Dermatology Handbook
Dermatology Handbook
Dermatology Handbook
Dermatology
A handbook for medical students & junior doctors
Contents
Preface
Foreword
What is dermatology?
8
9
10
Background Knowledge
23
23
23
27
Emergency Dermatology
28
29
30
31
32
33
34
35
36
37
38
39
Skin Cancer
41
42
43
44
46
Atopic eczema
Acne vulgaris
Psoriasis
47
49
50
Blistering Disorders
52
Bullous pemphigoid
Pemphigus vulgaris
53
54
55
56
58
60
62
64
Management
65
Emollients
Topical/Oral steroids
Oral aciclovir
Oral antihistamines
Topical/Oral antibiotics
Topical antiseptics
Oral retinoids
66
66
66
66
67
67
67
Practical Skills
68
Patient education
Written communication
Prescribing skills
Clinical examination and investigations
71
69
70
70
71
Acknowledgements
72
Preface
This Handbook of Dermatology is intended for senior medical students and newly qualified
doctors.
For many reasons, including modern medical curriculum structure and a lack of suitable
patients to provide adequate clinical material, most UK medical schools provide inadequate
exposure to the specialty for the undergraduate. A basic readable and understandable text
with illustrations has become a necessity.
This text is available online and in print and should become essential reading. Dr Chiang is to
be congratulated for her exceptional industry and enthusiasm in converting an idea into a
reality.
Julian Verbov
Professor of Dermatology
Liverpool 2009
Julian Verbov
Professor of Dermatology
Liverpool 2014
Dr Mark Goodfield
President of the British Association of Dermatologists
What is dermatology?
Dermatology is the study of both normal and abnormal skin and associated
structures such as hair, nails, and oral and genital mucous membranes.
Skin diseases are very common, affecting up to a third of the population at any one
time.
Skin diseases have serious impacts on life. They can cause physical damage,
embarrassment, and social and occupational restrictions. Chronic skin diseases may
cause financial constraints with repeated sick leave. Some skin conditions can be
life-threatening.
In 2006-07, the total NHS health expenditure for skin diseases was estimated to be
around 97 million (approximately 2% of the total NHS health expenditure).
http://www.bad.org.uk/Portals/_Bad/Education/Undergraduate%20Edu
cation/(Link2)%20Core%20curriculum.pdf).
This handbook addresses these learning outcomes and aims to equip you with the
knowledge and skills to practise competently and safely as a junior doctor.
Detailed history taking and examination provide important diagnostic clues in the
assessment of skin problems.
Learning outcomes:
1. Ability to take a dermatological history
2. Ability to explore a patients concerns and expectations
3. Ability to interact sensitively with people with skin disease
4. Ability to examine skin, hair, nails and mucous membranes systematically
showing respect for the patient
5. Ability to describe physical signs in skin, hair, nails and mucosa
6. Ability to record findings accurately in patients records
Taking a dermatological history
Using the standard structure of history taking, below are the important points to
consider when taking a history from a patient with a skin problem (Table 1).
For dark lesions or moles, pay attention to questions marked with an asterisk (*).
Key questions
Presenting complaint
Family history
Social history
There are four important principles in performing a good examination of the skin:
INSPECT, DESCRIBE, PALPATE and SYSTEMATIC CHECK (Table 2).
