DERMATO NOTES

PSORIASIS

INTRO CLINICAL FEATURES IX MX

- Chronic (relapsing and Presentations : CLINICAL DIAGNOSIS - Reassurance
remitting) inflammatory, - Educate on CVD risk factors
hyperproliferative skin disease I) Plaque Psoriasis (Most common) : Raised, well - Infection screen (Throat
characterised by well-defined, demarcated erythematous plaque with erythematous swab Streptococcus -> Step ladder management :
erythematous scaly plaques OR friable skin underneath. Site : extensor surface (elbow, Guttate psoriasis) - Topical Therapies -> UVB phototherapy or
complex, chronic, multifactorial, knee), lower back, scalp, nail, flexures - Skin Biopsy (Only if doubt PUVA -> Systemic Agents
inflammatory disease in dx) ______________________________
characterized by well defined Scalp (60%) : easily palpable, erythematous scaly plaque. - Impact on life
erythematous plaque with silvery Associated with temporary hair loss (Dermatology Life Quality 1 General advice :
scale Nails : thimble pitting, oncholysis, subungual Index, or DLQI) - Stress reduction
hyperkeratosis, periungual involvement ____________________ - Moisturizers / Emollients
- Site : elbows, knees (extensor Flexures : natal cleft, submammary, axillary folds - Sunshine/sea bathing
surfaces), scalp, lumbosacral Palms : Difficult to differentiate from eczema Complication :
areas, intergluteal clefts, and 2 Topical Therapy :
glans penis II) Guttate Psoriasis (Most common in children and - Secondary infections
adolescents) : After strep throat infection/ URTI, small - Psoriatic arthritis - Mild to moderate topical steroids
- 1.2 % prevalence, M: F erythematous, scaly and numerous/widespread (Water - Mitral valve prolapsed - Vitamin D analogues (Calcipotriol, calcitriol,
drop appearance). Can precipitate into plaque psoriasis - Possible increased risk of tacalcitol)
- Bimodal Age of distribution : in adult lymphoma and - Tar preparations (Dithranol) : Messy, stain
I) Teenage/early adults (More cardiovascular disease clothes, causes skin irritation
common, + ve Family Hx and III) Erythrodermic Psoriasis : A medical emergency.
More severe) Generalised erythema with fine scaling. It is often 3 Phototherapy : For moderate severe
II) Elderly : 50-60y/o (No Family associated with pain, irritation, and sometimes severe psoriasis / site that are difficult to treat such
Hx, less severe) itching. Involving more or equal 90% of the body as palms, soles, scalp, genitals
- UV-
- Pathogenesis : Multifactorial IV) Pustular Psoriasis : (combination treatment of oral methoxsalen
I) Family : - SYSTEMIC (Emergency) : Sudden onset with many and UVA)
1 Parent -> 15 20% chance small sterile pustules on erythematous background -> - Adverse effect : Increase risk of skin
2 Both Parents -> 50% chance Merging into sheets with wave of new pustules. (von cancer, phototoxicity and burning

#MisiLegasi by Md Zaki MBBS240 UITM 11TH BATCH

the risk is increased further if a Zumbusch: rare, severe, urgent)
sibling 4 Oral systemic therapy :
has the disease - LOCALIZED : Sterile pustules at palms and soles -> - Methotrexate
II) Environment : Exacerbating Resolve with pigmentation and scaling (Chronic - Apremilast
factors in psoriasis involvement at hands and feet) - Oral retinoids (Eg. Acitretin)
- Trauma - Cyclosporine
- Infection IN GENERAL :
- Drugs Antimalaria, beta A. Clinical Features : 5- Biologic therapy :
blocker, lithium, NSAIDs - Eg. Etanercept, adalimumab, secukinumab,
- Psychological Anxiety, stress - Most common Skin manifestation : scaling Infliximab, Ustekinumab
erythematous macules, papules, and plaques + Would
Genetic predisposition / bleed if peel off scaly skin (Auspitz sign -> Due to
Autoimmune + Trigger factors -> hypervascularity below the lesion)
hyperproliferation of the - Pain, Pruritis, Dystrophic nail (Pitting, Subungual
keratinocytes in the epidermis hyperkeratosis, Onycholysis)
(with an increase in the - Joint involvement -> Joint pain
epidermal cell turnover rate) + - Ocular involvement -> Redness (Conjunctivitis,
Inflammatory cell infiltrate Blepharitis)

