Dermatology

Question 1

Cells in epidermis

Answer 1

a) Keratinocytes
b) Melanocytes
c) Langerhans cells = antigen- presenting cells. Pale dendritic cells which contain
Birbeck granules on electron microscopy
d) Merkel cells- epidermal nerve cells.

Question 2

epidermal appendages

Answer 2

Pilosebaceous follicles: hair plus sebaceous glands (which open into hair canal); occur everywhere except on palms and soles.
Apocrine sweat glands: modified sebaceous glands; open into hair follicle or directly
onto skin; localized to axillae, nipples, perineum, genitalia
Eccrine sweat glands: on whole skin surface; secrete clear fluid containing electrolytes; sympathetic innervation.

Question 3

functions of skin

Answer 3

sensation
physical protection
temp regulation
chemical protection and lubrication
immunological
hormonal- Sex hormone metabolism, Production of vitamin D
display- cosmetic
toxic substance excretion

Question 4

pathological terms

Answer 4

Hyperkeratosis -thickening of stratum corneum (SC)
Acanthosis -thickening of stratum spinosum
Parakeratosis -nuclei retained in cell of thickened SC
Acantholysis -loss of adhesion between epidermal cells

Question 5

what can be used in topical treatments

Answer 5

Wet dressing- physiological saline can be made at home (2 teaspoons salt/litre water);
potassium permanganate (crystals in water to make pale pink solution) - useful if infection is present
Active ingredients such as sulphur, coal tar or corticosteroids can be incorporated into some
of the above vehicles
unguentum) emulsificans (= UE, contains liquid paraffin, white vaseline and emulsifying waxes) and Ung. Emulsificans aquosum (UEA = UE + 20% water

Question 6

Useful antiseptic preparations include

Answer 6

povidone-iodine (Betadine) cream or ointment,
Furacin ointment (nitrofurazone- causes allergic contact dermatitis)
Hibitane cream (chlorhexidene- causes irritant dermatitis, avoid in eczema) cream

Question 7

Antibiotic ointments

Answer 7

Terramycin (oxytetracycline plus polymyxin B), Polysporin (polymyxin + bacitracin),
Bactroban (mupirocin) skin and nasal ointment

Question 8

corticosteroids indications

Answer 8

include acute eczema, pemphigus vulgaris, systemic lupus erythematosus and leprosy reactions

Question 9

what antibiotics for widespread, deep or severe skin infections. Most skin infections are mixed Staph and Strep.

Answer 9

Penicillin VK is usually note effective for both and is
poorly absorbed in adults and older children
erythromycin,
cloxacillin

Question 10

anti fungals used in dermatology

Answer 10

Griseofulvin - effective only for dermatophytes
Nystatin - effective only for Candida
Amphotericin B – very useful for oral candidiasis.
Imidazoles: broad spectrum anti-fungal agents active against both yeasts and dermatophytes
Triazoles: Itraconazole (Sporonox) – used orally for candidiasis, deep fungi
Fluconazole - Mainly used for candidiasis
and cryptococcal meningitis.
Terbinafine – mainly for dermatophyte infections, including Amorolfine (Loceryl) - nail laquer used 1-2 times per week

Question 11

other drugs used in dermatology

Answer 11

Retinoids- Inhibit keratinization, sebum secretion and
inflammation, teratogenic
Dapsone - very useful in
dermatology especially for dermatitis herpetiformis, pemphigoid, various pustular dermatoses and Vasculitis
5-Fluorouracil (Efudix): 5% cream used for removal of solar keratosis

Question 12

which dz is vitiligo occasionally associated with

Answer 12

Hashimoto’s
pernicious anaemia
diabetes mellitus
Addison’s hypoadrenalism
alopecia areata

Question 13

vitiligo Rx

Answer 13

Potent topical corticosteroid creams- try for 3 months only
PUVA (psoralen) (oral or topical) + UVA) or narrow band UVB
Sunscreens and cosmetic covers

Question 14

cosmetic onchronosis facts

Answer 14

Due to the use of bleaching creams containing
hydroquinone
Worst on sun-exposed parts of face and neck; maximal on malar region andaround the eyes

