Session 5.4a - Lecture 2 - Dermatology Flashcards
30th October 2017 - 12:00 - 13:00 Slides 1 - 13
Learning resources/info
D@nderm (Danish)
DermNet NZ (New Zealand)
Note: the photographs and videos included in this lecture are CONFIDENTIAL.
What should I be able to do in dermatology?
- Take a dermatology history
- Perform a good thorough skin exam
- Become confident in diagnosing and managing common skin conditions
- – Eczema
- – Psoriasis
- – Acne
- Understand what it’s like to have these uncomfortable and difficult conditions, and understand what it’s like to live with a skin condition
Explain how you take a dermatology hx.
See Geeky Medics
How do you perform a good skin examination?
Thorough
See Integration module
What skin conditions do you need to know in Year 1?
- Eczema
- Psoriasis
- Acne
(Diagnosis and management)
How do you diagnose eczema?
x
How do you manage eczema?
x
How do you diagnose psoriasis?
By clinical presentation
How do you manage psoriasis?
Corticosteroids, coal tar treatment, vitamin D analogs
How do you diagnose acne?
x
How do you manage acne?
x
Other than physical symptoms, what other impact does living with a skin condition have?
These conditions have a huge psychological impact on patients, thus impacting greatly on their quality of life.
The visible presentation of their diagnoses can lead to low self-esteem, thus further leading to depression and anxiety in patients.
Skin conditions are therefore uncomfortable and difficult, as they need to be managed holistically, as well as physically.
Fig. 4 (left)
What is this picture showing?
Eczema
Fig. 4 (top middle)
What is this picture showing?
Acne
Fig. 4 (bottom middle)
What is this picture showing?
Stasis dermatitis?
Fig. 4 (right)
What is this picture showing?
Plaque psoriasis
Describe the presentation of eczema.
See Fig. 4 (left)
Describe the presentation of acne.
See Fig. 4 (top middle)
Describe the presentation of stasis dermatitis.
See Fig. 4 (bottom middle)
Describe the presentation of plaque psoriasis.
See Fig. 4 (right)
Fig. 6
What are these images showing?
Eczema (as a child)
Describe how eczema presents as a child.
See Fig. 6
How is eczema managed?
- Topical steroids
- Emollients
- Antihistamine
In severe cases:
- Immunosuppressant medication
How is eczema managed in severe cases?
Immunosuppressant medication
When is immunosuppressant medication used for eczema, and how?
In severe cases, so that the eczema is not so active.
What is a disadvantage to using immunosuppressant medications for eczema?
- Patient needs constant blood tests
- Has side effects
- Patients can get more infections
What is a typical symptom of eczema?
Scratching
Which areas are scratched in eczema?
Exposed areas
Which areas are particularly scratched in small children?
Exposed areas are scratched - especially the face in small children
The face is often scratched in which group of patients who have eczema?
Small children
Small children are particularly likely to scratch which area of the body in eczema?
The face
What condition does the patient have from the video?
Eczema
What is the presenting complaint from the patient about his eczema?
“It’s annoying”
How long can patients have had eczema for?
They may have had it all their life.
What symptoms do patients with eczema present with?
- Dry skin
- Weak skin
- Itchy skin (always itchy)
What is the most common symptom of patients with eczema?
Itchy skin
How does the itchy skin from eczema patients impact their quality of life?
- Patients can wake at night from it
- Often painful and sore
What tends to control the itching?
Medication can help control/manage the symptoms
What is an aggravating factor for eczema?
- Contact with water can make itching worse
- Allergies
- Stress
Can patients with eczema get blisters?
Sometimes
On what parts of the body is the eczema worse on?
- Face
- Arms
- Under legs
- Ankles
How can patients present who have allergies and eczema?
When they have an allergic reaction they can have spots on their face.
What are common allergies eczema patients can have?
- Dairy
- Wheat
- Soya
- Gluten
- Nuts
- Eggs
- Chicken
- Animals
What happens when a patient with eczema and a known allergy comes into contact with the allergen?
Contact with allergens flare up symptoms
Is eczema present all year around?
Often worse in summer - seasonal changes have a big effect.
