2. Introduction 2.pptx

Introduction and overview for treatment of skin disorders Prof Andrija Stanimirović,MD, Ph D Why to learn Dermatology ? 54% of people reported a skin problem in preceding 12 months Overall population with any form of skin disease is 55% Among this 22,5% considered worth of medical care Why to learn...

Introduction and overview for treatment of skin disorders Prof Andrija Stanimirović,MD, Ph D Why to learn Dermatology ? 54% of people reported a skin problem in preceding 12 months Overall population with any form of skin disease is 55% Among this 22,5% considered worth of medical care Why to learn Dermatology ? 54% of population affected by skin disease 69% will self-care 65,1% patients with skin problems consult only their GPs In UK 13 million GP consultations for skin diseases per year ! 716830 new referrals Why to learn Dermatology ? Around 21% of patients in GP offices come with skin problems There is a large iceberg of unmet dermatological need The prevalence of some commonest skin diseases is increasing The distinction between skin disease and „cosmetic problem” is unclear Why to learn Dermatology ? The majority (80%) of GPs consultations for skin diseases referr to 10 most common skin conditions Increasing demand for patients with skin cancer Rising expectations about skin, nail and hair appearance GPs should be managing the common skin conditions Diagnosis of skin conditions in primary care is a serious area of weakness Skin diseases 80% of dermatological workload : Skin cancer Acne Atopic dermatitis Psoriasis Viral warts Infective skin disorders Benign tumours and vascular lesions Leg ulceration Contact dermatitis coarse teleangiectatic vessels nodular basal cell carcinoma Basal cell carcinoma (rodent ulcer) 85% appears on the face, the most common invade locally, very rarely metastize well-defined aggregates of darkly blue staining basal cells outer layer is arranged in a palisade nodulo-ulcerative basal cell cracinoma 1-2 cm/5-10 years coarse teleangiectatic vessels squamous cell carcinoma SCC on photo-damaged skin less aggressive most SCC carry typical UV-induced p53 mutation – significant part UV radiation SCC in scar after X-rays more aggressive Keratosis actinica: carcinoma planocellulare in situ 60% squamous cell carcinomas 1/3 of men over 70 years had AK rough-surfaced lesions sun-damaged skin not seen in black skin liquid nitrogen 5-FU 1-2xd 4-6 w 2-3x /week/16 weeks lower cure rate photodynamic therapy PRIMAR Y – non-inflammatory lesions Acne papulo pustulosa ( severe ) THERAPY ? http://www.theallergyshop.com.au/pages/Eczema-FactSheets.html Small Plaque Large Plaque Psoriasis Phenotypes 36 Psoriasis Susceptibility Loci DIFFERENT FACES OF PSORIASIS P. punctata P. guttata P. follicularis P. nummularis P. in placibus P. geographica P. erythrodermica PSORIASIS IN PLACIBUS – most common 90% of psoriatic cases OTHER CLINICAL FEATURES OF PSORIASIS Psoriasis guttata, Psoriasis pustulosa, Psoriasis erythrodermica, Psoriasis inversa Nail changes Frequence : 20-50% punktiformne udubine na površini nokta oniholiza uljne mrlje leukonihija subungualna keratoza onihodistrofija PSORIATIC ARTHRITIS 8-30% Adults between 30 and 50 yrs Equale: ♂♀ ♂: spine and distant carpal joints ♀: simmetric distribution Cherry angiomas __________________________ middle-aged and elderly Cherry angioma Venous lake venous haemangioma of lower lip in elderly vascular lesion other benign dermal tumours (dermatofibroma, keloid, lipomas) Dermatofibroma firm, solitary nodule often on the extremities they feel larger than they look on squeezing dimple appear Dermatofibroma Lipomas common benign tumours of mature fat cells soft rubbery consistency may be one or many proximal part of limbs Keloid Treatment: - silicone sheeting - CS intralesional - cryotherapy 20’ before CS overgrowth of dense fibrous tissue arising in response to trauma, infection, foreign material inherited tendency for development Epidermal benign tumours _______________________ Skin tags Seborrhoeic keratosis Cutaneous horn Skin tags: common benign outgrowths of skin most common in middle-aged and elderly most common in obese women sometimes familial trait look unsightly may catch on clothing and jewellery skin tags Treatment: snipped of with scissors