Question 15

impetigo

Answer 15

Lesions start as superficial, subcorneal, thin walled vesicles which soon rupture to exude serum (streptococci) or purulent (staphs) which dries to form crusts
Rx- Antiseptic or anti biotic ointments (e.g. Furacin, Terramycin, Polysporin,
Bactroban)

Question 16

ecthyma

Answer 16

Same as impetigo but infection extends into dermis and lesions heal with scarring.
Most common on lower legs following insect bites or trauma.
Treatment: Always give systemic antibiotic such as erythromycin, cloxacillin or sulphonamide
(not tetracycline in children)

Question 17

folliculitis

Answer 17

most common in the beard area (sycosis barbae) but may occur on any hairy part of the body.
Treatment: antiseptic lotions; antibiotics, topical and / or systemic

Question 18

furuncles

Answer 18

Deep staphylococcal infection in and around hair follicle
Recurrent boils (furunculosis) underlying precipitating
factors- diabetes, other causes of immunosuppression and poor hygiene.
Treatment: Topical antiseptics, according to culture results, and treat carrier state in patient
and contacts

Question 19

strep skin infx

Answer 19

cellulitis- deep diffuse dermal infection, ill circumscribed, usually warm and tender
with lymphadenitis
erysipelas -supf well circumscribed rash extending to the subcutaneous lymphatic vessels, common
sites face and legs
Treatment: I.V. penicillin
Eliminate source of infection

Question 20

Common wart

Answer 20

raised nodular type common in children in whom they undergo spontaneous regression sooner or later.
Treatment- Topical irritants: e.g. lactic acid and salicyclic acid paints , silver nitrate sticks. If necessary freezing with liquid nitrogen or curettage with or without light
electrodessication
Home remedy: Cut lemon peel to size of warts

can apply 25% salicylic acid ointment under plaster
or paint with 20% formalin or monochloracetic acid in plantar wart

Question 21

Plane warts

Answer 21

multiple flat warts on face or limbs usually in children and young adults.
Treatment- topical irritants: benzyl benzoate, retinoic acid. 5- fluorouracil cream, Lemon peel home remedy

Question 22

Venereal warts

Answer 22

there may be warts in urethra, vagina or anus as well.
Treatment- Topical imiquimod
electrocauterization, freezing, CO2 laser
20% podophyllin- Do not use podophyllin on mucosal
surfaces or in pregnancy (absorption and toxicity).

Question 23

molluscum contagiosum

Answer 23

Dome shaped papules with a central
umbilication through which a white cheesy material can be expressed.
Treatment: Topical imiquimod
produce local inflammation (after which they regress) by either inserting sharpened match stick dipped in phenol into central umbilication, or freezing with liquid N₂, or light curettage
rubbing on retinoic acid or benzyl benzoate 2-3 times daily
express contents with comedo expressor

Question 24

herpes simplex

Answer 24

Primary infection: usually gingiva-stomatitis in infants Secondary infection: “fever blisters” (herpes febrilis, “cold sores”): mostly on face,
especially lips but may occur anywhere.
Recurrent herpes simplex: in some individuals; precipitated by fever, sun exposure,
menstruation etc. Mostly on
face, then genitalia, but may occur anywhere.
Generalized herpes simplex – mainly in immunosuppressed patients; vesicles are diffuse,
not grouped
Rx- valacyclovir/ famciclovir

Question 25

herpes zoster

Answer 25

Zoster results from reactivation of latent virus in dorsal root ganglia of peripheral and cranial nerves Mostly in adults and geriatrics Highly suggestive of HIV infection in young persons Rx- oral acyclovir /famciclovir/valaciclovir which should be started in the first 72 hours IV acyclovir for severe disseminated zoster Antibiotics if secondarily infected Eye consult for ophthalmic zoster

Question 26

HIV drug sensitivity

Answer 26

Especially co-trimoxazole and anti-TB drugs (widespread erythematous maculo-papular and lichenoid drug rashes) SJS and TEN due to drugs such as sulphonamides and HAART (especially efavirenz and nevirapine)

Question 27

leprosy Rx

Answer 27

rifampicin, dapsone and clofazimin | Treatment must be continued during reactions

