Taken from Oxford Handbook of General Practice (OHGP)

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3. (Atopic, Irritant, Seborrhoeic, varicose)
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4. Atopic Dermatitis
Presentation itchy condition.
If no itching then it’s not eczema.
Infants Itchy vesicular eczema on face ± hands. May cause
sleep disturbance.
Children >18mo Involves antecubital and popliteal fossae, neck, wrists, and ankles.
Lichenification, excoriation, and dry skin.
Adults Most commonly hand dermatitis in a person with past history of atopic eczema. A
few continue to have generalized atopic eczema. Exacerbated by stress.
Associated with
other atopic
conditions, e.g.
asthma, hay fever.
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5. Assessment Ask about:
• Family and personal history
• distribution of the disease
• Aggravating factors (pets, irritants, e.g. soaps/detergents, allergens)
• Impact on quality of life (school work, career, social life)
Diagnosis Itchy skin plus ≥3 of:
• Itching in skin creases
• History of asthma or hay fever
• Generally dry skin
• Visible flexural eczema
• Onset in the first 2y of life
Complications
• Skin thickening and scaling
• Bacterial infection Secondary infection (usually with Staph. aureus)
• Viral infection, e.g. viral warts, molluscum. Eczema herpeticum
• Cataracts Rarely occur in young adults with very severe eczema
• Growth retardation Children with severe eczema, cause unknown.
A growth chart should be kept for children with chronic severe eczema
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7. Non Pharmalogical Management
• Advise—loose cotton clothing; avoid wool (exacerbates eczema);
avoid excessive heat; keep nails short; gloves in bed
• If a specific irritant is identified (e.g. house dust mite, pets) then avoid
Pharmalogical Management
• Emollients Topical creams/ointments and bath emollients—use
as soap substitutes, even if skin is clear. May Ideally apply 3–4x/d
• Topical steroids least potent strength that is effective.
Use od or bd. Ointments are preferable on dry, scaly eczema; creams
on wet, exudative eczema.
• Antibiotics For infected eczema—topical (alone or in combination
with steroid, e.g. Fucidin) or oral (e.g. flucloxacillin or erythromycin
qds for 2wk). Swab if antibiotic treatment is ineffective
• Oral steroids Rescue therapy
•Sedative antihistamines
• Bandages Excoriated or lichenified eczema—zinc and
calamine. Bandages can be applied at night on top of steroid ointment.
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8. Contact Dermatitis
• Irritant (water, abrasives, chemicals, detergent), or
• Allergic (nickel; chrome; rubber)
site and knowledge of occupation, hobbies, sports, help find the
cause.
• Acute itchy erythema and skin oedema, papules, vesicles, or
blisters
• Chronic lichenification, scaling, and fissuring
Management
• Identification of the allergen or irritant Consider referral for patch
testing
• Exclusion of the offending allergen or irritant from the environment
Although this may be impossible. There is some evidence that nickel
avoidance diets can help patients with nickel sensitivityG.
• Hand care
• Emollients
• Topical steroids
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10. Seborrhoeic Dermatitis
Scalp and facial
involvement Most
common in young
men. Excessive
dandruff, itchy scaly
erythematous eruption
affecting sides of the
nose,
eyes, ears, hairline.
Petaloid Dry,
scaly eczema
over the pre-sternal
area
Pityrosporum
folliculitis
Erythematous
follicular eruption
with
papules/pustules
over the back
Flexural Most
common in the elderly.
Axillae, groins, and
submammary areas.
Moist intertrigo.
Associated with s
candida
infection
Infantile
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12. Varicose Dermatitis
• Associated with underlying varicose viens
• haemosiderin deposition around the
ankles over prominent veins >>Later signs Eczema ±
fibrosis of the dermis and subcutaneous tissue ±
ulceration
• Management
Emollients ± mild or moderate steroid ointment (avoid
long-term use) .
Treat venous disease
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15. •
• ASSOCIATIONS:
• CAUSE
15

