Dermatology

Lichen planus

Features:  Lichen planus is a skin disorder of unknown aetiology, most probably being immune mediated.  Itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms.  Rash often polygonal in shape, 'white-lace' pattern on the surface (Wickham's striae).  Koebner phenomenon may be seen (new skin lesions appearing at the site of trauma).  Oral involvement in around 50% of patients.  Nails: thinning of nail plate, longitudinal ridging. Dr Khaled Elmagraby

Polymorphic eruption of pregnancy

 Pruritic condition associated with last trimester.  Lesions often first appear in abdominal striae.  Management depends on severity: emollients, mild potency topical steroids and oral steroids may be used Dr Khaled Elmagraby

Pemphigoid gestationis

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Pruritic blistering lesions. Often develop in peri-umbilical region, later spreading to the trunk, back, buttocks and arms Usually presents 2nd or 3rd trimester and is rarely seen in the first pregnancy. Oral corticosteroids are usually required. Dr Khaled Elmagraby

Shin lesions The differential diagnosis of shin lesions includes the following conditions: 1) 2) 3) 4)

Erythema nodosum Pyoderma gangrenosum Pretibial myxoedema Necrobiosis lipoidica diabeticorum

Below are the characteristic features

Dr Khaled Elmagraby

1) Erythema nodosum:

 Symmetrical, erythematous, tender, nodules heal without scarring.  It is an inflammation of the subcutaneous tissue (panniculitis) and is tender and palpable.  Most common causes are streptococcal infections, sarcoidosis, inflammatory bowel disease and drugs (penicillins, sulphonamides, oral contraceptive pill). Dr Khaled Elmagraby

Cont. Erythema nodosum

the commonest potentially serious causes (and therefore those that should be excluded first) include sarcoidosis and tuberculosis. A CXR is an important investigation to exclude both of these causes. Dr Khaled Elmagraby

2) Pyoderma gangrenosum:

 Initially small red papule.  Later deep, red, necrotic ulcers with a violaceous border.  Idiopathic in 50%, may also be seen in inflammatory bowel disease, connective tissue disorders and myeloproliferative disorders. Dr Khaled Elmagraby

Pyoderma gangrenosum

Pyoderma gangrenosum typically is an expanding ulcer with a polycyclic or serpiginous outline and a characteristic undermined bluish edge. It can be associated with:  Inflammatory bowel disease  Rheumatoid arthritis  Monoclonal gammopathies, and  Leukaemia. It usually responds to oral steroids. The pathogenesis is unknown, and is presumed to be immunological. Dr Khaled Elmagraby

3) Pretibial myxoedema:

 Symmetrical, erythematous lesions seen in Graves' disease  Shiny, orange peel skin

Dr Khaled Elmagraby

4) Necrobiosis lipoidica diabeticorum:

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Shiny, painless areas of yellow/red skin typically on the shin of diabetics Often associated with telangiectasia It is seen in 0.3-1% of patients with DM. Around 40-60% of patients with Necrobiosis lipoidica have DM and the condition may pre-date the development of abnormal blood sugar.  More common in females. Khaled Elmagraby  TTT: Topical / injectable steroids, skin grafting Dr and camouflage creams

Cellulitis It is an inflammation of the skin and subcutaneous tissues. Typically due to infection by: Streptococcus pyogenes or Staphylococcus aureus.

Features: Commonly occurs on the shins. Erythema, pain, swelling. There may be some associated systemic upset such as fever.

Management: The BNF recommends flucloxacillin as first-line treatment for mild/moderate cellulitis. Clarithromycin or clindamycin is recommend in patients allergic to penicillin. Many local protocols now suggest the use of oral clindamycin in patients who have failed to respond to flucloxacillin. Severe cellulitis should be treated with intravenous benzylpenicillin + flucloxacillin. Dr Khaled Elmagraby

Granuloma annulare

 Papular lesions that are often slightly hyperpigmented and depressed centrally.  It is characterised by a raised annular configuration.  It is not clear from recent studies if there is actually a significant association between DM and granuloma annulare, but it is often listed in major textbooks.  The treatment is 'masterful inactivity‘, The eruption should disappear spontaneously. Dr Khaled Elmagraby

Scabies Crusted (Norwegian) scabies:  Crusted scabies is seen in pt. with suppressed immunity, especially HIV.  The crusted skin will be teeming with hundreds of thousands of organisms.  Ivermectin is the treatment of choice and isolation is essential.

