This is the summary of 80% of the dermatology clinical round with important photos that solidify the important information needed by medical students.
Also in these slides, a summary for STDs and HIV was added near the end including their most special features and the drugs of choice to manage such cases.
6. Cold dry climates exacerbate psoriasis
Hot humid climates decrease psoriasis
Sun exposure is mostly protective against
psoriasis in the majority of psoriatic patients
but in some it could aggravate it.
Pregnancy
decreases
psoriasis but
psoriasis will be
aggravated
after labor
Hypocalcemia aggravates psoriasis
9. HISTOLOGY IMAGE OF PSORIASIS:
• Hyperkeratosis (increased horny
layer thickness)
• Parakeratosis (incomplete
ketinization of the horny layer “you
still see nuclei”)
• Munro-Micro Abscesses
• Absent granular cell layer
• In the dermis there is:
• Dilated tortuous capillaries
• Cellular infiltrate
10. Psoriatic nail manifestations:
• Onycholysis ( separation of the nail
plate from its bed)
• Thimble pitting (just like the photo,
a thimble is the item seen above).
• Subungual hyperkeratosis.
11. Management of psoriasis
TOPICAL THERAPY (1st line in mild to moderate plaque psoriasis)
• Topical steroids
• Salicylic acid 3%
• Tar “antimitotic”
• Anthralin
• Topical calcipotriol
PHOTOTHERAPY
• PUVA
• Broad and narrow band UVB
• Sunlight
SYSTEMIC THERAPY (for severe extensive cases “done in hospitals”)
• Methotrexate
• PUVA
• Cyclosporin
• Oral retinoids
• Biologicals
AVOID SYSTEMIC STEROIDS
IN PSORIASIS
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!
13. Lichen planus is a disease in
which the pathognomonic
clinical picture is severe
itching with flat-topped
violaceous “purple” papules.
There is hypergranulosis; so
you might see white
networks on these papules
called “Wickhams striae”.
Note that lesions in the palms and soles are NOT
itchy, and NOT purple. They are yellow and non itchy.
15. Lichen planus really hates the nails, so the
nail manifestations are particularly brutal:
• Longitudinal ridging.
• Irregular pitting.
• Nail plate splitting.
• Perygium formation.
16. Pterygium
(in the conjunctivitis chapter of
ophthalmology)
Also pterygium
(but in the nail manifestations of LP in
DERMA)
Not so different right ??
18. The etiology of LP is unknown,
but it is hypothesized that it is
due to immune origin.
Lichen planus is associated
closely with
HCV
19. Histology of lichen planus:
• Hyperkeratosis
• Hypergranulosis
• Sawtooth rete ridges (long and
with pointy end)
• Cellular infiltrate in upper
dermis
• Liquefactive degeneration of the
basal cell layer.
20. Management of Lichen Planus
1.Topical steroids
2.Intralesional steroids (in cases or oral ulcer or
hypertrophic skin lesion)
3.Oral antihistamines
4.Systemic steroids in extensive lesions
23. Clinical types of dermatophytes
T. corporis T. Capitis T. Barbae
onychomychosis
T. Pedis
T. Manus
T. Cruris
24. Notice the ring appearance in
dermatophyte infection. This
is due to the peripheral
extension and central clearing
with progression. Hence the
name ring worm lesion or
Tinea
25. Tenia capitis
Scaly type
Black dot
type
Inflammatory
type
Favus
• Microsporum
Canis
• Microsporum
audouinii
• Trichophyton
violaceum
• Trichophyton
Tonsaurans
• Animal fungi
• KERION
• PUSTULAR
FOLLICULITIS
• Trichophyton
schoenleinii
26. OSCE
Description of the lesion:
• A painful inflammatory, inflammatory, boggy, well
circumscribed, bald swelling on the scalp that is studded
with folliculo-pustules and an edematous weeping surface
that could come with thick crusting.
If you pull a hair that overlays the lesion, what do you
expect?
• Sero-pus comes out of the follicle that I pulled the hair
from.