Key features
INSPECT in general
General observation
Site and number of lesion(s)
If multiple, pattern of distribution and configuration
SCAM
Size (the widest diameter), Shape
Colour
Associated secondary change
Morphology, Margin (border)
Surface
Consistency
Mobility
Tenderness
Temperature
SYSTEMATIC CHECK
Meaning
Pruritus
Itching
Lesion
Rash
An eruption
Naevus
Comedone
10
Meaning
Generalised
Widespread
Extensive
Localised
Flexural
Body folds i.e. groin, neck, behind ears, popliteal and antecubital fossa
Extensor
Photosensitive Affects sun-exposed areas such as face, neck and back of hands
Example:
Sunburn
Kebner
phenomenon Example:
Psoriasis
11
Meaning
Discrete
Confluent
Linear
In a line
Target
Erythema multiforme
Annular
Tinea corporis
(ringworm)
Discoid /
A coin-shaped/round lesion
Nummular
Example:
Discoid eczema
12
Table 6. Colour
Terms
Meaning
Erythema
Palmar erythema
Purpura
Red or purple colour (due to bleeding into the skin or mucous membrane)
which does not blanch on pressure petechiae (small pinpoint macules) and
ecchymoses (larger bruise-like patches)
Example:
Henoch-Schnlein purpura
(palpable small vessel vasculitis)
13
Hypo-
pigmentation Example:
Pityriasis versicolor
(a superficial fungus infection)
De-
pigmentation Example:
Vitiligo
Hyper-
pigmentation Example:
Melasma
(increased melanin pigmentation)
14
Meaning
Macule
Freckles
Patch
Vascular malformation
(naevus flammeus / port wine stain)
Papule
Xanthomata
15
Nodule
Pyogenic granuloma
(granuloma telangiectaticum)
Plaque
Psoriasis
Vesicle
Bulla
16
Pustule
Acne
Abscess
Periungual abscess
(acute paronychia)
W(h)eal
Urticaria
Carbuncle
17
Table 8. Morphology - Secondary lesions (lesions that evolve from primary lesions)
Terms
Meaning
Excoriation
Excoriations in eczema
Scales
18
Crust
Rough surface consisting of dried serum, blood, bacteria and cellular debris
that has exuded through an eroded epidermis (e.g. from a burst blister)
Example:
Impetigo
Scar
New fibrous tissue which occurs post-wound healing, and may be atrophic
(thinning), hypertrophic (hyperproliferation within wound boundary), or
keloidal (hyperproliferation beyond wound boundary)
Example:
Keloid scars
Ulcer
Leg ulcers
19
Fissure
Eczema
Striae
Linear areas which progress from purple to pink to white, with the
histopathological appearance of a scar (associated with excessive steroid
usage and glucocorticoid production, growth spurts and pregnancy)
Example:
Striae
20
Table 9. Hair
Terms
Meaning
Alopecia
Loss of hair
Example:
Alopecia areata
(well-defined patch of complete hair loss)
Hirsutism
Hirsutism
Hypertrichosis
21
Meaning
Clubbing
Loss of angle between the posterior nail fold and nail plate
(associations include suppurative lung disease, cyanotic heart disease,
inflammatory bowel disease and idiopathic)
Example: (Picture source: D@nderm)
Clubbing
Koilonychia
Koilonychia
Onycholysis
Separation of the distal end of the nail plate from nail bed
(associations include trauma, psoriasis, fungal nail infection and
hyperthyroidism)
Example: (Picture source: D@nderm)
Onycholysis
Pitting
Pitting
22
Background Knowledge
This section covers the basic knowledge of normal skin structure and function
required to help understand how skin diseases occur.
Learning outcomes:
1. Ability to describe the functions of normal skin
of normal skin
These include:
i)
ii)
Temperature regulation
iii)
Sensation
iv)
Vitamin D synthesis
v)
Immunosurveillance
vi)
Appearance/cosmesis
The skin is the largest organ in the human body. It is composed of the epidermis and
dermis overlying subcutaneous tissue. The skin appendages (structures formed by
skin-derived cells) are hair, nails, sebaceous glands and sweat glands.
Epidermis
The epidermis is composed of 4 major cell types, each with specific functions (Table
11).
23
Keratinocytes
Langerhans cells
Melanocytes
Produce melanin, which gives pigment to the skin and protects the
cell nuclei from ultraviolet (UV) radiation-induced DNA damage
Merkel cells
There are 4 layers in the epidermis (Table 12), each representing a different stage of
maturation of the keratinocytes. The average epidermal turnover time (migration of
cells from the basal cell layer to the horny layer) is about 30 days.
Composition
Stratum basale
Differentiating cells
Stratum corneum
(Horny layer)
In areas of thick skin such as the sole, there is a fifth layer, stratum lucidum, beneath
the stratum corneum. This consists of paler, compact keratin.
24
Cell types
Background Knowledge
Background Knowledge
Dermis
The dermis also contains immune cells, nerves, skin appendages as well as lymphatic
and blood vessels.
Hair
Each hair consists of modified keratin and is divided into the hair shaft (a keratinized
tube) and hair bulb (actively dividing cells, and melanocytes which give pigment to
the hair).
