
Goeckermann regimen: UVB 290-320 nm
UVB + tar
Table 11. Systemic Treatment of Psoriasis

Treatment Adverse Effects
Methotrexate Bone marrow toxicity, hepatic cirrhosis
Steroids Rebound effect when withdrawn
PUVA (8 methoxy-psoralen Pruritus, burning, cataracts, skin cancer
and UVA 360-440 nm)
Acetretin Alopecia, cheilitis, teratogenicity, epistaxis,
xerosis, hypertriglyceridemia
Cyclosporine Renal toxicity, hypertension, immunosuppression
Guttate Psoriasis (“drop-like”)
• discrete, scattered salmon-pink scaling papules
• sites: generalized (mainly trunk and proximal extremities), sparing palms and soles
• often antecedent streptococcal pharyngitis
❏ treatment
• UVB phototherapy, sunlight, lubricants
• penicillin V or erythromycin if Group A beta-hemolytic Streptococcus on throat culture
Erythrodermic Psoriasis
• generalized erythema with fine desquamative scale on surface, with islands of spared skin
• may present in patient with previous mild plaque psoriasis
• aggravating factors: lithium, beta-blockers, NSAIDs, antimalarials, phototoxic reaction, infection
• associated symptoms: worse arthralgia, severe pruritus
❏ treatment
• hospitalization, bed rest, IV fluids, sun avoidance, monitor fluid and electrolytes
• treat underlying aggravating condition
• methotrexate, PUVA and retinoids
Pustular Psoriasis
• sudden onset of erythematous macules and papules which evolve into pustules rapidly
• can be generalized (von Zumbusch type) or localized
(acropustulosis or pustulosis of palms and soles)
• uncommon variant
• patient may have no history of psoriasis, or was recently inappropriately withdrawn from
steroid therapy; may occur in the 3rd trimester of pregnancy (impetigo herpetiformis)
• associated symptoms: fever, arthralgias, diarrhea, increased WBCs
❏ treatment
• bed rest, withdraw exacerbating medications, monitor electrolytes
• methotrexate and etretinate (start with low dose)
• localized PUVA for pustulosis of palms and soles
PAPULOSQUAMOUS DISEASES . . . CONT.
PSORIATIC ARTHRITIS (see Colour Atlas RH22)
❏ 5 categories
• asymmetric oligoarthropathy
• distal interphalangeal (DIP) joint involvement is predominant
• rheumatoid pattern – symmetric polyarthropathy
• psoriatric arthritis mutilans
• predominant spondylitis or sacroileitis
Table 12. Psoriasis by distribution

Location Signs and Symptoms Treatment
Scalp • Dry, scaling, well demarcated, reddish, • Tar shampoo followed by betamethasone
lichenified plaques (no hair loss), valerate 0.1% lotion biweekly
mild to severe itching, • If severe (thick plaques), remove plaque with 10%
sunlight does not cause remission salicylic acid in mineral oil and cover with
plastic cap overnight (1-3 treatments)
• Fluocinolone cream/lotion with cap overnight
• Maintenance with scalp lotion (clobetasol
propionate 0.05%; apply qd/bid)
Nails • Onycholysis, pitting, subungal hyperkeratosis, • Intradermal triamcinolone acetonide 5 mg/mL
oil spots • PUVA
• Methotrexate
Palms and Soles • Sharply demarcated dusky-red plaques with • PUVA
thick scales on pressure points; • Retinoids
can be pustular • Methotrexate
LICHEN PLANUS
• acute or chronic inflammation of mucous membranes or skin characterized by distractive papules
that have a prediliction for flexural surface
❏ epidemiology
• precipitating factor: severe emotional stress
• associated with hepatitis C
• pathogenominic papule: small, polygonal, flat-topped, shiny, violet; Wickham’s striae
(greyish lines over surface)
• resolves to leave hyperpigmented macules
• mucous membrane lesions - lacy, whitish network, milky white plaques/papules;
may be ulcerative and erosive in mouth and genitalia
• nails - longitudinal ridging; pterygium; dystrophic, striae, graves
• scalp - scarring alopecia
• spontaneously resolves in weeks or lasts for years (mouth and shin lesions)
• Koebner phenomenon: trauma
• sites: wrists, ankles, mucous membranes (mouth, vulva, glans), nails, scalp
• mnemonic “6 P’s”: Purple, Pruritic, Polygonal, Peripheral, Papules, Penis
❏ treatment
• topical corticosteroids with occlusion or intradermal steroid injections
• short courses of oral prednisone (rarely)
• PUVA for generalized or resistant cases
• oral retinoids for erosive lichen planus in mouth
❏ differential
• skin
• drug eruption (chloroquine or gold salts)
• lichenoid graft vs. host disease
• lupus erythematosus
• contact with colour film development chemicals
• mucous membranes
• leukoplakia
• thrush
• HIV associated hairy leukoplakia
• lupus erythematosus
PITYRIASIS ROSEA (see Colour Atlas ID6)
• acute self-limiting erythematous eruption characterized by red, oval plaques/patches and papules
with marginal collarette of scale (inward pointing scales - do not extend to edge of lesion)
• sites: trunk, proximal aspects of arms and legs
• long axis of lesions follow lines of cleavage producing “Christmas tree” pattern on back
• varied degree of pruritus
• most start with a “herald” patch which precedes other lesions by 1-2 weeks
• clears spontaneously in 6-12 weeks
❏ etiology
• human herpes virus 7
❏ treatment
• no treatment needed unless itchy
• UVB in first week of eruption (5 exposures) may help pruritis
VESICULOBULLOUS DISEASES
PEMPHIGUS VULGARIS
❏ definition
• autoimmune blistering disease characterized by flaccid, non-pruritic bullae/vesicles on an
erythematous or normal skin base
❏ epidemiology
• 40-60 years old, patients are often Jewish or Mediterranean
❏ etiology
• autoimmune
• associated with thymoma, myasthenia gravis, malignancy, D-penicillamine
❏ pathophysiology
• IgG produced against epidermal desmoglein 3 leads to acantholysis (epidermal cells separated
from each other) which produces intraepidermal bullae
• may present with erosions and secondary bacterial infection
• sites: mouth (90%), scalp, face, chest, axillae, groin, umbilicus
• Nikolsky’s sign: pressure on skin induces lesion
• Asboe-Hanson sign: bulla extends with finger pressure
❏ investigations
• immunofluorescence shows IgG and C3 deposited in epidermal intercellular spaces
❏ clinical course
• initially mouth lesions, followed by skin lesions
• first localized (6-12 months) then generalized
• lesions heal with hyperpigmentation but no scar
• may be fatal unless treated with immunosuppressive agents
❏ management
• prednisone 2.0-3.0 mg/kg until no new blisters, then 1.0-1.5 mg/kg until clear, then taper
• steroid sparing agents - azathioprine, methotrexate, gold,
cyclophosphamide, cyclosporin, IV immunoglobulin (IVIG)
• plasmapheresis for acutely high antibody levels
BULLOUS PEMPHIGOID
❏ definition
• chronic autoimmune bullous eruption characterized by pruritic, tense, subepidermal bullae on an
erythematous or normal skin base
❏ epidemiology
• 60-80 years old
❏ etiology
• autoimmune
• associated with malignancy in some
❏ pathophysiology
• IgG produced against dermal-epidermal basement membrane
• sites: flexor aspect of forearms, axillae, medial thighs, groin, abdomen, mouth (33%)
❏ investigations
• direct immunofluorescence shows deposition of IgG and C3 at basement membrane
• anti-basement membrane antibody (IgG)
❏ clinical course
• generalized bullous eruption
• healing without scars if no infection
❏ management
• prednisone 50-100 mg/day (to clear) +/– steroid sparing agents
such as azathioprine
• tetracycline 500-1 000 mg/day +/– nicotinamide is effective for some cases
• dapsone 100-150 mg/day for milder cases
DERMATITIS HERPETIFORMIS
❏ definition
• intensely pruritic grouped papules/vesicles/urticarial wheals on an erythematous base
❏ etiology
• 90% have HLA B8, DR3, DQWZ
• 90% associated with gluten sensitive enteropathy (80% are asymptomatic),
30% have thyroid disease, and some have intestinal lymphoma
• iron or folate deficiency
❏ epidemiology
• 20-60 years old, M:F = 2:1
• sites: extensor surfaces of elbows/knees, sacrum, buttocks, scalp
• lesions grouped in bilateral symmetry
• pruritus, burning, stinging
❏ investigations
• immunofluorescence: granular IgA and complement deposition in dermis
❏ clinical course
• lesions last days - weeks
❏ management
• dapsone 50-200 mg/day for pruritus, multiple side effects include
hemolytic anemia, peripheral neuropathy, toxic hepatitis, aplastic anemia
• gluten free diet
VESICULOBULLOUS DISEASES . . . CONT.
Table 13. Vesiculobullous Diseases