16. Erthrodermic psoriasis >> Admit as
an emergency
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22. Plantopalmar pustulosis
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23. Management
Frequent emollients ±
• Salicylic acid decrease surface scale.
• Coal tar Anti-inflammatory + anti-scaling. The thicker the patch the
stronger the preparation needed.
• Vitamin D analogue (e.g. calcipotriol, tacalcitol).
• Dithranol Plaque psoriasis—apply to lesion only.
• Topical retinoids Mild/moderate plaque psoriasis
• Topical steroids Can be used on localized plaques.
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28. (Impetigo, erysipelas, cellulitis, folliculitis, carbuncle)
28

29. Impetigo
Erysipelas
Cellulitis
Folliculitis
Furuncle
Carbuncle
Epidermis
Dermis
Hair 29

30. Bullous Non-Bullous
Caused by Staph A.
Very common in children
Caused by Staph A. and
Strept.
Common in all ages
Management:
Non pharmalogical: Avoid spreading to other children—no sharing of towels, face flannels. Reassure that
non-scarring
Pharmalogical:
Localized Treat with topical antibiotics (e.g. fusidic acid cream)
Widespread Treat with oral flucloxacillin or clarithromycin
30

31. CELLULITIS ERYPSIPELAS
They infect the dermis and manifest as areas of skin erythema, edema, and
• cellulitis involves the deeper dermis
and subcutaneous fat >> lesions will
not raise
• Systemic symptoms after few days
• involves the upper dermis and
superficial lymphatics >>> lesions are
raised above the level of surrounding
skin, and there is a clear line of
demarcation between involved and
uninvolved tissue
• Acute systemic symptoms
warmth
31

32. Management:
• SEVERE INFECTION ADMIT FOR IV ANTIBIOTICS
• IF SYSTEMICALLY WELL MARK THE AREA BEFORE STARTING FLUCLOXACILLIN OR
CLARITHROMYCIN FOR 7–14D. ADVISE TO SEEK HELP IF INFECTION IS SPREADING OR
BECOMING SYSTEMICALLY UNWELL
• FACIAL INFECTION TREAT WITH PENICILLIN V QDS OR CLARITHROMYCIN BD
• RECURRENT INFECTIONS (>2 EPISODES AT ONE SITE) MAY NEED PROPHYLACTIC LONG-TERM
PENICILLIN WITH ATTENTION TO SKIN CARE
32

33. FURUNCLE CARBUNUCLE
• Occurs when a group of
hair follicles become deeply
infected with Staph. aureus.
• May be associated with
fever ± malaise
• Swollen, painful area
discharging pus from
several points.
• Acute infection of a hair
follicle with Staph. aureus.
Occasionally associated with
fever ± malaise
• A hard, tender, red nodule
surrounding a hair follicle
becomes larger and fluctuant
after several days.. Later may
discharge pus and a central
‘core’ before healing; may
leave a scar.
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34. Management:
•
•
•
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35. •
•
•
•
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36. (Candidiasis, Tinea)
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Management of Fungal infections:
Mouth lesions Remove tongue deposits with a toothbrush by brushing
2x/d. Treat with oral suspensions or gels (e.g. nystatin, miconazole).
Genital lesions Imidazole cream or pessaries
• Nail infections amorolfine Avoid nail varnish/articifial nails during treatment
• Skin lesions Imidazole cream, spray, or powder; terbinafine cream

48. • TINEA VERSICOLOR
• PINKISH BROWN
•
•
48

49. (Warts, HSV)
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50. 50

51. Viral Warts
Genital warts
Presentation in women
asymptomatic but may be
associated
with itching or vaginal
discharge. Warts enlarge
during pregnancy.
Presentation in men Warts
are usually found on the
penis or perianally.
Common Warts
Dome-shaped
papules with
papilliferous surface.
Usually
>1. Most common
on hands but may
affect other areas.
Plantar warts
On soles of feet.
Pressure
makes them grow into
the dermis, painful.
Characterized by dark
punctate spots on the
surface
Plane warts
Smooth, flat-topped
papules often slightly
brown in colour.
Most common on
face/backs of hands
51