Do you expect hair to regrow after this lesion heals?
• No; it leaves scarring alopecia.
What is your diagnosis?
• KERION (abscess like swelling)
What is the causative organism?
• Animal fungi
28. OSCE
LESION:
• FAVUS
DESCRIBTION:
• Saucer-shaped crusted lesions
(called sulphur cups or scutula)
that form around the infected
hair. They are concave, yellow,
and centered around a single dull
dry hair and have a mousy odor.
CAUSE?
• The chronic scarring form of T.
schoenlinii.
HAIR EXPECTED TO REGROW?
• No.
29. KERION
BIOGENIC
ABSCESS IN
THE SCALP
ROUGH surface SMOOTH surface
Less painful and no
constitutional symptoms
SEVERE PAIN with
constitutional symptoms
If incised, no pus will drain out (don’t
incise it)
If incised pus will drain out
30. Some strains of
fungi causing
Tinea capitis give
GREEN
FLORESCENCE
under woods light
(but not all of
them)
31. MANAGEMENT OF TINEA CAPITIS and
BARBAE
1.SYSTEMIC ANTIFUNGALS (to all cases)
2.TOPICAL ANTIFUNGALS
3.In kerion
• Topical antiseptics to remove the crusts
• Systemic antibiotics for 1 week
32. DESCRIBE THE LESION AND IDENTIFY THE CAUSE
DESCRIBTION:
• Well defined plaques over the hairless areas of the body. The plaques shows
active spreading with a raised border that is covered by
scales/vesicles/pustules/crusts/papules.
• The causative organism could cause a lesion that spreads peripherally and
clears in the center (picture below), and other causative organism could cause a
lesion that spreads peripherally and DOESN’T clear centrally.
• The lesion below shows concentric rings (the central clearing is developing a
new lesion).
INVESTIGATIONS:
1. Woods light.
2. Scraping the raised border, then using KOH and microscopy.
3. Culture on Sub Araud Agar media.
MANAGEMENT?
• If lesion is localized: topical antifungal.
• If lesion is extensive: systemic antifungals
PROVISIONAL DIAGNOSIS:
• TINEA CORPORIS
33. All those pictures show T. corporis, it presents with many
dermatological features and thus it could have many DD:
1. circinate psoriasis
2. Circinate impetigo (inflammatory types are similar)
3. Pityriasis rosea (differ by scraping and looking for fungus)
4. Annular LP
5. Discoid eczema
34. DESCRIBE and DIAGNOSE
DESCRIPTION: an arch like red plaque in the
groin that extends to the thigh with a well-
defined raised border. In the lower picture the
scrotum is affected BUT usually the genitalia are
spared.
DD: flexural psoriasis, erythrasma, candidiasis,
tinea cruris, dermatitis, flexural psoriasis.
PROVISIONAL DIAGNOSIS: T. Cruris (of course
I would know after investigations only, I can’t
know without them “i’m not a wizard”)
MANAGEMENT?
1. IF LOCALIZED: TOPICAL ANTIFUNGALS
2. IF EXTENSIVE: SYSTEMIC ANTIFUNGALS
M<F
Center is somewhat clear
35. Wearing tight shoes
for a long time,
hyperhidrosis, hot
weather, and
excessive water use
MACERATION of the
skin in the foot
Tinea pedis infection
(commonest form of
dermatophyte
infection)
36. Tinea Pedis
Interdigital type
“commonest”
Scaly
hyperkeratotic
type
Vesiculo-bullous
type
More in lateral 3
toe clefts
Sodden (very moist), fissured, has
opaque white scales, with eroded
areas. With bad smell.
The sole has erythema,
fine scaling and
hyperkeratosis. This type
is resistant to treatment
and chronic
Vesicles or bullae that are tense
progress to contain pus and rupture
leaving a collar of scales. Worsens in
hot weather.
37. dermatophytid reaction is the body's reaction to a dermatophyte
(fungal) infection and is a skin eruption that appears on an area of the
body that is not the area where the infection first began. It is not
dermatophytosis, but it is an allergic reaction. You will see this usually
with vesiculobollus tinea pedis as a sterile vesicular reaction in the
hand in the form of pompholyx.