How do you treat eczema?
- Creams
- Medications
- Happiness (reducing stress)
How often (disregarding seasonal changes) is eczema present?
For some patients, half the time eczema is always present.
What are other medical conditions that can predispose a patient to having eczema?
- Allergies
- Asthma
- Hay fever
What are the symptoms of a patient with eczema?
- Skin it itchy, dry, weak, red, cracked painful, sore
- Often on face, arms (inside of elbows), under legs (backs of knees) and ankles; although can affect anywhere
- This can be in small patches or widespread
- No blisters
When do patients tend to present with eczema?
Often presents in children, often manifests before a patients’ first birthday (“had all my life”)
What are the aggravating factors (and triggers) for eczema?
- contact with water
- allergies (e.g. dairy, wheat, soya, gluten, nuts, eggs, chicken, animals)
- soaps/detergents
- weather (summer)
- stress
What are the relieving factors (and treatments) for eczema?
- Emollients
- Topical corticosteroids
- Destress
What other medical conditions are closely associated with eczema?
- Allergies
- Asthma
- Hay fever
What is the long term impact on a patient with eczema?
- Very annoying/irritating
- Long-term (chronic) condition which has profound psychological impact
- severe eczema can impact daily life
- physical and mental strain
- increased risk of skin infections
What is the aetiology of atopic eczema?
- most common form of eczema
- more common in children
- often develops before 1st birthday
- can develop for the first time in adults
How often do symptoms occur in patients with eczema?
- normally develops before a patients’ first birthday
- sometimes there will be periods of no symptoms; other times they will have flare-ups
- seasonal impacts can make it worse, e.g. in summer
- triggers will worsen symptoms
What is important in the PMHx for eczema patients?
- Allergies
- Asthma
- Hay fever
What is important in the FHx for eczema patients?
If atopic eczema runs in the immediate (parents, siblings) family
What is important in the SHx for eczema patients?
Diet:
- are there any foods which trigger symptoms?
- any allergies to particular foods which trigger symptoms
Lifestyle:
- any lifestyle impacts that make things better/worse
What questions should you ask eczema patients who present with a rash?
- Is the rash itchy?
- Where is the rash?
- When did symptoms first begin?
- Do symptoms come and go over time?
- Is there a FHx of atopic eczema?
- Do you have any allergies?
- Do you have asthma or hayfever?
- Do any particular foods make it worse/any allergies to any foods?
- Is there anything in your lifestyle that makes it better or worse?
How is an atopic eczema diagnosis made?
From history and clinical examination of the skin. Skin must be itchy for the last 12 months and patient must have 3 or more of the following:
- visibly irritated skin in skin creases (inside elbows, behind knees) [pts <18 months can be located in cheeks, outside elbows, fronts of knees) AT THE TIME of examination
- hx of skin irritation in aforementioned areas
- generally dry skin in the last 12 months
- hx of asthma or hay fever (if pt <4 y/o, then hx in immediate relative)
- condition started <2 y/o (only if pt is >4 y/o)
What are the causes of eczema?
Exact cause unknown, but NOT a single cause
- often occurs in people with allergies, inc. food allergies
- FHx (genetics)
- often develops alongside asthma and hayfever
- triggers: soaps, detergents, stress, weather, food allergies
What does atopic mean?
Sensitivity to allergens
What is the word used to describe sensitivity to allergens?
Atopic
What is the treatment for eczema
Lifestyle:
- food diary to determine whether specific foods make symptoms worse
- (occasionally) allergy tests –> used to identify whether a food allergy may be triggering symptoms
- self care - reduce scratching, avoiding triggers
Pharmacological:
No cure, treatment relieves symptoms only
- emollients (moisturising treatment) - used daily for dry skin e.g. E45?
- topical corticosteroids - reduces swelling, redness, itching during flare-ups e.g. hydrocortisone?
What are patients who have eczema at an increased risk of?
Skin infections
How does eczema impact on the quality of life?
