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Preface

Dermatitis herpetiformis

Primary Lesions

Pemphigoid

Secondary lesions

Pemphigus

Investigations

Bullous Diseases

Red Rash

Scabies

Urticaria

Infestations

Types of urticaria

Hirsutism and Hypertrichosis

Alopecia
Rosacea
Acne Presentation
Acne

Reactive Erythemas

Map
of
Contents

Eczema
Types of eczema
Bacterial infections
Staphylococcal infections

Hypopigmentation

Varicella zoster

Hyperpigmentation

Herpes simplex

Pityriasis rosea
Lichen planus
Psoriasis Treatment and DDx
Psoriasis Presentation
Maen K. Abu Househ | Reviewed by Reem Al-qudah

Viral warts
Dermatophyte infections (Tinea)
Fungal Infections
Psoriasis

Eczema

Poikiloderma is a combination of
atrophy, reticulate
hyperpigmentation and
telangiectasia.

Erthyroderma is a generalized
redness of skin that may be
scaling (exfoliative
erythroderma) or smooth.

Horn is a keratin projection that is

taller than it is broad.
Rosacea

Erythema is redness caused by

vascular dilatation.

Telangiectasia is the visible

dilatation of small cutaneous blood
vessels.

Topical
steroids

A comedo is a plug of greasy

keratin wedged in a dilated
pilosebaceous orifice. Open
comedones are
blackheads
. The
follicle opening of a closed comedo
is nearly covered over by skin so
that it looks like a pinhead-sized,
ivory-coloured papule.
A burrow is a linear or curvilinear
papule, with some scaling, caused
by a scabies mite.

Scabies

Melasma
vitiligo

A haematoma is a swelling from

gross bleeding.
Trauma
Post
surgery

HSP

An ecchymosis (bruise) is a larger

extravasation of blood into the skin
and deeper structures.
The term purpura describes a
larger macule or papule of blood in
the skin. Such blood-filled lesions
do not blanch if a glass lens is
pushed against them

Vasculitis
Clotting
disorder

Petechiae are pinhead-sized

macules of blood in the skin.

A papilloma is a nipple-like
projection from the skin.
A tumour is harder to define as
the term is based more correctly
on microscopic pathology than on
clinical morphology. We keep it
here as a convenient term to
describe an enlargement of the
tissues by normal or pathological
material or cells that form a mass,
usually more than 1 cm in
diameter. Because the word

tumourcan scare patients,

tumours may courteously be called

large nodules
, especially if they
are not malignant.

Primary
lesions

Lichen
planus
Cutaneous
Lymphoma

Urticaria
cellulitis

A papule is a small solid elevation

of skin, less than 0.5 cm in
diameter.

Acne

A plaque is an elevated area of

skin greater than 2 cm in diameter
but without substantial depth.

Psoriasis

A macule is a small flat area, less

than 5 mm in diameter, of altered
colour or texture.

Freckles

A vesicle is a circumscribed
elevation of skin, less than 0.5 cm
in diameter, and containing fluid.

A patch is a large macule.

Psoriasis

A bulla is a circumscribed
elevation of skin over 0.5 cm in
diameter and containing fluid.

A pustule is a visible accumulation

of pus in the skin.

An abscess is a localized
collection of pus in a cavity, more
than 1 cm in diameter. Abscesses
are usually nodules, and the term

purulent bullais sometimes used

to describe a pus-filled blister that
is situated on top of the skin rather
than within it.

Lichen
planus

Pityriasis
rosea

lentigines

Herpes
simplex
Chicken
pox

Pemphigus
Pemphigoid

Acne
Pustular
psoriasis

Conglobate
acne
Carbuncle

A wheal is an elevated white

compressible evanescent area
produced by dermal oedema. It is
often surrounded by a red
axon-mediated flare. Although
usually less than 2 cm in diameter,
some wheals are huge.
Angioedema is a diffuse swelling
caused by oedema extending to
the subcutaneous tissue.
A nodule is a solid mass in the
skin, usually greater than 0.5 cm in
diameter, in both width and depth,
which can be seen to be elevated
(exophytic) or can be palpated
(endophytic).

3/25/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah Primary lesions

Erythema
nodosum
PAN

Pigmentation, either more or less

than surrounding skin, can develop
after lesions heal.
A stria (stretch mark) is a
streak-like linear atrophic pink,
purple or white lesion of the skin
caused by changes in the
connective tissue.

Steroids
Pregnancy

Eczema

Topical
steroids
Lichen
sclerosus

Acne
Keloid

A scale is a flake arising from the

horny layer. Scales may be seen
on the surface of many primary
lesions

Lichen
planus

A keratosis is a horn-like
thickening of the stratum corneum.
A crust may look like a scale, but
is composed of dried blood or
tissue fluid.

Lichenification is an area of
thickened skin with increased
markings.

Atrophy is a thinning of skin

caused by diminution of the
epidermis, dermis or subcutaneous
fat. When the epidermis is atrophic
it may crinkle like cigarette paper,
appear thin and translucent, and
lose normal surface markings.
Blood vessels may be easy to see
in both epidermal and dermal
atrophy.

Psoriasis

Secondary
lesions

A scar is a result of healing, where

normal structures are permanently
replaced by fibrous tissue.
A sinus is a cavity or channel that
permits the escape of pus or fluid.

3/23/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Secondary lesions

Impetigo
Ecthyma

An ulcer is an area of skin from

which the whole of the epidermis
and at least the upper part of the
dermis has been lost. Ulcers may
extend into subcutaneous fat, and
heal with scarring.
An erosion is an area of skin
denuded by a complete or partial
loss of only the epidermis.
Erosions heal without scarring.
An excoriation is an ulcer or
erosion produced by scratching.

A fissure is a slit in the skin.

Eczema
Pemphigus

Scabies
Eczema

Eczema

Tinea capitis

Biopsy
Prick Test
Diagnosis

Patch tests

Green on shaft of hair

P.versicolor

Golden yellow

Pitrysporum

Orange

Erythrasma

Coral pink
Blue

Pseudomonas

Woods light
Pigmentary
disorders

magnifying lens

Hypopigmentation
Depigmentation

Dermatoscopy

Dermatology
Investigations
Prognosis

Giant multinucleated cells

Herpes
simplex

Hyperpigmentation

Pemphigus

name given to the technique in which a

glass slide or clear plastic spoon is
pressed on vascular lesions to blanch
them and verify that their redness is
caused by vasodilatation and to unmask
their underlying colour

Poor
enhancement

Poor prognosis

Good
enhancement

Good prognosis

Tzanck smear

Acantholysis

Samples

KOH

Skin

Scraping

Nail

Clipping

Hair

Plucked hair

Diascopy

3/25/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Dermatology Investigations

KOH is keratinolytic
We see hyphae and spores

Chalky white
appearance

Deep lesion

Superficial lesion

Urticaria

<24h
1-2 Weeks
Acrofacial

Erythema Multiforme

Target lesions
4-6 Weeks

Blanchable

Non-scaly

Shines
Painful

Erythema nodosum

Nodules
Bruises on resolving
Vasculitis
Non-Blanchable

Bleeding disorder

Red Rash
ill Defined

Eczema

Unilateral

Commonest
skin disease

Fungal infections
Psoriasis

Scaly

Commonest
Purple

Margins

Pruritic

Well Defined
Bilateral

Lichen Planus

5P

Papule
Plane
Polygonal

Pityriasis
3/25/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Red Rash

2-10 weeks

50% of patients with

chronic urticaria and
angioedema will be
clear in 5 years

Course

50% of those with

urticaria only will
clear within 6 months

reaction
pattern
results
in

an elevated white
compressible evanescent
area produced by dermal
oedema. It is often
surrounded by a red
axon-mediated flare.
Although usually less than
2 cm in diameter, some
wheals are huge.

