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Revision Lecture Dermatology

Revision Lecture Dermatology. C Wong Manchester Royal Infirmary. Common conditions. Skin tumours Inflammatory dermatoses – psoriasis, eczema Acne vulgaris Rosacea Disorders of pigmentation Blistering disorders Associations with systemic disease. Basal Cell Carcinoma.

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Revision Lecture Dermatology

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  1. Revision LectureDermatology C Wong Manchester Royal Infirmary

  2. Common conditions • Skin tumours • Inflammatory dermatoses – psoriasis, eczema • Acne vulgaris • Rosacea • Disorders of pigmentation • Blistering disorders • Associations with systemic disease

  3. Basal Cell Carcinoma • Commonest form of skin cancer • Usually face ( exposed sites) • Pearly papule with telangiectasia • Ulcerate with rolled edges ( rodent ulcer) • Locally invasive • Rarely metastasizes • UV exposure, type I and II skin, genetic predisposition ( Gorlin’s syndrome), immunosuppression, arsenic, Xrays and ionizing radiation

  4. Basal Cell Carcinoma • Pearly papule or nodule • Telangiectasia • May ulcerate • Exposed sites

  5. Treatment • Surgery • Mohs’ micrographic surgery for high risk sites and ill defined • Curettage and cautery • Radiotherapy • Cryotherapy - superficial • Photodynamic therapy - superficial

  6. Bowens disease • Intraepidermal carcinoma (premalignant) • Lower legs elderly women • May transform into SCC • May resemble discoid eczema, psoriasis, superficial BCC • Treatment : cryotherapy, curettage, excision, topical 5-fluorouracil, photodynamic therapy

  7. Bowen’s disease • Pink or erythematous plaque • Well demarcated • Scaly • Lower legs • trunk

  8. Squamous cell carcinoma • Malignant tumour derived of keratinocytes • Often arises in sun damaged skin • Can metastasize • Risks • Cumulative UV exposure, xrays and ionizing radiation, chronic ulceration and scarring, genetic ( xeroderma pigmentosa), immunosuppression

  9. Treatment • Surgical excision • radiotherapy

  10. Squamous Cell Carcinoma • Indurated papule, plaque or nodule • Fleshy • Hyperkeratotic with firm margin • Eroded or ulcerated

  11. Malignant melanoma • Malignant tumour of melanocytes • May arise in preexisting mole or in normal looking skin • Change – size, colour, bleeding, itching • A – asymmetry • B – border • C – colour • D – Diameter • metastasize

  12. Malignant melanoma • Repeated short intensive exposure to UV • Family history • Previous MM • Dysplastic naevi • Type I skin

  13. Malignant Melanoma • Wide excision • Prognosis dependent tumour depth – Breslow thickness • Good prognosis < 1mm • Poor prognosis > 4 mm

  14. Seborrhoeic keratoses • Basal cell papilloma • Trunk and face elderly and middle aged • Stuck on appearance with keratin plugs • Treatment • Curettage • cryotherapy

  15. Psoriasis • Chronic often life long inflammatory condition with spontaneous exacerbations and remissions • Characterised by well demarcated erythematous plaques topped by silvery scale • Disfiguring, causes significant psychological morbidity • 2-3 % western europe

  16. Psoriasis • Bimodal age of onset • 20 – 25 50 - 55 • Type 1 < 40 • Type 2 > 40 • Hyperproliferation of epidermis • T cell mediated disease

  17. Psoriasis • Complex interaction between genetic predisposition and environmental factors • Genetic : positive FH ~ 30% • Polygenic – multiple susceptible loci • HLA Cw6 – most strongly associated with type I

  18. Psoriasis • Environment • Infection – acute streptococcal infections • Stress • Alcohol • Drugs eg lithium, antimalarials • Sunlight • Trauma – koebner phenomenon

  19. Psoriasis • Arthropathy • 8-10% patients • Seronegative • Symmetrical peripheral polyarthropathy • Monoarthritis • Distal interphalangeal arthritis • Sacroiliitis • ‘arthritis mutilans’

  20. Topical Treatment • Emollients • Tar • Dithranol • Vitamin D analogues • Retinoids • Topical steroids – mild for flexures and face

  21. Treatment • Phototherapy – UVB, PUVA • Systemic • Methotrexate • Cyclosporin • Acitretin • Hydroxyurea • New biologicals

  22. Eczema • Chronic itchy inflammatory condition of the skin • Endogenous – constitutional : atopic • Exogenous • Irritant contact dermatitis • Allergic contact dermatitis • Drug induced • Photosensitive

  23. Atopic eczema • Atopy – eczema, asthma, hayfever • High Ig E • Infants – within 1st 6 months • Childhood – antecubital fossae, popliteal fossae, neck, wrists, ankles, face • Adults – hands, generalised and lichenified

  24. Atopic eczema • Increased risk of bacterial infections • Staphylococcal infection • Increased risk of viral infections • Molluscum contagiosum • Herpes simplex ( eczema herpeticum )

  25. Treatment • Emollients • Topical steroids • Topical tacrolimus/pimecrolimus • Topical antibiotics ( if infected ) • Phototherapy • Immunosuppressants – azathioprine, cyclosporin