52. HSV Infection
transmitted by direct contact with lesions.
Lesions appear on around the mouth and on the lips, conjunctiva, cornea, and genitalia. Diagnosis is usually
clinical.
Primary HSV stomatitis After a prodromal period (<6h) of tingling,
discomfort, or itching, small tense vesicles appear on an erythematous
base. These burst to form multiple, small, painful mouth ulcers. Can be accompanied by systemic symptoms, e.g.
fever, malaise, and tender
lymph nodes..
Management
Give symptomatic relief—analgesic mouthwashes, If seen <48h
after onset give oral antivirals, e.g. aciclovir 5x/d for 5d
Recurrent infection (cold sores) HSV remains dormant in the nerve ganglia so Recurrent eruptions can occur
52

53. Herpetic whitlow Swollen, painful, and erythematous lesion of the distal phalanx, results
from inoculation of HSV through a skin break or abrasion and is most common in health
workers.
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55. (Scabies, Pediculosis)
55

56. Scabies
Extremely contagious. The scabies mite (Sarcoptes scabei) is spread by direct physical contact
Presentation Symptoms of intense itching appear 4–6wk after infection.
Examination reveals burrows (irregular, tortuous, <1cm long) on the sides of fingers, wrists, ankles, and
nipples.
Management
Pharmalogical:
Treat with. permethrin 5% or malathion lotion. All close contacts need treatment simultaneously. Apply to
whole body including scalp, neck, face, and ears. Ensure finger/toe webs are covered, and brush lotion
under the ends of finger/toenails.
Non Pharmalogical
Advise patients to launder all worn clothing and bedding after application. Itching may persist for
some time after elimination of infection
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58. Pediculosis
Symptoms/signs asymptomatic.
Detected by contact tracing of other cases or routine inspection at home or school. Occasionally
present as itchy scalp. Presence of ‘nits’ (eggshells—white dots attached
to hair), a moving louse must be found to confirm active infection.
Management Treat all household contacts simultaneously.
• Dimeticone Lotion or spray. Coats lice and interferes with their
water balance by preventing the excretion of water. Advise to rub
into dry hair and scalp in the evening, allow to dry naturally, then
shampoo off the next morning. Repeat after 7d
• Insecticides. 4 types: malathion, phenothrin, permethrin, and carbaryl (prescription only).
Malathion and phenothrin/permethrin are used as first-/second-line;
carbaryl is reserved for third-line.
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59. (Flushing, Nodusum, Multiforme, Rosacea, Lyme)
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60. Flushing
Cause:
• Physiological: exertion, heat
• Emotion: anger, anxiety, embarrassment
• Foods: spices, chillies, alcohol
• Endocrine: menopause, Cushing’s syndrome
• Drugs: opioids, tamoxifen, danazol, GnRH analogues, nitrates, calcium channel blockers
• Inflammatory SLE; dermatomyositis
• Infection: slapped cheek syndrome (Fifth disease); cellulitis/erysipelas
• Tumour :Pancreatic tumours, medullary thyroid cancer, carcinoid, phaeochromocytoma
Management : Treat cause if possible (e.g. avoid alcohol, HRT). Embarrassing flushing may be helped
with propranolol or clonidine
If severe > refer
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61. Erythema nodosum
Tender erythematous nodules on extensor surfaces of limbs—especially shins ± fever.
Resolves in <8wk, non-scarring.
No treatment only analgesia
Associations:
• Streptococcal infection
• Drugs, e.g. oral contraceptives, sulfonamides
• Acute sarcoidosis
• Inflammatory bowel disease— UC, Crohn’s
• Malignancy
• TB
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62. Erythema Multiforme
Immune-mediated disease characterized by
target lesions on hands and feet
Causes:
• Idiopathic (50%)
• Infective Streptococcal, HSV, hepatitis B, mycoplasma
• Drugs Penicillin, sulfonamide, barbiturate
• Other SLE, pregnancy, malignancy
Presentation Target lesions on hands and feet. Frequently oral, conjunctival,
and genital mucosa is affected—if severe termed Stevens–Johnson syndrome.
Management Identification and removal of the underlying cause. Mild
cases resolve spontaneously and require symptomatic measures only.
Admit if extensive involvement.
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63. Rosacea
Relapsing-remitting chronic inflammatory facial dermatosis
characterized by erythema and pustules
No cure.
Cause: unknown
Presentation Earliest symptom is flushing. Erythema, telangiectasia,
papules, pustules affect cheeks, nose, forehead, and chin
Aggravating factors Sun exposure; emotional stress ; hot
weather ; alcohol; spicy foods ; exercise; cold
weather or wind; hot baths; hot drinks; cosmetics/
skin care products.
Complications Rhinophyma ; eye involvement—blepharitis, dry eye, and conjunctivitis.
Management
• Avoid triggers
• Antibiotics
• Refer to dermatology if rhinophyma, ocular complications, or failure to
respond to treatment.
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64. Lyme Disease
Cause: Borrelia burgdorferi. Spread: transmitted by ticks—usually from deer or sheep.
Presentenation:
• Erythema migrans: a red macule/papule on the upper arm, leg, or trunk 7–10d after a tick bite, which
expands over days/weeks to form a ring with central clearing;
• Flu-like illness
• Lymphadenopathy ± splenomegaly
• Arthralgia
Symptoms are typically intermittent and changing.
Complications:
neurological abnormalities, aseptic meningitis, myocarditis, and arthritis.
Management:
Confirm diagnosis with serology. Treatment is usually with 2–3wk course of 64

