Acanthosis nigricans

Causes

 type 2 diabetes mellitus

 gastrointestinal cancer
 obesity
 polycystic ovarian syndrome
 acromegaly
 Cushing's disease
 hypothyroidism
 familial
 Prader-Willi syndrome
 drugs
o combined oral contraceptive pill
o nicotinic acid

Management of moderate to severe acne: CKS

 a 12-week course of one of the following options:

o a fixed combination of topical adapalene with topical benzoyl peroxide
o a fixed combination of topical tretinoin with topical clindamycin
o a fixed combination of topical adapalene with topical benzoyl peroxide
+ either oral lymecycline or oral doxycycline
o a topical azelaic acid + either oral lymecycline or oral doxycycline
 important points about oral antibiotic usage:
o tetracyclines should be avoided in pregnant or breastfeeding women
and in children younger than 12 years of age. Erythromycin may be
used in pregnancy
o minocycline is now considered less appropriate due to the possibility of
irreversible pigmentation
o only continue a treatment option that includes an antibiotic (topical or
oral) for more than 6 months in exceptional circumstances
o a topical retinoid (if not contraindicated) or benzoyl peroxide should
always be co-prescribed with oral antibiotics to reduce the risk of
antibiotic resistance developing. Topical and oral antibiotics should not
be used in combination
o Gram-negative folliculitis may occur as a complication of long-term
antibiotic use - high-dose oral trimethoprim is effective if this occurs
  combined oral contraceptives (COCP) are an alternative to oral antibiotics in
women
o as with antibiotics, they should be used in combination with topical
agents
o Dianette (co-cyprindiol) is sometimes used as it has anti-androgen
properties. However, it has an increased risk of venous
thromboembolism compared to other COCPs, therefore it should
generally be used second-line, only be given for 3 months and women
should be appropriately counselled about the risks
 oral isotretinoin: only under specialist supervision
o pregnancy is a contraindication to topical and oral retinoid treatment

To reduce the risk of antibiotic resistance developing the following should not be
used to treat acne: CKS

 monotherapy with a topical antibiotic

 monotherapy with an oral antibiotic
 a combination of a topical antibiotic and an oral antibiotic

NICE referral criteria CKS

 the following patients should be referred to a dermatologist:

o patients with acne conglobate acne: a rare and severe form of acne
found mostly in men that presents with extensive inflammatory
papules, suppurative nodules (that may coalesce to form sinuses) and
cysts on the trunk.
o patients with nodulo-cystic acne
 referral should be considered in the following scenarios:
o mild to moderate acne has not responded to two completed courses of
treatment
o moderate to severe acne has not responded to previous treatment that
includes an oral antibiotic
o acne with scarring
o acne with persistent pigmentary changes
o acne is causing or contributing to persistent psychological distress or a
mental health disorder
Actinic keratoses

premalignant skin lesion that develops as a consequence of chronic sun exposure

Features

 small, crusty or scaly, lesions

 may be pink, red, brown or the same colour as the skin
 typically on sun-exposed areas e.g. temples of head
 multiple lesions may be present

Management :

 prevention of further risk: e.g. sun avoidance, sun cream

 fluorouracil cream: typically a 2 to 3 week course. The skin will become red
and inflamed - sometimes topical hydrocortisone is given following
fluorouracil to help settle the inflammation
 topical diclofenac: may be used for mild AKs. Moderate efficacy but much
fewer side-effects
 topical imiquimod: trials have shown good efficacy
 cryotherapy
 curettage and cautery

Alopecia areata

autoimmune condition causing localised, well demarcated patches of hair loss. At

the edge of the hair loss, there may be small, broken 'exclamation mark' hairs

Hair will regrow in 50% of patients by 1 year, and in 80-90% eventually.

treatment options include:

 topical or intralesional corticosteroids

 topical minoxidil
  phototherapy
 dithranol
 contact immunotherapy
 wigs

Examples of sedating antihistamines

 chlorpheniramine

As well as being sedating these antihistamines have some antimuscarinic properties

(e.g. urinary retention, dry mouth).