38. MANAGEMENT OF TINEA PEDIS
1.AVOID RISK FACTORS
2.FOR INTERDIGITAL TYPE: topical
antifungal
3.FOR HYPERKERATOTIC AND VB TYPES:
systemic antifungals
39. The commonest
form of Tinea
Manus is the scaly
hyperkeratotic
type
Diffuse powdery scaling and
hyperkeratosis of the palm with
accentuation of flexural creases (50%
unilateral) “TTT SAME AS PEDIS”
40. DIAGNOSIS:
Onychomycosis
FEATURES:
• Whitish/yellowish discoloration of the free edge of the nail
plate that spreads proximally.
• Subungual hyperkeratosis
• onycholysis
MANAGEMENT:
1. Topical antifungal (Miconazole or Tioconazole)
2. Systemic antifungals
DIFFERENTIAL DIAGNOSIS
PSORIASIS
You will see fine pitting
CANDIDAL ONYCHIA
Paronychia is present; nail dystrophy is proximally and
laterally
Bad prognosis in toe nail
affection especially the
elderly
41. PityriasisVersicolor
A common macular/patchy eruption of the trunk and proximal limbs. The color
could be erythematous, whitish “hypopigmented”, or brownish “hyperpigmented”.
The surface is covered by fine scales detected by scrabbing the lesion. Remission in
winter and exacerbation in summer. Heals with hypopigmented macules that either
persist or disappear on their own
By woods light: yellow florescence of involved skin
DD: vitiligo (no scaling), pityriasis alba (scaly), erythrasma (coral red on woods
lamp), seborrheic dermatitis (greasy scales).
42. TREATMENT OF P.VERSICOLOR
TOPICAL OPTIONS:
• Ketoconazole shampoo (5mins daily for 5 days)
• Selenium sulphide or Zinc pyrithione shampoo (10 mins daily for 10
days or overnight once every week) “don’t apply to face or genitals”
• Topical antifungal creams (Clotrimazole or Miconazole; daily for 2-4
weeks)
SYSTEMIC OPTIONS “FOR RESISTANT OR EXTENSIVE CASES”
• Fluconazole 300mg/week for 2 weeks.
• Itraconazole 200mg/day for 1 week.
IN CASES OF POST INFLAMMATORY HYPOPIGMENTATION:
• Takes months to return to normal
43. CANDIDIASIS
CUTANEOUS NAIL
MUCOUS
MEMBRANE
interdigital intertrigo
Napkin
candidiasis
In groin, axilla and
submammary
Moniliasis after
contact dermatitis or
the diaper
White
macerated
skin at webs
• Nail thickening
• Lateral fold
discoloration
• Irregular
transverse
ridging
• Proximal nail
fold seperation
• Subungual
hyperkeratosis
((paronychia))
oral
vulvovagin
al
balanitis
Oral thrush
Acute atrophic
(denture stomatitis)
Candidal leucoplakia
45. TREATMENT OF CANDIDA INFECTION
1. Treat the causing factor (disease, drug use etc…)
2. Topical treatment:
• Imidazole, nystatin, amphotericin.
• 2-4 weeks for skin and oral candidiasis.
• If nail candidiasis given for 3 months alongside systemic antibiotic.
• If vaginal candidiasis: vaginal cream or tablets must be given “and treat the husband too”
3. Systemic treatment:
1. Oral nystatin (500k units 4 times/day “hold in mouth for some mins then swallow”) “for oral
and vaginal”
2. Fluconazole ( 150mg/day for 3 days if oral candidiasis. And 150mg/week for 2 weeks for vaginal
candidiasis)
3. Itraconazole (200mg/day “for 3 days in vaginal and for 2 weeks in oral”)
50. Note that in SLE the hair becomes brittle and hair
loss is most evident at the hairline. It this case the
hair has a chance of regrowing after the flare of SLE
is controlled. But in discoid lupus lesion, the scarring
that is done causes permanent hair loss that is only
managed by hair restoration treatments after
controlling SLE.