pink,
itchy or

burning
swellings
Wheals
Lesions last less than 24h

Types
of
Urticaria

release of
histamine

increased capillary
permeability

mast cell degranulation

Vasculitis
ESR

Cause
Investigations

Parasitic
infections

against (IgE) receptor

antibodies
chronic urticaria
chemical

Eosinophilia
direct degranulation

trauma
complement activation

Insect bites

Urticaria

Erythema multiforme

Acute

longer than 24 h,
urticarial
vasculitis

leave bruising
dermatitis
herpetiformis
bullous pemphigoid

Chronic

sudden appearance
Bullous
Disease

pink itchy wheals

Differential
diagnosis

most disappear within few hours

Sharp margin
Fever

Disease not lesion last

more than 6 weeks

Divided into

blanch incompletely

resolve centrally
to take up an
annular shape

erysipelas

more red
may enlarge rapidly
anabolic steroids
as a prophilaxis
C1 inhibitor
concentrate as a
treatment

wheals may cover

most of the skin
surface

Hereditary
angioedema

Presentation

anaphylactic reaction
few wheals
chronic urticaria

depression
acute anaphylactic
reactions
asphyxiation

edema of subcutaneous tissues

less demarcated

Complications

oedema of
the larynx

less red
junctions between skin
and mucous membranes

Angioedema
Sites

peri-orbital, peri-oral
and genital

accompanies chronic urticaria

3/18/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Urticaria

hepatitis,
infectious
mononucleosis

cycling

areas exposed to cold

reproduced by holding an ice cube, in a

thin plastic bag to avoid wetting, against
forearm skin for 10 mins

Viral
Bacterial

Infection
Cold

Mycoplasma

Avoid Cold
Protective clothing

Treatment

Intestinal parasites

Endogenous

Antihistamines

Connective tissue disorders

IgE-mediated

Hypereosinophilic syndrome

Exclude connective
tissue diseases

Hyperthyroidism
Investigations

Cancer
Lymphomas

SLE

CBC, ANA
Avoid sun exposure

Solar

Protective clothing
IgE mediated or pharmacological

Treatment

Foods
food
additives

most often around the mouth

Sunscreens and sun blocks

Beta-carotene

Contact

Antihistamines
Heat

Latex allergy

Anxiety, heat, sexual excitement

or strenuous exercise
non-allergic

macules or papules for 10 - 15 min

aspirin
NSAIDs

Physical

Avoid heat
Minimize anxiety

Pharmacological
Cholinergic

ACE

Treatment

morphine

Avoid excessive exercise

Anticholinergics
Antihistamines

IgE-mediated (type I)

Types
of
Urticaria

Tranquillizers
Aquagenic

Ingestion

most common type of physical

Inhalation

mast cells releasing extra

histamine after rubbing or
scratching

Instillation

Dermographism

Injection

Treatment

Insertion
Insect bites

Due to Sustained pressure

Develop 3-6h later

Infection

May last up to 48h

Hypersensitivity

Infusion
Inunction (contact)

Delayed Pressure

Cased by

Remove cause

kinins
Prostaglandins

feet after walking

Antihistamines
(H1 + H2)

Sites

hands after clapping

buttocks after sitting

Sympathomimetics

Avoid
aspirin-containing
drugs

Antihistamines

10 I
s

Infestations

Systemic steroids
(rarely justified)

Avoid trauma

Treatment
Autoimmune

IgG antibodies to IgE or FcIgE

receptors on mast cells

3/18/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Types of Urticaria

Herpes Simplex

Viral infections, especially:

hepatitis A, B and C

mycoplasma
Bacterial infections
coccidioidomycosis

Fungal infections
Urticaria

Causes

Parasitic infestations
Drugs

panniculitis
immunological reaction
Bacteria (e.g. streptococci,
tuberculosis, brucellosis,
leprosy, yersinia)

Pregnancy

inflammation of the
subcutaneous fat

Malignancy, or its treatment with radiotherapy

50%

Idiopathic

symptoms of an upper
respiratory tract infection

Infections
Viruses

annular

Mycoplasma

non-scaling plaques

Rickettsia

Acrofacial

Chlamydia
Causes

Fungi (especially coccidioidomycosis)

forearms and legs

Presentation

Face
lesions enlarge and clear centrally

Systemic disease (e.g. sarcoidosis,

ulcerative colitis, Crohn
s disease,
Behet
s disease)

lesion may begin at the same

site as the original one

Pregnancy

two concentric plaques look like a target lesion

tender red nodule

Some lesions blister

Erythema
nodosum

shins

is a severe variant

Site

fever
Presentation

thighs, face, breasts

painful joints
fever

walking is difficult

Reactive
Erythemas
Erythema
multiforme

resolve in 68 weeks

associated
with

Stevens-Johnson
syndrome

mucous
membrane
lesions

oral
mucosa,
lips
conjunctivae
pharynx,
larynx

Course
appear for 12 weeks

cellulitis or abscess
phlebitis

palms, soles

Site

Drugs (e.g. sulphonamides, oral

contraceptive agents)

Forearms

may precede

Differential diagnosis
Course

Chest x-ray
antistreptolysin-O (ASO) titre

site of resolved lesions

Investigations

asphyxia

Serological testing

Corneal ulcers

identify and eliminate its cause

anterior uveitis

blindness

Complications

Bed rest and leg elevation

NSAIDs

transiently by
grey or brown
patches

panophthalmitis

Treatment

urinary retention

antibiotic

Annular Urticaria
Differential diagnosis

bullous disorders

Biopsy
PCR
Herpes
simplex
Investigations

Gimsa stain
Tzanc smear

Mycoplasma

Giant
multinucleated cells

Chest x-ray

identify and remove its cause

mild cases

antihistamines
IVIg

Treatment

StevensJohnson
syndrome

Ciclosporin

If no
infection

Good nursing care

HSV

3/18/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Reactive Erythemas

Valciclovir

absence of a sharp margin

bullae

most common skin conditions

coalescing
vesicles

epithelial
disruption

oedematous papules
on pink plaques

General
features

If it does not itch, it is

probably not eczema
itch

intense itching

spongiosis

Weeping and Crusting

vesicles

blistering
Acute eczema

redness, papules and swelling

scaling

Clinical
appearance

in the acute
stages
Intro

worsening

more scaly, pigmented

and thickened

rubbing

tense blisters appear

may weep plasma

dry leathery thickened

scratching

appears as a red, smooth,

oedematous plaque
oedema becomes more severe

less vesicular and exudative

increased skin markings

early disease the stratum

corneum remains intact

Chronic
eczema

lichenification

less severe
or chronic

scaling
epithelial disruption

secondary to
activated keratinocyte

more likely to fissure

infection

Eczema

bacterial
colonization
Affects sleep

Pathogenesis

Increased proliferation of basal cells

IL-1

secretion of various
cytokines by epidermis
IL-8 acts as a chemotactic
factor for neutrophils

Complications

sporting

thicken

work

Hyperproliferation

interfere with

scale

sex lives
spongiosis
Sharply marginated,
strong colour

intra-epidermal vesicles
acute stage

very scaly
Points of elbows
and knees involved

Shiny flat-topped
papules?

or rupture

psoriasis

less spongiosis and vesication

Papulosquamous
dermatoses

nail and joint changes

Mouth lesions?
Violaceous tinge?

larger blisters

Histology
acanthosis

lichen
planus

chronic
stages
Differential
diagnosis

Itchy social contacts? Face spared?

Burrows found?

thickening of the
prickle cell layer

hyperkeratosis
parakeratosis
vasodilatation
infiltration with lymphocytes

Scabies

Genitals and nipples affected?

lotion to decrease the edema
Annular lesions with
active scaly edges
Fungal infections

asymmetrical
Localized to palms and soles

Acute weeping eczema

Topical steroids

Unusually swollen
Treatment

Subacute eczema

dryness

Fucidic acid
Neomycin

telangectesia
hirsutism

Non-steroidal use
Wet wrap dressing

palmoplantar
pustulosis
angioedema

Rest and liquid

applications

Topical steroids

Topical steroids S\E

Chronic eczema

Systemic antibiotics
ointment to lubricate the skin

Systemic Steroids
Severe

3/18/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Eczema

Calcineurin inhibitors

Tacrolimus

industrial cases
80% of all cases
bubble bath
occur in children

lip-licking
brief contact

Strong irritants

Prolonged

weak irritants

Cause

Detergents, alkalis, solvents, cutting oils

and abrasive dusts
Past or present atopic dermatitis
doubles the risk of irritant hand eczema
patients with dry or fair skins
are especially vulnerable

Irritant
contact
dermatitis

second most common occupational disorder

Chemical plant workers
Machine tool setters

reversible in the early stages

Men

Course
loss of work.