Dr Khaled Elmagraby

Pityriasis versicolor

Dr Khaled Elmagraby

Seborrhoeic dermatitis

Dr Khaled Elmagraby

Acne Rosacea

Mild papules and erythema Moderate papules and early pustules Severe erythema, papules and pustules

Inflammatory papules and early Rhinophyma

AdvancedDrRhinophyma Khaled Elmagraby

Telangiectasia

Acne Rosacea (cont.) Acne rosacea is a chronic skin disease of unknown aetiology.

Features: • Typically affects nose, cheeks and forehead • Flushing is often first symptom • Telangiectasia are common • Later develops into persistent erythema with papules and pustules • Rhinophyma • Ocular involvement: blepharitis Management: • Topical metronidazole may be used for mild symptoms (i.e. Limited number of papules and pustules, no plaques). • More severe disease >> systemic antibiotics: oral Oxytetracycline. • Recommend daily application of a high-factor sunscreen. • Camouflage creams may help conceal redness. • Laser therapy may be for patients with prominent telangiectasia. Dr Khaled Elmagraby

Pityriasis rosea

 Cause unknown, herpes hominis virus 7 (HHV-7) a possibility.  Tends to affect young adults.  Features:  Herald patch (usually on trunk).  Followed by erythematous, oval, scaly patches which follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer. This may produce a 'fir-tree' appearance. Dr Khaled Elmagraby  Management: Self-limiting, usually disappears after 4-6 weeks.

Pityriasis rosea

Dr Khaled Elmagraby

Impetigo

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Impetigo is a superficial bacterial skin infection usually caused by either Staphylococcus aureus or Streptococcus pyogenes. 'Golden', crusted skin lesions typically found around the mouth. It is Very contagious. Topical Fusidic acid is first-line ttt. Dr Khaled Elmagraby

Erythema ab igne

 Erythema ab igne is a skin disorder caused by over exposure to infrared radiation.  It is a reticulated, erythematous patches with hyperpigmentation and telangiectasia.  A typical history would be an elderly women who always sits next to an open fire (e.g. Patient with Hypothyroidism can make patients feel cold and hence more likely to sit next a heater / fire).  If the cause is not treated then patients may go on to develop squamous cell skin cancer. Dr Khaled Elmagraby

Erythema ab igne (Cont.)

Dr Khaled Elmagraby

Psoriasis

Dr Khaled Elmagraby

Psoriatic nail changes

 This patient has psoriatic nail changes as evidenced by pitting, onycholysis and subungual debris.  It usually affects multiple nails.  The description of the rash is classical for psoriasis vulgaris which presents with well-demarcated, symmetrical, pink, scaly papules and plaques on extensor surfaces.

Dr Khaled Elmagraby

Beau's lines at nails

 This patient has Beau's lines, a benign nail condition that presents as a jagged transverse groove on the nail plate corresponding to an episode of nail growth arrest, which can occur during an episode of severe medical illness. It usually affects several nails.

Dr Khaled Elmagraby

Scalp and hairline psoriasis.

First line treatment would involve topical corticosteroid preparations as well as medicated shampoos containing zinc, coal tar, salicylic acid, corticosteroids or ciclopirox.

Dr Khaled Elmagraby

Guttate psoriasis

 Guttate psoriasis is more common in children and adolescents.  It may be precipitated by a streptococcal infection 2-4 weeks prior to the lesions appearing. Features: Tear drop papules on the trunk and limbs.  Management:  Most cases resolve spontaneously within 2-3 months  There is no firm evidence for the use of antibiotics to eradicate streptococcal Dr Khaled Elmagraby infection.

Dermatitis herpetiformis

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Dermatitis herpetiformis is an autoimmune blistering skin disorder associated with coeliac disease. It is caused by deposition of IgA in the dermis. Features: Itchy, vesicular skin lesions on the extensor surfaces (e.g. elbows, knees, buttocks). Diagnosis: Skin biopsy: direct immunofluorescence shows deposition of IgA in a granular pattern in the upper dermis.  Management: Gluten-free diet and Dapsone. Dr Khaled Elmagraby

Herpes simplex virus (HSV)

Pap smear. Multinucleated giant cells representing infection by the herpes simplex virus. Note the 3 M's; Multinucleation, Margination of the chromatin, Molding of the nuclei. The cytopathic effect of HSV (multi-nucleation, ground glass & marginated chromatin). Dr Khaled Elmagraby

Erythema multiforme (EM)

Dr Khaled Elmagraby

Erythema multiforme (Cont.) Features: 

Target lesions.

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Initially seen on the back of the hands / feet before spreading to the torso.

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Upper limbs are more commonly affected than the lower limbs.

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Pruritus is occasionally seen and is usually mild.

