1. Primary Care Dermatology
Dr Mick McKernan

2. Description of skin lesions
Papule
Macule
Nodule
Patch
Vesicle
Bulla
Plaque

3. Papule
Small palpable circumscribed lesion
<0.5cm

4. Macule
Flat, circumscribed non-palpable lesion

5. Pustule
Yellowish white pus-filled lesion

6. Nodule
Large papule >0.5cm

7. plaque
Large flat topped elevated palpable lesion

8. patch
Large macule >2cm

9. vesicle
Small fluid filled blister < 1/2cm

10. Bulla
A large fluid filled blister > 1/2cm

11. ECZEMA =dermatitis 10% of population at any one time
40% of population at some time

12. Features of eczema Itchy Erythematous Dry Flaky Oedematous Crusted
Vesicles
lichenified

13. Types of eczema Atopic Discoid eczema Hand eczema Seborrhoeic eczema
Varicose eczema
Contact and irritant eczema
Lichen simplex

14. Atopic eczema Endogenous Atopic i.e asthma, hay fever 5% of population
10-15% of all children affected at some time

15. Atopic eczema individual must have:
An itchy skin condition in the last 12 months+ three or more of:
Onset before 2 years of age
History of flexural involvement
or flexural eczema currently present
History of generally dry skin
History of other atopic disease or FH

16. Exacerbating factors Infection Teething Stress Cat and dog fur
? House dust mite
? Food allergens

17. Clinical features Itchy erythematous patches
Flexures of knees and elbows
Neck
Face in infants
Exaggerated skin markings
Lichenification
Nail – pitted

23. complications Bacterial infection
Viral infections – warts, molluscum, eczema herpeticum ( refer stat).
Keratoconjunctivitis
Retarded growth

24. Prognosis Most grow out of it 15% may come back – often very mildly
Chronic skin dryness common after

25. Treatment Avoid irritants especially soap Frequent emollients
Topical steroids
Sedating antihistamines – oral hydroxyzine
Treat infections
Bandages
Second line agents

26. Triple combination of therapy
Topical steroid bd as required
Emollient frequently
Bath oil and soap substitute

27. Principles of treatments
Creams
Ointments
Amounts required
Potential side effects
Soap substitutes

28. creams Cosmetically more acceptable Water based Contain preservatives
Soap substitutes

29. ointments Oil based Don’t contain preservative Feel greasy
Good for hydrating

30. Topical steroids Mild – “hydrocortisone Moderate – “eumovate”
Potent – “betnovate”
Very potent – “dermovate”

31. Amounts required Emollients – 500g per week for total body
FTU – steroids- the least potent that controls the symptoms.
Bath oils – 2-3 capfuls per bath

32. FTU
Finger tip unit
Helps to give estimation of topical steroid amount used
To avoid over and under use of steroid

33. FTU

34. FTU 2 FTU = nearly 1 gram Enough for twice size of adult hand
A hand and fingers (front and back) = 1FTU
A foot (all over) + 2FTU
Front of chest and abdomen = 7FTU
Back and buttocks = 7FTU
Face and neck = 2.5 FTU
An entire arm and hand = 4 FTU
An entire leg and foot = 8 FTU

35. Discoid eczema Variant of eczema Easily confused with psoriasis
Well demarcated scaly patches
Limbs
Often infective component (staph aureus)

38. Hand eczema
Pompholoyx – itchy vesicles or blisters of palm and along fingers
Diffuse erythematous scaling and hyperkeratosis of palms
Scaling and peeling at finger tips

40. Hand eczema Not unusual in atopic More common in non atopics
Cause often uncertain
Irritants
Chemicals
Occupational history
Consider patch testing – 10% positive

41. Seborrhoeic eczema
Over growth of yeast (pityrosporum ovale, hyphal form malassezia furfur)
Strong cutaneous immune response
More common in Parkinson’s and HIV

42. Clinical features
Infancy – cradle cap, widespread rash, child unbothered, little pruritus
Young adults – erythematous scaling eyebrows, nasolabial folds, forehead scalp
Elderly – more extensive

43. Treatment Suppressive Mild steroid and antifungal combination
Ketoconazole or dentinox shampoo
Emollients
Soap substitutes