Metal workers

Occupational
dermatitis

Complications

Coach and spray painters

Hairdressers

Atopic eczema

Biological scientists
Differential diagnosis

Allergic contact dermatitis

Women

laboratory workers
Nurses

Avoidance
Protection

Catering workers

Treatment

Topical steroids
Excess IgE produced as a response to allergen
75% begin before 6 months

specific to one chemical

90% before age of 5 years

Characteristics

On face
Patchy all over the body,
sparring napkin area

Previous
contact is
needed

delayed
(type IV)
hypersensitivity

all skin will react to same allergen

Sensitization persists indefinitely
Desensitization is seldom possible

Infancy

Cement

Weeping and vesicular

Knees and elbows flexural areas
Childhood

Leathery, dry, with excoriations

Types of
Eczema

Nickel

Distribution similar to that in childhood

More Lichenification

Adults
Allergic
contact
dermatitis

Major

Well-known
allergens

History of eczema

Fake jewellery
Jean studs

Cosmetics
Fragrance mix
Medicaments

Personal or first degree

family history of atopy
Dry skin

Tatoos

Metals

Ankles and wrists

Chronic Itching and scratching

Paint

Chrome

Neomycin

Rubber
3 out of
5 minor

Criteria

Resins

Atopic
eczema

Colophony

Visible flexural eczema

certain areas are involved

Bacterial superinfections

suspected if:

Viral superinfections
Disturb sleep

Patch Test
Investigations

Prick test
High IgE level

Avoidance
Investigation

RAST test

Treatment

Avoid exacerbating factors

Topical
steroids
Treatment

Avoid potent steroids

S/E: Burning
sensation

Topical steroids
Moisturizer

Explain and reassure

Tacrolimus

3/18/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Types of Eczema

hands
feet

known contact
work carries a high risk

Complications

Poor growth

Review their use regularly

plaster
eyelids

Onset before 2 years of age

Weakest to control

adhesives

Affect hair area

irritant in origin

Greasy yellowish scales

aggravated by the use of waterproof plastic pants

Presentation

most common in adult males

faecal enzymes

may affect infants

ammonia

scalp, ears

Cause

prolonged contact

face, eyebrows

overgrowth of yeasts

red scaly or exudative eruption

glazed and sore erythema

Presentation

sparing of the skin folds

Superinfection with Candida albicans
vesicopustules appearing around the
periphery of the main eruption

presternal

Napkin
(diaper)
dermatitis

satellite lesions "pustules

around the rash"

Sites

Dry scaly lesions

interscapular areas
papules or pustules on the trunk

Complications

armpits, umbilicus
Seborrhoiec
Eczema

infantile seborrhoeic eczema

Intertriginous lesions

groins, or under
spectacles or hearing aids

Differential diagnosis

candidiasis

not obviously related to seborrhoea

keep this area clean and dry

run in some families

increase the napkin free time

superabsorbent napkins

affecting those with a tendency to dandruff

Cause

overgrowth of yeast

Treatment

Protective ointments

early sign of AIDS

topical imidazole

Furunculosis

skin is damaged as a result of repeated

rubbing or scratching

Complications
Intertriginous lesions

habit or in response to stress

Suppressive

single, fixed, itchy,

lichenified plaque
neck in women
legs in men

associated with
chronic blepharitis
and otitis externa

Presentation

Site

Topical imidazole

Treatment

Localized
neurodermatitis

Topical Li

anogenital area

Reaction to bacterial Ag

Potent topical steroids

occlusive bandaging

Types of
Eczema

Treatment

break the scratchitch cycle

Discoid
Eczema

old age
dry skin

Chronic stress

Causes

Not really known

Limbs of middle aged males
Multiple lesions
Coined shaped

Presentation

Vesicular and crusted

over-washing
low humidity

Itchy plaque
Topical Steroids

Risks

central heating

Treatment

Asteatotic
eczema

use of diuretics
hypothyroidism

Topical Antibiotics

Poor circulation, often but not always

accompanied by obvious venous
insufficiency

fine red superficial fissures

Presentation

chronic patchy

topical steroid
Treatment

Gravitational
(stasis)
eczema

Presentation
ulcer formation
Complications
Elevation
Treatment

Diuretics
Avoid strong steroids

3/18/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Types of Eczema

Added
candida
infection

skin flora

diphtheroid
Overgrowth
symptom-free
macular wrinkled

slightly scaly pink, brown or macerated white areas

armpits

Erythrasma

Site

groins
between the toes
larger areas of the trunk may be involved

In diabetics
coral pink fluoresce
On Woods light examination
Topical
Treatment

fusidic acid
miconazole

often malaise

first warning

shivering and a fever

skin becomes red

well-defined advancing edge
Blisters may develop on the red plaques
not extending beyond the dermis

Erysipelas

If untreated can be fatal

responds rapidly to systemic penicillin
Causative organisms enter via skin split
Episodes can affect the same area
repeatedly and so lead to persistent
lymphoedema
Minor tinea pedis may
cause recurrent Erysipelas

Streptococcal
infections

inflammation of the skin occurs at a

deeper level than erysipelas
subcutaneous tissues are involved
area is more raised and swollen

Bacterial
infections

erythema less marginated than in erysipelas

Cellulitis

Streptococci, staphylococci or other

organisms may be the cause
elevation
Treatment

rest
systemic
antibiotics

Can be IV

Infection of deep Fascia

Necrotizing fasciitis

mixture of pathogens

Staphylococcal infections

3/24/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Bacterial infections

staphylococcal toxin
Follow overgrowth of staph in vagina

Cause

Associated with using tampons.

fever

Toxic
shock
syndrome

rash
widespread erythema
circulatory collapse

not part of the resident flora

Presentation

Mostly nostrils

Staphylococcus aureus

Fingers

desquamation

Hand

perineum

Carriage

armpits

Erythema and tenderness

staphylococci
caused by

followed by the loosening of

large areas of overlying
epidermis

streptococci
staphylococci
Exfoliative
toxins

Occurs mostly in children

Exfoliative toxins
affects desmoglein 1

Cause

Organism is localized but the toxin is widespread

bullous
type

Scalded
skin
syndrome

full thickness

toxic epidermal
necrolysis

In adults

bullous impetigo

Not local

scalded skin syndrome

crusted ulcerated type

Differential
diagnosis

usually drug induced

toxin is
localized

Types

Affects only stratum corneum

desmoglein 1

beta hemolytic
streptococcus

highly contagious
the erosion is at the stratum corneum

(boils)

thin-walled flaccid clear blister

acute pustular infection of a hair follicle

may become pustular

Impetigo

Staphylococcus aureus

Rupture leaving yellow exudate and crust

Presentation

cause

host ( low immunity as DM and systemic steroids)

Around face

Multiple lesion

source (carrier)

heals without scarring

predisposing factors

route (skin disease, minor trauma)

clear even without treatment

Course

mainly adolescent boys

Staphylococcal
infections

tender red nodule

enlarges
May discharge pus
leave a scar
Fever and enlarged draining nodes are rare

acute glomerulonephritis
Complications
Recurrent
impetigo

Differential
diagnosis

Presentation
and course

Gram stain and culture

Most patients have one or two boils only

suggests a virulent
staphylococcus

Investigation
and
treatment

appearance of many

susceptibility of follicles

chronic furunculosis

Cavernous sinus thrombosis

Septicaemia
if only
the groin and axillae are involved

Complications

Ecthyma

Differential
diagnosis

Culture swabs

crust is blackish
ulcer is full thickness

group of adjacent hair

follicles becomes
deeply infected with

General examination
Investigations
in chronic
furunculosis

Staphylococcus aureus

must exclude DM

Carbuncle

swollen painful suppurating area

discharging pus
pain and systemic upset are greater than those of a boil

simple incision and drainage

topical and systemic antibiotics

Acute episodes

Treatment

antibiotics
treat carrier sites

appropriate topical
antiseptic or antibiotic
systemic antibiotic

topical antibiotic

heals with scarring

Immunological evaluation

if it is associated
with fever and
systemic symptoms

minor cases

cefalexin

ulcers forming under a crusted surface infection

Furunculosis

hidradenitis
suppurativa

Test the urine for sugar. Full blood count

lesions and carrier sites

Systemic antibiotics

Due to

colonization of nares or groins

underlying skin disease

search for scalp lice

In stubborn cases

Treatment
chronic
furunculosis

Daily bath using an antiseptic soap

Improve hygiene and nutritional state

3/23/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Staphylococcal infections