- Flaking of skin and itching can be very irritating/distressing
- Those with severe eczema from allergens have to worry about what they’re eating and what people around them are eating
- In school age children this can lead to separation as at lunchtime they may not be able to be around other people eating dairy, for example
- Patients are often able to adjust to allergies but find eczema distressing due to the physical impact on their appearance as it shows on the outside.
Explain how the physical impact of eczema can lead to a psychological impact.
The flaking of the skin (and associated itchiness) can be very distressing as it shows on the outside, as skin is so visible to each other, leading to a psychological impact.
What do patients with severe eczema sometimes have to consider?
What others are doing around them - if they have certain allergens, if the allergen is very severe they need to consider what other people are doing and whether they need to be separated from these people to prevent allergen triggers.
How can eczema lead to separation in school age children?
- Patients may feel isolated due to physical appearance and can get quite depressed
- Patients may have to be separated from other children if they are particularly allergic to something (which can set off their eczema) and so cannot sit with them at lunchtime, for example.
What questions do you need to explore in the HPC?
Site of onset and evolution
Distribution i.e.
- asymmetrical/symmetrical
- flexors/extensors
- mucous membranes
- sun-exposed/sun-protected areas
Duration
- acute/chronic
Fig. 7 (left)
A patient presents with this rash. How can you describe this rash in terms of distribution?
- Asymmetrical
- Appears on flexors/extensors
- Not commonly a sun-exposed area
- Not a mucous membrane
Fig. 7 (left)
A patient presents with this rash. What other questions need to be elicited?
- Is this the site of onset?
- How did the rash evolve?
- Do you expose this area to sun?
- When did you notice the rash?
- Do you have any other rashes?
Draw an image of an asymmetrical rash located on a patients’ flexors/extensor area.
See Fig. 7 (left)
Fig. 7 (right)
A patient presents with this rash. What information can be elicited from this image?
The rash appears inside the mouth, and therefore mucus membranes. It is not a sun-exposed area, or a flexor/extensor.
Fig. 7 (right)
What other questions need to be elicited before coming up with DDx?
- Do you have any other rashes in other places?
- When did you first notice this rash?
- Has the rash changed over time?
- Is the rash symmetrical (examine other cheek)
- Have you had any other symptoms?
Draw a picture of a rash that would appear on a mucous membrane.
See Fig. 7 (right)
What conditions often go hand-in-hand with eczema?
- Asthma
- Hayfever
What can support a diagnosis of atopic eczema?
An itchy rash with a FHx of atopic conditions can support the diagnosis and make it more likely.
What other conditions must you ask about when taking a history of a patient with a skin rash?
- Allergies
- Asthma
- Hayfever
(they make atopic eczema diagnosis more likely)
What virus causes genital herpes?
Herpes simplex
What virus causes cold sores?
Herpes simplex
What conditions do the herpes simplex viruses cause?
Genital herpes
Cold sores
What virus causes chicken pox?
Herpes zoster
What virus causes shingles?
Herpes zoster
What conditions do the herpes zoster viruses causes?
Chicken pox
Shingles
What type of microorganism is herpes simplex?
Virus
What type of microorganism is herpes zoster?
Virus
What do herpes simplex and herpes zoster cause?
Herpes simplex:
- Cold sores
- Genital herpes
Herpes zoster:
- Chicken pox
- Shingles
What type of microorganism causes cold sores?
Virus - Herpes simplex
What type of microorganism causes genital herpes?
Virus - Herpes simplex
What type of microorganism causes chicken pox?
Virus - Herpes zoster
What type of microorganism causes shingles?
Virus - Herpes zoster
How does a Herpes zoster virus present?
Often appears on one side of the body and is linear
A patient presents with a rash that appears on one side of the body and is linear. What virus is likely to have caused this?
Herpes simplex or Herpes zoster?
Herpes zoster often presentsi n this way
What is the difference in presentation between Herpes simplex and Herpes zoster?
Although herpes zoster can look a similar rash to herpes simplex, it often starts on one side of the body and is linear.
Why is a full examination on patients with skin rashes important?
So you don’t miss things and can identify where the distribution is.
As well as the flexors/extensors, what other areas should be carefully examined?