Pemphigus Vulgaris Bullous Pemphigoid Dermatitis Herpetiformis
Antibody IgG IgG IgA
Site Intercellular space Basement membrane Dermal
Infiltrate Eosinophils and neutrophils Eosinophils Neutrophils
Treatment High dose steroids Moderate dose steroid Gluten-free diet/dapsone

Cyclophosphamide Cyclophosphamide
association Thymoma, myasthenia gravis, Malignancy Gluten enteropathy

malignancy Thyroid disease
Intestinal lymphoma
PORPHYRIA CUTANEA TARDA

❏ definition
• autosomal dominant or sporadic skin disorder associated with
the presence of excess heme characterized by tense vesicles/bullae
in photoexposed areas subjected to trauma
❏ epidemiology
• 30-40 years old, M>F
❏ etiology
• associated with alcohol abuse, DM, drugs (estrogen therapy, NSAID),
HIV, hepatitis C, increased iron
• facial hypertrichosis, brown hypermelanosis, “heliotrope” around eyes,
conjunctival injection
• vesicles and bullae in photodistribution (dorsum of hands and feet)
• may complain of fragile skin on dorsum of hands
• sites: light-exposed areas subjected to trauma dorsum of hands and feet,
nose, upper trunk
❏ investigations
• Wood’s lamp of urine + 5% HCl shows orange-red fluorescence
• 24 hour urine for uroporphyrins (elevated)
• stool contains elevated coproporphyrins
• immunofluorescence shows IgE at dermal-epidermal junctions
❏ management
• discontinue aggravating substances (alcohol, estrogen therapy)
• phlebotomy to decrease body iron load
• low dose hydroxychloroquine if phlebotomy contraindicated
DIFFERENTIAL OF PRIMARY BULLOUS DISORDERS
❏ Drug eruptions
❏ Erythema multiforme (EM) and related disorders
❏ Infections – bullous impetigo
❏ Infestations – scabies (dermatitis herpetiformis)
❏ Inflammation – acute eczema

DRUG ERUPTIONS
EXANTHEMATOUS ERUPTIONS
(MACULOPAPULAR ERUPTIONS/MORBILLIFORM)
❏ symmetrical, widespread, erythematous patches or plaques with or without scales
• the “classic” adverse drug reaction
• often starts on trunk or on areas of sun exposure
• may progress to generalized exfoliative dermatitis especially if the drug is continued
• penicillin, sulfonamides, phenytoin (in order of decreasing probability)
• incidence of ampicillin eruption is > 50% in patients with mononucleosis, gout or
chronic lymphocytic keukemia (CLL)
URTICARIA (also known as “Hives”)
❏ transient, red, pruritic well-demarcated wheals
• second most common type of drug reaction
• due to release of histamine from mast cells in dermis
• lasts less than 24 hours
• can also result after contact with allergen
ANGIOEDEMA
❏ deeper swelling of the skin involving subcutaneous tissues often with
swelling of the eyes, lips, and tongue
❏ may or may not accompany urticaria
❏ hereditary angioedema - does not occur with urticaria
• onset in childhood; 80% have positive family history
• recurrent attacks; 25% die from layngeal edema
• triggers: minor trauma, emotional upset, temperature changes
• diagnosis: reduced C1 esterase inhibitor level (in 85%) or reduced function (in 15%),
diminished C4 level
❏ acquired angioedema
• autoantibodies to C1 esterase inhibitor
• consumption of complement in lymphoproliferative disorder
• diagnosis: C1 esterase inhibitor deficiency, decreased C1 (unique to acquired form),
diminished C4 level
❏ treatment: prophylaxis with danazol or stanozolol
• Epinephrine pen to temporize until patient reaches hospital in acute attack
FIXED DRUG ERUPTION
❏ sharply demarcated erythematous oval patches on the skin or mucous membranes
• sites: face, genitalia
• with each exposure to the drug, the patient develops
erythema at the same location as before (fixed location)
• antimicrobials (tetracycline, sulfonamides) anti-inflammatories,
psychoactive agents (barbituates), phenolphthalein
DELAYED HYPERSENSITIVITY SYNDROME
❏ initial fever, followed by symmetrical bright red exanthematous eruption and may lead
to internal organ involvement (hepatitis, arthralgia, carditis, interstitial nephritis,
interstitial pneumonitis, lymphadenopathy, and/or hematologic abnormalities)
• classically the patient has a first exposure to a drug and
develops the syndrome 10 days later
• symmetric
• sites: trunk, extremities
• siblings at risk
• sulfonamides, anticonvulsants, etc.
• 10% mortality if undiagnosised and untreated
PHOTOSENSITIVITY ERUPTIONS
❏ phototoxic reaction: “an exaggerated sunburn” confined to light exposed areas
❏ photoallergic reaction: an eczematous eruption that may spread to areas not exposed to light
❏ chlorpromazine, doxycycline, thiazide diuretics, procainamide
SERUM SICKNESS - LIKE REACTION
❏ a symmetric drug eruption resulting in fever, arthralgia, lymphadenopathy, and skin rash
• usually appears 5-10 days after drug
• skin manifestations: usually urticaria; can be morbilliform
• cefaclor
ERYTHEMA MULTIFORME (EM), STEVENS-JOHNSON SYNDROME (SJS),
TOXIC EPIDERMAL NECROLYSIS (TEN) (see D32)

