1. Dermatology in General Practice
Dr Lynne Rees

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

9. vesicle
Small fluid filled blister

10. Bulla
A large fluid filled blister

11. ECZEMA Synonymous with dermatitis
Large proportion of skin disease in developed world
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. Exacerbating factors Detergents Infection Teething Stress
Cat and dog fur
???? House dust mite
???? Food allergens
Theory of protection from parasite

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

22. complications Bacterial infection
Viral infections – warts, molluscum, herpes
Keratoconjunctivitis
Retarded growth

23. investigations
Clinical
??IgE
??RAST

24. Prognosis
Most grow out of it!
15% may come back – often very mildly

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
Bath oils – 2-3 capfuls per bath

32. Discoid eczema Variant of eczema Atopic and non atopic
Easily confused with psoriasis
Well demarcated scaly patches
Limbs
Often infective component (staph aureus)

35. 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

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

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

39. Clinical features Affects body sites rich in sebacceous glands
Infancy – cradle cap, widespread rash, child unbothered, little pruritus
Young adults – erythematous scaling eyebrows, nasolabial folds, forehead scalp
Elderly – more extensive

40. Treatment Suppressive Mild steroid and antifungal combination
Ketoconazole shampoo
Emollients
Soap substitutes

44. Venous eczema Lower legs Venous hypertension Endothelial hyperplasia
Extravasation of red and white cells
Inflammation
Purpura
pigmentation

45. Clinical features
Older women
Past history DVT
Haemosiderin deposition

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

48. Asteatotic eczema Dry skin Repeated soaping Worse in winter
Hypothyroidism
Avoid soap
Emollients
Bath oils

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

51. irritant Can occur in any individual Repeated exposure to irritants
Common in housewives, hairdressers, nurses

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

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

57. treatment
Stop rubbing!
Very potent steroids
Occlusion

58. PSORIASIS

60. 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

61. Chronic plaque
Extensor surfaces
Sacral area
Scalp
Koebners phenomenon

66. 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

69. Guttate psoriasis

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

73. Treatment
Calcipotriol too irritant
Steroid

74. Erythrodermic and pustular psoriasis
More severe
Need dermatologist!
Usually need oral therapy

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

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

84. treatment Suit patient Control rather than cure Topical therapies
Light treatments
Oral therapy

85. Topical therapy Emollients
Vit D analogues- calcipotriol, calcitriol, tacalcitol (dovonex, silkis, curatoderm)
Tazarotene – (zorac)
Coal tar – alphosyl, exorex, cocois, polytar
Dithranol –dithrocream, dithranol 0.1% to 2% for short contact
Steroids – eumovate
Combinations – dovobet, alphosyl HC, etc

86. Light treatments
Not the same as sun beds!!!!
UVB
UVA

87. ACNE VULGARIS

88. Cause of acne Common facial rash Usually adolescents
May occur in early and mid adult life
Blockage of pilosebacceaous unit with surrounding inflammation
Androgens lead to increase sebum production
Increased colonisation by propionibacterium acnes

89. Clinical features Increased seborrhoea Open comedones Closed comedones
Inflammatory papules
Pustules
Nodulocystic lesions

94. Acne distribution

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

96. Topical treatments Benzoylperoxidase – OTC, PanOxyl 5 to 10%,
Azelaic acid – skinoren ,avoid in pregnancy
Antibiotics – clindamycin, erythromycin, steimycin
Retinoids – adapalene, tretinoin, avoid in pregnancy, avoid uv light, differin, retin-A

97. Combination topical treatments
Antibiotics plus benzoyl peroxidase – benzamycin
Retinoid plus antibiotic – isotrexin
Antibiotic plus zinc - zineryt

98. 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.
Consider side effects and interactions when starting antibiotics
3 to 4 months before any improvement

99. Antibiotics Oxytetracycline 500mg bd Tetracycline 500mg bd
Doxycycline 100mg od
Minocycline 100mg od
Erythromycin 500mg bd

100. Hormone treatment for acne
Dianette - not if COCP contraindicated
Withdraw when acne controlled
VTE occurs more frequently in women taking dianette than other cocp.

101. Oral retinoids Hospital only Long list of side effects Teratogenic
Very effective

102. ROSACEA

103. Clinical features rosacea
Onset middle age
Facial flushing / erythema
Inflammatory papules
Pustules
No comedones
Telangectasia
Blepharitis
rhinophyma

108. Treatment Supressive rather than curative Topical metronidazole 0.075%
Tetracycline 500mg bd for 3 months
Metronidazole 400mg bd
Roaccutane
Plastic surgery and some laser therapy for rhinophyma

109. COFFEE
TIME