Mucous membranes including the mouth, eyes and even genital dermatoses
Where else can dermatoses likely present, other than the flexors/extensors?
Mouth, eyes, genital dermatoses
Give an example of a rash that can affect the mouth.
Lichen planus
How does Lichen planus typically present?
It normally gives you clusters of shiny, raised, purple-red blotches on your arms, legs or body (you may see fine white lines on the blotches)
Typically gives you a “white lace-like pattern” - Wickham’s striae
Other than specific areas of the skin, such as the flexors/extensors, mucous membranes, why might a rash on the shoulders be different to a rash in the lower back?
The shoulders may typically be a sun-exposed area, whereas a rash on the lower back is typically a sun-protected area: you need to consider whether an area(s) is sun-exposed or sun-protected and whether that has an impact on the distribution.
Why is the distribution of a rash important?
Different diseases give different distributions, therefore these distributions give you a clue to different conditions,
What elements do you need to include when taking a dermatological history?
- Symptoms - e.g. itching, soreness
- Exacerbating and relieving factors
- Past medical history
- Personal and family of skin disease including atopy
- Thorough drug history including timeline and non prescribed treatments
- Social , occupational and travel +/- sexual history
- Psychosocial impact of skin disease
What drug history do you need to obtain from a patient?
- Prescribed medication
- Non-prescribed treatment (OTC - very important!)
- Herbal remedies/supplements (rom the Internet)
- Drugs not often considered medications e.g. creams, eye drops etc.
- Illicit/recreational drugs
What is the first thing you need to elicit when taking a history for dermatological patients?
What symptoms specifically?
Symptoms - e.g. itching, soreness
After you have elicited the symptoms of a dermatological patient, what then, do you need to find out?
Exacerbating and relieving factors (SQITARS, SOCRATES)
After the symptoms have been fully explored, what do you next ask about the dermatological patient?
Past medical history
Once the past medical history of a dermatological patient has been covered, what should you find out next, specifically?
Personal and family of skin disease including atopy
After the PMHx and FHx have been elicited, what should you ask next?
Thorough drug history including timeline and non prescribed treatments
Once the DHx has been comprehensively covered, what questions come next?
Social, occupational and travel
+/- sexual history
Finally, what should you always ask the patient?
Psychosocial impact of skin disease
What things should you ask specifically to a dermatological patient?
- specific symptoms, e.g. ITCHING, SORENESS
- personal/family hx of SKIN DISEASE
- personal/family hx of skin disease INCLUDING ATOPY
- psychosocial impact of skin disease
How do you take a good drug history?
Include timeline and non-prescribed treatments
1) What is it? (Name)
2) What do you take it for? (Indication)
3) How much? (Dosing)
4) How often? (gives info about compliance/adherence)
5) For how long?
6) How do you take it? (Tells us how they take it e.g. with a meal, on an empty stomach)
What 5 things do you need to consider on a dermatological examination?
• Adequate exposure and good lighting are essential – dermatology is a visual
specialty!
• Examination should include hair/scalp, mucous membranes and nails
• Comment on morphology i.e. how individual lesions look and distribution/ sites
involved
• Palpate!
• Examine other systems if appropriate e.g. Joints, lymph nodes
What do you need to consider about your environment on dermatological examination?
• Adequate exposure and good lighting are essential – dermatology is a visual
specialty!
As well as the skin, where else should the patient be examined?
• Examination should include hair/scalp, mucous membranes and nails
What should you note when discovering dermatoses?
Comment on morphology i.e. how individual lesions look and distribution/ sites
involved
What is the typical morphology of a herpes simplex virus?
Little vesicles grouped together
A patient presents with many little vesicles grouped together. What microorganism is likely to have caused this?
Herpes simplex
How do herpes simplex and herpes zoster present?
Herpes simplex - little vesicles grouped together
Herpes zoster - asymmetrically on one side in a linear fashion
As well as a visual inspection, what else should be done upon dermatological examination?
Palpate!
Why should you palpate the skin in a dermatological examination?
Can feel the lesion, sometimes not much to see, but can, for example, be quite rough when there is sun damage, or feels quite hard, skin can be quite fibrous, when there is sclerosis of the skin.