If symptoms are severe and involve blistering and mucosal involvement the term Stevens-Johnson syndrome is used.

Causes: 

Viruses: HSV (the most common cause), Orf (Orf is a skin disease of sheep and goats caused by a parapox virus).

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Idiopathic

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Bacteria: Mycoplasma, Streptococcus

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Drugs:

Penicillin,

Sulphonamides,

Carbamazepine,

NSAIDs, Oral contraceptive pill, Nevirapine. 

Connective tissue disease e.g. SLE.

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Sarcoidosis

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Malignancy

Dr Khaled Elmagraby

Allopurinol,

Stevens-Johnson syndrome (SJS) Stevens-Johnson syndrome is the severe form of erythema multiforme associated with mucosal involvement and systemic symptoms. Features: 1) 2) 3) 4)

Rash is typically maculopapular with target lesions being characteristic. These rash may develop into vesicles or bullae. Mucosal involvement. Systemic symptoms: fever, arthralgia.

 Causes: Same like the causes of Erythema multiforme (EM).

The antibiotic which is most associated with the development of StevensJohnson syndrome is >>> Sulphonamides (Co-trimoxazole). Dr Khaled Elmagraby

Onycholysis

Onycholysis describes the separation of the nail plate from the nail bed.

Dr Khaled Elmagraby

Vitiligo

Dr Khaled Elmagraby

Skin disorders associated with malignancy Paraneoplastic syndromes associated with internal malignancies:

Sweet's syndrome >> Haematological malignancy e.g. Myelodysplasia, AML - tender, purple plaques

Dr Khaled Elmagraby

Cont.

Acanthosis nigricans >>> Gastric cancer Describes symmetrical, brown, velvety plaques that are often found on the neck, axilla and groin. Dr Khaled Elmagraby

Cont.

Dermatomyositis >>> Lung and Ovarian cancer

Dr Khaled Elmagraby

Cont.

Erythema gyratum repens >>> Solid organ malignancies such as Lung cancer & Breast cancer.

Dr Khaled Elmagraby

Pyoderma gangrenosum (bullous and non-bullous forms) >>> Myeloproliferative disorders

Dr Khaled Elmagraby

Actinic keratosis (AK)

 It is a common premalignant skin lesion that develops as a consequence of chronic sun exposure.  Features:  Small, crusty or scaly, lesions. May be pink, red, brown or the same colour as the skin.  Typically on sun-exposed areas e.g. temples of head.  Multiple lesions may be present. Dr Khaled Elmagraby  TTT: Fluorouracil cream.

Toxic epidermal necrolysis (TEN)

 TEN is a potentially life-threatening skin disorder that is most commonly seen secondary to a drug reaction.  Features:  Systemically unwell e.g. pyrexia, tachycardia  Positive Nikolsky's sign: the epidermis separates with mild lateral pressure. Dr Khaled Elmagraby

Drugs known to induce TEN: 1) 2) 3) 4) 5) 6)

Phenytoin Sulphonamides Penicillins Allopurinol Carbamazepine NSAIDs

Management:

• Stop precipitating factor. • Supportive care, often in ICU. • IVIG Intravenous immunoglobulin has been shown to be effective and is now commonly used first-line. • Other treatment options include: immunosuppressive agents (cyclosporine and cyclophosphamide), Plasmapharesis. Dr Khaled Elmagraby

Skin disorders associated with tuberculosis: Possible skin disorders: 1) 2) 3) 4) 5) 6)

Lupus vulgaris (accounts for 50% of cases) (see pic) Erythema nodosum Scarring alopecia Scrofuloderma: breakdown of skin overlying a tuberculous focus Verrucosa cutis Gumma

Dr Khaled Elmagraby

Lupus vulgaris

 Lupus vulgaris is the most common form of cutaneous TB seen in the Indian subcontinent.  It generally occurs on the face and is common around the nose and mouth.  The initial lesion is an erythematous flat plaque which gradually becomes elevated and may ulcerate later. Dr Khaled Elmagraby

Scrofuloderma

breakdown of skin overlying a tuberculous focus

Dr Khaled Elmagraby

Porphyria cutanea tarda

 Porphyria cutanea tarda is the most common hepatic porphyria.  It is due to an inherited defect in uroporphyrinogen decarboxylase or caused by hepatocyte damage e.g. alcohol, hepatitis C, oestrogens.  Features: 1) Classically presents with photosensitive rash with blistering and skin fragility (extremely fragile and tears easily) on the face and dorsal aspect of hands (most common feature). 2) Hypertrichosis. 3) Hyperpigmentation. Dr Khaled Elmagraby