Each hair follicle enters its own growth cycle. This occurs in 3 main phases:
a) anagen (long growing phase)
b) catagen (short regressing phase)
c) telogen (resting/shedding phase)
25
Nails
The nail is made up of a nail plate (hard keratin) which arises from the nail matrix at
the posterior nail fold, and rests on the nail bed.
The nail bed contains blood capillaries which gives the pink colour of the nails.
Sebaceous glands
Sweat glands
Sweat glands regulate body temperature and are innervated by the sympathetic
nervous system.
They are divided into two types: eccrine and apocrine sweat glands.
Apocrine sweat glands are found in the axillae, areolae, genitalia and anus, and
modified glands are found in the external auditory canal. They only function from
puberty onwards and action of bacteria on the sweat produces body odour.
26
Mechanisms
Haemostasis
Inflammation
Vasodilatation
Migration of neutrophils and macrophages
Phagocytosis of cellular debris and invading
bacteria
Proliferation
and migration)
Remodelling
27
Emergency Dermatology
These are rapidly progressive skin conditions and some are potentially lifethreatening. Early recognition is important to implement prompt supportive care
and therapy.
Some are drug reactions and the offending drug should be withdrawn.
The essential management for all dermatological emergencies, like any emergency,
consists of:
i)
ii)
iii)
iv)
Learning outcomes:
1. Ability to recognise and describe these skin reactions:
- urticaria
- erythema nodosum
- erythema multiforme
28
Emergency Dermatology
Causes
products), drugs (e.g. penicillin, contrast media, non-steroidal antiinflammatory drugs (NSAIDs), morphine, angiotensin-converting
enzyme inhibitors (ACE-i)), insect bites, contact (e.g. latex), viral or
parasitic infections, autoimmune, and hereditary (in some cases of
angioedema)
Description
Complications
and death
Urticaria
Angioedema
29
Erythema nodosum
Description
Causes
Presentation
Erythema nodosum
30
Emergency Dermatology Erythema multiforme, Stevens-Johnson syndrome and Toxic epidermal necrolysis
Description
Mortality rates are 5-12% with SJS and >30% with TEN with
death often due to sepsis, electrolyte imbalance or multi-system
organ failure
Erythema multiforme
Stevens-Johnson syndrome
31
Acute meningococcaemia
Description
Presentation
Further reading: Hart CA, Thomson APJ. Meningococcal disease and its management in children.
BMJ 2006;333:685-690 (http://www.bmj.com/cgi/content/full/333/7570/685)
32
Description
Causes
Management
Complications
Erythroderma
33
Description
Presentation
Management
Complications
Eczema herpeticum
34
Necrotising fasciitis
Description
tissue necrosis
Causes
aerobic bacteria
Risk factors include abdominal surgery and medical co-morbidities
Presentation
Severe pain
Erythematous, blistering, and necrotic skin
Systemically unwell with fever and tachycardia
Presence of crepitus (subcutaneous emphysema)
X-ray may show soft tissue gas (absence should not exclude the
diagnosis)
Management
Prognosis
Mortality up to 76%
Further reading: Hasham S, Matteucci P, Stanley PRW, Hart NB. Necrotising fasciitis. BMJ 2005;330:830-833
(http://www.bmj.com/cgi/content/full/330/7495/830)
35
The normal skin microflora and antimicrobial peptides protect the skin against
infection. However, when there is skin damage, microorganisms can penetrate
resulting in infection.
There are 3 main types of skin infections according to their sources: bacterial (e.g.
staphylococcal and streptococcal), viral (e.g. human papilloma virus, herpes simplex
(see page 34) and herpes zoster (see below)), and fungal (e.g. tinea (see page 39 &
40), candida (see page 39 & 40) and yeasts). Infestations (e.g. scabies (see page 58 &
59), cutaneous leishmaniasis) can also occur.