Incision and drainage

varicella-zoster
result of the reactivation
virus that has remained dormant in a
sensory root ganglion
old age
Hodgkin
s disease
AIDS

Occur in

leukaemia

spread by the respiratory route

patients with zoster can transmit the virus to others

Slight malaise

start with a burning pain

itchy

followed by erythema

papules

grouped, sometimes blood-filled, vesicles

clear vesicles quickly become purulent
a few days burst and crust
leaving depressed depigmented scars

Presentation
and
course

Presentation

characteristically unilateral
thoracic segments
ophthalmic division

next few days the lesions

crust and then clear
sometimes leaving
white depressed scars
centripetal
Mostly on trunk

Second attacks are rare

Secondary bacterial infection

Pneumonitis

ocular muscles,

Herpes zoster

bladder

Complications
Complications

corneal ulcers and scarring

Secondary infection
of skin lesions

Varicella

Motor nerve involvement

diaphragm

pustules

Site

Affects commonly

trigeminal nerve

facial muscles

pink base

clear vesicles

over a dermatome

Zoster of the
ophthalmic
division

Varicella
zoster

Haemorrhagic or
lethal chickenpox
Scarring

Differential
diagnosis

Smallpox

Persistent neuralgic pain

Tzanck smear
appendicitis

before the rash

myocardial infarction

Investigations
Differential
diagnosis

live attenuated
vaccine

Biopsy or Tzanck smear

Investigations
to all patients
within the first 5 days of an attack

rest
supportive

calamine

Treatment

carbamazepine

gabapentin

systemic

Systemic
Aciclovir

Patients under 2
or older than 12

Otherwise

calamine lotion
topically

Treatment

Systemic
treatment

Reduces post-herpetic neuralgia

analgesics

prophylactic

post-herpetic
neuralgia

amitriptyline

3/25/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Varicella zoster

most common
in children
usually extragenital

acute gingivostomatitis
soon turning into ulcers

type I

Vesicles

scattered over the lips

mainly on the genitals

type II

Cause

malaise
headache
fever

virus may become latent

Primary infection
Herpes encephalitis or meningitis

lasts about 2 weeks

pus-filled blisters on a fingertip

or abraded skin.

With

enlarged
cervical
nodes

direct inoculation of the virus

through mucous membranes

route of
infection

type I

Disseminated herpes simplex

herpetic
whitlow

usually transmitted sexually

cause multiple and painful
genital or perianal blisters
which rapidly ulcerate

Complications

recurrent dendritic ulcers leading to

corneal scarring

Primary
type II

erythema multiforme

Presentation

strike in roughly the same place each time

Herpes
simplex

respiratory tract infections

ultraviolet radiation
menstruation

Eczema herpeticum

precipitated by

sunblock
cut down the
length of attacks
used in the first 24 hrs

stress

Treatment

Aciclovir
cream

when the first

symptoms appear

face
lips
genitals

Recurrent

Tingling
burning

for those with

widespread or
systemic
involvement

sites

oral aciclovir
Starts with

pain
erythema
clusters of tense vesicles

Then

Crusting occurs within 2448 h

whole episode lasts about 12 days

3/25/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Herpes simplex

tingling
burning

smooth
skin-coloured papule

first

Then lesion enlarges

And has irregular
hyperkeratotic surface

prevalence is highest in childhood

Common
warts

HPV

Cause

human papilloma virus

Gives classic
warty
appearance
hands
face

Site

genitals
salicylic acid
Keratolytic

often multiple than single

Wart Paint

Painless

applied for at least 3 months

1st choice

rough surface

Except on face and

on genital area

protrudes only slightly

from the skin

imiquimod

surrounded by a horny collar

genital warts

podophyllotoxin

Treatment
Plantar
warts

with liquid nitrogen

cryotherapy

presence of bleeding
On
paring

distinguishes
it
from
corns

electrosurgery

also
interruption
of skin
lines

laser
painful

Scarring
Surgery Contraindicated

rough marginated plaques

Molluscum contagiosum
Plantar corns

made up of many small,

tightly packed warts

Presentation
Differential
diagnosis

Condyloma lata

Viral
warts

Mosaic
warts

soles
palms

Sites

around finger nails

Painless
smooth flat-topped
skin-coloured or light brown

Some plantar warts are very painful

Epidermodysplasia verruciformis

most common on
the face and brow

Complications

cervical carcinoma

Plane
warts

Malignant change

backs of the hands

Site

shaven legs
resolve spontaneously

resolve spontaneously in the healthy people

multiple

within 6 months in 30%

painless

within 2 years in 65%.

Mosaic warts are notoriously slow to
resolve and often resist all treatments

most common in the beard

Course
Facial warts

spread by shaving
ugly but are painless

persist and spread in

immunocompromised

condyloma acuminata
cauliflower-like lesions
Anogenital
warts

may coalesce to form

huge fungating plague
vaginal and anorectal
mucosae may be affected
Must look for other STDs

3/23/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Viral warts

Trichophyton skin, hair and nail infections

(athlete
s foot)

Microsporum skin and hair

Epidermophyton skin and nails
zoophilic

most common type of fungal infection

Cause

anthopophilic

Tinea
pedis

Spread either

Human to human

sharing of wash places

Risk

Animal to human

Soggy interdigital scaling, particularly in

the fourth and fifth interspace

three
patterns

diffuse dry scaling of the soles

Recurrent episodes of vesication

for minor skin infections

miconazole
clotrimazole

associated with tinea pedis

imidazole

Local

initial changes occur at the free edge of the nail

terbinafine

Tinea
of
the
nails

Tinea Capitis
Tinea of the nail

Treatment

Indications

Widespread
infections

Nail becomes crumbly

Yellow Discoloration
Changes

Subungual hyperkeratosis
Onycholysis

Resistant infections
Terbinafine

usually asymmetrical

Systemic
Tinea
of
the
hands

Itraconazole
Drug of choice in
Tinea Capitis

Separation of the nail

plate from its bed

Griseofulvin

tinea pedis

associated with

unilateral onychomycosis

powdery scale in the creases

common
affects men more

In Tinea Capitis

sometimes unilateral

Green fluorescence
on the hair shaft

Presentation

Not present in all cases

The most common cause
Trichophyton tonsurans
gives negative result
scaly margin

Crumbly area

Scraping

Clipping
Plucked hair

Wood
s
light

Skin

Nail

Dermatophyte
infections
(Tinea )

upper inner thigh is involved

Tinea
of the
groin

few vesicles or pustules can occur

plaques with scaling and erythema most
pronounced at the periphery
Tinea of the
trunk and
limbs
corporis

Hair

few vesicles or pustules can occur

lesions expand slowly and healing in the
center leaves a typical ring-like lesion
disease of children

KOH is keratinolytic
We see hyphae and spores

sharply demarcated plaques with

peripheral scaling
scrotum is usually spared

Investigations
Samples

lesions expand slowly

Use KOH
preparation

Causing a patch of red scaly

non-scarring hair loss

Fungal Cultures

Variant with more intense inflammation

boggy swelling

permanent scarring alopecia

vesication on the sides of the fingers and palms
Epidemics of ringworm
Masking of usuall signs of
Infection by mistreatment
with topical steroids