DRUG ERUPTIONS . . . CONT.
Table 13. Classification of Urticaria

Type Provocative agents/tests Comments
Acute Urticaria • Foods (nuts, shellfish, eggs, fruits) • Attack lasts <6 weeks
• Insect stings • Each lesion lasts <24 hrs
• Drugs (especially aspirin, NSAID’s) • Occurs with or without
• Contacts – cosmetics, work exposures angioedema
• Infection – viral (hepatitis, upper respiratory), bacterial, parasitic
• Systemic diseases – SLE, endocrinopathy (TSH), neoplasm
• Stress
• Idiopathic
Chronic Urticaria • Most commonly idiopathic • Attack lasts > 6 weeks

• Aggravating and causative factors may be similar to those in • Each lesion lasts <24 hrs
acute urticaria
Cholinergic • Increased core body temperature • Tiny flesh coloured wheals

Urticaria • Hot shower, exercise with surrounding red flare
Contact Urticaria • Latex rubber – patch test, allergy test
Physical
Urticarias
Aquagenic urticaria • Exposure to water
Adrenergic urticaria • Stress
Cold urticaria • Ice cube, swimming pool • Can be life threatening
Dermographism • Friction, rubbing skin • Immediate and possible

delayed types
Heat urticaria • Local heat
Pressure urticaria • Located over pressure areas of body (shoulder strap, buttocks) • Immediate and delayed types
Solar urticaria • Caused by a specific wavelength of UV radiation
Vibratory urticaria • Vibration
Vasculitic urticaria • Infections – hepatitis • Painful non-pruritic lesions

• Autoimmune diseases – SLE • Lesions last > 24 hrs
• Drug hypersensitivity • Must biopsy these lesions

ERYTHEMA MULTIFORME (EM) / STEVENS-JOHNSON
SYNDROME (SJS) / TOXIC EPIDERMAL NECROLYSIS (TEN)
❏ spectrum of disorders with varying presence of characteristic skin lesions,
blistering, and mucous membrane involvement
EM (minor) EM (major) SJS TEN
Table 14. Comparison of Erythema Multiforme, Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis
Erythema Multiforme (EM) Stevens-Johnson Syndrome (SJS) Toxic Epidermal Necrolysis (TEN)
(see Colour Atlas D16) (see Colour Atlas D14)
Lesion • Macules/papules with central vesicles • EM with more mucous membrane • Severe mucous membrane involvement
• Classic bull’s-eye pattern of concentric involvement, and blistering • “Atypical lesions” – 50% have no target
light and dark rings (target lesions) • “Atypical lesions” - red circular lesions
• Bilateral and symmetric patch with dark purple center • Diffuse erythema then necrosis and
• EM minor - no mucosal involvement, • “Sicker” (high fever) sheet-like epidermal detachment in >30%
bullae, or systemic symptoms • Sheet-like epidermal detachment in <10%
• EM major – mucosal involvement, bullae, • Nikolsky sign
systemic symptoms, usually drug induced
• Nikolsky sign (see pemphigus vulgaris)
Sites • Mucous membrane involvement (oral, • Generalized with prominent face and • Generalized
genital, conjunctival) trunk involvement • Nails may also shed
• Extremities with face > trunk • Palms and soles may be spared
• Involvement of palms and soles
Other organs/ • Corneal ulcers, keratitis, anterior uveitis, • Complications: scarring, eruptive • Tubular necrosis and acute renal
Complications stomatitis, vulvitis, balanitis nevomelanocytic nevi, corneal scarring, failure, epithelial erosions of trachea,
• Lesions in trachea, pharynx, larynx blindness, phymosis and vaginal synechiae bronchi, GI tract
Constitutional • Fever, weakness, malaise • Prodrome 1-3 days prior to eruption with • High fever > 38ºC
symptoms fever and flu-like illness
Etiology • Drugs – sulfonamides, NSAIDs, • 50% are drug related • 80% are definitely drug related
anticonvulsants, penicillin, allopurinol • Occurs up to 1-3 weeks after drug exposure • < 5% are due to viral infection,
• Infection – herpes, mycoplasma with more rapid onset upon rechallenge immunization
• Idiopathic - >50%
Pathology/ • Perivascular PMN infiltrate in dermis and • Cytotoxic cell-mediated attack on • Same as Stevens-Johnson Syndrome
Pathophy- epidermis, edema of upper dermis epidermal cells
siology • No dermal infiltrate
• Epidermal necrosis and detatchment above
basement membrane
Differential • EM minor – urticaria, viral exanthems • Scarlet fever, phototoxic eruption, GVHD, • Scarlet fever, phototoxic eruption,
diagnosis • EM major – SSSS, pemphigus vulgaris, SSSS, exfoliative dermatitis GVHD, SSSS, exfoliative dermatitis
bullous pemhigoid
Course and • Lesions last 2 weeks • < 5% mortality • 30% mortality due to fluid loss,
Prognosis • Regrowth of epidermis by 3 weeks secondary infection
Treatment • Prevention – drug avoidance • Withdraw suspect drug • As for Stevens-Johnson syndrome
• Symptomatic treatment • Intravenous fluids • Admit to burn unit
• Corticosteroids in severely ill • Corticosteroids – controversial • Debride frankly necrotic tissue
(controversial) • Infection prophylaxis
SSSS = Staphylococcal Scalded Skin Syndrome

GVHD = Graft versus Host Disease

ERYTHEMA NODOSUM
(see Colour Atlas D15)
❏ definition
• acute or chronic inflammation of panniculus and venules in the subcutaneous fat
❏ epidemiology
• 15-30 years old, F:M = 3:1
• lesions last for days and spontaneously resolve in 6 weeks
❏ etiology
• infections: Group A Streptococcus, primary TB,
coccidioidomycosis, histoplasmosis, Yersinia
• drugs: sulfonamides, oral contraceptives (also pregnancy),
analgesics, trans-retinoic acid
• inflammation: sarcoidosis, Crohn’s > Ulcerative Colitis
• malignancy: acute leukemia, Hodgkin’s lymphoma
• 40% are idiopathic
• superficial thrombophlebitis, panniculitis, erysipelas,
panarteritis nodosa, pretibial myxedema
• round, red, tender, poorly demarcated nodules
• sites: asymmetrically arranged on lower legs, knees, arms
• associated with arthralgia, fever, malaise
❏ investigations
• chest x-ray (to rule out chest infection and sarcoidosis),
throat culture, ASO titre, PPD skin test
❏ management
• symptomatic: bed rest, compressive bandages, wet dressings
• NSAIDs
• treat underlying cause
MALIGNANT SKIN TUMOURS