How can the skin feel on palpation if there is skin damage?
Quite rough
What might rough skin on palpation indicate?
Skin damage
What might hard skin on palpation indicate?
Fibrous skin, e.g. in sclerosis of the skin (scleroderma)
How might the skin feel on palpation in scleroderma?
Quite hard
What is scleroderma?
Scleroderma is an uncommon condition that results in hard, thickened areas of skin and sometimes problems with internal organs and blood vessels.
What causes scleroderma?
It’s thought scleroderma occurs because part of the immune system has become overactive and out of control. This leads to cells in the connective tissue producing too much collagen, causing scarring and thickening (fibrosis) of the tissue.
After you have performed a dermatological examination, what else might you do?
Examine other systems if appropriate e.g. Joints, lymph nodes
What other system might you examine, other than the integumentary system, in psoriasis?
Joints
In what condition might you also examine the joints in a dermatological examination?
Psoriasis
What condition can develop from psoriasis which affects the joint?
Psoriatic arthritis
What is psoriatic arthritis?
Psoriatic arthritis is a type of arthritis that develops in some people with the skin condition psoriasis. It typically causes affected joints to become inflamed (swollen), stiff and painful.
How common is psoriatic arthritis?
Between 1 and 2 in every 5 people with psoriasis develop psoriatic arthritis.
It usually develops within 10 years of psoriasis being diagnosed, although some people may experience problems with their joints before they notice any symptoms affecting their skin.
In what other conditions might you also examine the lymph nodes in a dermatological examination?
- Infectious conditions e.g. fungal infection of the scalp
- Skin cancer
What other system might you examine, other than the integumentary system, in a fungal infection of the scalp in a child?
Lymph nodes
What other system might you examine, other than the integumentary system, for a patient with suspected skin cancer?
Palpable lymph nodes
How would you describe a red rash?
Erythematous
What do you say to describe a rash that is slightly flaky with dry skin on top?
Scaling
What does erythematous mean?
Red
What is a scaling rash?
A rash that is slightly flaky with dry skin on top.
What is an erythematous, scaling rash typical of?
Eczema or psoriasis
What sort of rashes would you find in eczema or psoriasis?
An erythematous, scaling rash
What is a pus-filled elevated area described as?
Pustule
What is a pustule?
A yellow pus-filled elevated area
What colour are pustules?
Yellow
What are small little water-filled blisters called?
Vesicles
What are vesicles?
Small little water-filled blisters
What are vesicles typical of?
Cold sores
What type of lesion is typical in a cold sore?
Little vesicles
Small water-filled blisters are called vesicles. What are bigger ones called?
Bulla
What are bulla?
Big water-filled blisters (bigger than vesicles)
What lesions would you find in cold sores - vesicles or bulla?
Vesicles (smaller water-filled blisters; bulla are bigger)
Describe what you might find on skin examination in:
- eczema
- psoriasis
- cold sore
Eczema & psoriasis: erythematous, scaling rash (red, flaky and dry rash)
Cold sore: little vesicles grouped together (small water-filled blisters)
E’s story
- A 20-year old female has come to see you at the GP. The GP has already taken a history, but you are the medical student with the doctor, asked to practice taking a history.
a) Please open the consultation.
Washes hands
Hello my name is [insert name] and I am a [insert position]. I’ve been asked to take a history from you today, can I just confirm your name and DOB?
confirms
Okay lovely. So if you don’t mind, if you’d like to tell me a bit more about the problems you’ve been experiencing with yourself lately?
E’s story
- A 20-year old female has come to see you at the GP. You are the medical student with the doctor, asked to take a history.
You have opened the consultation with an open-ended question. The patient tells you this:
“I’ve had a skin problem for years, but recently it’s just been red, itchy, bumpy, raw and really sore.”
b) What do you want to ask next?
Okay so it’s been going on for years, but it’s got worse recently.
Confirms
When did it start getting worse?
E’s story
- A 20-year old female has come to see you at the GP. You are the medical student with the doctor, asked to take a history.
The patient’s HPC is this: “I’ve had a skin problem for years, but recently it’s just been red, itchy, bumpy, raw and really sore.”