Complications

Tinea
of
the
scalp
(Capitis)

inflammation
pustulation
Kerion

lymphadenopathy
Causing permanent scarring hair loss
looks like a carbuncle

tinea incognito
Favus

Must be
differentiated

yellowish crusts
Causing permanent scarring hair loss

3/23/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Dermatophyte infections (Tinea)

Candida albicans is a classic opportunistic pathogen

obesity

old name: tinea versicolor

moisture

regarded as non-infectious

maceration
immobility

Cause

diabetes
pregnancy
contraceptive pill

superficial scaly patches

predisposing
factors

fine wrinkling
slightly itchy

Leucopenia

fawn or pink on non-tanned skin

Thymic tumours
Low serum iron

Presentation

Endocrinopathy
Immersion in water

Pityriasis
versicolor

Oral candidiasis

Staph. Aureus

can become widespread

slow to regain their former colour

Treatment
border is clearly defined
scaling is absent

Candidiasis
Candida intertrigo

Fungal
Infections

Genital candidiasis
usually bacterial

upper trunk

Untreated lesions persist

Poor hygiene

in body folds, erythema and maceration

with satellite papulopustules

paler than the surrounding skin

after exposure to sunlight
Site

Cold hands

whitish adherent plaque with

erythematous base, in denture wearers

Overgrowth

Carboxylic acids released by the

organisms inhibit the increase in
pigment production by melanocytes

use of broad-spectrum antibiotics

Immunosuppression

commensal yeasts

Pityrosporum orbiculare

Acute

Differential
diagnosis

Vitiligo

lesions are larger

Affect limbs and face more
depigmentation is
more complete
branched hyphae
and spores

Candida
proximal and sometimes the lateral nail folds

Presentation

cuticles are lost

small amounts of pus can be expressed
nail plate becomes ridged and discoloured

Paronychia

Scrapings

Investigations

spaghetti and
meatballs
appearance

chronic
wood's light

wet work
poor peripheral circulation

KOH

Predisposing factors

golden yellow
imidazole group

vulval candidiasis

Treatment

systemic and topical antifungal

Chronic mucocutaneous candidiasis
Systemic candidiasis
culture

Swabs

Investigation
Predisposing factors should be sought and eliminated
Amphotericin, nystatin and the imidazole

Treatment

3/25/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Fungal Infections

topical preparation

Induction of new lesion in normal

skin by trauma or scratching
Warts
Psoriasis

+ve in

Lichen planus

chronic, non-infectious, inflammatory

Kbner
phenomenon

well-defined salmonpink plaques bearing large

adherent silvery centrally attached scales

Intro

Trauma

Vitiligo
guttate
psoriasis

Affects white people mainly

one affected parent has a 16%

beta-haemolytic streptococci

genetic predisposition

rises to 50% if both

Infection

explosive forms

HIV

hidden antigens
environmental trigger

in postpartum
have a rebound

improves in pregnancy
Hormonal

hypothyroidism

excessive number of
germinative cells
enter the cell cycle

Precipitating
factors

hypocalcemia

Cause

hyperproliferation
of keratinocytes

Improves
Sunlight

withdrawal of systemic
steroids or potent
topical steroids

rebound

Palmoplantar Pustular Psoriasis

Normally
30-60 days

turnover time
is greatly
shortened

key
abnormalities

Antimalarials, beta-blockers

growth fraction is almost

100% compared with 30%
in normal skin

Becomes
10 days

Drugs
neutrophils
inflammatory cell infiltrate

Cigarette smoking
and alcohol

exacerbations

lymphocytes

Th17
T1

nuclei retained in the horny layer

Emotion

Parakeratosis
Irregular thickening of the epidermis

Usually diagnosed clinically

guttate psoriasis

Epidermal polymorphonuclear leucocyte infiltrates

Throat swabbing for

beta-haemolytic streptococci

Fungal infections
Skin scrapings and nail clippings

Munro

Histology

Biopsy

Dilated and tortuous capillary loops in the dermal papillae

Psoriasis

T-lymphocyte infiltrate in upper dermis

Arthropathy

Distal arthritis

Radiology
Dermatology Life
Quality Instrument
Questionnaire

Investigations
DLQI

thickness
>10% severe

quantifies

Complications

Oligoarthritis
Polyarthritis

Metabolic syndrome
Severity
assessment

scaliness
erythema

Arthropathy

Erythrodermia

Psoriasis Area
and Severity
Index

in stratum
corneum

IHD

PASI

Presentation

extent

3/18/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Psoriasis

Most charecteristic
Single joint
Most common

psoriasiform spread
outside the napkin

recurrent episodes
of pustulation

most common type

Napkin
psoriasis

Acute generalized
pustular psoriasis

withdrawal of potent topical or

systemic steroids
skin becomes universally
and uniformly red
Malaise

well demarcated
pink or red
Plaque
pattern

Less
common
patterns

Triggered by streptococcal tonsillitis

Psoriasis

Guttate
pattern

drop-shaped
small round red macules
Then scales develop

Presentation

Areas of scaling are interspersed with normal skin

Scalp

Causes

Drug allergy

overflows just beyond the scalp margin

Significant hair loss is rare

Common
patterns

Thimble pitting

Erythroderma

separation of the nail from the nail bed

onycholysis

Sepsis
Dehydration

lower back

children and adolescents

Eczema

poor thermal control

knees
scalp

Erythrodermic
psoriasis

generalized redness of skin

that may be scaling (exfoliative
erythroderma)

cutaneous lymphoma

elbows
Symmetrical sites

shivering

Psoriasis

large, centrally adherent,

silverywhite, polygonal scales

Nails

Complications

subungual hyperkeratosis
Oil drop sign

high output heart failure

Splinter hemorrhage
submammary, axillary and anogenital
not scaly
Flexures
appearance of punctate
bleeding spots when psoriasis
scales are scraped off

glistening sharply demarcated

red plaques with fissuring.
most common in women and elderly
negative auspitz sign

Auspitz sign

poorly demarcated
Less erythematous
Palms and soles

painful fissures on fingers

pustules
negative auspitz sign

3/12/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Psoriasis Presentation

Explanation and reassurance

Calcipotriol

exudative or crusted
lack thick scales

Tacalcitol

Vitamin D analogue

less well defined

mild to moderate
psoriasis
Discoid
eczema

Tazarotene

retinoids

Don't favor extensor surfaces

more diffuse
less lumpy
overflowing the scalp
margins and interspersed
with normal skin in psoriasis

limited
choiceareas
Topical
Treatment

Seborrhoeic
eczema

not so sharply marginated

ear, face, eyebrows

patients who cannot use

vitamin D analogues
corticosteroids

Sites

unresponsive
psoriasis

confused with guttate psoriasis

Differential
diagnosis

lesions are oval

Scaling is of
collarette type

Salicylic acid

Treatment

Coal tar

Psoriasis

confined to the upper trunk

2ndry syphilis

Treatment
and DDx

S/E
UV

Skin cancer

photochemotherapy

more asymmetrical
Pitting is not seen

Acute Phototoxicity

When Severe

Cutaneous t-cell lymphoma

obvious tinea of neighboring skin

short periods

Dithranol

Pityriasis
rosea

herald plaque

scalp,
palms and
soles

minor localized psoriasis

run along rib lines

Christmas tree

face, ears,
genitals
and
flexures

retinoids
Tinea
unguium

Nails are crumbly and discoloured

Acitretin
Liver failure

methotrexate
Systemic
ciclosporin

S/E

Renal failure
HTN

hydroxyurea
Sulfasalazine
never use systemic steroids for psoriasis
resistant cases
Combined