Question 28

reactions in leprosy Rx

Answer 28

cell mediated- Corticosteroids started in high doses) and tapered slowly. For reversal reactions at least 6 months of corticosteroids required as treatment perpetuates the reaction. Shorter corticosteroid treatment needed for downgrading reactions humoral- Mild cases- no treatment or anti-inflammatory drugs. Severe cases- systemic corticosteroids, increased dose of clofazimine and thalidomide if available

Question 29

what develops in humoral leprosy reaction

Answer 29

Erythema nodusum leprosum: painful skin nodules, neuritis, arthritis, uveitis, glomerulonephritis

Question 30

true TB infx

Answer 30

Tuberculous chancre- Nodule or ulcer with enlarged regional nodes Lupus vulgaris- mostly head and neck, often starts in nos Warty tuberculosis- (tuberculosis verrucosa cutis) mainly on extremities; hyperkeratotic warty surface Scrofuloderma- sinuses and fistulae on skin resulting from tuberculous abcess formation in underlying organ- usually lymph node but may be bone or joint, most common in neck and axillae. Tuberculous gummas- Multiple lesions resembling scrofuloderma, resulting from haematogenous spread. Miliary TB- with HIV infection

Question 31

immunolgoical reactions of TB

Answer 31

1. Papulonecrotic tuberculides (PNT): Widespread, symmetrical, mostly over elbows, knees and buttocks but anywhere. Papules, pustules, ulcers and round to oval atrophic scars (so-called varioliform scars). 2. Nodular tuberculides- mainly on lower legs Erythema nodosum and nodular Vasculitis Erythema induratum- nodules with ulceration- mainly on calves. 3. Lichen scrofulosorum- small, firm papules, grouped or diffuse on trunk or limbs

Question 32

cutaneous sarcoidosis

Answer 32

A. SUBACUTE, TRANSIENT- erythema nodosum on lower legs plus hilar lymphadenopathy. B. CHRONIC, PERSISTENT- skin lesions either localized or widespread sometimes associated with bone and/or lung involvement Lupus pernio: name given to type of sarcoidosis presenting with purplish plaques on nose, cheeks and ears.

Question 33

eczema

Answer 33

An immunologically mediated inflammatory skin disorder characterized in its acute stage by vesicle formation in the epidermis acute, subacute, chronic, exfoliative

Question 34

atopic eczema

Answer 34

association with asthma, hayfever raised serum IgE in some patients, Association with dryness of skin and ichthyosis. A relatively common type of eczema in infants and children.

Question 35

seborrhoeic dermatitis

Answer 35

Sometimes elicited or aggravated by infection (Staph, Strep, Pityrosporum yeasts) Mostly subacute or chronic with erythema and scaling but may become acute and weeping. Scalp, face, presternal and moist and hairy flexures (axillae, groins) commonly affected

Question 36

eczema elicited by various factors

Answer 36

local- Dryness, Infection, Contact dermatitis- Primary irritant or Allergic- e.g. nickel , Venous hypertension, Trauma, UVL, Sweating systemic- Infections e.g. tonsillitis Drugs e.g. penicillin