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66. 66
(MM, SCC, BCC)

67. Malignant Melanoma
Superficial
spreading
site: lower leg ; back
Macular lesion with
variable
pigmentation
Nodular
on
trunk. Pigmented
nodule grows
rapidly and
ulcerate
Lentigo maligna
arises in sun
damaged skin
usually on the face—
and melanoma
develops many years
after
Acral
lentiginous
melanoma in black-skinned
populations.
Affects palms, soles,
and nail beds. Often
detected late. Poor
prognosis
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68. Risk factors Sun exposure; genetic;
multiple benign moles (>50 of >2mm diameter); congenital naevus;
previous malignant melanoma; immunosuppression; fair skin type (red hair,
blue eyes); severe sunburn in childhood/adolescence.
Check the ABCDEF criteria:
• Asymmetry of outline
• Border irregularity
• Colour variation
• Diameter
• Evolution—changes in size, shape, colour, and/or elevation
• Funny-looking’ mole—‘ugly duckling’ moles that stand out from the
others are very discriminatory for nodular melanoma
68

69. Management:
69

70. Squamous cell carcinoma (SCC)
• common >55y
• Usually develops in sun-exposed sites, e.g. face, neck, hands.
• May start within an solar keratosis or de novo as a nodule which progresses to ulcerate
and crust
• Causes Chronic sun damage, X-ray exposure, chronic ulceration and
scarring (aggressive SCC may develop at the edge of chronic ulcers),
smoking pipes and cigars , industrial carcinogens (tars, oils),
wart virus, immunosuppression, genetic.
• Management : Refer 70

71. Basal cell carcinoma (rodent ulcer, BCC)
• Most common form of skin cancer—accounts for >75% of skin cancer.
• Locally invasive, locally aggressive, locally destructive
• multiple and appears mainly on light-exposed areas—most commonly the face.
Nodular Most
common. Starts as small
pearly nodule. May
necrose centrally leaving a
small crusted ulcer with
pearly, rolled edge
Cystic
Multicentric
Plaque like, large
superficial+/- central
depression
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73. Urticaria (hives or nettle rash)
73
Superficial, itchy swellings of the skin or weals
come and go in an attack giving the appearance of a shifting rash.
Management of acute urticaria
• antihistamines for itch—non-sedating for daytime ± sedative if
interferes with sleep (e.g. chlorphenamine, hydroxyzine).
• Topical menthol 1% cream is an alternative/adjunct to antihistamines
• If severe, consider short-course steroids (e.g. prednisolon).

74. 74
angio-oedema
Deeper longer-lasting swellings; painful rather than itchy.
affect eyes, lips, genitalia, hands, and/or feet.
May affect bowel (abdominal pain, nausea, vomiting, diarrhoea) or airway (tongue swelling,
shortness of breath, wheeze). If airway compromise, consider
Management of angio-oedema
• If anaphylaxis is suspected, give adrenaline
and admit
• If any airway compromise, admit—even if
anaphylaxis is not suspected
• Otherwise treat as for acute urticaria; monitor
for airway compromise

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