3/12/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Psoriasis Treatment and DDx

difficult
Stop them
if drugs are suspected
extensive involvement
nail destruction

mediated immunologically
Systemic steroid

painful and erosive oral

genetic susceptibility

reduce pruritus
photochemotherapy

Treatment

alopecia areata

Oral ciclosporin

associated with
autoimmune disorders

Resistant cases

acitretin

vitiligo
ulcerative colitis

For itching
Antihistamines
Usually asymptotic
corticosteroid
tacrolimus

plain
Topical

If symptomatic

Mucous
membrane

purple

5p's

pruritic
papule

Individual lesions may last for many months

For many years

polygonal
hypertrophic variant

become darker

violaceous

Course

flatter
leave discrete
brown or grey
macules

intensely itchy
As lesions resolve

flat-topped

papules

on extremities

Lichen
planus

legs

white streaky pattern on the

surface of these papules

Wickham
s
striae

lacy lines
dots
white plaques

in mouth

Investigations

wrists

Ulcers

SCC

Presentation
genital skin
excoriations are
uncommon

biopsy

Groves
other papulosquamous diseases
Gold and other
heavy metals

Drug
eruption

Differential diagnosis

nails

Ptyrigium

Since patients rub

and not scratch

Longitudinal
inward advance
of skin over the
nail plate

Thinning

discoid lupus erythematosus

destruction

Oral candidiasis
patchy scarring alopecia.
Scalp
Nail and hair loss can be permanent
Complications

squamous cell carcinoma

ulcerative form

3/12/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Lichen planus

herpes virus 7
Cause

reactivation of

herpes virus 6.

herald plaque precedes the generalized eruption

Subsequent lesions enlarge
Common during winter

systemic symptoms such as aching and tiredness

Course

affects children and young adults

eruption lasts 210 weeks

second attacks are rare

resolves spontaneously

larger than later lesions

leaving hyperpigmented patches

No Cure
topical steroid

Rounder
Redder
more scaly
smaller plaques appear

calamine lotion
Sunlight

Pityriasis
rosea

At first herald or

motherplaque

For itching

Treatment
Presentation

After several days

On trunk mainly
also on neck and extremities

UVB
are oval

ointment reduces scaling

salmon pink
delicate
scaling

tinea corporis
pityriasis versicolor
guttate psoriasis

plaques

gold
captopril

drug eruption

3/12/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Pityriasis rosea

collarette scales
Christmas tree

Differential diagnosis

secondary syphilis

adherent peripherally

configuration

axes run down and

out from the spine
along the lines
of the ribs

PIGMENTED
Phaeomelanins
trichochromes

Tyrosine>>

Lichen planus

phenylalanine>>

Eumelanins

Eczema
Melanin is made within melanosomes

Secondary syphilis

Pi: Post-inflammatory

Melanocytes inject melanin to nearby keratinocytes

all together for Epidermal melanin unit

Systemic sclerosis

Melanin

Lichen and macular amyloidosis

Don't have more melanocytes

Cryotherapy

melanocytes produce more and larger melanosomes

Blacks

broken down less rapidly

seen most often in the

red-haired or blond person

Melanin
Oxyhaemoglobin

sharply demarcated

Control of skin color

brownginger macules

Carotene

usually less than 5 mm

Photosensitizing drugs

become darker with sun exposure

D: Drugs

Increased melanin is
seen in the basal layer

Freckles
acquired
face

without elongation
of the rete ridges

on sun-exposed skin
well defined

light or dark brown macules

common in women
becomes darker after exposure to the sun
Pregnancy

Melasma

sunlight
oral contraceptives

TE:
Trauma
and
Exogenous

1 mm to 1 cm
irregular outline

Simple
and
senile

G: Genetic

photosensitizing drugs
sunscreen
Treatment

Malabsorption
Pigmented naevi

On areas not
exposed to sun

Simple in
children

causes

thyroid dysfunction

bleaching agents

Only sunscreens

No treatment needed

edges may be scalloped

hydroquinone

without any increase in the

number of melanocytes

Histopathology

symmetrical hypermelanosis

Hyper
pigmentation

Pregnancy

on the backs of the hands

on the face
"liver spots"

Histopathology

increase in the number

of melanocytes
elongation of the rete ridges

Treatment is usually
unnecessary

Addison
s disease
Cushing
s syndrome

after middle age

Senile
or
solar

Lentigines

N: Nevi | Nutrition

on mucous
membranes

E: Endocrine

Only sunscreens

PeutzJeghers syndrome
Multiple in

Renal failure

Cronkhite-Canada Syndrome
LEOPARD syndrome

Xeroderma pigmentosum
Biliary cirrhosis
Haemochromatosis

autosomal dominant

M: Medical/Metabolic

Malignant melanoma

around the lips

M: Malignancy

PeutzJeghers
syndrome

lentigines

buccal mucosa, gums, hard palate

hands and feet

polyposis of the small intestine

3/15/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Hyper pigmentation

cell-mediated autoimmune attack

Cause

Trauma and sunburn can precipitate both types

acrofacial variant
starts after the second decade

A PIGMENTED
common generalized

family history in 30%

DM 1

types
Associated with

thyroid disorders
pernicious anaemia

rare segmental
hydroxychloroquine

sharply defined

D: Drugs

symmetrical
backs of the hands
Trauma

wrists

T:
Sites

Halo naevus

neck

N:

around body orifices

Generalized
type

Hypopituitarism

E: Endocrine

Malignant melanoma

fronts of knees

hair of the scalp and beard

may depigment too

Clinical
course

M: Malignancy

A: Autoimmune

Induction of new lesion in normal

skin by trauma or scratching
Kbner
phenomenon

Vitiligo

Vitiligo
+ve in

oculocutaneous albinism

Hypo
pigmentation

little or no melanin is made

Skin

Affects

occasionally, they repigment

spontaneously from the hair follicles
Segmental
type

Albinism

G: Genetic

have poor sight, photophobia

and a rotatory nystagmus

Spontaneous repigmentation occurs more often

depigmenting chemicals

whole epidermis is white

Differential diagnosis

Pityriasis versicolor
Post-inflammatory
leprosy

Phenylketonuria
ChediakHigashi syndrome:

Sun avoidance and screening

preparations
topical corticosteroid

Eczema
Pityriasis alba

calcineurin inhibitors

Psoriasis
Sarcoidosis

Psoriasis
Lichen planus

defect in the synthesis or packaging of

melanin in the melanocyte
Iris

Warts

Treatment

Pi: Post-inflammatory

Cryotherapy

3/18/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Hypo pigmentation

strength should be gradually tapered

tacrolimus ointment

PUVA
transplant

Lupus erythematosus
Lichen sclerosus et atrophicus

for 12 months

completely and irreversibly

extensive vitiligo

depigmented by

monobenzyl
hydroquinone

comedones
Papules
Pustules

Mild

Moderate
According
to severity

Nodules
Cysts

Severe

Scars
Topical
Isotretinoin
Adapalene

Retinoids

disorder of the pilosebaceous apparatus

Mild

Tazarotene

comedones
Azelaic acid

papules

Topical and systemic

pustules

clindamycin
erythromycin

Intro

Topical
antibiotics

lesions

nodules
Cysts

zinc &
erythromycin

Scars
Nearly all teenagers

Minocycline
Prevalence

Doxycycline

clears by the age of 2325

years in 90% of patients

GIT upset
Photosensitivity

Poral occlusion

Hepatotoxicity
Teeth staining

Tetracycline

dental hypoplasia

Bacterial
colonization of duct

systemic
antibiotics

Pathogenesis

S/E

Propionibacterium acnes

Dermal inflammation
Increased Sebum secretion rate

Pigmentation
Increased ICP

Moderate

contraindicated
in children and
pregnancy

Presentation
Systemic
exclude a pyogenic infection
Cultures

Treatment

In all females
High estrogen low progesterone
Anti androgens
just given for females
antiandrogen
antiandrogen

LH

Diane-35

LH:FSH 2.5:1

FSH
Hormonal

ketoconazole

Investigations

dehydroepiandrosterone
sulphate

Hormones

androstenedione

spironolactone

17-hydroxyprogesterone

For PCOS

Acne

metformin

urinary free cortisol

Pelvic U/S

Systemic

Imaging

Depression

CT
MRI

Hepatotoxicity
Teratogenic
Most imp.
LIPS

comedones absent
Dryness of Mucous
membranes and skin

Triglycerides
Pancreatitis

Rosacea

Differential
diagnosis

Hyperlipidemia
S/E

Hair loss

folliculitis

Isotretinoin

Severe

poor night-time vision

hearing loss
Headache
Increased ICP
CBC
Fasting lipid profile

Hidradenitis
suppurativa
Pseudofolliculitis

photosensitivity
muscle aches

only face

Monitoring

LFT
Used alone with no other antibiotic
Cosmetic camouflage

3/13/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Acne

axillae and groin

Face

clitoromegaly
deepening of voice

Site

Systemic
virilization

breast atrophy

Androgen-secreting
tumours

Upper trunk

Seborrhoea
Open comedones

Cutaneous virilization
Common type
dominated by papulopustules

closed comedones
papules, nodules
and cysts

suddenly

Depressed or hypertrophic scarring

Corticosteroids

hyperpigmentation can follow

androgens
anabolic steroids
gonadotrophins
Progesterone
containing

ball

Drug
induced

oral
contraceptives

Nodules

E.G..