BASAL CELL CARCINOMA (BCC) (see Colour Atlas D21)
❏ definition
• malignant proliferation of basal cells of the epidermis
• subtypes: noduloulcerative; pigmented; superficial; sclerosing
❏ epidemiology
• 75% of all malignant skin tumours > 40 years, increased prevalence in the elderly
• M>F, skin phototypes I and II, prolonged sun exposure
• usually due to UV light, therefore > 80% on face
• may also be caused by scar formation, radiation, trauma or arsenic exposure
• nodular malignant melanoma (biopsy)
• sebaceous hyperplasia
• eczema
• tinea corporis
• squamous cell carcinoma (SCC)
• intradermal melanocytic nevus
• noduloulcerative (typical)
• skin-coloured papule/nodule with rolled, translucent (“pearly”)
telangiectatic border and depressed/eroded/ulcerated centre
• pigmented (variant)
• flecks of pigment in translucent lesion with surface telangiectasia
• may mimic malignant melanoma
• superficial (variant)
• scaly plaque with fine telangiectasia at margin
• sclerosing (variant)
• flesh/yellowish-coloured, shiny papule/plaque with indistinct borders
• sites: sun-exposed regions (mainly head and neck)
❏ clinical course
• 95% cure rate if lesion is less then 2 cm in diameter
• slow growing lesion, locally invasive and rarely metastatic (< 0.1%)
❏ management
• surgical excision +/– MOHS
• radiotherapy
• cryotherapy
• electrodessication and curettage
• carbon dioxide laser
• lifeling follow-up

MALIGNANT SKIN TUMOURS . . . CONT.
SQUAMOUS CELL CARCINOMA (SCC) (see Colour Atlas D17)
❏ definition
• a malignant neoplasm of keratinocytes
❏ epidemiology
• primarily on sun exposed skin in the elderly, M>F, skin phototypes I and II, chronic sun exposure
• predisposing factors include UV radiation, ionizing radiation therapy/exposure, immunosuppression,
PUVA, atrophic skin lesions, chemical carcinogens such as arsenic, coal tar and topical nitrogen
mustards, Marjolin’s ulcers in burn scars
• BCC
• melanoma
• numular eczema
• psoriasis
• Bowen’s disease
• Paget’s disease
• indurated erythematous nodule/plaque with surface scale/crust, and eventual ulceration
• more rapid enlargement than BCC
• sites: face, ears, scalp, forearms, dorsum of hands
❏ clinical course
• prognostic factors include: immediate treatment, negative margins, and small lesions
• SCCs that arise from solar keratosis metastasize less frequently (≤ 1% of cases) than other SCCs
(e.g. arising de novo in old burns) (2-5% of cases)
• overall control is 75% over 5 years, 5-10% metastasize
❏ management
• surgical excision with primary closure, skin flaps or grafting
• lifelong follow-up
Bowen’s Disease (Squamous Cell Carcinoma in situ)
❏ definition
• erythematous plaque with a sharply demarcated red and scaly border
• often 1-3 cm in diameter and found on the skin and mucous membranes
• evolves to SCC in 10-20% of cutaneous lesions and > 20% of mucosal lesions
❏ management
• biopsy required for diagnosis
• as for basal cell carcinoma
• topical 5-fluorouracil (Efudex) used if extensive and as a tool to identify margins of poorly
defined tumours
MALIGNANT MELANOMA (see Colour Atlas D23)
❏ definition
• malignant neoplasm of pigment forming cells (melanocytes and nevus cells)
❏ epidemiology
• incidence 1:100
• risk factors: numerous moles, fair skin, red hair, positive personal/family history, people who burn
but do not tan, large congenital nevi, familial dysplastic nevus syndrome (100%)
• most common sites: back (M), calves (F)
• worse prognosis if: male, on scalp, hands, feet, late lesion
• better prognosis if: pre-existing nevus present
• malignant characteristics of a mole include (ABCDE)
A - Asymmetry
B - Border (irregular)
C - Colour (varied)
D - Diameter (increasing or > 6 mm)
E - Enlargement, elevation
• sites: skin, mucous membranes, eyes, CNS
❏ classification of invasion (see Plastic Surgery Chapter)
• Breslow’s Thickness of Invasion
• 1. <0.76 mm - mets in 0%
• 2. 0.76-1.5 mm - mets in 25%
• 3. 1.5-3.99 mm - mets in 50%
• 4. > 4 mm - mets in 66%
• Clark’s Levels of Cutaneous Invasion
• Level I - above basement membrane - rare mets
• Level II - in papillary dermis - mets in 2-5%
• Level III - to junction of papillary and reticular dermis - mets in up to 20%
• Level IV - into reticular dermis - mets in 40%
• Level V - into subcutaneous tissue - mets in 70%
Superficial Spreading Melanoma
❏ atypical melanocytes initially spread laterally in the epidermis then invade the dermis
❏ irregular, indurated, enlarging plaques with red/white/blue discoloration, focal papules and nodules
❏ ulcerate and bleed with growth
❏ 60-70% of all melanomas
MALIGNANT SKIN TUMOURS . . . CONT.
Nodular Melanoma
❏ atypical melanocytes that initially grow vertically with little lateral spread
❏ uniformly ulcerated, blue-black, and sharply delineated plaque or nodule
❏ rapidly fatal
❏ 30% of melanomas
Lentigo Maligna (Premalignant Lesion)
❏ malignant melanoma in situ (normal and malignant melanocytes confined to the epidermis)
❏ 2-6 cm, tan/brown/black uniformly flat macule or patch with irregular borders
❏ lesion grows radially and produces complex colours
❏ sites: face, sun exposed areas
❏ 1/3 evolves into lentigo maligna melanoma
Lentigo Maligna Melanoma
❏ malignant melanocytes invading into the dermis
❏ flat, brown, stain-like that gradually enlarges with loss of skin surface markings
❏ raised focal papules and nodules within the lesion
❏ with time, colour changes from uniform brown ––> dark brown with black and blue hues
❏ found on all skin surfaces, especially those chronically exposed to sun
❏ 15% of all melanomas
❏ not associated with preexisting acquired nevi
Acrolentiginous Melanoma
❏ ill-defined dark brown, blue-black macule
❏ palmar, plantar, subungual skin
❏ histologic picture as lentigo-maligna melanoma
❏ metastasize via lymphatics and blood vessels
❏ melanomas on mucous membranes have poor prognosis
❏ 5% of melanomas
Management
❏ excisional biopsy preferable, otherwise incisional biopsy
❏ remove full depth of dermis and extend beyond edges of lesion only after histologic diagnosis
❏ lymph node dissection shows survival advantage if nodes uninvolved
❏ chemotherapy (cis-platinum, BCG) for stage II (regional) and stage III (distant) disease
❏ radiotherapy is curative for uveal melanomas, palliative for bone and brain metastases
OTHERS
Leukoplakia
❏ definition
• white patch/plaque on lower lip, floor of mouth, buccal mucosa, tongue border or retromolarly
❏ epidemiology
• 40-70 years old, M > F, fair-skinned
• premalignant lesion arising from chronic irritation or inflammation
• lichen planus
• oral hairy leukoplakia
❏ management
• excision
• cryotherapy
Cutaneous T-Cell Lymphoma (Mycosis Fungoides)
❏ definition
• T cell lymphoma, first manifested in skin
❏ epidemiology
• etiology: human t-cell lymphotrophic virus (HTLV)
• > 50 years old
• Sezary’s syndrome - erythroderma, lymphadenopathy, WBC > 20,000 with Sezary cells,
hair loss, pruritus
• psoriasis
• nummular dermatitis
• “large plaque” parapsoriasis
• characterized by erythematous patches/plaques/nodules/tumours which could be pruritic
• eventually invades internal organs
❏ management
• PUVA
• topical nitrogen mustard
• radiotherapy ––> total skin election beam radiation