liquid nitrogen elecrocoagulation snipped of skin tags with scissors Epidermal benign tumours _______________________ Skin tags Seborrhoeic keratosis Cutaneous horn Seborrhoeic keratosis common benign epidermal tumour unrelated to sebaceous gland usually arise after the age of 50 years unknown causative agent multiple – may be inherited “stuck-on” appearance surface: smooth or verrucous greasy scaling scattered keratin plugs seborrhoeic keratosis (seborrhoeic wart) “Salmon” patches or “stork bites” composed of capillary network in superficial dermis in 50% of babies nuchal region may remain unchanged “salmon” patch patches from other areas usually disappear within a year slight lymphadenopathy self-limited disease – tends to clear without treatment primary infection incubation 3-7 days common warts start as smooth skin-coloured papule enlarges, hyperkeratotic surface classic warty appearance often multiple Verrucae vulgares plantar warts have rough surface often multiple can be painful verrucae plantares verrucae vulgares notoriously slow to resolve and often resist all treatments Verrucae vulgares plantares mosaic warts – tightly packed but descrete individual warts plane warts – smooth flat-topped papules most common on the face, back of the hands and shaven legs skin coloured or light brown inflamed as result of an immunologic reaction – spontaneous resolving Verrucae planae juveniles anogenital warts – papillomatous cauliflowerlike lesion with a moist macerated vascular surface Condylomata acuminata HPV 6 and 11 HPV 16 and 18 70-90% of cervical carcinoma Condylomata acuminata Stasis dermatitis with eczema Exudation and itch very common- eczematisation acute chronic large and shallow prominent granulation tissue ulceration is most common near the medial malleolus Acute irritative contact dermatis „Wet” dermatitis-cleaners So.... If you can make the diagnosis you are there! Most people try and do pattern recognition and when that fails are confused and lost A systematic approach enables most diagnoses to be made Dermatology is no different from other things but there are some special points Diagnosis of skin disorders History Examinatiom Distribution Morphology Diagnosis of skin disorders History Examinatiom Distribution Morphology Dermatological history History of present skin condition duration site at onset, details, spread itch, burning, pain wet, dry, blisters exacerbating factors growth bleeding Careful inquiry into drugs taken for other conditions Dermatological history Past history of skin disorders asthma, hay fever General health – ask about fever Family history of skin disorders – inherited or not, does any member of family have symptoms Family history of other skin disorders Social and occupational history –hobbies, travels,alch. Drugs systemic and topical Examination The lighting must be uniform and bright Daylight is best The patients should be undress (although sometimes this is neither desirable) Make-up must be washed off, wigh removed Distribution Distribution of lesions – localized, universal or symmetric symmetry implies a systemic orign, unilateral and asymmetry implies an external cause Morphology shape, size, colors, margins, surface, look in the mouth, hair and nails The Koebner phenomenon or isomorphic phenomenon (“Koebner response”) skin lesions that appear in the site of trauma and injury Terminology of lesions Primary lesions Secondary lesions erythema papule plaque macule patch vesicle bulla pustule wheal nodule tumour scale keratosis crust ulcer erosion excoriation fissure sinus scar atrophy papilloma purpura ecchymosis haematoma burrow comedo teleangiectasia poikiloderma horn erythroderma lichenification stria pigmentation History - 1 Time When - did it start, how long Where - did it start, is it now Spread Course - episodic, previous rashes, continuous History - 2 Description Patients description - distribution, shape, size, previous variation Symptoms Itch - think of scabies, lice, eczema, urticaria, exanthemata, psoriasis, dermatitis herpetiformis Pain History 3 Symptoms Weeping/bleeding Provoking factors - environment, sunlight, temporal, drugs, temperature, occupation, hobbies Relieving factors - as above treatment including OTC History - 4 Symptoms of associated structures Mucous