47. Venous eczema Gravitational = stasis eczema Lower legs
Venous hypertension
Inflammation
Purpura
pigmentation

48. Clinical features Older women Past history DVT Haemosiderin deposition
often misdiagnosed as cellulitis. Cellulitis is nearly always unilateral, tender and has a well demarcated edge

49. treatment Emollients Topical moderately potent steroids
Soap substitutes
Compression – check arterial supply first
Leg elevation

51. Champagne bottle appearance
of lipodermatosclerosis

52. Lipodermatosclerosis
and venous leg ulcer

53. Cellulitis – unilateral painful and well demarcated.

54. Asteatotic eczema =eczema craquele Dry skin Worse in winter
Hypothyroidism
Avoid soap
Emollients
Bath oils

56. Contact and irritant eczema
Exogenous
Unusual
Worse at workplace
History of exacerbations

57. irritant Can occur in any individual Repeated exposure to irritants
Common in housewives, hairdressers, nurses –bleaches and chemicals

58. contact
Occurs after repeated exposure but only in susceptible individuals
Allergic reaction
Common culprits – nickel, chromates, latex etc
Patch testing

61. Lichen simplex =Neurodermatitis Cutaneous response to rubbing
Thickened scaly hyperpigmentation
Emotional stress
May need biopsy to diagnose

63. treatment
Stop rubbing!
Very potent steroids
Occlusion

64. PSORIASIS

66. Psoriasis Affects 2% of population Well-demarcated red scaly plaques
Skin inflamed and hyperproliferates
Males and females equally
Two peaks of onset (16- 22) and later (55-60)
Usually family history

67. Chronic plaque
Extensor surfaces
Sacral area
Scalp
Koebners phenomenon

72. Guttate psoriasis Raindrop Children and young adults
Associated with streptococcal sore throats
Not all go onto get chronic plaque
May resolve spontaneously over 1-2 months

75. Guttate psoriasis

76. Flexural psoriasis Later in life Well demarcated red glazed plaques
Groin
Natal cleft
Sub mammary area
No scale

79. Treatment
Step 1:Prescribe copious emollients - make the skin more comfortable and reduce the amount of scale
Step 2:Dovobet is the most effective vitamin D analogue Avoid on areas of thin skin eg the face, flexures and the genitalia. Also consider dithranol and tar. Flares use topical steroids 2 weeks- erythroderma or generalised pustular psoriasis if overused.
Step 3 : for hospitals. Phototherapy , cyclosporin , UV, methotrexate
Step 4: biologicals : Etanercept, Infliximab, Adalimumab and Ustekinumab belong to the class of biological medicines called tumour necrosis factor (TNF) blockers. These work by blocking the activity of TNF.

80. Erythrodermic and pustular psoriasis
More severe > 90% involvement
Need dermatologist!
Usually need oral therapy

86. Associated features Arthritis
Nail changes- onycholysis, pitting, discolouration, subungal hyperkeratosis

89. prognosis Chronic plaque tends to be lifelong
Guttate – 2/3 further attacks, or develop chronic plaque

90. ACNE VULGARIS

91. Acne Vulgaris Common facial rash Usually adolescents
3% may persist after 25yrs especially women.

92. Clinical features Increased seborrhoea Open comedones= blackheads
Closed comedones= whiteheads
Inflammatory papules
Pustules
Nodulocystic lesions
scars

97. Acne distribution

98. Treatment Consider site Compliance
Inflammatory/non inflammatory lesions
Scarring
Fertility
Psychological effect

99. Topical treatments Benzoylperoxidase – OTC, PanOxyl 5 to 10%,
Azelaic acid – skinoren
Antibiotics – clindamycin, erythromycin, steimycin
Retinoids – adapalene

100. Oral therapy Use if topical therapy ineffective or inappropriate
Anticomedonal topical treatment may be required in addition
Don’t combine topical with oral antibiotic as encourages resistance.
3 to 4 months before any improvement

101. Antibiotics Oxytetracycline 500mg bd Tetracycline 500mg bd
Doxycycline 100mg od
Erythromycin 500mg bd
Lymecycline 408mg od

102. Hormone treatment for acne
Dianette - not if COCP contraindicated
Withdraw when acne controlled
VTE occurs more frequently in women taking dianette than other COCP – caution ++ at this point.

103. Oral retinoids Hospital only Long list of side effects Teratogenic
Very effective
Suicide- no proven link

104.
Rashes are difficult!