HERITABLE DISORDERS
ICHTHYOSIS VULGARIS
❏ definition
• a generalized disorder of hyperkeratosis leading to dry skin,
associated with atopy and keratosis pilaris
❏ epidemiology
• 1:300 incidence
• “2 A.D.”: atopic dermatitis and autosomal dominant
• “fish-scale” appearance especially on extremities with sparing of flexural creases,
palms and soles, scaling without inflammation
❏ management
• immersion in bath and oils
• emollient or humectant creams, creams and oils containing urea
NEUROFIBROMATOSIS (NF; VON RECKLINGHAUSEN’S DISEASE)
❏ definition
• autosomal dominant disorder with excessive and abnormal proliferation of neural crest elements
❏ epidemiology
• NF gene at 17q11.1 (inactivation of ras/p21 oncogene)
• incidence 1:3,000
• characterized by cafe-au-lait macules, axillary freckling, Lisch nodules and neurofibromas
• diagnostic criteria include
1) more than 6 cafe-au-lait spots > 1.5 cm in an adult,
and more than 5 cafe-au-lait spots > 0.5 cm in a child under age 5
2) axillary freckling
3) iris hamartomas (Lisch nodules)
4) optic gliomas
5) neurofibromas, and others
• associated with pheochromocytoma, astrocytoma, bilateral acoustic neuromas,
bone cysts, scoliosis,precocious puberty, developmental delay, renal artery stenosis
❏ management
• follow closely for malignancy, transformation of neurofibroma to neurofibrosarcoma
• excise suspicious or painful lesions
VITILIGO (see Colour Atlas D13)
❏ definition
• primary pigmentary disorder characterised by hypopigmentation and depigmentation
❏ epidemiology
• 1% incidence, polygenic
• 30% with +ve family history
• associated with autoimmune disease especially thyroid disease, DM,
Addison’s disease, pernicious anemia
• may be precipitated by trauma, sunburn
• acquired destruction of melanocytes characterized by sharply marginated white patches
• sites: extensor surfaces and periorificial areas (mouth, eyes, anus, genitalia)
• associated with streaks of depigmented hair, chorioretinitis
• may be generalized or segmented
❏ investigations
• do blood work to rule out thyroid dysfunction, pernicious anemia, Addison’s disease, DM
• Wood’s lamp to detect lesions in fair-skinned patients
❏ management
• camouflage preparations
• PUVA (psoralens and UVA)
• minigrafting
• “bleaching” normal pigmented areas (total white colour)
• done in widespread loss of pigmentation
• sun avoidance and protection

SKIN MANIFESTATIONS OF INTERNAL CONDITIONS
`
PRURITUS
❏ definition
• a sensation provoking a desire to scratch
• careful history is important, since a medical workup may be
indicated in 20% of cases
❏ etiology
• dermatologic - generalized
• winter itch or”xerotic eczema” = dry and cracked skin
• senile pruritus (may not have dry skin, any time of year)
• infestations - scabies, lice
• drug eruptions - ASA, antidepressants, opiates
• psychogenic states
• dermatologic - local
• atopic and contact dermatitis, lichen planus,
urticaria, insect bites, dermatitis herpetiformis
• infection – varicella, candidiasis
• neurodermatitis (lichen simplex chronicus, vicious
cycle of itching and scratching leads to excoriated
lichenified plaques)
• systemic disease - usually generalized
• obstructive biliary disease, (e.g. PBC, chlorpromazine
induced biliary cholestasis)
• chronic renal failure, cholestatic liver disease of pregnancy,
uremia secondary to hemodialysis
• hematologic - Hodgkin’s lymphoma, multiple myeloma,
leukemia, polycythemia vera, mycosis fungoides, hemochromatosis,
Fe2+ deficiency, anemia
• carcinoma - lung, breast, gastric
• endocrine - carcinoid, DM, hypothyroid/thyrotoxicosis
• infectious - HIV, onchocerciasis, trichinosis, echinococcosis
• psychiatric - depression
❏ management
• treat underlying cause and itch (minimize irritation and scratching)
• topical corticosteroid and antipuritics such as menthol, camphor or phenol
• systemic antihistamines - H1 blockers are most effective
• avoid topical anaesthetics which may sensitize the skin
• phototherapy with UVB or PUVA for urenia, obstructive biliary disease
• Danazol for myeloproliferative disorders and other systemic illnesses

SKIN MANIFESTATIONS OF INTERNAL CONDITIONS . . . CONT.
Table 16. Skin Manifestations of Internal Conditions

Disease Related Dermatoses
AUTOIMMUNE DISORDERS
Systemic lupus erythematosus (SLS) Malar erythema, discoid rash, (erythematous papules or plaques with keratotic scale, follicular
(see Colour Atlas RH1) plugging, atrophic scarring on face, hands, and arms), hemorrhagic bullae, palpable purpura, urticarial
purpura, patchy/diffuse alopecia, mucosal ulcers, photo sensitivity
Cutaneous lupus erythematosus Sharply marginated annular or psoriaform bright red plaques with scales, telangiectasia, marked
scarring, diffuse non-scarring alopecia
Scleroderma Raynaud's, nonpitting edema, waxy/shiny/tense atrophic skin (morphea), ulcers, cutaneous
(see Colour Atlas RH8) calcification, periungal telangiectasia, acrosclerosis
Dermatomyositis Periorbital and perioral violaceous erythema, heliotrope with edema, Gottron's papules
(see Colour Atlas (violaceous flat-topped papules with atrophy), periungal erythema, telangiectasia, calcinosis cutis
MRH2 and RH4)
Polyarteritis nodosa Polyarteritic nodules, stellate purpura, erythema, gangrene, splinter hemorrhages, livedo reticularis
Ulcerative colitis (UC) Pyoderma gangrenosum
Rheumatic fever Petechiae, urticaria, erythema nodosum, erythema multiforme, rheumatic nodules
Buerger's disease Superficial migraine thrombophlebitis, pallor, cyanosis, gangrene, ulcerations
ENDOCRINE DISORDERS
Cushing’s syndrome Moon facies, purple striae, acne, hyperpigmentation, hirsutism, atrophic skin with telangiectasia
(see Colour Atlas E1)
Hyperthyroid Moist, warm skin, seborrhea, acne, nail atrophy, hyperpigmentation, toxic alopecia,
(see Colour Atlas E2 and E3) pretibial myxedema acropachy, onycholysis
Hypothyroid Cool, dry, scaly, thickened, hyperpigmented skin; toxic alopecia with dry, coarse hair, brittle nails,
myxedema, loss of lateral 1/3 eyebrows
Addison’s disease Generalized hyperpigmentation or limited to skin folds, buccal mucosa and scars
Diabetes mellitus (DM) Infections (boils, carbuncles, candidiasis, S. aureus, dermatophytoses, tinea pedis and cruris, infectious
eczematoid dermatitis), pruritis, eruptive xanthomas, necrobiosis, lipoidica diabeticorum, granuloma
annulare, diabetic foot, diabetic bullae, acanthosis nigricans, calciphylaxis
HIV
Infections Viral (HSV, HZV, HPV, CMV, molluscum contagiosum, oral hairy leukoplakia), bacterial
(impetigo, acneiform folliculitis, dental caries, cellulitis, bacillary epithelioid angiomatosis, syphilis),
other (candidiasis)
Inflammatory dermatoses Seborrhea, psoriasis, pityriasis rosea, vasculitis
Malignancies Kaposi’s Sarcoma (see Colour Atlas D20), lymphoma, BCC, SCC, malignant melanoma
MALIGNANCY
Adenocarcinoma
Gastrointestinal (GI) Peutz-Jeghers: pigmented macules on lips/oral mucosa
Cervix/anus/rectum Paget’s Disease: eroding scaling plaques of perineum
Carcinoma
Breast Paget’s Disease: eczematous and crusting lesions of breast
GI Palmoplantar keratoderma: thickened skin of palms/soles
Thyroid Sipple’s Syndrome: multiple mucosal neuromas
Breast/GU/lung/ovary Dermatomyositis: heliotrope erythema of eyelids and purplish plaques over knuckles
Lymphoma/Leukemia
Hodgkin’s Ataxia Telegectasia: telengectasia on pinna, bulbar conjunctiva
Acute Leukemia Ichthyosis: generalized scaling especially on extremities
Bloom’s Syndrome: butterfly erythema on face, associated with short stature
Multiple Myeloma Amyloidosis: large, smooth tongue with waxy papules on eyelids,
nasolabial folds and lips, as well as facial petechiae
OTHERS
Liver disease Pruritis, hyperpigmentation, spider nevi, palmar erythema, white nails, porphyria cutanea tarda,
xanthomas, hair loss
Renal disease Pruritis, pigmentation, half and half nails
Pruritic urticaria papules and Erythematous papules or urticarial plaques in distribution of striae distensae: buttocks, thighs,
Plaques of pregnancy (PUPPP) upper inner arms and lower backs
Cryoglobulinemia Palpable purpura in cold-exposed areas, Raynaud's, cold urticaria, acral hemorrhagic necrosis,
bleeding disorders, related to hepatitis C infection