  26. Lichen planus • Acute or chronic inflammatory pruritic dermatosis involving skin or mucous membranes • Characterised by flat topped, violaceous, polygonal papules with Wickham’s striae

  27. Lichen planus • Cause unknown • Can be drug induced • Affects nails, can affect scalp • Can be self limiting • Topical steroids

  28. Acne vulgaris • Chronic inflammation of pilosebaceous units • Increased sebum production • Pilosebaceous duct hyperkeratosis • Colonisation with Propionibacterium acnes • Release of inflammatory mediators • Formation of comedones, inflammatory papules, pustules and cysts

  29. Acne vulgaris • Face, upper chest and back • Age ~ pre, at puberty – decade after • Can persist into 4th , 5th decades • Treatment • Topical - benzoyl peroxide, retinoids, antibiotics • Systemic – antibiotics, OCP, retinoids

  30. Rosacea • Chronic inflammatory facial dermatoses characterised by erythema and pustules • Cause unknown • Middle aged • Flushing • Erythema, telangiectasia, papules, pustules, occasional lymphoedema : rhinophyma

  31. Rosacea • Eye involvement – blepharitis, conjunctivitis • No comedones • Treatment • Topical – metronidazole • Systemic – antibiotics, retinoids, • Rhinophyma – laser, plastic surgery • Avoid topical steroids

  32. Vitiligo • Acquired idiopathic disorder with white non scaly macules • Autoimmune – associated with pernicious anaemia, thyroid disease, addison’s disease, diabetes • FH ~ 30%

  33. Vitiligo • Treatment – unsatisfactory • Camouflage cosmetics • Sunscreens • Potent topical steroids • Phototherapy – UVB, PUVA

  34. Bullous Pemphigoid • Chronic autoimmune blistering eruption • Affects elderly • Very itchy • Tense blisters • Arising from erythematous, sometimes urticated or normal skin

  35. Bullous pemphigoid • IgG autoantibodies to bullous pemphigoid antigens in the hemidesmosomes at the basement membrane zone bind complement which induces inflammation and protease release • Subepidermal bulla formation

  36. Treatment • Superpotent topical steroids • Systemic steroids • Steroid sparing agents eg azathioprine • Minocycline, nicotinamide

  37. Pemphigus vulgaris • Autoimmune blistering disorder affecting skin and mucuous membranes • IgG autoantibodies bind with desmoglein ( desmosomal cadherin involved in epidermal intercellular adhesion ) results in loss of adhesion and an intraepidermal split • Less common than pemphigoid • Middle aged or young adults

  38. Pemphigus • Flaccid superficial blisters scalp, face, back, chest and flexures • Blistering not always obvious • Crusted erosions • Oral involvement common

  39. Treatment • High dose systemic steroids • Azathioprine • cyclosphosphamide

  40. Pemphigoid Subepidermal blisters Tense blisters Itchy Elderly Oral involvement less common Pemphigus Intraepidermal blisters Flaccid blisters or erosions Middle aged/ young adults Oral involvement common

  41. Necrobiosis Lipoidica • Yellow brown • Atrophic • Telangiectactic • Plaques surrounded by raised violaceous rims • Pretibial region

  42. Necrobiosis Lipoidica • Cause unknown - ? Microangiopathy resulting in collagen degeneration, dermal inflammation • < 1% diabetics • > 2/3 of patients with NL are diabetic • No correlation between diabetic control and development or improvement of necrobiosis lipoidica

  43. Pretibial myxoedema • Hyperthyroidism • Erythematous to skin coloured • Purple-brown, yellow • Waxy, indurated nodules or plaques • Peau d’orange appearance • Anterolateral lower legs

  44. Discoid Lupus Erythematosus • Chronic cutaneous disorder characterised by scaly atrophic plaques in sun exposed sites • Treatment – photoprotection, topical steroids, antimalarials • SLE – facial butterfly rash, photosensitivity, alopecia, vasculitis

  45. Systemic Lupus Erythematosus • Multisystem disease involving connective tissue and blood vessels • Fever • Skin lesions • Arthritis • Renal disease • Cardiac involvement • Pulmonary disease • Positive autoantibodies - ANA

  46. Dermatitis Herpetiformis • Uncommon itchy blistering eruption affecting extensors • Associated with coeliac disease • Treatment – gluten free diet • dapsone

  47. Vasculitis • Inflammation within or around blood vessels • Infections – streptococcal, hepatitis B and C • Drug induced • Connective tissue disease • Cryoglobulinaemia, macroglobulinaemia • Inflammatory bowel disease

  48. Small vessel Henoch Schonlein purpura Wegener’s granulomatosis Churg Strauss syndrome Essential cryoglobulinaemia Medium vessels Polyarteritis nodosa Large vessel Giant cell arteritis Takayasu’s arteritis

  49. Erythroderma • Erythema and scaling affecting > 90% body surface area • Eczema • Psoriasis • Lymphoma / Sezary syndrome • Acute drug eruptions • Pityriasis rubra pilaris

  50. Complications of erythroderma • Cardiac failure • Hypothermia • Sepsis

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