Trigger Factors : Cold, trauma, B. Examination :

infection (Eg. Strep throat), - Dermatologic: Scaling erythematous macules, papules,
alcohol , sunlight, drugs (eg, and plaques etc.
steroid withdrawal, aspirin,
lithium, beta-blockers, - Ocular: Ectropion, trichiasis,
antimalarials) conjunctivitis, conjunctival hyperemia, corneal dryness
with punctate keratitis, corneal melt, blepharitis

- Musculoskeletal: Stiffness, pain, throbbing, swelling, or

tenderness of the joints (distal joints most often
affected)

Type Plaque Guttate Erythrodermic Pustular Inverse

Features -Erythematous plaque -Drop-like -Generalized -Erythematous maculo- -Erythematous plaque on
 with silvery white -Scattered erythema papular that evolves into flexures
scale -Antecedent strep -S&S: arthralgia, pustules -May be macerated
-Auspitz sign: bleeds pharyngitis pruritus, -Painful
from minute points dehydration, -Sudden withdrawal from
when scale is electrolyte imbalance steroid
removed -Aggravated by:
-blocker,
NSAISs, antimalarial,
sunlight, infection
Manage Topical -UVB phototherapy -IV fluid & -Methotrexate -Topical corticosteroid
ment -Emolients -Moisturizer electrolytes -Cyclosporine -Topical Vit D : calcitriol or
-Salicylic acid 1-12% -penicillin V or -Treat underlying -Acitretin calcipotriene
-corticosteroid erythromycin if Group cause -topical calcineurin
-Vit D analogue -hemolytic -Avoid sunlight inhibitors : tacrolimus or
-Tazarotene (nail) Streptococcus on -Cyclosporine, pimecrolimus
throat culture acitretin
Systemic
-Acitretin
-Cyclosporin
-Methotrexate
-Apremilast
-PUVA
-UVB
Picture
PSORIATIC ARTHRITIS :

- Occurs in 10 40% with psoriasis and can present BEFORE skin changes (But, cutaneous psoriatic lesions precede arthritis in 70% of cases)

- Patterns :

Symmetrical polyarthritis (like RA). Most commonly oligoarthritis involvement (Below 4 joints) affected at Distal Interphalangeal joints
DIP joints
Asymmetrical oligoarthritis spinal (similar to AS)
Psoriatic arthritis mutilans (rare, ~3%, severe deformity)
- -in-
rashes and palmo-plantar pustulosis

- Management: NSAIDS, sulfasalazine, methotrexate. Anti-TNF agents are also effective

KERATODERMA BLENNORRHAGICUM (REACTIVE ARTHRITIS)

Reactive immune disorder characterised by psoriasiform plaques, urethritis/cervicitis, conjunctivitis, and arthritis.
Circular, scaly, scalloped-edged hyperkeratotic psoriasiform papules and plaques, which is sometimes painful and pustular (at the centre
of lesions), appears on soles and toes, and, less commonly, legs, palms, scalp, and penis.
Occurs in genetically susceptible people with HLA-B27 following an infection (particularly Yersinia enterocolitica and Y
pseudotuberculosis).
FUNGAL INFECTION

Local Systemic
Superficial Involve tissue and organs
Cutaneous Eg: Candidiasis
Subcutaneous Aspergillosis
Infection of skin, hair, and nails caused by dermatophytes (fungi that Cryptococcus
live within the epidermal keratin or hair follicle and do not penetrate
into deeper structures)

Subcutaneous fungal infection (Dermatophytoses)

- Clinical Presentation

Itchy skin
Ring-shaped rash (erythematous, raised, scaly ring with central clearing)
Hair loss

- Pathophysiology

- Causative agents

Microsporum, Epidermophyton species (Pityrosporum is a superficial yeast and not adermatophyte)

- Investigations
Type Features Picture Investigation Management
TineaCapitis -head scaly patches of alopecia, Terbinafine
TineaFaciei-face possibly examination Adjunctive antifungal
TineaBarbae-beard with broken off hairs Culture of scales/hair shampoos
kerion shaft or lotions
occipital lymphadenopathy Microscopic
examination of
KOH prep of scales or
hair shafts
TineaCorporis Pruritic, scaly, round/oval Microscopic Topicals: 1%
plaque with examinations clotrimazole, 2%
active erythematous of KOH prep of scales ketoconazole
margin, and central 2% miconazole,
clearing terbinafine
Site: trunk, limbs, face Oral Terbinafine if
extensive

TineaCruris Jock-itch Same as tineacorporis

Site: medial thigh
TineaPedis Pruritic scaling and/or
maceration of the
web spaces, and powdery
scaling of soles
Secondary bacterial
infection may occur

TineaManuum Primary fungal infection of

the hand is rare

TineaUnguum Crumbling, distally Culture of subungual Terbinafine (Lamisil®)