Learning outcomes:
Ability to describe the presentation, investigation and management of:
- cellulitis and erysipelas
- staphylococcal scalded skin syndrome
- superficial fungal infections
36
Description
Causes
erysipelas
Erysipelas is distinguished from cellulitis by a well-defined, red
raised border
Management
analgesia
Complications
37
Erysipelas
Description
Cause
Develops within a few hours to a few days, and may be worse over
Management
38
Description
and inflammation
Tinea unguium (tinea infection of the nail) yellow discolouration,
Management
39
or nail infections
Avoid the use of topical steroids can lead to tinea incognito
Correct predisposing factors where possible (e.g. moist
Tinea corporis
Tinea capitis
Pityriasis versicolor
40
Skin Cancer
Skin Cancer
In general, skin cancer can be divided into: non-melanoma (basal cell carcinoma and
squamous cell carcinoma) and melanoma (malignant melanoma).
Malignant melanoma is the most life-threatening type of skin cancer and is one of
the few cancers affecting the younger population.
Sun exposure is the single most preventable risk factor for skin cancer.
Learning outcomes:
Ability to recognise:
- basal cell carcinoma
- squamous cell carcinoma
- malignant melanoma
41
Description
Causes
Management
Prognosis
42
Description
Causes
Management
Squamous cell carcinoma adjacent to ear (left) and glans penis (right)
43
Malignant melanoma
Description
Asymmetrical shape*
Border irregularity
Colour irregularity*
Diameter > 6mm
Evolution of lesion (e.g. change in size and/or shape)*
Symptoms (e.g. bleeding, itching)
More common on the legs in women and trunk in men
Types
Prognosis
44
Nodular melanoma
45
Eczema, acne and psoriasis are chronic inflammatory skin disorders that follow a
relapsing and remitting course. There are many types of eczema but we shall just
consider atopic eczema here.
Learning outcomes:
Ability to describe the presentation, demonstrate assessment, formulate a
differential diagnosis, instigate investigation and discuss how to provide
continuing care of:
- atopic eczema
- acne
- psoriasis
46
Atopic eczema
Description
an erythematous base
Atopic eczema is the most common type - usually develops by
early childhood and resolves during teenage years (but may recur)
Epidemiology
Causes
lichenification
May show nail pitting and ridging of the nails
Management
47
Atopic eczema
Further reading: NICE guidelines. Atopic eczema in children, Dec 2007. http://www.nice.org.uk/Guidance/CG57
48
Acne vulgaris
Description
Epidemiology
Causes
Hormonal (androgen)
Contributing factors include increased sebum production,
Management
Complications
Comedones
49
Psoriasis
Description
Causes
environmental factors
Precipitating factors include trauma (which may produce a
bleeding)
50% have associated nail changes (e.g. pitting, onycholysis)
5-8% suffer from associated psoriatic arthropathy - symmetrical
to reduce scales
Topical therapies (for localised and mild psoriasis) - vitamin D
50
Kebner phenomenon
Plaque psoriasis
Scalp involvement
51
Blistering Disorders
The fragility of blisters depends on the level of split within the skin an intraepidermal split (a split within the epidermis) causes blisters to rupture easily;
whereas a sub-epidermal split (a split between the epidermis and dermis) causes
blisters to be less fragile.
The common causes of blisters are impetigo (see below), insect bites, herpes simplex
infection (see page 34), herpes zoster infection (see page 36), acute contact
dermatitis, pompholyx (vesicular eczema of the hands and feet, see below) and
burns.
Bullous pemphigoid (see page 53) and pemphigus vulgaris (see page 54) are
uncommon conditions due to immune reaction within the skin.
Pompholyx
Learning outcomes:
1. Ability to recognise common causes of blisters
2. Ability to recognise:
- Bullous pemphigoid
- Pemphigus vulgaris
52
Blistering Disorders
Bullous pemphigoid
Description
Cause
common)
Management
Bullous pemphigoid
53
Pemphigus vulgaris
Description
Cause
Management
Pemphigus vulgaris
54
Learning objectives:
Ability to formulate a differential diagnosis, describe the investigation and
discuss the management in patients with:
- chronic leg ulcers
- itchy eruption
- a changing pigmented lesion
- purpuric eruption
- a red swollen leg
55
56
Venous ulcer
56
Arterial ulcer
In clinical practice, there can be mixture of arterial, venous and/or neuropathic components in an ulcer.