Examples of non-sedating antihistamines

 loratidine
 cetirizine

Basal cell carcinoma

also known as rodent ulcers and are characterised by slow-growth and local
invasion. Metastases are extremely rare.
the most common type of cancer in the Western world.

Features

 many types of BCC are described. The most common type is nodular BCC,
which is described here
 sun-exposed sites, especially the head and neck account for the majority of
lesions
 initially a pearly, flesh-coloured papule with telangiectasia
 may later ulcerate leaving a central 'crater'
Referral

 generally, if a BCC is suspected, a routine referral should be made

Management options:

 surgical removal
 curettage
 cryotherapy
 topical cream: imiquimod, fluorouracil
 radiotherapy

Bullous pemphigoid

autoimmune condition causing sub-epidermal blistering of the skin

secondary to the development of antibodies against hemidesmosomal proteins
BP180 and BP230.

more common in elderly patients

Features :

 itchy, tense blisters typically around flexures

 the blisters usually heal without scarring
 there is stereotypically no mucosal involvement (i.e. the mouth is
spared)classic differentiating feature between pemphigoid and pemphigus.

Skin biopsy

 immunofluorescence shows IgG and C3 at the dermoepidermal junction

Management

 referral to a dermatologist for biopsy and confirmation of diagnosis

 oral corticosteroids are the mainstay of treatment
  topical corticosteroids, immunosuppressants and antibiotics are also used

Burns

Assessing the extent of the burn

 Wallace's Rule of Nines: head + neck = 9%, each arm = 9%, each anterior part of leg
= 9%, each posterior part of leg = 9%, anterior chest = 9%, posterior chest = 9%,
anterior abdomen = 9%, posterior abdomen = 9%
 Lund and Browder chart: the most accurate method
 the palmar surface is roughly equivalent to 1% of total body surface area (TBSA). Not
accurate for burns > 15% TBSA

Assessing the depth of the burn

Former
Modern terminology Appearance
terminology

Superficial epidermal First degree Red and painful, dry, no blisters

Par al thickness (superficial

Second degree Pale pink, painful, blistered. Slow capillary refill
dermal)

Par al thickness (deep Typically white but may have patches of non-blanching erythema. Redu
Second degree
dermal) sensa on, painful to deep pressure

Full thickness Third degree White ('waxy')/brown ('leathery')/black in colour, no blisters, no pain

Referral to secondary care

 all deep dermal and full-thickness burns.

 superficial dermal burns of more than 3% TBSA in adults, or more than 2% TBSA in
children
 superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any
flexure, or circumferential burns of the limbs, torso, or neck
 any inhalation injury
 any electrical or chemical burn injury
 suspicion of non-accidental injury
Initial management of burns

 initial first aid as above

 review referral criteria to ensure can be managed in primary care
 superficial epidermal: symptomatic relief - analgesia, emollients etc
 superficial dermal: cleanse wound, leave blister intact, non-adherent dressing, avoid
topical creams, review in 24 hours

Chronic plaque psoriasis

most common form of psoriasis s- 80% of presentations.

Features

 erythematous plaques covered with a silvery-white scale

 typically on the extensor surfaces such as the elbows and knees. Also common
on the scalp, trunk, buttocks and periumbilical area
 clear delineation between normal and affected skin
 plaques typically range from 1 to 10 cm in size
 if the scale is removed, a red membrane with pinpoint bleeding points may be
seen (Auspitz's sign)

Contact dermatitis

two main types :

 irritant contact dermatitis: common - non-allergic reaction due to weak acids

or alkalis (e.g. detergents). Often seen on the hands. Erythema is typical,
crusting and vesicles are rare
 allergic contact dermatitis: type IV hypersensitivity reaction. Uncommon -
often seen on the head following hair dyes. Presents as an acute weeping
eczema which predominately affects the margins of the hairline rather than
the hairy scalp itself. Topical treatment with a potent steroid is indicated
Dermatitis herpetiformis

autoimmune blistering skin disorder associated with coeliac disease

caused by deposition of IgA in the dermis
More than 90% of patients exhibit small bowel biopsy findings consistent with some
degree of gluten-sensitive enteropathy.