(Onychomycosis) dystrophic nails; scraping or nail (6 wk for
yellowish, opaque with clippings on fingernails, 12 wk for
subungual toenails)
hyperkeratotic debris Itraconazole
Toenail infections usually (Sporanox®) 7 d on,
precede 3 wk off (2 pulses for
fingernail infections fingernails,
3 pulses for toenails)
 SKIN CARCINOMA

Disease BASAL CELL CARCINOMA (BCC) SQUAMOUS CELL CARCINOMA (SCC) MALIGNANT MELANOMA
INTRO Aka Rodent Ulcer 2nd most common skin malignancy - Malignant neoplasm of pigment-forming cells
Most common skin malignancy Grows Upwards (Can present as cutaneous horn) (melanocytes and nevus cells)
Elderly (>40y/o), M>F Elderly, M>F - Site : Back (M), Calves (F)
RF : Prolonged Sun Exposure (Most Common), Sites: face, ears, scalp, forearms, dorsum of hands - Common in young adult
Radiation, Arsenic exposure, Family hx, RF : Sunlight, Radiation, Chemicals (Arsenic, Tar- - RF : Fair skin, Multiple moles, Large/dysplastic
Immunocompromised smokers lip), Immunosuppression, previous scar , nevi (50% arrive from pre-existing naevus),
Subtype : Marjolin ulcer Sunlight (Short period of intense UV),
- Typical (Nodulo-ulcerative) Immunosuppression
- Pigmented - Subtype :
- Superficial I) Lentigo Maligna
- Sclerosing (Morpeaform) Ii) Lentigo Malignant Melanoma
Site : Moderate sun exposure Face, trunk, shoulder Iii) Superficial Spreading Melanoma (60-70%):
Grow slowly, mets later, better prognosis
Iv) Nodular Melanoma (10-15%) : Elderly,
Invade deeply, mets early
V) Acral Lentiginous Melanoma
CF - Nodular/ Noduloulcerative : Pale/ Translucent - More locally aggressive than BCC, Rarely mets (LN) -
nodule -> typically a pearly nodule with rolled - Usually presents as an ulcerated lesion, with hard, Asymmetry
telangiectatic edge, on the face or a sun-exposed site raised edges, in sun-exposed sites or painful keratotic Border (irregular and/or indistinct)
+/- Central Ulcer nodule Colour (varied/non-uniform)
- Superficial: lesions appear as multiple, large (>10cm) Diameter (increasing or >6/7 mm)
red scaly plaques with a raised smooth edge, often on Elevation or evolution (i.e. change in colour,
the trunk or shoulders size, or shape)
- Slow growing; but can be Locally aggressive, Very - Most high potential to metastasis
Rarely metastatic - Superficial Spreading Melanoma : slowly
enlarging, macular, pigmented lesion with
irregular shape
- Nodular : rapidly growing nodule that may
bleed and ulcerate
lesion
IX BIOPSY :
- Shallow : Shave biopsy
- Deeper : Punch/excisional biopsy
MX Superficial : - Complete Surgical excision with 3-4mm margin - Urgent Excisional Biopsy (Remove full depth of
- Topical Imiquimod 5% cream (Aldara) or - Other options : Radiotherapy , Curettage and dermis) With margin according to Breslow
cryotherapy cautery thickness of tumor (i.e. the maximal depth from
- Topical Fluorouracil - Mohs surgery granular cell layer to deepest)
tumour cells
Most types : Shave Excision + Electrodessication and - Sentinal node biopsy (If Breslow thickness
curettage / Cryotherapy >1mm)
- Mohs Microsocopic Surgery (Complex surgical - Stage II : IFN therapy / Ipillimumab
excision) : Infiltrative BCC and /or lesion at difficult (Monoclonal antibody)
sites - Stage III : Chemo + IFN Therapy
- Advance cases: Radiotherapy
Pic
 IMMUNOBULLOUS DISEASE

DISEASE BULLOUS PEMPHIGOID (most common) PEMPHIGUS VULGARIS (less common)