You have asked when it started getting wrose.
“It varies, got worse about a week ago, but it gets worse with the weather”.
c) What would you like to ask next?
When you were first aware of the skin condition, how long ago was that?
E’s story
- A 20-year old female has come to see you at the GP. You are the medical student with the doctor, asked to take a history.
The patient’s HPC is this: “I’ve had a skin problem for years, but recently it’s just been red, itchy, bumpy, raw and really sore.”
You have since found out that it gets worse at certain times:
“It varies, got worse about a week ago, but it gets worse with the weather”,
and that: “I first noticed these symptoms about 8 months ago, but when I was first diagnosed it was when I was 18 months old”.
d) What would you like to ask next?
You mentioned that it was quite itchy and sore. Have you had any other symptoms?
E’s story
- A 20-year old female has come to see you at the GP. You are the medical student with the doctor, asked to take a history.
The patient’s HPC is this: “I’ve had a skin problem for years, but recently it’s just been red, itchy, bumpy, raw and really sore.”
She tells you it gets worse with the weather, so it varies, and she first went to the doctors at 18 months old. She has no other symptoms.
e) What would you like to ask next?
What areas does it normally affect?
E’s story
- A 20-year old female has come to see you at the GP. You are the medical student with the doctor, asked to take a history.
The patient’s HPC is this: “I’ve had a skin problem for years, but recently it’s just been red, itchy, bumpy, raw and really sore.”
She tells you it gets worse with the weather, so it varies, and she first went to the doctors at 18 months old. You ask if she has any other symptoms, she says not really, just itchy and sore. It mainly affects her elbows, neck, face, hands and backs of legs - creases mainly.
f) What would you like to clarify?
Okay, so it’s quite widespread.
Have you noticed any other symptoms such as leakage or crusting or anything like that?
- probing questions to ensure patient hasn’t forgotten to tell you anything, despite saying no to no other symptoms.
E’s story
- A 20-year old female has come to see you at the GP. You are the medical student with the doctor, asked to take a history.
The patient’s HPC is this: “I’ve had a skin problem for years, but recently it’s just been red, itchy, bumpy, raw and really sore.”
She tells you it gets worse with the weather, so it varies, and she first went to the doctors at 18 months old. You ask if she has any other symptoms, she says not really, just itchy and sore. It mainly affects her elbows, neck, face, hands and backs of legs - creases mainly.
Upon further questioning, however, she tells you she has a bit of crustiness on her elbow.
g) What questions would you like to ask next?
“Otherwise, what about yourself?”
E’s story
- A 20-year old female has come to see you at the GP. You are the medical student with the doctor, asked to take a history.
The patient’s HPC is this: “I’ve had a skin problem for years, but recently it’s just been red, itchy, bumpy, raw and really sore.”
She tells you it gets worse with the weather, so it varies, and she first went to the doctors at 18 months old. You ask if she has any other symptoms, she says not really, just itchy and sore. It mainly affects her elbows, neck, face, hands and backs of legs - creases mainly.
Upon further questioning, however, she tells you she has a bit of crustiness on her elbow.
You then ask how the patient is in herself, and she tells you she’s happy.
h) What could you ask next to clarify further?
“Any flu, or fever?”
The patient says no.
In general, what areas does psoriasis normally affect?
Extensor surfaces of the elbows and knees (back of elbows/front of knees)
In general, what areas does eczema normally affect?
Flexor surfaces of the elbows and knees (front of your arms and backs of knees)
How can psoriasis and eczema be differentiated upon by location?
Although not black and white, as patients can have a mixture of both and can affect anywhere in the body, in general:
PSORIASIS affects EXTENSOR surfaces of the elbows and knees (back of elbows/front of knees)
whereas
ECZEMA affects FLEXOR surfaces of the elbows and knees (front of your arms and backs of knees)
How would you determine where to examine on a patient in a dermatological examination?
Ask them where is affected.