65. The following types of vitiligo show bad
response to treatment:
1. Segmental vitiligo
2. Vitiligo over bony prominences
3. Vitiligo on the palms and soles
4. Acrofacial vitiligo
5. Vitiligo affecting mucous membranes
68. Lesion: multiple
vesicles on an
erythematous base
Diagnosis: herpes
simplex
Treatment: topical
acyclovir with oral
acyclovir 200x5x10
69. Lesion: started as papules that
changed into vesicles that ruptured
and formed crusts. This lesion
shows centripetal distribution.
Causative organism: Varicella
zoster virus (primary infection).
Name of disease: chicken pox.
Management: symptomatic TTT
only. But immunocompromised
patients need Acyclovir 800x5x7
70. Lesion: grouped vesicles on an
erythematous base with a
characteristic unilateral
DERMATOMAL distribution.
Causative organism: reactivated
latent Varicella Zoster virus
Name of disease: herpes zoster
Management: oral acyclovir
800x5x7 and analgesics
71. Lesion: dome shaped
papule, sessile, firm, and
with ROUGH SURFACE.
Causative organism: HPV
Management: must destroy
(by chemical, cryo, or
electrocautery) “this is not
the only type of warts”
74. Erythema multiforme “TARGET LESIONS”
The lesion fades within two weeks with residual pigmentation that stays for months. The
commonest precipitating factor is herpes simplex virus (HSV).
79. Erythema
nodosum (which is
the inflammation
of subcutaneous
fat “allergic
reaction”
The lesion takes 2 to 6 weeks to resolve leaving a bruised
appearance. Those are nodules not macules
Give NSAIDS for pain and treat the causing factor.
+Remember this lesion is connected to IBD and is
infamous for recurrence
80. DRUG REACTIONS
Severe
reactions
Exenthema
tous R.
photose
nsitivity
blistering SLE like Acneform hyperpigm
entation
alopecia Fixed
eruption
anaphylactic
shock
-penicillin and
plasma
products
Exfoliative
erythroderma
-BDZ
-allopurinol
-sulfa and
gold
Epidermal
necrolysis
Morbiliform
Urticarial
-penicillin
-opiate
-aspirin
-radiocontrast
Purpuric
E.M.
Lichenoid
-captopril
-chloroquine
P. Rosea like
-metronidazol
-captopril
-gold
-psoralen
-thiazide
-tetracycline
-phenothiazide
-penicillin
-
penicillamine
- captopril
-
procaineami
de
-hydralazine
-ACTH
-Steroids
-Iodide
-INH
-OCP
-Gold
-
Antimalaria
-
CHEMO
-NSAIDS
-Sulphonamide
-Phenopthaline
82. ORGANISM:
- Mite (Sarcopetes scabii var hominis).
How long is its incubation period?
- 2 weeks to 2 months
What skin disease does it cause
and what is its characteristic
lesion?
- Scabies, and the characteristic lesion is Burrows.
What is the characteristic
symptom of this disease?
- Severe itching that is worse at night.
Is itching here localized or
generalized?
- It is generalized, because its due to the allergic
reaction of the body to the mite.
83. Anterior aspects of wrists and ulnar
border of hands and forearm and
elbow
Around the nipples
Finger webs
Medial aspects of the
thigh
Natal cleft and
lower buttox
The axilla
Dorsal foot and
around the ankle Male genitals
Abdomen and
periumbilical
H&N of infants only
Characteristic
sites for scabies
84. IDENTIFY THE LESIONS
INDICATED BY THE
ARROWS AND DESCRIBE
THEIR SIGNIFICANCE:
- lesion: Burrows
- Significance: they are the
characteristic lesions for
scabies
85. You can catch scabies from infested animals
like a dog “ANIMAL SCABIES”. So don’t touch
any dog on the street and if you do touch one
make sure you wash your hands with soap and
water and change your clothes or take a
shower as soon as possible
Animal scabies is characterized by:
1- short IP
2- not transmitted man to man
3- burrows are absent
4- self limiting
5- finger webs and genitals are free
86. •Yes, only if the patient is
immunodeficient. Or is on
steroid therapy.