Features

 itchy, vesicular skin lesions on the extensor surfaces (e.g. elbows, knees,
buttocks)

Diagnosis

 skin biopsy: direct immunofluorescence shows deposition of IgA in a

granular pattern in the upper dermis

Management

 gluten-free diet
 dapsone

Dermatofibroma

also known as histiocytomas

common benign fibrous skin lesions
caused by the abnormal growth of dermal dendritic histiocyte cells, often following a
precipitating injury
Common areas include the arms and legs.

Features

 solitary firm papule or nodule, typically on a limb

 typically around 5-10mm in size
 overlying skin dimples on pinching the lesion
  Eczema herpeticum

severe primary infection of the skin by herpes simplex virus 1 or 2.

It is more commonly seen in children with atopic eczema and often presents
as a rapidly progressing painful rash.

On examination, monomorphic punched-out erosions (circular, depressed,

ulcerated lesions) usually 1–3 mm in diameter are typically seen.

As it is potentially life-threatening children should be admitted for IV

aciclovir.

Eczema: topical steroids

Use the weakest steroid cream which controls patient's symptoms

The table below shows topical steroids by potency

Mild Moderate Potent Very potent

Betamethasone valerate 0.025% Fluticasone propionate 0.05%
(Betnovate RD) (Cutivate)
Hydrocortisone 0.5- Clobetasol propionate 0
2.5% (Dermovate)
Clobetasone butyrate 0.05% Betamethasone valerate 0.1%
(Eumovate) (Betnovate)

Finger tip rule

 1 finger tip unit (FTU) = 0.5 g, sufficient to treat a skin area about twice that of
the flat of an adult hand

Topical steroid doses for eczema in adults

Area of skin Fingertip units per dose

Hand and fingers (front and back) 1.0
A foot (all over) 2.0
Front of chest and abdomen 7.0
Back and buttocks 7.0
 Area of skin Fingertip units per dose
Face and neck 2.5
An entire arm and hand 4.0
An entire leg and foot 8.0

The BNF makes recommendation on the quantity of topical steroids that should be
prescribed for an adult for a single daily application for 2 weeks:

Area Amount
Face and neck 15 to 30 g
Both hands 15 to 30 g
Scalp 15 to 30 g
Both arms 30 to 60 g
Both legs 100 g
Trunk 100 g
Groin and genitalia 15 to 30 g

Erythema ab igne

caused by over exposure to infrared radiation.

Characteristic features include reticulated, erythematous patches with

hyperpigmentation and telangiectasia.

A typical history would be an elderly women who always sits next to an open fire.

If the cause is not treated then patients may go on to develop squamous cell skin
cancer.
Erythema multiforme

hypersensitivity reaction

commonly triggered by infections.

divided into minor and major forms.

Features

 target lesions
 initially seen on the back of the hands / feet before spreading to the torso
 upper limbs are more commonly affected than the lower limbs
 pruritus is occasionally seen and is usually mild

Causes

 viruses: herpes simplex virus (the most common cause), Orf*

 idiopathic
 bacteria: Mycoplasma, Streptococcus
 drugs: penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral
contraceptive pill, nevirapine
 connective tissue disease e.g. Systemic lupus erythematosus
 sarcoidosis
 malignancy

Erythema multiforme major

The more severe form, erythema multiforme major is associated with mucosal involvement.

*Orf is a skin disease of sheep and goats caused by a parapox virus

Erythema nodosum

 inflammation of subcutaneous fat

 typically causes tender, erythematous, nodular lesions
 usually occurs over shins, may also occur elsewhere (e.g. forearms, thighs)
 usually resolves within 6 weeks
 lesions heal without scarring

Causes

 infection
o streptococci
o tuberculosis
o brucellosis
 systemic disease
o sarcoidosis
o inflammatory bowel disease
o Behcet's
 malignancy/lymphoma
 drugs
o penicillins
o sulphonamides
o combined oral contraceptive pill
 pregnancy