Roshana Mallawaarachchi 1. Physical barrier 2. Protection against infection, UV and chemicals 3. Prevention of excessive water loss 4. UV induced synthesis of Vit D 5. Temperature regulation 6. Sensation (Pain, Touch, Temperature) 7. Antigen presentation, Immunological reactions, Wound healing Time course of rash Distribution of rash Symptoms (Itch, pain) Family History Drug/allergy History Past medical History Provocating factors (Sunlight, Diet) Previouse skin treatments Examination: Should include nails, hair, and mucosal surfaces. Distribution ± Flexures, Extensor, Unilateral, Bilateral, Symmetrical, Localized, facial, Reticulate Investigations: Skin swabs (Bacterial Culture) Skin scrapes (Fungal Culture) Nail sampling (Fungal culture) Blood test (Serology) Skin biopsy Patch test Bacterial Infections: Impetigo Cellulitis Boils (Furuncles) Mycobacterial infections ± (TB, Leprosy) Viral Infections Slapped cheek syndrome Herpes simplex virus Herpes Zoster Human Papilloma virus Bacterial Infections: Impetigo Cellulitis Boils (Furuncles) Mycobacterial infections ± (TB, Leprosy) Viral Infections Slapped cheek syndrome Herpes simplex virus Herpes Zoster Human Papilloma virus Fungal Infections: Dermatophyte infection - Tinea corporis - Tinea cruris - Tinea pedis - Tinea capitis Candida albicans Highly infectious. (Staph. aureus) Common in Children. Present as exudate areas with Honey coloured crust on the surface. Spread by direct contact. Occasionally can cause blistering (Bullous Impetigo) Treatment: Localised disease topical fusidic acid Antiseptic ± Povidone iodine Extensive disease treated with oral antibiotics. Flucloxacillin ± Satph. Aureus Penicilin ± Streptococcus Other close contacts should be examined. Impetigo ±crusted blistering lesions on the chin. Infection of the deep subcutaneous layer. Often affects the lower leg. Often unwell with a high temperature. Usually caused by Streptococcus. Usually there is an entry for infection. (Wound) Confirmation of infection done by serology, Streptococcal titres. Treatment: Penicillin or Erthromycin In advanced disease Intravenous treatment may required. Any identifiable cause should be treated. Eg. Diabetes mellitis Recurrent cellulitis ± Low dose antibiotic prophylaxis (Eg. Penicillin twice daily) Cellulitis More deep seated infection. Caused by Staphylococcus. Painful red swelling. Commoner in teenagers. Often recurrent. (In Diabetics, Immunosuppression) Treatment: Oral Antibiotics (Eythromycin) Occasionally incision and Drainage. Antiseptics (Povidone iodine, Chloehexidine) Boils (Furuncles) Affects Children. Caused by parvovirus B19. Infection is followed by intense erythema on the cheeks. Treatment: Symptomatic ± Analgesics, Antihistamins, Moisturing lotions, Plenty of Fluids Slapped cheek syndrome 2 Subtypes HSV Type I HSV Type 2 HSV Type 1 ± Spread by direct contact and droplet. HSV Type 2- mainly after puberty and usually affects the genital area. Infections are transmitted sexually. Treatment: Oral aciclovir Reactivation of the Varicella zoster virus. (Chickenpox) Painful and tender blistering eruption. Maybe become pustular and then crust over. Lasts for 2-4 weeks. Complications: Post herpetic neuralgia (Severe, persistent pain) Ocular disease Treatment: Adequate analgesia Oral aciclovir High dose IV aciclovir is needed for immunosuppressed patients. Antibiotics (If secondary infection present) Viral warts Cause overgrowth of differentiated squamous epithelium. 1. Common warts ± Often on hands and feet. Children and adolescent are usually affected. Spread is by direct contact. 2. Plantar Warts ± soles and feet 3. Filiform warts ± on the face 4. Anogenital warts - Treatment: Difficult to treat effectively. But almost always resolve spontaneously. (Months to years) Regular use of topical keratolytic agent. (Eg. Salicylic acid) ± Speed up resolution A course of cryotherapy (freezing) Cautery Surgery µringworm¶ type of rash. Identified by Microscopy and culture of skin, hair or nail samples. Spread by direct contact. Tinea Corporis Ringworm of the body Slightly itchy Asymetrical Scaly Raised edges Dx- Skin scrapings/Microscopy Tinea cruris Ringworm of the groin. Lesions appear as well-demarcated red plaques. Few pustules or vesicles may be seen. Tinea Pedis Causing a diffuse