A 20 year-old patient upon examination of her hands and elbows shows skin that is quite thickened, vicious. The dermatoses are relatively symmetrical and it is noted that the antecubital fossa is affected. The skin is dry, fissured, and scaly but doesn’t show the typical erythematous and scales - it is more papular and spotty. Pustules on arms are present too. The skin is thickened and scaly with papules with some excoriation.
Give some differential diagnoses.
Eczema with recurrent infection from scratching
Psoriasis
Give some examples of clinical presentations with eczema?
- Worse on hands and elbows (antecubital fossa affected)
- Skin is quite thickened and vicious
- Distribution is relatively symmetrical
- Dry, fissured, scaly
- Papules, thickened and scaly with excoriation
- Can have pustules
- Thickened skin, more clearly see the skin markers
A 20 year-old patient upon examination of her hands and elbows shows skin that is quite thickened, vicious. The dermatoses are relatively symmetrical and it is noted that the antecubital fossa is affected. The skin is dry, fissured, and scaly but doesn’t show the typical erythematous and scales - it is more papular and spotty. Pustules on arms are present too. The skin is thickened and scaly with papules with some excoriation.
Explain why this is likely to be eczema.
- Tends to affect flexor use aspects of adults (antecubital fossa)
- Oedema and vesicles can be present?
- Signs of infection present - weepy or yellow crusts
- As skin starts to get infected by eczema, recurrent redness or infection occurs.
A 20 year-old patient upon examination of her hands and elbows shows skin that is quite thickened, vicious. The dermatoses are relatively symmetrical and it is noted that the antecubital fossa is affected. The skin is dry, fissured, and scaly but doesn’t show the typical erythematous and scales - it is more papular and spotty. Pustules on arms are present too. The skin is thickened and scaly with papules with some excoriation.
Why are the pustules present?
Excoriation of the skin leads to risk of skin infections, leading to weepy or yellow crusts, manifesting as pustules (yellow pus-filled vesicles).
A 20 year-old patient upon examination of her hands and elbows shows skin that is quite thickened, vicious. The dermatoses are relatively symmetrical and it is noted that the antecubital fossa is affected. The skin is dry, fissured, and scaly but doesn’t show the typical erythematous and scales - it is more papular and spotty. Pustules on arms are present too. The skin is thickened and scaly with papules with some excoriation.
Why does the patients’ skin condition appear to be getting worse?
The patient is likely to have eczema, which is very itchy, leading to excoriation of the skin. Scratching increases the risk of skin infections, thus, as the skin starts to get infected by eczema, recurrent redness or infection occurs.
How can you find out if a patient with eczema has signs of infection?
Sometimes as you examine a pt with eczema you can see signs of infection - weeping or yellow crusts
What are signs of infection in a patient with eczema?
Weeping or yellow crusts on examination
What signs can you see on examination which indicate whether this is a first flare-up of eczema or whether they’ve had it before?
You can have an idea if this is the first time they had a flare of eczema or if they’ve had it before, bc as the skin starts to get infected by eczema then redness or inflammation occurs, then skin starts to get thicker – indication of reddened skin, thickened skin
A patient with eczema presents to you. On examination, you see an indication of reddened, thickened skin. What does this indicate?
This indicates they have had a flare up of eczema before, bc as the skin starts to get infected by eczema then redness or inflammation occurs
A 20-year-old patient presents with eczema on her elbow. You want to determine whether this is a first flare-up or whether she has had a flare up before. How can you tell?
Do an examination - if the skin has flared up before it will be relatively thickened, as it becomes thickened you can long-term see the skin marking as they become more clear - if this occurs then you know she has had a flare up before and she has scratched as the skin here becomes red and inflamed from infection.
If thickened skin is not present it is likely to indicate a first flare up of eczema.
Fig. 11
Describe the rash seen.
Erythematous and scaly rash.
Fig. 11
Give a differential diagnosis for this patient and explain your reasoning.
Erythematous and scaly rash (1) which coincides with the metal bands of the jeans (1). Thus, we are suspicious of a nickel contact allergy (1).
How would a rash present for a patient who has a nickel contact allergy to their jeans? Include an image.
See Fig. 11
Erythematous and scaly rash which coincides with metal bands of the jeans
What objects can cause a nickel allergy?