WOUNDS AND ULCERS
Table 17. Different Types of Ulcers and Management
Ulcer Type Symptoms and signs Management
Arterial Wound at tip of toes, cold feet 1. Doppler study

with claudication, gangrene, 2. If ankle: brachial ratio < 0.4, may consider amputation
distal hyperemia, decreased 3. If gangrenous, paint with betadine
pedal pulses 4. Otherwise promote moist interactive wound healing
Venous Wound at malleolus, stasis change, 1. Local wound dressing: moist interactive healing
edema, previous venous injury 2. Compression: preferably four layer
3. After wound heals, support stocking for life
Neurotropic Wound at pressure point or 1. Pressure downloading by using proper shoes or seats
secondary to unknown trauma 2. Promote moist interactive wound healing
Vasculitic Livedo reticularis, petechiae, 1. Biopsy to determine vasculitis

extreme tenderness, 2. Serum screening for vasculitis
delayed healing 3. Treat vasculitis
4. Local moist interactive wound healing
ALOPECIA (HAIR LOSS)

NON-SCARRING (NON-CICATRICIAL) ALOPECIA
Mnemonic (TOPHAT)
T telogen effluvium, tinea capitis
O out of Fe2+, Zn2+
P physical - trichotillomania, “corn-row” braiding
H hormonal - hypothyroidism, androgenic
A autoimmune - SLE, alopecia areata
T toxins - heavy metals, anticoagulants, chemotherapy, Vit. A
Physiological
❏ male-pattern alopecia (androgenetic alopecia)
❏ epidemiology
• early 20’s-30’s (female androgenetic alopecia is
diffuse and occurs in 40’s and 50’s)
❏ pathophysiology
• action of testosterone on hair follicles
• temporal areas progressing to vertex,
entire scalp may be bald
❏ clinical course
• relentless hair loss
❏ management
• minoxidil lotion to reduce rate of loss/partial restoration
• spironolactone in women
• hair transplant
• finasteride 1 mg/d in men
Physical
❏ trichotillomania: impulse-control disorder characterized by
compulsive hair pulling with irregular patches of hair loss, and with
remaining hairs broken at varying lengths
❏ traumatic (e.g. tight “corn-row” braiding of hair)
Telogen Effluvium
❏ definition
• uniform decrease in hair density secondary to an increased
number of hairs in telogen phase (resting phase)
• 15% of hair normally in resting phase, about to shed (telogen)
❏ precipitating factors
• post-partum, high fever, oral contraceptives, malnutrition,
severe physical/mental stress, Fe2+ deficiency
❏ clinical course
• 2-4 month latent period after stimulus
• regrowth occurs within few months and may not be complete
ALOPECIA (HAIR LOSS) . . . CONT.
Alopecia Areata (see Colour Atlas D12)

❏ definition
• autoimmune disorder characterized by patches of complete
hair loss (loss of telogen hairs) localized to scalp, eyebrows, beard, eyelashes
• alopecia totalis - loss of all scalp hair and eyebrows
• alopecia universalis - loss of all body hair
• associated with dystrophic nail changes - fine stippling
• “exclamation mark” pattern (hairs fractured and have tapered shafts, i.e. looks like”!”)
• may be associated with pernicious anemia, vitiligo, thyroid disease, Addison’s disease
❏ clinical course
• spontaneous regrowth may occur within months of first attack
(worse prognosis if young at age of onset and extensive loss)
• frequent recurrence often precipitated by emotional distress
❏ management
• generally unsatisfactory
• intralesional triamcinolone acetonide (corticosteriods) can be used for isolated patches
(eyebrows, beards)
• wigs
• UV or PUVA therapy
• support groups
Metabolic Alopecia
❏ Drugs: e.g. chemotherapy, Danazol, Vitamin A, retinoids,
anticoagulants, thallium, antithyroid drugs,
oral contraceptives, allopurinol, propanoid,
salicylates, gentamycin, lerodopa
❏ Toxins: e.g. heavy metals
❏ Endocrine: e.g. hypothyroidism
SCARRING (CICATRICIAL) ALOPECIA

❏ definition
• irreversilbe and permanent
❏ etiology
• physical: radiation, burns
• infections: fungal, bacterial, TB, leprosy, viral (herpes zoster)
• collagen-vascular
• discoid lupus erythematosus (treatment with topical/intralesional
steroid or antimalarial); note that SLE can cause an alopecia unrelated
to discoid lupus lesions which are non-scarring
• scleroderma - “coup de sabre” with involvement of centre of scalp
❏ investigations
• biopsy from active border
Clinical Pearl
❏ Scarring alopecia: absent hair follicles on exam; biopsy required
❏ Non-scarring alopecia: intact hair follicles on exam; biopsy not required.