Question 37

eczema Rx

Answer 37

``` AB- flucloxacillin jor clartithromtcin Corticosteroids- topical mostly; systemic only if severe and for shortest possible time. Ultraviolet light (UVB or PUVA), cyclosporine and azathioprine pimecrolimus (Elidel), tacrolimus ```

Question 38

ptyriasis rosea

Answer 38

relatively common disease in young adults tends to occur in minor epidemics, mostly in spring and autumn Rash characteristically involves trunk and proximal parts of extremities Self- limiting within about 8 weeks Treatment: Diluted corticosteroids creams and sun exposure may shorten attacks

Question 39

lichen planus

Answer 39

Aetiology -unknown (but increasing association with certain drugs, e.g. thiazide diuretics, oral hypoglycea emic agents, methyldopa and anti-TB drugs reported). Course- sudden onset; most cases subside within 3 months to 2 years, but many relapse Clinical: Anywhere, but commonly on anterior aspects of wrists and ankles, wickams striae, koebner phenomenom characteristic severe itch and violaceous colour Treatment: topical corticosteroids, under occlusion where practical. If severe enough, oral steroids.

Question 40

Lichenoid Drug Eruptions

Answer 40

Rash resembles lichen planus but may be more severe and extensive; slow resolution after drug withdrawal. Commonest drugs implicated are gold, antimalarials (chloroquine, mepacrine), thiazide diuretics, antituberculotics (PAS, streptomycin, INH). Also from external contact with photographic colour developers

Question 41

psoriasis

Answer 41

Start at any age, mostly 20’s -30’s, unpredictable with spontaneous exacerbartions and remissions Auspitz sign- on firmly scraping away the scale, underlying bleeding points (due to dilated capillaries in dermal papillae) are seen. Koebner phenomenom

Question 42

psoriasis Provoking factors

Answer 42

Infection Psychogenic factors – stress often aggravates Trauma, e.g. sunburn Drugs- antimalarials, lithium Endocrine- tends to improve with pregnancy

Question 43

psoriasis Rx

Answer 43

Rx- Topical applications: Coal tar, Corticosteroids, Calcipotriol, Tazarotene Ultraviolet light- narrow band UVB or PUVA Systemic therapy- Methotrexate, Synthetic vitamin A derivatives Cyclosporin A New therapies: biologics NB Systemic steroids should only be used as crisis management in acute stages of severe erythrodermic or generalized pustular psoriasis, otherwise BEST AVOIDED.

Question 44

urticaria

Answer 44

Causes: Often not found, but must always be sought Infections: commonest in children, especially streptococcal tonsillitis Drugs: especially aspirin, penicillin, ACE inhibitors Dietary: specific foods or additives (dyes Parasites: intestinal, bilharziasis. Physical urticarial: provoked by pressure, heat, cold Rx- AB: Dapsone, Omezilumab antihistamnines corticosteroids

Question 45

allergic vascultis

Answer 45

Type III reaction resulting in leukocytoclastic Vasculitis. Causes: a) Unknown – e.g. Henoch- Schonlein b) infections such as tonsillitis or pyelonephritis c) drugs

Question 46

Erythema nodosum

Answer 46

More common in females. Two main forms:- a) Classical, acute: Mainly young adults. Crops of deep, painful, warm nodules or plaques. Lower legs, mainly shins (seldom elsewhere) b) Chronic EN- (nodular Vasculitis): smaller nodules, more widespread, mainly on legs. Causes: Immune – complex mediated. 1. Bacterial infections especially streptococcal tonsillitis, sinusitis, dental sepsis; tuberculosis, Yersinia. 2. Viral and chlamydial infections – often presenting as “flu”. 3. Sacroidosis. 4. Drugs- especially sulphonamides Treatment: Remove cause. Symptomatic – analgesics, anti- inflammatories; corticosteroids seldom help for long; potassium iodide by mouth helps some patients.

Question 47

Fixed drug eruption

Answer 47

Lesions recur on same spot and increase in number and site with each successive attack. Typically large, round, well circumscribed, purplish, slatecoloured residual macules are seen between attacks

Question 48

erythema multiform

Answer 48