Neuropathic ulcer
vasculitic ulcers (purpuric, punched out lesions), infected ulcers (purulent discharge, may have systemic signs) and malignancy (e.g. squamous cell
Leg ulcers are classified according to aetiology. In general, there are three main types: venous, arterial and neuropathic ulcers. Other causes include
Lesion
57
Management
Possible
investigations
- Compression bandaging
(after excluding arterial insufficiency)
- Warm skin
- Normal peripheral pulses
- Leg oedema, haemosiderin and melanin
deposition (brown pigment),
lipodermatosclerosis, and atrophie
blanche (white scarring with dilated
capillaries)
- Normal ankle/brachial pressure index
(i.e. ABPI 0.8-1)
Common sites
Associated
features
Venous ulcer
History
57
- Cold skin
- Weak or absent peripheral pulses
- Shiny pale skin
- Loss of hair
Arterial ulcer
- Wound debridement
- Regular repositioning, appropriate
footwear and good nutrition
- Often painless
- Abnormal sensation
- History of diabetes or neurological disease
Neuropathic ulcer
58
Scabies
58
Urticaria
Lichen planus
reaction (e.g. some cases of urticaria) or an unknown cause, possibly autoimmune (e.g. lichen planus).
Wickhams striae
An itchy (pruritic) eruption can be caused by an inflammatory condition (e.g. eczema), infection (e.g. varicella), infestation (e.g. scabies), allergic
Itchy eruption
59
Management
Possible
investigations
Associated
features
Lesion
Common sites
History
Itchy eruption
- Patch testing
- Serum IgE levels
- Skin swab
- Emollients
- Corticosteroids
- Immunomodulators
- Antihistamines
Eczema
- Personal or family history of
atopy
- Exacerbating factors (e.g.
allergens, irritants)
- Variable (e.g. flexor aspects in
children and adults with atopic
eczema)
- Dry, erythematous patches
- Acute eczema is
erythematous, vesicular and
exudative
- Secondary bacterial or viral
infections
59
Scabies
- May have history of contact
with symptomatic individuals
- Pruritus worse at night
- Antihistamines
- Corticosteroids
- No specific tendency
Urticaria
- Precipitating factors (e.g. food,
contact, drugs)
- Corticosteroids
- Antihistamines
Lichen planus
- Family history in 10% of cases
- May be drug-induced
60
Congenital naevus
60
Seborrhoeic keratoses
Malignant melanoma
A changing pigmented lesion can be benign (e.g. melanocytic naevi, seborrhoeic wart) or malignant (e.g. malignant melanoma).
Management
Lesion
Common sites
History
61
61
Benign
Malignant
Melanocytic naevi
Seborrhoeic wart
Malignant melanoma
- Not usually present at birth but develop
- Tend to arise in the middle-aged or elderly - Tend to occur in adults or the middle-aged
- Often multiple and asymptomatic
- History of evolution of lesion
during infancy, childhood or adolescence
- May be symptomatic (e.g. itchy, bleeding)
- Asymptomatic
- Presence of risk factors
- Variable
- Face and trunk
- More common on the legs in women and
trunk in men
- Warty greasy papules or nodules
- Features of ABCDE:
- Congenital naevi may be large,
- Stuck on appearance, with well-defined
Asymmetrical shape
pigmented, protuberant and hairy
edges
Border irregularity
- Junctional naevi are small, flat and dark
Colour irregularity
- Intradermal naevi are usually dome-shape
papules or nodules
Diameter > 6mm
- Compound naevi are usually raised, warty,
Evolution of lesion
hyperkeratotic, and/or hairy
- Rarely needed
- Rarely needed
- Excision
62
Henoch-Schnlein purpura
62
Platelet counts and a clotting screen are important to exclude coagulation disorders.
Senile purpura
thrombocytopenic purpura) or non-thrombocytopenic e.g. trauma, drugs (e.g. steroids), aged skin, vasculitis (e.g. Henoch-Schnlein purpura).