NAILS
Definitions
❏ hourglass nail/finger clubbing (lung disease, cyanotic heart disease, colitis, etc.)
❏ koilonychia = hollowing/spoon shaped (iron deficiency, malnutrition, diabetes)
❏ hypoplastic (fetal alcohol syndrome (FAS), etc.)
❏ onycholysis = separation of nail plate from nail bed (dermatophytes, psoriasis, etc.)
❏ onychogryphosis = thickening of nail plate (chronic inflammation, tinea, etc.)
❏ onychohemia = subungual hematoma (trauma to nailbed most common)
❏ onychocryptosis = ingrown toenail (bad shoes, bad nail cutting)
Surface Changes
❏ tranverse ridging (serious acute illness may stop nail growth)
❏ transverse white lines (poisons, hypoalbuminemia)
❏ pitting (psoriasis, alopecia areata, inflammation)
Colour Changes
❏ yellow (tinea, jaundice, tetracycline, etc)
❏ green (pseudomonas)
❏ black (melanoma, hematoma)
❏ brown (nictotine use, psoriasis, poisons)
❏ splinter hemorrhages (trauma, bacterial endocarditis, blood dyscrasias)
• due to extravasation of blood from longitudinal vessels of nailbed
• blood attaches to overlying nail plate and moves distally as it grows
• NOT specific to subacute bacterial endocarditis
Local Changes
❏ paronychia = local inflammation of the nailfold around the nailbed,
acutely a painful infection and chronically from constant wetting
(e.g. dishwashing, thumbsucking)
TOPICAL THERAPY
VEHICLES
❏ for acute inflammation (edema, vesiculation, oozing, crusting, infection) use aqueous drying preparation
❏ for chronic inflammation (scaling, lichenification, fissuring) use a greasier, more lubricating compound
Powders
❏ promote drying, increase skin surface area (i.e. cooling)
• used in intertriginous areas to reduce moisture and friction
• inert or contain medication
Lotions
❏ suspensions of powder in water
• cool and dry as they evaporate
• leave a uniform film of powder on skin
• easily applied to hirsute areas
Cream
❏ semisolid emulsions of oil in water
• water-soluble, containing emulsifiers and preservatives
• cosmetically pleasing
Gel
❏ crystalline with a lattice
• transparent, colourless, semisolid emulsion with aqueous, acetone, alcohol or propylene glycol base
• liquifies on contact with skin
• dries as a thin, greaseless, nonocclusive, nonstaining film
Ointment
❏ semisolid water in oil emulsions (more viscous than cream)
• inert bases - petroleum
• most effective to transport medications into skin
• retain heat, impede water loss, increase hydration
• occlusive, not to be used in oozing or infected areas

TOPICAL THERAPY . . . CONT.
TOPICAL STEROIDS
Table 18. Potency Ranking of Topical Steroids
Relative Potency Relative Strength Generic Names Trade Names Usage
Weak x1 Hydrocortisone Emo Cort Intertriginous areas,

children, face, thin skin
Moderate x3 Hydrocortisone - 0.2% Westcort Arm, leg, trunk

17-valerate - 0.2%
Desonide Tridesilon
Mometasone furorate Elocom
Potent x6 Betamethasone - 0.1% Betnovate Body

17-valerate - 0.1% Celestoderm - V
Amicinonide Cyclocort
Very Potent x9 Betamethasone Diprosone Palms and soles

Dipropionate - 0.05% Lidex, Topsyn gel
Fluocinonide - 0.05%
Extremely Potent x12 Clobetasol propionate Dermovate Palms and soles

Betamethasone Diprolene
Dipropionate ointment
Halobetasol propionate Ultravate
Body site: Relative Percutaneous Absorption

forearm 1.0 scalp 3.7
plantar foot 0.14 forehead 6.0
palm 0.83 cheeks 13.0
back 1.7 scrotum 42.0
❏ calculation of strength of steroid compared to hydrocortisone on forearm:
relative strength of steroid x relative percutaneous absorption
DRY SKIN THERAPY
❏ encourage use of humidifier (in summer and winter months)
❏ decrease excess exposure to water or soap
❏ use mild soaps such as Dove, Aveeno and bath oils
❏ apply emollients to moist skin after bathing (petroleum, Eucerin)
❏ lubricating lotions and creams are occlusive and soften the skin
❏ humectant agents such as uremol (urea), LacHydrin (lactic acid) and Neostrata (glycolic acid)
hold water to skin or affect desquamation of stratum corneum
• topical steroid ointment for symptomatic dryness with eczema

COSMETIC DERMATOLOGY
CHEMICAL PEELING
(Chemexfoliation, Chemical Resurfacing)
❏ application of caustic agent(s) to skin to produce a controlled destruction of epidermis or dermis with
subsequent re-epitheliazation
❏ topical keratolytics are applied 2-3 weeks preoperatively
❏ 3 different categories of chemical peeling agents used, depending on their depth of cutaneous
penetration required:
Table 19.
Penetration Type Peeling Agents Indications
Superficial AHA (glycolic acid) Fine wrinkling

10-30% trichloroacetic acid Acute actinic damage
Jessner’s solution Postinflammatory pigment changes
Acne vulgaris/rosacea
Medium CO2 ice + 35% TCA Moderate wrinkling
Jessner’s + 35% TCA Chronic photodamage
Glycolic acid + 35% TCA Pigment changes
Epidermal/premalignant lesions
Deep Baker-Gordon formula Severe wrinkling
Chronic photodamage
Superficial neoplasms
Pigment changes
Epidermal lesions
❏ complications
• erythema, infection, postinflammatory hyper/hypopigmentation, hypertrophic scars
LASER THERAPY
❏ wavelength is inversely proportional to absorption and directly proportional to penetration depth
❏ purpose: to remove/lessen unwanted pigmentation or vascular lesions (capillary hemangiomas, tattoos,
epidermal nevi, seborrheic keratoses)
❏ hemoglobin, water and melanin are the main targets of lasers
❏ lasers destroy unwanted skin abnormalities based on 3 mechanisms
• heat energy – absorption of heat with 2º spread to adjacent tissues
• mechanical energy – rapid thermoelastic expansion destroys target
• selective photothermolysis – wavelength that is maximally absorbed by target only and does not
spread to adjacent tissues
❏ complications
• erythema, hyper/hypopigmentation, scarring, infection
SUNSCREENS AND PREVENTATIVE THERAPY