target lesions mainly on face and extensor surfaces of limbs, especially knees and elbows but may occur anywhere. a) Stevens- Johnson syndrome: widespread round blisters and erosions include skin eyes, mouth, genitalia: some cases associated with Mycoplasma pneumonia. b) Toxic epidermal necrolysis (TEN): generalized or locarized sheets of despuamation of necrotic epidermis resembling burns Causes: 1. Infections- viral (commonly herpes simplex), bacterial, Mycoplasma. 2. Drugs-especially sulphonamides and phenophtalein. 3. L.E. 4. Malignancy 5. Radiotherapy and cytostatic drugs Rx- remove cause, AB if secondary infx (macrolide, tetracycline, or azithromycin)

Question 49

pemphigus vulgaris

Answer 49

Jewish race especially. Middle and old age, mostly 40-60 years, Relatively common in black South Africans. Clinical: Often presents with erosions in mouth, no itch Rx- High dose corticosteroids azathioprine/cyclophosphamide/cylcosporien

Question 50

bullous pemphigoid

Answer 50

Elderly, generally older than 60 years Large bullae tend to occur over wide areas especially on upper arms and thigh, Mucosal lesions uncommon. Treatment: Corticosteroids (lower doses than for pemphigus) Additional dapsone often useful and steroid sparing

Question 51

linear IgA dz

Answer 51

Chronic, recurrent, pruritic blisters mainly on limbs. Small peripheral rings of blisters around central erythema are characteristic (“string of pearls”). Relatively common in balck South African children Treatment: Long-term dapsone 100mg/ day for adult, less for children according to age. Children do well on dapsone alone but adults need prednisone and azathioprine in addition.

Question 52

dermatitis herpetiformis

Answer 52

Clinical: age: 20-50 years, occasionally in childhood. Acute or gradual onset. Pruritus is severe and often the initial symptom The distribution is characteristic: extensor surfaces of the limbs, especially knees and elbows, shoulders, trunk and buttocks. Oral lesions are unusual. Most patients have gluten-sensitive enteropathy Treatment: Dapsone by mouth in lowest possible dose. Gluten free diet helpful in some patients.

Question 53

porphyria

Answer 53

Two main types in South Africa: 1. P variegate – SA genetic porpohyria Quiescent phase: raised stool porphyrins Acute attack: Porphobilinogen in urine 2. Porphyria cutanea tarda: - Liver disease mostly due to alcohol, in genetically predisposed individuals. - Raised urinary porphyrins. Clinical: In both types photosensitivity results in hyperpigmentation and a weatherbeaten, waxy, winkled facial appearance Hirsutism is common

Question 54

icthyosis

Answer 54

group of inherited disorders of eratinisation characterized by dryness and scalines of the skin. Ichthyosis vulgaris Manifestations of ichthyosis in the newborn: a) Collodion baby: diffuse, dry shiny membrane present at birth, subsequently cracks and peels off b) Harlequin foetus is the most severe form form of ichthyosis. The neonate is encased in thick armour plate- like hypekeratotic epidermis transversed by deep polygonal fissures. Death usually occurs shortly after birth. Treatment: Bland, greasy ointments e.g. Ung.emulsificans. Etretinate reserved for severe cases.

Question 55

palmo plantar keratoderma

Answer 55

sometimes seen in black African men. This type of punctate keratoderma may be associated with increased sweating (hyperhidrosis) of the palms and soles Treatment: reduce sweating e.g. with 10% formalin soaks, and pare corns with a blade. Etretinate for very severe cases

Question 56

yeasts

Answer 56

Candida albicans - Skin and mucous membranes, more rarely internal organs 2. Pityrosporum orbiculare (ovale)- lipophilic yeast=Malassezia furfur Skin surface- tinea (pityriasis) versicolor Hair follicle- Pityrosporum folliculitis

Question 57

dermatophytes

Answer 57

Human and animals affected. The fungi grow in keratin. 3 genera: - Microsporum – skin and hair -Epidermaphyton – skin, mainly feet and groins -Trichophyton- skin, hair and nails

Question 58

depp fungal infx

Answer 58

1. Sporotrichosis – S. schenkii 2. Achinomycosis – A. Israeli 3. Nocardiosis – N. asteroids 4. Chromomycosis – Cladosporium carrionii, Fonsecaea pedrosoi etc. 5. Mycetoma

Question 59

candidiasis

Answer 59