membranes Scalp Nails General Family, Contact, occupation PMHx, Drug use, Atopy, bowels, joints Examination Knowing what the special dermatology morphological words mean is half the story Distribution Symmetry Area affected - exposed, seborrheic, gravitational, napkin, dermatomal Pattern - linear, clustered Examination - 2 Morphology Primary lesion - Macule, papule, nodule, pustule, vesicle, bulla, weal, plaque Size Colour / shine Surface - scale, lichenification, exudate, ulceration. Edge - regularity, distinctiveness Associated features - Telangiectasis, vascularity, purpura, excoriation, scarring, involvement of hair follicles Examination 3 Related structures Hair / scalp Nails Mucous membranes Other structures as relevant E.g. lymph glands, joints etc Investigation Ultraviolet light: Fungal specimens: how much, scrapings and clippings Biopsy: special points, difficulties of dermal histopathology Summary History Examination Dermatological Pharmacology Nomenclature Investigations Definitions Primary lesions macule – small flat area 0,5 cm wheal – elevated compressible produced by dermal edema, usually less than 2 cm wheal - urtica angioedema – diffuse swelling caused by oedema tumour – harder to define, enlargment of the tissue by normal or patholgical cells,>1cm petechiae - pihead-sized macules of blood in the skin purpura – larger macule or papule of blood in the skin ecchymosis (bruise) larger extravasation of blood into the skin and deeper structures haematoma is a swelling from gross bleeding burrow – linear or curviliner papule, caused by a scabies mite comedo – plug of greasy keratinin a dilated pilosebaceous orifice “blackheads” “whiteheads” teleangiectasis – visible dilatation of small cutaneous blood vessels poikiloderma – combination of atrophy, reticulate hyperpigmentation and teleangiectasia horn – keratin projections that is taller than it is broad erythroderma – generalized redness of skin that may be scaling Secondary lesions scale – flake arising from the horny layers keratosis – a horn like thickening of the stratum corneum crust – composed of dried blood and tissue fluid fissure – slit in the skin excoriation – ulcer or erosion produced by scratching erosion – area of skin denuded by complete or partial loss of epidermis. Heal without scarring ulcer – whole epidermis and upper part of dermis has been lost. Heal with scarring atrophy – thinning of the skin caused by diminution of the epidermis, dermis and s.c. fat atrophy – thinning of the skin caused by diminution of the epidermis, dermis and s.c. fat scar – result of healing, normal structures are permanently replaced by fibrous tissue lichenification – area of thickened skin with increased markings stria (strech mark) – streak-like linear atrophic pink , purple or white lesions caused by changes in connective tissue pigmentation – after lesions heal colour (salmon-pink , lilac, violet) sharpness of edge (well defined, ill-defined) surface contour (dome-shape, umbilicated, spire like) Surface contours of papules geometric shape (nummular, oval, irregular) texture (rough, silky, smooth, hard) smell temperature (hot or warm) Configuration The Koebner phenomenon or isomorphic phenomenon – induction of skin lesions by and at site of trauma round or coin-like ring like papule patch wheal (urtica) solid mass > 0,5 cm nodule Diagnosis? magnifying magnifyinglens lens Wood Wood‘s‘slight light fungal infections Dermatoscopy for distinguishing pigmented lesions covered coveredwith withmineral mineraloil, oil,water water ororalcohol alcohol Dermatoscopic examination dermatoscope – regularly cleaned and disinfected to prevent nosocomaila infections Dg. Dg.Melanoma Melanoma Dg. Dg.Haemorrhagia Haemorrhagia Side-room and office tests Potassium hydroxide preparations for fungal infections (20%KOH + 40% dimethyl sulphoxide) 1-2 drops KOH solution is run under the cover slip after 10-15 min is examined (nail-1 hour) Patch test: detection of contact allergens Patch test applying a chemicals of standard allergens Patch test The patches are left in place for 48 hours Results: Results: ++ ++ Results: Results: +++ +++ Patch test – for contact dermatitis (IV type) Dermatitis allergica contacta skin biopsy shaving biopsy punch biopsy incisional/excisional biopsy (lesion