A purpuric eruption can be thrombocytopenic (e.g. meningococcal septicaemia, disseminated intravascular coagulation, idiopathic
Purpuric eruption
- Bloods
- Lumbar puncture
- Antibiotics
Management
- Petechiae, ecchymoses,
haemorrhagic bullae and/or
tissue necrosis
- Systemically unwell
- Acute onset
- Symptoms of meningitis and
septicaemia
- Extremities
Meningococcal septicaemia
Associated
features
Possible
investigations
Lesion
Common sites
History
Purpuric eruption
63
63
Disseminated intravascular
coagulation
- History of trauma, malignancy,
sepsis, obstetric complications,
transfusions, or liver failure
- Spontaneous bleeding from
ear, nose and throat,
gastrointestinal tract,
respiratory tract or wound site
- Petechiae, ecchymoses,
haemorragic bullae and/or
tissue necrosis
- Systemically unwell
Vasculitis
- No treatment is needed
- No investigation is needed
- Systemically unwell
- Non-palpable purpura
- Surrounding skin is atrophic
and thin
- Systemically well
Senile purpura
- Painful lesions
Lesion
Associated
features
Possible
- Anti-streptococcal O titre (ASOT)
investigations - Skin swab
Management - Antibiotics
Cellulitis/Erysipelas
64
- D-dimer
- Doppler ultrasound and/or venography
- Anticoagulants
Venous thrombosis
The main differential diagnoses for a red swollen leg are cellulitis, erysipelas, venous thrombosis and chronic venous insufficiency.
History
64
Management
Management
Treatment modalities for skin disease can be broadly categorised into medical
therapy (topical and systemic treatments) and physical therapy (e.g. cryotherapy,
phototherapy, photodynamic therapy, lasers and surgery).
Topical treatments directly deliver treatment to the affected areas and this reduces
systemic side effects. It is suitable for localised and less severe skin conditions. They
consist of active constituents which are transported into the skin by a base (also
known as a vehicle). Examples of active ingredients are steroids, tar,
immunomodulators, retinoids, and antibiotics. The common forms of base are lotion
(liquid), cream (oil in water), gel (organic polymers in liquid, transparent), ointment
(oil with little or no water) and paste (powder in ointment).
Systemic therapy is used for extensive and more serious skin conditions, if the
treatment is ineffective topically or if there is systemic involvement. However, they
have the disadvantage of causing systemic side effects.
Learning objectives:
65
Emollients
Examples
Indications
Side effects
in creams)
Topical/Oral corticosteroids
Examples
Quantity
Usually 30 grams per tube (enough to cover the whole body once)
Indications
Oral aciclovir
Examples
Aciclovir
Indications
Side effects
Oral antihistamines
Examples
66
Topical/Oral antibiotics
Examples
Useful for bacterial skin infections, and some are used for acne
Side effects
Topical antiseptics
Examples
Indications
Side effects
Oral retinoids
Examples
Isotretinoin, Acitretin
Indications
Side effects
Mucocutaneous reactions such as dry skin, dry lips and dry eyes,
before, during and at least one month after isotretinoin, but for two years
after Acitretin (consult current BNF for further details)
67
Practical Skills
This section highlights several general points on the important clinical skills in
dermatology.
Learning objectives:
68
Practical Skills
Patient education
69
Description
II
III
IV
Written communication
Prescribing skills
Writing a prescription
General tips:
Include drug name, dose, frequency and an intended duration/review date
30 grams of cream/ointment covers the whole adult body area
1 fingertip unit covers the area of two palms and equals gram
70
Prescribing emollients
General tips
Emollients come in 500 gram tubs
In general, ointment-based emollients are useful for dry, scaling skin
whereas creams and lotions are for red, inflamed and weeping lesions
Skin swabs can be taken from vesicles, pustules, erosions, ulcers and mucosal
surfaces for microbial culture.
Skin scrapes are taken from scaly lesions by gentle use of a scalpel in suspected
fungal infection (to show evidence of fungal hyphae and/or spores) and from
burrows in scabies (see page 59).
ABPI is used to identify the presence and severity of peripheral arterial insufficiency,
which is important in the management of leg ulcers.
Measure the cuff pressure of dorsalis pedis or posterior tibial artery using a Doppler
and compare it to the pressure of brachial artery.
The ABPI is measured by calculating the ratio of highest pressure obtained from the
ankle to highest brachial pressure of the two arms, and is normally >0.8.
71
Acknowledgements
Dr Niels K. Veien for allowing us to use his photographs. All illustrations in this
handbook were obtained from "D@nderm" with his permission.
Mr Kian Tjon Tan, Specialty Registrar in Plastic Surgery, Royal Preston NHS
Foundation Trust for contributing the chapter Background Knowledge.
72