endocrine- diabetes mellitus, pregnancy, drugs (the Pill, broad spectrum antibiotics, and corticosteroids Mucosal candidiasis: “Thrush” – white flecks in mouth and throat Cutaneous: Typical lesions are small superficial white pustules on glazed red skin with outlying, satellite pustules Rx- nystatin, imidazoles, amphoteracin B systemic- amphoteracin B, nystatin, fluconazole

Question 60

tinea versicolor

Answer 60

Common in adults in hot climates. Mostly upper chest and back (greasy areas); also less commonly on neck, abdomen, upper limbs, groins. Treatment: topical selenium sulphide (Selsun), or 20% sodium thiosulphate solution (“hypo”), or topical imidazoles

Question 61

Tinea capitis

Answer 61

Scalp, prepubertal children, very rare in adults Treatment: Griseofulvin, terbinafine. Topical antifungals- Whitfield’s ointment, imidazoles, etc not effective alone

Question 62

Tinea corporis

Answer 62

body ringworm, more common in children, but also in adults, especially in HIV infection, Usually in males with tinea pedis

Question 63

Tinea pedis (athlete’s foot)

Answer 63

Itch, scalling, vehicles; secondary infection common. Spreads by contact, including from floors Treatment: topical antifungals; systemic griseofulvin or terbinafine if severe

Question 64

Tinea unguium

Answer 64

Nailplates thickened, friable and opaque, or white | Treatment: griseofulvin, terbinafine (Lamisil) or itraconazole (Sporonox)

Question 65

Tinea barbae

Answer 65

beard area; very rare; usually due to animal ringworm | Treatment: oral griseofulvin, terbinafine or itraconazole plus topical antifungals.

Question 66

Pityriasis Amiantacea

Answer 66

is a reaction of the scals without erident cause. it may complicate seborrhaic dermatitis, Paoriasis, Lichen simplex. - Occurs in young people < 25 years (girls).

Question 67

sporotrichosis

Answer 67

Trauma, direct inoculation, usually from soil or plants. Suspect it in inflammatory skin lesions not responsive to antibiotics. Two main types: 1) Lymphocitaneous- skin + lymphatics; nodules, ulceration, LINEAR, CENTRIPETAL SPREAD, OFTEN UP A LIMB. 2) Cutaneous- “fixed” – single warty or ulcerated plaque. Disseminated forms- cutaneous only or systemic, are rare. Treatment: Potassium iodide by month for about 3 months. Start with 300mg/day (100mg tds), increase to 600mg/day or more. Alternatively itraconazole

Question 68

chromomycosis

Answer 68

Inaculation through minor injury, mostly on legs. Very slow growing warty plaques or fungating masses. May extend to cover large areas. Treatment: Surgical excision where possible; plus itraconazole or terbinafine.

Question 69

nocardosis

Answer 69

Discharging sinuses on skin, usually from underlying lung or bone involvement. One cause of Madura foot. Treatment: Six months or longer of cotrimoxazole (Bactrim), sulphonamide or tetracyclines. Can add potassium iodide.

Question 70

actinomycosis

Answer 70

Endogenous, from mouth, GIT. Three main types: cervico-facial, abdominal and throracic. Skin: nodules, abscesses, sinuses, “sulphur granules” in discharge. Treatment: Penicillin for 6-12 months. Can add potassium iodide.

Question 71

mycetoma

Answer 71

Commonest on feet, hence “Madura Foot”. Swelling, abscess formation, discharge. Eumycetoma- surgery; poor response to chemotherapy (itraconazole, amphotericin B)

Question 72

blastomycosis

Answer 72

Relatively rare in SA. Lungs, bones, skin: nodules, abscesses, sinuses, ulcers, granulomas. Slowly progressive, may disseminate. Treatment: itraconazole, amphotericin B.

Question 73

scabies

Answer 73

Secondary infection is common. Main sites of involvement are around axillae, wrists, webspaces of fingers and toes, genitalia and buttocks NORWEGIAN SCABIES: Severe crusted, hyperkeratotic lesions, seen in mentally deficient and immunosuppressed patients: contain myriads of mites. Very pruritic. Very contagious. Treatment: Benzyl benzoate emulsion (Ascabiol) or 2% sulphur, ivermectn

Question 74

pediculus capitis

Answer 74

Head lice cause epidemics in schoolchildren (even in Houghton). Itchy and infected scalp lesions occur especially around the ears. Treatment consists of gamma benzene hexachloride, Lyclear or Topical/oral Ivermectin PEDICULUS CORPORIS: Mainly seen in tramps

Question 75

pthirus pubis

Answer 75