scaly erythema of the soles. Tinea capitus Ringworm of scalp Tinea capitis Tinea corporis Tenea pedis Treatment: Localized ± is treated with topical antifungal creams. (Clotrimazole, Micanazole) Wide spread infections - Oral antifungal In children for scalp ringworm - Griseofulvin Is a yeast. Acts as an opportunist. Flexural areas affected are red with few small pustules. May also affect the moist interdigit clefts. Treatment: Apply a topical antifungal. Eg: Clotrimazole, Miconazole Itchy red papules caused by the mite, Sarcoptes scabiei. Common in children and young adults. Spread by prolong close contact. Between web spaces of the fingers and toes. And also axillae, and male genitalia. Pathognomic sign ± linear or curved skin burrows Secondary bacterial infection may complicate. Confirmed by skin scraping and microscopy for the mite/eggs. Treatment: Application of topical scabicide. (5% Permethrin) All the skin below the neck should be treated. All close contacts should be treated even asymptomatic. Benzyl benzoate also can be used, but it is very irritant. Scabies ± Itchy papules and pustules centered on the web space. Blood sucking ectoparasites. 3 Types. 1. Head lice 2. Body lice 3. Pubic lice Head Lice Is a common infection among children and female. Spread is by direct contact. Treatment: Antilice treatment ± Permethrin, Phenothrin Atopic eczema ± occurs in individual who are atopic. Commoner in early life. Itchy erythematous scaly patches. Especially in flexures. (Elbow, ankles) Scratching can cause excoriations. And repeated rubbing leads to skin thickening. Complications: Secondary infection by bacteria. (Staph. aureus) Cutaneous viral infections spread by scratching (Viral wart) Conjunctival irritation / Cataract Growth retardation in children. Diagnosis by clinically. Prognosis: Early onset atopic eczema will spontaneously improve. A few get recurrence. Treatment: Avoiding known irritant (Soap) Manipulating the diet. Treatment: (Cont«) Topical therapies to control the disese. Triple combination1. Topical steroid 2. Emollient ± Soften and soothe skin 3. Bath oil or soap substitute Use of topical steroids Appropriate strength should be used. Topical streoids can be divided into 5 groups. Very potent - Clobitasol propionate Potent - Betamethasone Diluted potent Moderately potent Mild ± 1% Hydrocortisone Action of topical steroids Antiinflammatory Reduces mediator release Reduces inflammatory cell function Reduces lysosomal enzyme release Immune suppressive Catabolic effect Reduces Dermal collagen synthesis Anti mitotic action on some cells- scaly dermatosis Use of topical steroids Face should be treated with mild steroids. In adult body should be treated with mild ± diluted potent steroids. Potent steroids may be used for short period. Palms and soles may require potent or very potent steroids. Regular use of emollients may lessen the steroid need. Use weaker steroids in flexures. (Because apposition of the skin increase absorption) Side effects of topical steroids Local infections (Folliculitis, Candidiasis) Exacerbation of existing dermatoses. (Fungal infections, acne, scabies) Atrophic changes ±striae, Bruising, Pupura Peri oral dermatitis ± Erythema, Papules & pustules on face. Hypopigmentation Delayed wound healing Increase hair growth The newer topical corticosteroids The ideal topical corticosteroid will be -Potent at the target site of the skin -Less absorbed or absorbed in biodegradable formminimizes side effects The newer topical steroids-mometasone furoate -fluticasone propionate -Methyl prednisolone aceponate Antibiotics: If bacterial infection. (Eg. Flucloxacillin) Combination topical steroid and antibiotics can be used. Sedating antihistamins: For the sedation at night. Bandaging: It helps absorption of treatment. Act as a barrier prevent scratching. Second line agents: Considered in severe non responsive cases. UV Phototherapy Prednisolone Azathioprine Ciclosporin ± Selective immunosuppresant Side effects ± Renal damage and Hypertension. UVB and UVA Treatment of inflammatory dermatoses. They have a suppressive effect. Both can cause skin ageing and predispose to malignancy if excessive doses are used. UVB is less carcinogenic than UVA. UVB used in eczema. Eye protection needs to be worn during therapy.