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Dermatology Atlas

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Dermatology Atlas

  1. 1. Sarah Wood
  2. 2. Acute Wounds
  3. 3. Wound Healing Keloid scars: (children, young adults, genetics, black skin). No improvement with time. Can continue to enlarge. Overgrowth of dense fibrous tissue. HLA associated. No hair follicles or sweat glands on scar. Overgrows margins of original wound. Starts red, becomes pale or brown. Options for Tx: occlusive dressings, intralesional corticosteroid injections, compressive dressings, cryosurgery, radiation, laser. Hypertrophic Scars: Lumpy within the confines of the wound. Elevated, rarely painful, regresses spontaneously.
  4. 4. Acute Wounds - burns 1st degree – extend to epidermis of upper dermal layer only. Very painful, dead skin can peal. 3rd degree – skin = black, brown, yellow, red or white. Burn reaches subcut fat. Pain minimal – nerve endings almost all destroyed. No blistering, but hard, inelastic eschar 2nd degree – extends to deeper dermal layers, can blister, more moderate pain (damage to nerve endings.) Fourth degree – the most serious. Reaches underlying fascia, can affect bone and tendons.no oedema, lots of eschar. Pain minimal.
  5. 5. Chronic Wounds
  6. 6. Venous Ulcers • Venous Ulcers – indicate severe venous insufficiency. (valve incompetence, increased hydrostatic pressure and capillary permeability, increased pericapillary fibrin deposition.) 80% of leg ulcers. Think about RFs. Haemosiderin, telangectasia, atrophie blanche, eczema, lipodermatosclerosis, ulceration Atrophie blanche with haemosiderin deposition telangectasia
  7. 7. Neuropathic Ulcers • Frequently seen in diabetes, decreased sensation, loss of autonomic function, anhidrosis, loss of intrinsic muscle function. Ulcers typically wet and deep. Often on pressure points and surrounded by callous. Tx: off-load weight, MDT, patient compliance, glucose control.
  8. 8. Arterial Ulcers • Usually below ankle. Look for signs of decreased blood flow – cooler, hair loss, thin and shiny skin, dependant rubor, thick nails, reduced or absent pulses. Ulcers are typically small, distal with steep “cliff edge” and a dry bottom. Pain at night when leg elevated. Patient can have intermittent claudication. Tx: restore blood flow! Stop smoking! Control RFs (eg hypertension), NO compression. Mixed arterial and venous ulcer
  9. 9. Photoaging and Skin Tumours
  10. 10. Photoaging (chronic sun exposure) • Course, wrinkled, pale- yellow skin • Telangectasia • Irregular pigmentation • Prone to purpura • Benign and malignant skin tumours.
  11. 11. Bengin Epidermal Tumours Actinic (solar) Keratoses Solar (senile) Lentigos (“age spots”) Seborrheic Keratoses (“seb warts”) Skin Tags Epidermal Cyst Milia Melanocytic naevi
  12. 12. Benign Dermal Tumours Dermatofibroma (commoner in females, can be a reaction to trauma Campbell de Morgan spots (cherry angiomas) Haemangioma Pyogenic granuloma Chondrodermatitis nodularis Intradermal Naevus
  13. 13. Low Grade Malignant Tumours Bowen’s Disease (intraepidermal carcinoma, squamous carcinoma in situ). Can look like infection to start with. Keratocanthoma – benign techincally? but can look like squamous carcinoma, so biopsy! Papular lesion with central umbilicated keratinous core. Lentigo Maligna (Hutchinson’s melanotic freckle). Light brown with development of darker areas. Can turn into cancer later in life. Flat (macular) and when invades dermal layer, becomes lentigo maligna melanoma.
  14. 14. Malignant Skin Tumours • 1) Basal Cell Carcinoma – commonest. Rarely spreads. Most are painless, history of sun exposure. Biopsy! Proliferation of atypical basal cells. Often clefts between tumour and dermis. Slow growing. Rolled-in edge, telangectasia, or nodular, or pigmented, pearly appearance. • 2) Squamous Cell Carcinoma Malignant tumour of epithelial keratinocytes – skin and mucous membranes. Sun exposure = major RF. Persists and grows. Can be solitary, keratotic or eroded, papular or nodular. Can arise from actinic keratoses. Lymph spread. Old men.