Crab lice on pubic hairs and eyelashes. Treat former with Ascabiol and use Vaseline for eyelashes. Permethrin shampoo, Lycur ereme/ rinse, or Gambex shampoo

Question 76

acne vulgaris

Answer 76

face, upper back and chest, upper arms (rarely axillae and groins) P. acnes produces Lipases & Proteases Factors influencing acne vulgaris Hormonal: androgens increase size of sebaceous glands Genetic: Family history Climate: UVL beneficial- improvement in summer Psychological- exacerbation of existing lesions and neurotic excoriations. Diet- controversial- ?? Aggravated by nuts, chocolates Drugs- corticosteroids, iodides Rx- benzoyl peroxide, retinoic acid, adapalene Tetracyclin, erythromycin, co-trimoxazole Systemic prednisone for severely inflammatory lesions- for short periods only

Question 77

rosacea

Answer 77

Usually middle aged and elderly, mostly women with fair skin. Relatively common, confined to face. Vasomotor instability results in frequent flushing or blushing which leads to persistent erythema, oedema, telangiectasia and sebaceous hyperplasia Rhinophyma may result. Trigger factors: spicy food, red wine, hot coffe/ tea, Eyes: blepharitis, conjunctivitis, keratitis.

Question 78

perioral dermatitis

Answer 78

Mostly women childbearing age; males rarely affected. Recurrent cycles with remissions and exacerbations. May be provoked, aggravated and perpetuated by topical steroids Rx-Oral: Tetracyclines, Metronidazole (Flagyl), Ampicillin- not as effective Topical:Sulphur cream or lotion 2%, Metronidazole Gel (Rosex) Wean off any topical steroids rapidly Plastic surgery or CO2 laser for rhinophyma

Question 79

miliaria rx

Answer 79

loose cotton clothes, fans and air conditioners.

Question 80

hidradenitis suppurativa

Answer 80

Chronic disease of apocrine glands in axillae, groins, sometimes in natal cleft and around anus relapse is usual Systemic retinoids not always helpful but must be tried. In females hormonal treatment as for severe acne may help. Oral steroids, excision and grafting may be needed. Antibioties: Clindamycin + Rifampicin for at least 3-4 months.

Question 81

androgenetic alopecia Rx

Answer 81

Minoxidil lotion

Question 82

alopecia areata

Answer 82

Reassurance, topical irritants, e.g. tretinoin (Retin –A) or UVB, topical steroids. Longterm PUVA- preferable for severe cases. DO NOT GIVE SYSTEMIC CORTICOSTEROIDS

Question 83

Trichorrhexis nodos

Answer 83

in hair damaged by bad perms, excessive bleaching, sun exposure and excessive brushing, hair shafts may fracture, forming a frayed nodule where the shaft then breaks off

Question 84

dandruff

Answer 84

Pityrosporum ovale growing on a greasy scalp, best treated with selenium sulphide shampoo (Selsum) or Nizshampoo (ketoconazole). Medicated shampoos should be used intermittently, not continuously – excessive use may cause dryness and hair loss. Moderate to severe dandruff is usually associated with Seborrhoeic dermatitis or psoriasis of the scalp

Question 85

leukonychia

Answer 85

Whiteness of nail plate which may be punctate (spotted), striate (in stripes), or total. Small white spots in the nail plate are probably due to inapparent trauma and not to any dietary deficiency of calcium or any other known cause. Longitudinal white bands are usually congenital. (N.B. history). If acquired and transverse, look for systemic disease or drugs. Irregular white patches are usually due to fungal infection which can be confirmed by microscopic examination and culture of the nail plate.

Question 86

pitting of nails cx

Answer 86

psoriasis or eczema

Question 87

paronychia

Answer 87

Almost always due to too much working in water. Acute | cases are due to staphylococcal infection, chronic cases to candidia

Question 88

lupus erythematous

Answer 88

hyperkeratosis, follicular plugging, epidermal atrophy, liquefaction degeneration of basal layer, pigment incontinence, perivascular and periadnexal infiltrate of lymphocytes Subacute LE- Skin lesions more acute, annular, scaling, more widespread- face, arms and upper trunk. Rx: Strong topical steroids, sunscreens, oral chloroquine (beware retinal damage: retinoids for refractory cases)

Question 89

Systemic LE (SLE)

Answer 89