INTRO Mean age : 40-60y/o ,F=M
Heal by scarring, usually chronic. Usually not fatal Heal with hyperpigmentation, no scar. Can be fatal
Pathophysio : IgG produced against dermal-epidermal basement Pathophysio : IgG against epidermal desmoglein-1 and -3 lead to loss
membrane proteins (hemidesmosomes) leads to subepidermal bullae of intercellular adhesion in the epidermis
Secondary causes : drugs (e.g. penicillamine or captopril) and
underlying
Tips PemphigoiD = Deeper, tense lesions at the dermal-epidermal junction VulgariS = Superficial, intraepidermal, flaccid lesions
CF Chronic bullous eruption characterized by pruritic, tense, subepidermal listering disease characterized by flaccid, non-pruritic
bullae on an erythematous skin rash intraepidermal bullae/vesicles on an erythematous/normal skin base
Can present as urticarial plaques without bullae ay present with erosions and secondary bacterial infection
Sites: flexor aspect of forearms, axillae, medial thighs, groin, abdomen, ites: mouth (90%), scalp, face, chest, axillae, groin, umbilicus
mouth (30%) hment with shear stress
-Hansen sign: pressure applied to bulla causes it to extend
laterally
IX 1. Direct Immunofluorescence from edge of blister: linear deposition of 1. Direct Immunofluorescence of edge of blister: shows IgG and C3
IgG and C3 along the basement membrane deposition intraepidermally
2. Histology : Subepidermal blistering with eosinophil rich inflammatory 2. Histology : Intraepidermal blistering and acantholysis, with positive
infiltrate direct immunofluorescence
3. Anti-basement membrane antibody (IgG) (pemphigoid antibody 3. Circulating serum anti-desmoglein IgG antibodies
detectable in serum)
Histology sample
Blister fluid Culture (TRO Viral/Bacterial infection)
MX Prednisone 0.5-1 mg/kg/day until clear, then taper ± steroid-sparing - Prednisone 1-2 mg/kg until no new blisters, then 1-1.5 mg/kg until
agents (e.g. azathioprine, cyclosporine, mycophenolate mofetil) clear, then taper ± steroid-sparing agents (e.g. azathioprine,
cyclophosphamide, cyclosporine, IVIg, mycophenolate mofetil,
Topical potent steroids (clobetasol) may be as effective as systemic rituximab)
steroids in limited disease
 TOXIC EPIDERMAL NECROLYSIS (TEN) @ STEVEN JOHNSON SYNDROME (SJS)

INTRO CF IX MX
- Medical Emergency - Prodromal phase : fever, malaise, arthralgia, myalgia ± CLINICAL - Remove precipitant (Identify and discontinue drugs)
- Extensive mucocutaneous Blistering vomiting and diarrhoea DIAGNOSIS - Supportive care : Calamine lotion, regular dressing, IV
- Cause : Usually drug-induced - Erythematous, blistering lesion -> ulceration of the skin Fluid, Analgesia
hypersensitivity reaction Usually 1-4 and mucosal surfaces, bullae, desquamation - Unsure : - Intensive Care/ Burn unit
weeks after admin(eg. allopurinol, - Typical target lesions develop, often on the palms or Skin snip
NSAIDs, sulfonamides, penicillin, soles with blistering in the centre. Can also involve eyes biopsy Mild disease : Self limiting
barbiturates, carbamazepine, and urethra .
phenytoin), but is also seen with - Positive Nikolsky sign Others : Steroid / IVIG / Plasmapheresis
infections or cancer - Complication : Sepsis and multi-organ failure
 PITYRIASIS (TINEA) VERSICOLOR

INTRO CF IX MX
Cause : Pityrosporum ovale (Malassezia furfur) d CLINICAL DIAGNOSIS
scaling macules or cream daily
RF : summer, tropical climates, excessive - Microscopic examination (By
sweating, Cushing s syndrome, prolonged skin scrapings with KOH prep) :
corticosteroid use back hyphae extensive
and spores
Pathophysio : Microbe produce azelaic acid -> Recurrence is common , thus maintenance
Inflammatory reaction inhibiting melanin topical therapy required
synthesis -> Hypopigmentation

VITILIGO

INTRO CF IX MX
- Acquired autoimmune destruction of - Sharply marginated white patches / Rule out autoimmune dz (thyroid
melanocytes -> Primary pigmentary Symmetrical patches of hypopigmentation disease, pernicious anemia,
disorder + Hyperpigmented borders (Normal ) pimecrolimus) or topical corticosteroids
sensation)
- Good prognosis : - Associated with streaks of depigmented -Up (Camouflage cosmetics)
I) The absence of leucotrichia (white hair, chorioretinitis illuminates UV light onto skin to
hairs in the area of vitiligo) - Sites: extensor surfaces of hand, wrist, detect amelanosis (porcelain monobenzyl ether of hydroquinone 20%) if
II) Trichrome pattern (3 colours knee and neck + periorificial areas (mouth, white discolouration) widespread loss of pigmentation
normal skin colour, hypopigmentation eyes, anus, genitalia)
and depigmentation) - Koebner phenomenon, may be
precipitated by trauma
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