Severe form

lithium

Cysts
Scar

Conglobate

abscesses or cysts with

intercommunicating sinuses

iodides
bromides

leaves deeply pitted or

hypertrophic scars

anticonvulsants

conglobate acne

ambiguous genitalia
Congenital adrenal hyperplasia

fever

Fulminans

salt-wasting

High (ESR)

Acne
Presentation

male-pattern balding

soon after birth

common in males

hirsutism
Acne

joint pains

Infantile
Cutaneous
virilization
oligomenorrhoea

last up to 3 years
Due to maternal androgens

Polycystic
ovarian
syndrome

only comedons

obesity

Tars

Glucose intolerance
Exogenous

oily cosmetics

on the trunk
Sweat causes follicular occlusion

chlorinated hydrocarbons

Can cause OR exacerbate acne

Tropical

Common in white ppl traveling to the tropics

common in young girls
Excoriated
With obsessional picking or rubbing

mainly in women
limited to the chin
Late onset
Nodular and cystic
stubborn

3/13/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Acne Presentation

avoidance of exacerbating factors + sunscreens

tetracyclines

papulopustular

Erythromycin

2 Types

Topical metronidazole
metronidazole
isotretinoin

stubborn
rosacea

systemic

vascular lasers

affects the
face of adults

Treatment

Erythematotelangiectatic
rosacea

usually women

peak incidence is in the thirties

surgical excision

Still Unknown

rhinophymas

cryotherapy

erythematotelangiectatic

Intro

papulopustular
rosacea

Demodex folliculorum
Helicobacter pylori

no erythema and
telangiectases

Cause

Warmth

comedones
Involves face, back
and shoulders

spicy food
Acne

Seen in those who flush easily

alcohol
embarrassment

Seborrhoeic eczema

Differential diagnosis

perioral dermatitis

centre of forehead

systemic lupus erythematosus

cheeks

photodermatitis

Sites

chin

menopausal symptoms
Superior vena
caval obstruction

periorbital and perioral areas are spared

flushing

Intermittent flushing
followed by a fixed erythema and telangiectases.

blepharitis
conjunctivitis

Eye

plaques
nodules

has no comedones or seborrhoea

Rhinophyma

Complications

Course

below the eyes

on the forehead

papulopustules
Lesions

hyperplasia of the
sebaceous glands
and connective
tissue on the nose
common in males

papules

Rosacea

keratitis

develop a
rebound flare of
pustules

nose

usually symmetrical
Prolonged course with
exacerbations and remissions
Heat

Lymphoedema

Sun exposure
some patients
treated with
potent topical
steroids

alcohol
embarrassment

erythematotelangiectatic
rosacea

Erythema
Telangiectasia
Swelling

spicy food

Exacerbating factors

Important
features

Papules
Pustules

3/16/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Rosacea

papulopustular
rosacea

Vascular features
predominate

Inflammatory features
predominate

T-cells
autoimmune

Loss of open
hair follicles

thyroid disease

Burns

vitiligo

Associated with

radiodermatitis

atopy

Aplasia cutis

affects 10% of those with Down

s syndrome

Kerion

patch of hair loss

Scaring

With no scaring
Skin colored
Not scaly
Well defined margin

carbuncle
Cicatricial basal
cell carcinoma

Scaring
and
non-scaring

lichen planus
lupus erythematosus

Localized

No specific arrangement

sarcoidosis

Scalp
beard
eyelashes

Alopecia areata
Presentation

Distribution is variable

Androgenetic
non-scaring

eyebrows

exclamation-mark
hairs
broken hair that is
4 mm long , less
pigmented and
thinner proximally

Alopecia
areata

Pathognomonic

Hair-pulling habit
Traction alopecia

localized
and
diffuse

non-inflammatory
tinea capitis
Telogen effluvium
hypopituitarism

unpredictable

hypo- or hyperthyroidism

Endocrine

hypoparathyroidism

onset before puberty

high androgenic states

association with
atopy or Down
s
syndrome

antimitotic agents
poor
prognostic
features

unusually widespread
involvement of the
scalp margin

retinoids
Course

diffuse

Drug-induced

anticoagulants
vitamin A excess

Alopecia

Recurrent
more than 3 months duration

oral contraceptives
Androgenetic
Iron deficiency

nail envolvement

Severe chronic illness

Differential diagnosis

Malnutrition

Intradermal/intralesional Corticosteroid

Diffuse type of alopecia areata

Topical corticosteroids
Minoxidil

Treatment

male-pattern baldness

PUVA
Contact sensitizer

clearly familial
Male-pattern baldness

childbirth
Surgery
haemorrhage

triggered by any
severe illness

Presentation

in men

from the temples

women

more diffuse

severe dieting

Androgenetic
alopecia

synchronize catagen
So large number of hairs are lost together
23 months after the provoking illness

anxiety
Complications
Scalp surgery, hair
transplants and wigs

Telogen
effluvium

minoxidil

Beau
s lines on nails
Beau
s lines:
Transverse grove due to
slow growth

Antiandrogens
Associated with

decreased libido

Treatment
Finasteride

reassured that their hair

fall will be temporary
Treatment

3/15/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Alopecia

erectile dysfunction
altered prostate-specific
antigen levels

decrease weight and exercise

Cushing syndrome

underlying disorder must be treated

waxing or shaving
Plucking should probably be avoided

Adrenal

androgen producing tumors

congenital adrenal hyperplasia

Treatment

androgen producing tumors

Laser

serum testosterone

Oral antiandrogens

LH:FSH

electrolysis

Causes

occurs in childhood;

Ovarian

Poly cystic
ovarian
syndrome

features of virilization
sudden or recent onset
menstrual irregularity
or cessation

2.5:1

sex hormone-binding globulin

dehydroepiandrosterone
sulphate (DHEA-S)
androstenedione

done
if

Pelvic U/S
lipid profile
fasting glucose

serum testosterone
2.5:1
LH:FSH

Hirsutism

Racial / Familial

sex hormone-binding globulin

dehydroepiandrosterone sulphate

Drugs

idiopathic

Investigations
on beard

androstenedione

chest

17-alpha hydroxyprogestrone
prolactin
Pelvic U/S
Transvaginal ovarian ultrasound
lipid profile
fasting glucose

3/15/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Hirsutism

Presentation

Excess hair

shoulder-tips
around the nipples

male pattern of pubic hair

Head lice
P. humanus capitis
Body lice
P. humanus corporis

Lice

10% of children
few or no symptoms

Pubic lice
Phthirus pubis

still common

peak between the ages of 4 and 11

more common in girls than boys

sexual contact
Spread
Severe itching in the pubic area

Cause
Eggs (nits)

eczematization
secondary infection

34 mm in length

about 10 adult lice

followed by

greyish

stuck to the hair shafts

head-to-head contact

small bluegrey macules

Spread

Presentation

shiny translucent nits are less obvious

than those of head lice

shared combs or hats

is mainly around
the sides and
back of the
scalp

Pubic
lice

spread most extensively in hairy males

and may even affect the eyelashes
Coexistant STD

Presentation
and
course

Carbaryl

take several months to develop

permethrin
malathion

later it spreads
generally over
the scalp

main symptom is itching

Investigations

Scratching and secondary infection soon follow

Head lice

Treatment

hair becomes matted and smelly

Infestation of the eyelashes is

particularly hard to treat

Draining lymph nodes often enlarge

Secondary bacterial
Complications

now uncommon

Search for lice

recurrent impetigo

infested bedding or clothing

Spread

Infestations

Self-neglect is usually obvious

widespread itching
Results in excoriations and crusts

Differential diagnosis

Presentation
and course

pigmented

Topical

carbaryl
synthetic pyrethroids

vagabond
s
disease

lymphadenopathy
burrows

Search for lice

Malathion

Skin is thickened
eczematized

crusted eczema

toothcomb
chronic
untreated
cases

Body lice

systemic antibiotic
Treatment

scabies

Pillow cases,
towels, hats and
scarves

severe secondary infection

laundered or dry cleaned

Differential diagnosis
Clothing should be examined
Investigations
permethrin
lindane