UV Radiation
❏ UVA (320-400nm)
• penetrates skin more effectively than UVB or UVC
• responsible for tanning, burning, wrinkling and premature skin aging
• penetrates clouds, glass and is reflected off water, snow and cement
❏ UVB (290-320nm)
• absorbed by the outer dermis
• is mainly responsible for burning and premature skin aging
• primarily responsible for BCC, SCC and melanomas
• does not penetrate glass and is substantially absorbed by ozone
❏ UVC (200-290nm)
• is filtered by ozone layer
Sunburn Prevention
❏ sunburn
• definition
• erythema 2-6 hours post UV exposure often associated with edema, pain and blistering with
subsequent desquamation of the dermis and hyperpigmentation
• phototoxicity (erythema, immediate, pain) vs. photoallergy (eczema, delayed reaction,
pruritis)
• UV index measures the time to burn for a fair skinned individual
• < 15 minutes = UV index > 9
• ~ 20 minutes = UV index 7-9
• ~ 30 minutes = UV index 4-7
SUNSCREENS AND PREVENTATIVE THERAPY . . . CONT.
Sunscreens
❏ SPF = sun protection factor (UVB>UVA): under ideal conditions a
SPF of 10 means that a person who normally burns in 20 minutes
will burn in 200 minutes following the application of the sunscreen,
no matter how often the sunscreen is subsequently applied
❏ sunscreens containing PABA esters may promote allergic contact dermatitis
❏ topical chemical: requires application, at least 15-60 minutes prior to
exposure, absorbs UV light
• UVB absorbers: PABA, Salicylates, Cinnamates, Benzylidene camphor derivatives
• UVA absorbers: Benzophenones, Anthranilates,
Dibenzoylmethanes, Benzylidene camphor derivatives
❏ topical physical: reflects and scatters UV light
• Titanium dioxide, Zinc oxide, Kaolin, Talc, Ferric chloride and
Melanin all are effective against the UVA and UVB spectrum
• less risk of sensitization then chemical sunscreens and waterproof,
but may cause folliculitis or miliaria
Sunburn Treatment
❏ if significant blistering present, consider treatment in hospital
❏ symptomatic therapy
• cool, wet compresses and baths
• moisturizers for dryness and peeling
• oral anti-inflammatory: 400 mg ibuprofen q6h to relieve pain,
minimize erythema and edema
• topical corticosteroids: soothes and decreases erythema,
does not reduce damage
• oral steroids and antihistamines have no role
REFERENCES
Textbooks
Fitzpatrick TB, Johnson RA, Wolff K, eds. Color atlas and synopsis of clinical dermatology: common and serious diseases. 4th edition. New
York: McGraw Hill, 2001.
Fitzpatrick JE and Aeling JL. Dermatology Secrets. 2nd edition. Philadelphia: Hanley & Belfus, 2001.
Articles
Cribier B et al. Erythema nodosum and associated diseases. Int J Dermatol 1998;37-667.
Cummings SR et al. Approaches to the prevention and control of skin cancer. Cancer Metastatis Rev 1997;16:309.
deShazo RD et al. Allergic reactions to drugs and biologic agents. JAMA 1997;278:1895.
Friedmann PS. Assessment of urticaria and angio-edema. Clin Exper Allergy 1999;29 (suppl 3):109.
Gordon ML et al. Caer of the skin at midlife: diagnosis of pigmented lesions. Geriatrics 1997;52:56,67.
Krafchik, BR. Treatment of atopic dermatitis. J Cut Med Surg 3 (suppl 2):16-23, 1999.
JAMA patient page. Skin cancer. JAMA 199;281:676.
Mastrolorenzo A, Urbano FG, Salimbeni L, et al. Atypical molluscum contagiosum in an HIV-infected patient. Int J Dermatol
27:378-380, 1998.
Price VH. Treatment of hair loss. NEJM 1999;341:964.
Roujeau JC. Stevens-Johnson syndrome and toxic epidermal necrolysis are severe variants of the same disease which
differs from erythema multiforme. J Dermatol 1997;24-276.
Whited JD et al. Does this patient have a mole or a melanoma? JAMA 1998;279-676.

Dermatology: Dr. N. Shear Blaise Clarkson and Elana Lavine, Chapter Editors Harriette Van Spall, Associate Editor

Uploaded by

Copyright:

Available Formats

Dermatology: Dr. N. Shear Blaise Clarkson and Elana Lavine, Chapter Editors Harriette Van Spall, Associate Editor

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Dermatology: Dr. N. Shear Blaise Clarkson and Elana Lavine, Chapter Editors Harriette Van Spall, Associate Editor

Uploaded by

Copyright:

Available Formats

DERMATOLOGY

APPROACH TO THE DERMATOLOGY . . . . . . . 2 DRUG ERUPTIONS . . . . . . . . . . . . . . . . . . . . . . . . 30

Table 1. Skin Phototypes

Raised Superficial Lesion Papule (e.g. wart) Plaque (e.g. psoriasis)

Palpable Deep (dermal) Nodule (e.g. dermatofibroma) Tumour (e.g. lipoma)

Flat Lesion Macule (e.g. freckle) Patch (e.g. vitiligo)

USEFUL DIFFERENTIAL DIAGNOSES

MCCQE 2002 Review Notes Dermatology – D3

Table 4. Differential Diagnosis by Location

D4 – Dermatology MCCQE 2002 Review Notes

MCCQE 2002 Review Notes Dermatology – D7

D8 – Dermatology MCCQE 2002 Review Notes

MCCQE 2002 Review Notes Dermatology – D9

MCCQE 2002 Review Notes

Table 6. Acne Types and Treatments

Type II - Pustular Topical Antibiotic (clindamycin, erythromycin); apply bid

Type III - Papular Topical Antibiotic

Type IV - Nodulocystic Isotretinoin (Accutane)

MCCQE 2002 Review Notes Dermatology – D11

Table 7. Acne Treatments and Mechanisms of Action

Benzoyl Peroxide Bactericidal - for mild inflammatory lesions

Adapalene Comedolytic - for comedones

Tretinoin/ Comedolytic - for comedones

Topical Antibiotic Bacteriostatic and anti-inflammatory - for inflamed lesions

ROSACEA (see Colour Atlas D6)

D12 – Dermatology MCCQE 2002 Review Notes

MCCQE 2002 Review Notes Dermatology – D13

ATOPIC DERMATITIS (ECZEMA) (see Colour Atlas D3)

Table 8. Phases of Atopic Dermatitis

Infant (onset at 2-6 months old) Face, scalp, extensor surfaces

D14 – Dermatology MCCQE 2002 Review Notes

STASIS DERMATITIS (see Colour Atlas D1)

DIAPER DERMATITIS (see Pediatrics Chapter)

Table 9. Comparison of Erysipelas and Cellulitis

Erysipelas (see Colour Atlas ID8) Cellulitis

Lesion • Upper dermis • Lower dermis/Subcutaneous fat

Complications • Scarlet fever, streptococcal gangrene, fat necrosis, • Less likely

MCCQE 2002 Review Notes Dermatology – D17

D18 – Dermatology MCCQE 2002 Review Notes

MCCQE 2002 Review Notes Dermatology – D19

D20 – Dermatology MCCQE 2002 Review Notes

D22 – Dermatology MCCQE 2002 Review Notes

MCCQE 2002 Review Notes Dermatology – D25

Table 11. Systemic Treatment of Psoriasis

Table 12. Psoriasis by distribution

Table 13. Vesiculobullous Diseases

Antibody IgG IgG IgA

Site Intercellular space Basement membrane Dermal

Infiltrate Eosinophils and neutrophils Eosinophils Neutrophils

Treatment High dose steroids Moderate dose steroid Gluten-free diet/dapsone

association Thymoma, myasthenia gravis, Malignancy Gluten enteropathy

PORPHYRIA CUTANEA TARDA

MCCQE 2002 Review Notes Dermatology – D29

D30 – Dermatology MCCQE 2002 Review Notes

Table 13. Classification of Urticaria

Chronic Urticaria • Most commonly idiopathic • Attack lasts > 6 weeks

Cholinergic • Increased core body temperature • Tiny flesh coloured wheals

Contact Urticaria • Latex rubber – patch test, allergy test

Aquagenic urticaria • Exposure to water