Females: males 8:1 Multi-system disease – joints, kidneys, lungs, lymph glands, heart, CNS Leukopaenia, anaemia, thrombocytopenia, renal dysfunction Rx: Systemic steroids and immunosuppressives (cyclophosphamide and azathioprine), chloroquine.

Question 90

Drug induced SLE – like syndrome

Answer 90

Mainly systemic manifestations; atypical rashes. Clears after stopping causative drugs which include methylopa, hydralazine, penicillamine, procainamide, INH, sulphonamides, phenytoin, minocycline.

Question 91

dermatomyositis

Answer 91

Two types- Juvenile and Adult. Adult type sometimes associated with underlying carcinoma which must be carefully sought. Carcinoma far less common in children, where vasculitis prevails Treatment: prednisone, immunosuppressive drugs (methotrexate, azathioprine or cyclophosphamide, cyclosporine), chloroquine

Question 92

scleroderma

Answer 92

With systemic involvement- Systemic steroids and immunosuppressives (methotrexate, cyclophosphamide) in acute stage. PUVA may be useful. No systemic involvement- none, or chloroquine, or Calcipotriol oint (Dovonex)- doubtful results.

Question 93

Mixed connective tissue disease

Answer 93

Features of SLE, sleroderma, dermatomyositis. Severe Raynaud’s, oedema of hands, arthritis, myositis, sclerodactaly, pulmonary hypertension, discoid LE type skin lesions; RNP positive Rx: steroids

Question 94

venous HT

Answer 94

Due to valvular incompetence (mainly hereditary) or deep vein thrombosis, or both REDUCE OEDEMA by bedrest and elevation in acute stage, later by elastic bandages and stockings. Vascular surgery if deep veins patent. Skin grafts for ulcers if needed. Wet dressings for acute eczema and ulcers- saline, or potassium permanganate if infected. Antibiotics – systemic for cellulitis; topical – (remember possibility of contact dermatitis). Topical corticosteroids for eczema but NOT ON OR NEAR ULCERS (they cause vasoconstriction)

Question 95

arterial occlusive dz

Answer 95

Ischaemia causes pain, coldness, pallor, and absent pulses if large vessels are involved. NB pressure bandages contra-indicated. Causes: arteriosclerosis (especially in diabetics), Burger’s disease, rheumatoid arthritis.

Question 96

Freckles (ephelides)

Answer 96

small brown macules on sun0exposed skin, appear in childhood in fair skinned individuals who sunburn easily. Due to increased pigment synthesis by melanocytes (which are normal in number) in response to sunlight

Question 97

Solar (actinic, senile) lentigines

Answer 97

Occur mainly on backs of hands and arms in elderly white people as multipkle well demarcated brown macules, often angulated and branched. Old lesions may become raised and warty and sesemble seborrhoeic keratosis

Question 98

melanocytic naevi

Answer 98

Three stages in process of maturation: a) Junctional- naevus cells attached to basal layer of epidermis; clinically lesions are flat. b) Compound – naevus cells also present in dermis; lesions more raised. c) Intradermal – all naevus cells in dermis; lesions domeshaped Treatment: Remove any mole of which patient complains. ALL removed moles must be examined histologically

Question 99

solar keraatoses

Answer 99

Consist of superficial, flat, non-infiltrated, hyperkeratotic (therefore palpably rough) hyperpigmented, ill-defined patches on sun damaged skin. Treatment of solar keratosis: The treatment of choice in young persons is 5-fluorouracil cream (EFUDIX) applied twice daily for about 3-4 weeks

Question 100

bcc

Answer 100

Slowly invasive locally; virtually never metastasizes. Very common on sun-exposed skin in whites. Characteristic histological picture of islands of basal cells with peripheral palisading Rx- either biopsy + cauterization and curettage, or surgical excision, or radiotherapy after confirmatory biopsy.

Question 101

scc

Answer 101

Malignant tumours derived from keratinocytes which tend to invade the dermis. Commonest types occur on sun damaged skin and arise from solar keratosis- these are relatively benign and easy to treat

Question 102

malignant melanoma

Answer 102

Back is commonest site in both sexes. Unless excised early while confined to epidermis , tends to cause widespread, fatal metastases