Can one have scabies and not
have itching?
87. IDENTIFICATION
Norwegian (crusted) scabies
PATHOPHYSIOLOGY
It’s a severe form of scabies with a huge number of mites and eggs and
thickened horny layer. It is due to the abnormal immune response of the
host. It is seen in the mentally retarded, immunosuppressed, AIDS, sensory
neuropathy, and elderly debilitated patients.
88. C/P:
- Crusted eruptions on the hands and feet
- Subungual hyperkeratosis
- Red scaly plaques on the head, neck and
trunk
- With or without severe itching
89. IDENTIFICATION
NODULAR SCABIES
DESCRIPITION
Nodular lesions that are itchy, NON-INFESTED,
reddish brown in color, that may persist for weeks
after treating scabies
Mostly seen at:
- Axilla
- Male genitals
- Groins
- umbilicus
Management?
Intralesional
steroids or surgical
excision
90. Norwegian scabies
Management?
1. Cut the nails short and apply a topical
scabicide under the nails.
2. Several applications of keratolytic creams
3. Several applications of topical scabicides
4. Two doses of oral ivermectin separated by
an interval of a week (could be repeated
more as needed)
91. Microphotograph of mineral oil scabies preparation
showing mite (below heavy black arrows), eggs (orange
arrows), and scybala “fecal pallets”(yellow arrows).In
preparing an ex vivo scabies preparation, mineral oil
preserves scabies’ scybala, whereas potassium hydroxide
does not.
92.
93. The red circle shows the
triangular structure (delta
sign or triangle sign), which
indicates the head parts of
scabies. The body of scabies is
relatively translucent. There is
a classic “S” shaped burrow
above the triangular structure.
94. TREATMENT OF SCABIES
GENERAL MEASURES
• Boiling all clothes and bed sheets, etc… (disinfection)
• Treating the other people in the house and spouses.
TOPICAL SCABICIDES (applied to entire skin except head and neck unless infant or old)
• Permethrin 5%(2 successive nights) “safe”.
• Sulfur “10% adult 5% child” (every night for 4 nights) “safe but has bad smell and stains so rarely
used”
• Gamma Benzine Hexachloride 1% (one application for 12 hours) “not safe for children >10y,
pregnant women, & epileptics”
• Benzyl benzoate 25% (for 2 nights)
• Crotamiton 10% (for 2 nights) “preferred for infants and young children, and postscabitic pruritus”
• Malathion 0.5% (for 12 hours then washed)
SYSTEMIC TREATMENT
• Ivermectin (antiscabetic) 6mg/15Kg
• Antihistamines and antibiotics.
96. This is a “nit”, which is
the egg of head louses
that are adherent to
the hair. We usually
don’t see the adult lice,
but we can clearly see
the nits in the hair in
cases of pediculosis
capitis
97. Management of pediculosis capitis
1- CUT THE HAIR SHORT.
2- GIVE CO-TRIMOXAZOLE if there is impetigo
3- GIVE PEDICULOSIDES AFTER CONTROLLONG BACTERIAL INFECTIONS:
• Malathion 0.5% lotion (12 hours then wash)
• Ivermectin lotion (12 hours then washed)
• GBH 1% shampoo (5 mins then washed)
• Repeat after 1 week and all family members should do the exact same.
4- ORAL IVERMECTIN (6mg/15Kg repeated in 10days)
5- REMOVE NITS
• Make a white vinegar solution diluted in water (1:1)
• Leave it for 1-2 hours until the cement dissolves
• Wash and comb the hair with a fine-toothed comb
98. This is pediculosis pubis also known as
Pubic lice. It is sexually transmitted and
could be seen at the groin hair, axilla,
eyelashes, beard, any body hair tuft.