  15. 15. Pigmented Skin Lesions Benign melanocytic naevus “mole” Seborrheic keratosis • 3) Cutaneous T-cell lymphoma (mycosis fungoides) Rare. Uncontrolled t-cell growth in the skin.
  16. 16. 4) Malignant Melanoma Questions: How long have you had it? Has it changed? Over what period of time? Larger? Changed in colour or shape? Has it become itchy? Facts: Incidence = 10/100k/year (increasing 7% each year) F:M = 2:1 (equal in hot countries). Commonest sites = lower leg in women, back in men. Pre-existing naevus in 30%. RFs: Previous Hx, FHx, Red hair, blue eyes, multiple melanocytic naevi, congential naevus. Is it worrying? Breslow thickness (depth) and Clarks level (where it is in dermis in relation to other structures). Prevention: SLIP, SLAP, SLOP! Report changes early.
  17. 17. Skin Manefestations of Systemic Diseases and Drug Eruptions
  18. 18. Vasculitis! • 1) Henoch-Schonlein Purpura necrotising vasculitis of small vessels. Children. Palpable purpuric rash, arthritis, haematuria, bowel angina and ischaemia. Post strep throat inf = most common. • 2) Polyarteritis Nodosa rare, autoimmune, necrotising vasculitis of medium vessels. Middle aged me. Renal failure, CHS, Cardiac involvement, pulmonary, GI, blood. Subcut nodules. Livedo Reticularis p-ANCA and ANA negative. Tends to follow artery lines. Can ulcerate and become necrotic. Common post HepB • 3) Wegener’s Granulomatosis granulomatous vasculitis. URT and LRT, renal involvement, arthritis, c-ANCA +ve. Saddle-shaped deformity. M>F Tx: find and treat cause and systemic involvement. Pred/immunosupression, dapsone for cutaneous involvement. 1 2 3
  19. 19. Erythema Nodosum • Inflammation of subcut fat causing painful red nodules on the legs • Causes: 20% idiopathic, infection (strep, TB), drugs (OCP), systemic diseases (IBD, Sarcoidosis) • Tx: rest, analgesia, treat underlying cause
  20. 20. Erythema Multiforme • Reaction of dermal vessels resulting in changes – papular and vesicobullous eruptions, TARGET-LIKE LESIONS!. • Palms, soles, mucosal membranes • If severe, “Stevens-Johnson Syndrome” • Causes: 50% idiopathic. HSV, Strep, pregnancy, SLE, drugs (sulphonamides, phenytoin, barbituates, penicillin, allopurinol) • Tx: Treat cause. Symptomatic care (analgesia, IV fluids if unable to drink etc)
  21. 21. Pyoderma Gangrenosum • Rapidly progressing ulcer, often with erythematous to violaceous undermined edge. Can occur at site of trauma/surgical wound • Causes: 50% idiopathic. • Associated with: RA, IBD, Haematological malignancy, trauma • Tx: Systemic steroids, immunosuppression.
  22. 22. Connective Tissue Diseases
  23. 23. SLE – Cutaneous Manifestations: • Photosensitvity • Malar Rash • Raynauds Phenomenon • SLE Vasculitis • Alopecia (typically scarring)
  24. 24. • * Subacute cutaneous lupus erythematosus * Positive autoantibodies, widespread rash, well defined, can get everywhere on body, photosensitive. Other body systems can be involved – heart (pericarditis), lungs (pneumonitis), CNS. • * Discoid Lupus Erythematosus * autoantibodies usually negative (<20% ANA). Only 5% develop SLE. Discoid lesions on sun-exposed sites. Scarring alopeica.
  25. 25. Systemic Sclerosis • Autoantibodies positive: Scl- 70, centromere antibodies. • F:M = 4:1 • Proximal skin sclerosis and any 2 of: sclerodactyly, digital pitting scars, pulp loss and bi-basal lung fibrosis • CREST Syndrome has less internal involvment and a better prognosis (Calcinosis, Raynauds, Oesophageal stricture, sclerodactyly, telangectasia) calcinosis
  26. 26. Morphea • Localised fibrotic plaques, atrophic changes, self-limiting, no internal involvment. Localised cutaneous sclerosis. Indurated plaques with erythematous edge or brown macules. F:M = 3:1.
