1. Lumps, bumps and rashes
By Sorcha Hodgson
5th year

2. What we are going to cover
Skin
Dermatology terminology
Dermatology history
Examination
Lumps and how to examine them
Rashes and how to examine them
Give it a go
Treatment
Paediatric rashes
Useful resources

3. Skin Skin has three layers:
The epidermis, the outermost layer of skin, provides a waterproof barrier and creates our skin tone.
The dermis, beneath the epidermis, contains tough connective tissue, hair follicles, and sweat glands.
The deeper subcutaneous tissue (hypodermis) is made of fat and connective tissue.
Covers 2m2 in average adult

4. Skin cont.. Epidermal appendages:
Hair follicles- newborns covered with 'lanugo hair' which is non-pigmented and has no central medulla
Sebaceous glands-epidermal downgrowths associated with hair follicles and comprised of modified keratinocytes. Sebocytes under hormonal control produce a range of lipids
Sweat glands- develop in second trimester. Major role in thermo-regulation and inner aged by cholinergic fibres of sympathetic nervous system
Eccrine- palms and sole of feet
Apocrine- axillae, mammary and genital area

6. Terminology General terms Lesion- area of altered skin
Rash- an eruption
Naevus- localised malformation of tissue structure
Comedone- plug in sebaceous follicle- open= blackhead, closed= whitehead
Distribution
Generalised- all over body
Widespread- extensive
Localised- restricted to one area
Flexural- body folds e.g. Groin, neck , popliteal and antecubital fossa
Extensor- knees, elbows and shins
Pressure areas- sacrum, buttocks, ankles and heels
Dermatomes- skin supplied by a single spinal nerve

7. Discrete- individual lesion separated from each other
Configuration
Discrete- individual lesion separated from each other
Confluent- lesions merging together
Linear- in a line
Target- concentric ring
Annular- like a circle or ring
Discoid/nummular- coin shaped
Colour
Erythema- redness which blanches on pressure
Purpura -red or purple colour as a result of bleeding into the skin and DOES NOT BLANCH
Petechiae-small pinpoint macules
Ecchymoses- larger bruise like patches
Target lesion- erythema multi forms- Lyme disease

8. Morphology
Macule- flat area of altered colour
Patch-larger flat area of altered colour or texture
Papule-solid raised lesion <0.5cm in diameter
Nodule-solid raised lesion >0.5cm with a deeper component
Plaque- palpable scaling raised lesion >0.5cm in diameter
Vesicle- raised clear fluid filled lesion <0.5cm in diameter
Bulla- raised clear fluid filled lesion >0.5cm in diameter

10. The all important history!!!
Pc- Nature, site and duration
HPC-
initial appearance and evolution of lesion
Symptoms particularly itch and pain
Aggravating and relieving factors
Previous and current treatments
Recent contact, stress, illness, travel, pets
History of sunburn/ tanning machine use
Skin type

11. FHx- skin/joint disease SHx- occupation, smoking an drinking
PMHx-
History of autopsy-asthma, eczema
History of skin cancer/ suspicious lesions
FHx- skin/joint disease
SHx- occupation, smoking an drinking
DHx- regular, recent and OTC medications
ICE!!!!!

12. Common skin lesions Melanocytes naevus Urticaria Eczema Ulcers
Campbell de Morgan spots/cherry haemangiomas
Striae
Skin tags
Psoriasis
Seborrhoeic keratosis
Erythema nodosum
Cancers- malignant melanoma, squamous cell, basal cell
Neurofibromatosis

13. Examination WIPE, expose relevant area, 3S's, 3C'S and 4T's Site Size
Shape
Colour
Contours
Consistency
Temperature
Tenderness
Tethering
Translucency

14. Don't forget: Lumps Rashes
ALWAYS PALPATE LYMPH NODES-head, neck and axilla
Concluding remarks- I would like to enquire about any changes that raise suspicion of malignancy
Investigations- USS, FNA, biopsy
Rashes
SYSTEMIC EXAMINATION-skin, nails, hair, ears, hands and joints
Investigations- bloods, skin scrapings, biopsy, serial photographs, dermatology referral

15. Lumps Introduction Wash hands
Introduction, explain examination, gain consent and general inspection
Expose relevant area
Inspection
Site
Relationship to surrounding structures
General idea of size and shape
Overlying skin- colour, punctum, discharge

16. Palpation
"Tell me if any discomfort?"
Centre of lump:
Surface
Consistency
Heat
Tenderness
Borders of lump
Shape
Size
Edge
Fluctuate
Bounce lump between two index fingers
Attachment to other structures
Special characteristics:
Transilluminates
Thrill
Pulsation

17. Differential diagnosis:
Intradermal lumps
Sebaceous cyst
Abscess
Dermoid cyst
Granuloma
Subcutaneous lumps
Lipoma
Ganglion
Neurofibromatosis
Lymph node

18. Rashes Introduction Wash hands
Introduction, explain examination, gain consent and general inspection
Expose relevant area
Inspection
Site/distribution
Size
Shape
Border
Colour
Discharge
Palpation
Feel if elevates
Tenderness
Heat

19. Differential diagnosis
Urticaria
Eczema
Psoriasis
Seborrhoeic keratosis
Lichen planus
"6 Ps" of lichen planus: planar (flat-topped), purple, polygonal, pruritic, papules, and plaques

20. Suspicious lesions If the lesion is pigmented don't forget ABCD:
A- asymmetry
B- border irregularities
C- 2+ colours
D- diameter > 6 mm
** Finals question favourite- Breslows thickness

21. Give it a go 12 year old girl Asthmatic Allergic to cats
Erythematous lesion over flexor surface, 15cm, irregular border licenification and scaling

22. Give it a go 2 79 year old man HTN COPD
Multiple widespread brown lesions with a stuck on appearence

23. Treatment Emollients Corticosteroids Tar Vitamin D agonists PUVA
Aqueous cream, emulsifying ointments and liquid paraffin
Rehydrate and re- establish surface lipid layer
Use regularly, after washing
Corticosteroids
HEBD (low to high potency):
Hydrocortisone
Eumovate- betametasone valerate
Betnovate- betametasone dipropionate
Dermovate- clobetasol proprionate
Tar
Vitamin D agonists
PUVA
Systemic therapies- methotrexate

24. Dermatology emergencies
Anaphylaxis and angioedema
Toxic epidermal necrolysis
Steven Johnson syndrome (SJS)
Acute meningoccaemia
Erythroderma
Eczema herpeticum
Necrotising fascitis
Anaphylaxis-
Antihistamines- 10 mg chlorphenamine
Corticosteroids- 200mg hydrocortisone
Adrenaline- 0.5ml 1:1000

25. Paediatric rashes

26. Meningococcal- Give benzylpenicillin unless there is history of immediate penicillin allergy after previous penicillin administration (eg, difficulty in breathing, collapse, generalised itchy rash). Benzylpenicillin dose is 1,200 mg for adults, 600 mg if aged 1-9 years, 300 mg if aged <1 year.
Cefotaxime may be used as an alternative

27. Useful resources Dermnet nz
British association of dermatologists (BAD)

28. Quiz
quiz/

29. Thank you