Treatment

3/18/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Infestations

Systemic
ivermectin

infestations resisting
topical treatment

Incubation for 1 month

treat all members of the family and sexual contacts
too, whether they are itching or not

Sarcoptes scabiei hominis

Adult mites are 0.30.4 mm long

permethrin

close bodily contact

malathion
Applied with paintbrush

Cause

scabicide

Transmission

Treatment

second application, a week after the first

produce two or three oval eggs

fertilized female

calamine lotion

Residual itching may last for several days,

or even a few weeks

turn into sexually mature mites in 2-3 weeks.

Caused by sensitization to the mites or their products

Itch

Ordinary laundering deals satisfactorily with clothing

and sheets. Mites die in clothing unworn for 1 week.
For 46 weeks

Only scabies shows characteristic burrows

Differential diagnosis

first infestation

thereafter

no itching

Severe itching
bad at night

Many people itch

with pustulation
glomerulonephritis

itching starts within a day or two

Secondary infection

Scabies

Persistent itchy red nodules

Venereal disease

second attack

excoriated

Complications

crusted eruption

Presentation

Result

eczematized
urticarial papules
sides of the fingers

vast numbers of mites

mental retardation
immunosuppression

victims already have immunity

finger webs

Crusted (Norwegian) scabies

IN

sides of the hand

Sites of burrows

wrists
elbows, ankles and feet

persists indefinitely unless treated

Course

nipples and genitals

Only in infancy does scabies affect the face

greywhite

On the genitals, burrows are associated with

erythematous rubbery nodules

slightly scaly
Linear or cervelinear papules
Pathognomonic for Scabies

3/19/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Scabies

Burrows are

tend to be tense

cold and friction injury

Penicillamine

Subepidermal
bulla

drugs

may contain blood

within the prickle
cell layer
thin roofs

Pemphigus
Pemphigoid

intact

Location of bullae

Autoimmune

Intra-epidermal
bulla

Dermatitis herpetiformis

Blisters in diabetes and renal disease

Bullous
Diseases

rupture easily
leave an oozing
denuded surface
beneath the
stratum
corneum

Subcorneal
bulla

thinner roofs
rupture more easily

impetigo

Porphyria cutanea tarda

Ecthyma

bullous lupus erythematosus

Infections

herpes simplex
herpes zoster

Genetic

epidermolysis bullosa

vesicular tinea pedis

Acute dermatitis

3/16/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Bullous Diseases

potent topical steroids

Mild
prednisolone or prednisone
acute phase

Treatment

Intro

dosage is reduced as soon as possible

Autoimmune
mainly affecting the elderly

Immunosuppressives

IgG mediate
At Basement membrane

subepidermal blister

Biopsy

filled with eosinophils

linear band of IgG and C3 along
the basement membrane

Cause

in 70% of patients

BP180
Complement is then activated

Direct
immunofluorescence

But UV play a part

Investigations

antibodies that bind to

normal skin at the
basement membrane

Usually no precipitating factors

chronic

Indirect immunofluorescence

titre does not correlate with clinical

disease activity

BP230

Bind to

itchy

Pemphigoid

blistering
smooth, itching red plaques

Differential diagnosis

Presentation

Lesion

in which tense vesicles and bullae form

flexures are often affected

Nikolsky test is negative

much discomfort
loss of fluid

old age

Complication

S/E of Systemic steroids and

high risk

immunosuppressives

need for high steroid dose

low serum albumin levels

self-limiting

Course

3/16/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Pemphigoid

treatment can often be stopped after 1-2 years

life-threatening
severe
it affects middle age
small doses of systemic corticosteroids

3/4 of cases
In superficial pemphigus

topical corticosteroids

common in Ashkenazi
Jews, Mediterraneans and Indian

azathioprine
gold salts
mmunosuppressives

cyclophosphamide

rare

Pemphigus vegetans

pemphigus vulgaris

high doses of systemic steroids

Treatment

generalized foliaceus

superficial pemphigus

localized erythematosus

Types

mycophenylate mofetil

penicillamine

plasmapheresis

Drug eruption

intravenous immunoglobulin

thymoma

paraneoplastic
pemphigus

Dapsone

Castleman
s tumour
lymphoma

vesicles are intra-epidermal

rounded keratinocytes floating freely
within the blister cavity

Acantholysis

intercellular epidermal
deposits of IgG and C3

serum from a patient with pemphigus contains

antibodies that bind to the desmogleins in the
desmosomes of normal epidermis

IgG mediated

Biopsy
Cause

All are autoimmune

desmoglein 3

main antigens

desmoglein 1

Direct
immunofluorescence

Trunk
flexures

On skin
flaccid blisters

Investigations

Pemphigus

Indirect
immunofluorescence

scalp
In mouth

Most patients develop the mouth lesions first

ELISA

blisters rupture easily

Pemphigus
vulgaris

correlates loosely with clinical activity

titre of these antibodies

Leaves widespread painful erosions

acantholysis

Shearing stresses on normal skin

can cause new erosions

Positive Nikolsky sign

Tzank smear

also positive in toxic epidermal necrolysis

Presentation

pyoderma

Vegetans variant

heaped-up, cauliflower-like weeping areas

are present in the groin and body folds

impetigo
ecthyma

Widespread
erosions

Blisters
pemphigus
foliaceus

epidermolysis bullosa
Differential diagnosis

Aphthous ulcer
Behet
s disease

so superficial
rupture so easily

Dominated more by weeping and crusting erosions than by blisters

facial lesions

Mouth ulcers

pemphigus erythematosus

herpes simplex infection

pink, rough and scaly

patient is in poor health bcoz of the diseases it self

bacterial or fungal infections

Scalp erosions

Course is prolonged
Due to high dose of steroids and immunosuppressives
severe oral ulcers make eating painful

15%
Complications

dehydration and electrolytes imbalance

Course

mortality rate
1/3 go into remission after 3 years
Superficial pemphigus is less severe

3/16/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Pemphigus

chronic
secondary eczematous dermatitis

Intro

dapsone

very itchy

'dermatitis'

sulfapyridine

erupt in groups

Treatment

gluten-free diet

subepidermal vesicles

Resolves later than enteropathy with

Gluten free diet

Autoimmune

subepidermal blister
neutrophils packing the
adjacent dermal papillae
IgA
C3

Antibodies
against

Biopsy

epidermal
transglutaminase

Can be asymptomatic

granular deposits of
Direct
immunofluorescence

in the dermal papillae

Investigations

Cause

Always associated
with Gluten-sensitive
enteropathy

anti-endomysial antibodies

patchy

involves only the

proximal small
intestine
tissue transglutaminase

Serum antibody tests

tissue transglutaminase

herpetiformis

reticulin
Other serum antibodies
diarrhoea

Dermatitis
herpetiformis

abdominal pain,
anaemia
malabsorption

endomysium

mainly affects adults

Complications

extremely itchy

Decreased risk with

Gluten free diet

often broken by
scratching

Small bowel lymphomas

grouped vesicles
Prolonged unless treated
Resolves later than enteropathy with
Gluten free diet

gliadin

Course

Presentation

shows only grouped

excoriations

urticated papules
elbows
knees

Site

buttocks
shoulders

secondary eczematous dermatitis develops

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3/16/2011 - Maen K. Abu Househ | Reviewed by Reem Al-qudah - Dermatitis herpetiformis