  27. 27. Dermatomyositis • Spectrum of disease • Polymyositis: high CK, CRP • Jo-1 Antibodies • 60% ANA positive • Photosensitive rash • Heliotrope (purple) changes on face • Red papules on dorsa of hands and fingers (gottron’s papules) • If >55yrs, associated with malignancy – breast, lung, stomach, uterus, colon Heliotrope rash Gottron’s papules Muscle biopsy: pink muscle cells being attacked by inflammatory cells
  28. 28. Manifestations of Malignancy, Endocrine Conditions, and Drug Eruptions
  29. 29. Manifestations of Malignancy Acanthosis Nigricans: typically neck and axillae. Papillomatous. Associated with GI malignancy. Pagets Disease of the Nipple: associated with Breast Ca, suspect if unilateral breast eczema. Secondary Cutaneous Metastases: various. Present late, represents poor prognosis. Usually scalp, trunk, umbilicus. Erythema Gyratum Repens: associated with Lung Ca.
  30. 30. Cutaneous Manifestations of Endocrine Disease HYPERPIGMENTATIO N: Addisons, pregnancy, Cushings VITILIGO: Addisons, organ specific autoimmunes, DM, thyroid disease HIRSUITISM: Cushings, PCOS GRANULOMA ANNULARE: generalised in IDDM NECROBIOSIS LIPIODICA: IDDM PRETIBIAL MYXOEDEMA: Grave’s Disease
  31. 31. Drug Eruptions • Almost all drugs can cause rashes. Certain ones more likely to cause a certain pattern. 2-3% of hospitalised patients. Ask about drugs started in the last 2-3 weeks, inc. OTCs. Erythema Mobilliform: eg. amoxicillin Fixed Drug Eruption: eg. Streptomycin, cephs. Generalised Fixed Drug Eruption: eg. Anticonvulsants, aspirin, NSAIDS, phenobarbs, doxycycline, metronidazole etc etc.
  32. 32. Hypersensitivty Reactions: • Type I: IgE mediated. Causes Urticaria, angioedema, anaphylaxis • Type II: cytotoxic leading to haemolysis, purpura. • Type III: immune comples reaction, resulting in vasculitis, serum sickness, urticaria • Type IV: delayed-type reaction with cell-mediated hypersensitivity resulting in contact dermatitis, exanthematous reactions, photoallergic reactions.
  33. 33. TEN – Toxic Epidermal Necrolysis • Erythema-multiforme => Steven-Johnsons Syndrome => toxic epidermal necrolysis • Allopurinol, Anticonvulsants, aspirin, isoniazid, sulphonamides, penicillins. (can also be cause by things like infection! herpies especially.) • Fever, chills, headache, D&V, no pruritis. Can get mouth involvment/GU involvment. • Macules => papules, vesicules, bullae, uritcarial plaques, erythema. • TEN: Muco-cutaneous detatchement. Burns unit. • TEN: up to 30% die
  34. 34. Eczema
  35. 35. Exogenous (contact) Eczema • 1) Irritant • 2) Allergic • 3) Photodermatitis
  36. 36. Endogenous and Mixed Eczema • 1) Atopic Eczema • 2) Seborrheic Eczema
  37. 37. • 3) Discoid Eczema • 4) Pompholyx Eczema • 5) Gravitational Eczema
  38. 38. • 6) Asteatotic Eczema • 7) Lichen Simplex Eczema
  39. 39. Psoriasis
  40. 40. Types of Psoriasis • 1) Chronic Plaque • 2) Guttate
  41. 41. • 3) Flexural • 4) Scalp Psoriasis • 5) Palmar-plantar pustulosis
  42. 42. • 6) Generalised Pustular Psoriasis • 7) Erythroderma <>
  43. 43. Nail Changes in Psoriasis Pitting Onycholysis ridging Nail loss discolouration