Management:
1- topical pediculocide (choose 1 agent and
repeat the TTT in one week, must apply it to
all the body even if not affected)
2- in cases of topical TTT failure, or perianal
or eyelash involvement, give oral ivermectin
on day 1 and 8
3- don’t forget the spouse
100. Urticaria (many wheals
are seen) and
angioedema of the face.
MANAGEMENT: (after removing the cause!!!)
1.Adrenaline
2.Antihistamines
3.Systemic steroids if severe
4.Local soothing lotion (calamine
lotion)
5.Calcium gluconate
109. Identify the disease and describe the
lesions and their distribution and the
causative agent:
Disease: Hand, foot and mouth disease
Description: multiple oval vesicles (or
crusts if the rupture) that are seen on the
oral region, palmar aspect of the hand,
and plantar surface of the foot. WITH NO
LESIONS ON THE TRUNK (to differ it
from chicken pox).
Causative agent: coxsackievirus
110. Psoriasis of the scalp
Seborrheic dermatitis of
the scalp
Area of affection: primarily the frontal
hair line “crown”
Scales: DRY and WHITE.
Auspitz sign: +ve.
Area of affection: the temporal and
occipital regions.
Scales: GREASY and YELLOWISH
111. Psoriasis in the palm Eczema in the palm
• Fiery red erythema
• Well defined border
• Oozes blood when scratched
• Auspitz sign +ve
• Less marked erythema
• Hazy border
• The 1ry lesion is vesicles so it oozes watery
fluid when scratched
125. The male urethra ( 4 parts):
1. Prostatic urethra “3 cm”
2. Membranous urethra “1.2cm and no glands open to it”
3. Bulbar urethra “widest part, receives openings for cowper
glands”
4. Penile urethra “Littres gland open here”
Epithelium of the male urethra:
Prostatic and membranous urethra: transitional epithelium
Bulbar and penile urethra and ducts: pseudostratified columnar
Fossa navicularis: stratified squamous
129. Priapism is the prolonged painful erection
more than 4 hours. It is mostly seen in
blood dyscriasis!!!!!!!!!!! And it is a medical
emergency!!!!!!!
136. chancre chancroid
• Caused by syphilis (Treponema
pallidum)
• It is painless
• Caused by Hemophilus Ducreyi
• It is painful!
((mnemonic to remember: if you have
chancroid, you DO CRY. “because it
sounds like ducreyi ”)
138. Drugs of choice
• Syphilis: Benzathine penicillin G.
• Genital Gonorrhea: Ceftriaxone or spectinomycin.
• Disseminated gonorrhea: Ceftriaxone of Cefotaxime.
• Chlamydia: Azithromycin or Doxycycline.
• Chancroid: ceftriaxone or azithromycin.
• Granuloma inguinale: Doxycycline.
• LGV: Doxycycline for 3 weeks.
• Moniliasis: antifungals (nystatin or miconazole)
139. • Commonest cause of male infertility: Varicocele “got this info from the
lecture”
• Most painful genital ulcer: chancroid
• Commonest STD: HPV
• Commonest cause of urethral discharge: Gonorrhea
• Commonest cause of genital ulcers: HSV
• Commonest cause of female abnormal discharge: moniliasis
Commonest causes:
140. Stages of HIV infection:
1. Subclinical stage
• Very infectious
• CD4+ T cells are more than 500 cells/mm3
2. Persistent generalized lymphadenopathy
• Unexplained, lasting more than 3 months.
• Should be in at least 2 extrainguial sites.
• Painless.
3. Aids related complex (ARC)
• At least 2 C/P combined with at least 2 lab findings (next slide)
4. AIDS
• Proven HIV infection
• CD4+ T cells less than 200/mm3
• Opportunistic infections or rare malignancies
141. Clinical picture Laboratory findings
• Night sweats
• Weight loss more than 10%
• Unexplained fever
• Extreme fatigue
• Unexplained diarrhea
• CD4+ T cells between 499-200
cells/mm3
• Helper/suppressor ratio less than 1
• Cytopenia's
• Cutaneous anergy
• Increased Ig levels