- Jewellery for body piercings, e.g. earrings
- Other jewellery, e.g. rings, necklaces, bracelets; including watches etc.
- Clothing fasteners & accessories e.g. zippers, snaps, bra hooks, belt buckles, glasses
- Coins, phones, keys
- Dog-tag IDs, medical devices
- Metal tools
- Laptops or computer tablets
Fig. 12
Label the image
- Little shiny papules (small lumps <5mm)
- Linear lesions/rash (Koebner phenomenon)
- (Little) small plaque (palpable, flat-topped area >2cm)
What do you always have to consider when inspecting a linear rash?
Could this be self-inflicted/have an external cause?
What do you always have to consider when inspecting an unnaturally circular rash?
Could this be self-inflicted/have an external cause?
In what instances might you suspect a rash to be self-inflicted?
- Linear rash
- Perfectly/unnaturally circular rashes
In what instances might you suspect a rash to have an external cause (other than medical)?
- Linear rash
- Perfectly/unnaturally circular rashes
Fig. 12
A patient presents with a linear rash, surrounded by a few small plaques and little papules.
Give some differential diagnoses.
- Lichen planus
- Psoriasis
- Self-inflicted/external cause of injury
What is Lichen planus?
Lichen Planus is a skin disease which is thought to be autoimmune in origin. It can affect many areas; the skin, inside the mouth, the genital area and more rarely can affect the nails, scalp, anus, oesophagus or tear ducts
What is Koebner’s phenomenon?
The Koebner phenomenon (also called the Koebner response or the isomorphic response) is the appearance of skin lesions on lines of trauma, not typical of where the condition normally occurs.
The Koebner phenomenon may result from either a linear exposure or irritation. It may present as linear lesions after a linear exposure to a causative agent, or secondary to scratching e.g. in psoriasis and Lichen planus.
i.e. it is the development of the condition in a place not typically associated with the condition, after the skin has been affected by trauma (e.g. scratching, surgical scar)
Name 2 conditions that can present with Koebner’s phenomenon.
Psoriasis
Lichen planus
(Other correct answers accepted!)
How does Koebner’s phenomenon present?
It is a linear lesion at a site not typically associated with the dermatological condition, that has developed secondary to some sort of trauma e.g. scratching, surgical scar.
Fig. 12
Give the most likely differential diagnosis and explain why.
Lichen planus - shiny papules and plaques forming which are a typical presentation. The linear lesions are due to Koebner’s phenomenon where a patient has scratched, and this is typical in Lichen planus as well.
Other DDx include psoriasis, although the lesions and site are not entirely in keeping with this condition, and self-infliction/external causes, which is unlikely with the papule presentation.
Draw an image depicting what Lichen planus would look like on a patient’s arms. Include the presence of Koebner’s phenomenon.
See Fig. 12
- Little shiny papules (small lumps <5mm) (purple-red)
- Linear lesions/rash (Koebner phenomenon)
- (Little) small plaque (palpable, flat-topped area >2cm)
Fig. 13
Describe the appearance of this rash
Rash has a target appearance, so the centre is different from the outer (middle) layer and the outermost layer is also different.
Fig. 13
Give a differential diagnosis of this rash.
Erythema multiforme
typically presents with target/bulls-eye appearance of rash
What is erythema multiforme caused by?
An infection or reaction to a medication.
An infection or reaction to a medication that develops into a rash is known as what?
Erythema multiforme
What do the targets look like in erythema multiforme?
often has patches that look like a target or “bulls-eye”, with a dark red centre that may have a fluid-filled blister (bulla) or crust, surrounded by a pale pink ring and a darker outermost ring
What is a bullous erythema multiforme?
A rash that has a bullous (large fluid-filled blister) in the centre that is surrounded by rings - giving the classic target appearance of erythema multiforme.
This disease develops from an infection or reaction to medication.
Draw an image depicting the typical presentation of erythema multiforme on the hands.
See Fig. 13
(often has patches that look like a target or “bulls-eye”, with a dark red centre that may have a blister or crust, surrounded by a pale pink ring and a darker outermost ring)