Blisters/bullae: No mucosal involvement >>> Bullous Pemphigoid Mucosal involvement >>> Pemphigus vulgaris

Dr Khaled Elmagraby

Pemphigus vulgaris

 Pemphigus vulgaris is an autoimmune disease.  Features:  Mucosal ulceration is common and often the presenting symptom. Oral involvement is seen in 50-70% of patients.  Skin blistering - flaccid, easily ruptured vesicles and bullae. Lesions are typically painful but not itchy. These may develop months after the initial mucosal symptoms. Nikolsky's describes the spread of bullae following application of horizontal, tangential pressure to the skin.  Acantholysis on biopsy. Dr Khaled Elmagraby  Management: Steroids and Immunosuppressants.

Bullous Pemphigoid

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Bullous Pemphigoid is an autoimmune condition causing sub-epidermal blistering of the skin. This is secondary to the development of antibodies against hemidesmosomal proteins BP180 and BP230. Bullous Pemphigoid is more common in elderly patients. Features include:  Itchy, tense blisters typically around flexures.  The blisters usually heal without scarring  Mouth is usually spared. Dr Khaled Elmagraby  TTT: Oral corticosteroids are the mainstay of treatment +Topical corticosteroids, immunosuppressants and antibiotics.

Bullous Pemphigoid

 Pemphigoid is a disease of the elderly (over 60 years) characterised by the development of large tense blisters that heal without scarring. It is caused by immunoglobulin (IgG) autoantibodies against components of the basement membrane.  Blistering in pemphigoid occurs at the sub epidermal level - deeper than the blisters of pemphigus vulgaris (which occur at the dermal-epidermal junction); hence the tense blisters seen in pemphigoid. Blisters are thin-walled and fragile in pemphigus - few intact blisters are ever seen.  Skin biopsy will reveal a sub epidermal blister withDran infiltrate Khaled Elmagraby of eosinophils. Direct immunofluorescence studies will reveal IgG and C3 in the basement membrane zone.

Pemphigus vulgaris

 Pemphigus vulgaris is a blistering disease seen predominantly in elderly patients. It is characterised by the formation of thin-walled blisters that rupture easily (intact blisters are rarely seen).  Large surface areas of the body can be affected and the mortality without treatment is high.  Mucosal involvement is common at presentation (unlike pemphigoid).  Treatment is with high-dose corticosteroids.  Immunofluorescent staining of a biopsy sample shows deposition of immunoglobulin (IgG) directed against intercellular cement, resulting in a 'chicken wire' appearance.  In comparison, pemphigoid rarely involves the mucosa and presents with large tense intact blisters. Immunofluorescence of pemphigoid shows deposition of IgG and complement atElmagraby the dermo-epidermal junction. Dr Khaled

Pemphigus vulgaris (Cont.)

 This patient presents with pemphigus vulgaris.  He has extensive mucosal erosions and a few flaccid blisters and erosions on his trunk.  Biopsy will reveal an intraepidermal blister with acantholytic cells (cells which have lost their intercellular connections).

Dr Khaled Elmagraby

Keratoacanthoma (KA)

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Keratoacanthoma is a benign epithelial tumour., low-grade malignancy that originates in the pilosebaceous glands. It resembles squamous cell carcinoma (SCC) pathologically. It is believed to develop from the hair follicle, and is said to be more common in males. Some experts support classifying KA as a variant of invasive SCC. Features - said to look like a volcano or crater:  Initially a smooth dome-shaped papule.  Rapidly grows to become a crater centrally-filled with keratin.  Spontaneous regression of Keratoacanthoma within 3 months is common, often resulting in a scar. Dr Khaled Elmagraby  Such lesions should however be urgently excised as it is difficult clinically to exclude squamous cell carcinoma.

Keratoacanthoma (KA) (Cont.)

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Keratoacanthomas are now considered as a well-differentiated variant of squamous cell carcinoma (SCC). It presents as a rapidly enlarging nodule with a central keratinous crateriform scab. There are reports of spontaneous regression but generally they should be treated with full excision. NB: Basal cell carcinoma most commonly presents as an ulcerated nodule with pearly, rolled edges with telangiectasias. Dr Khaled Elmagraby

Basal cell carcinoma (BCC)

This patient presents with a typical 'rodent ulcer' with rolled pearly edges and small telangiectasias. It is the commonest malignant skin tumour and most commonly occurs in elderly patients with sun-damaged skin.

Dr Khaled Elmagraby

Myxoid cyst (mucous cysts)

They are benign ganglion cysts usually found on the distal, dorsal aspect of the finger. It is firm dome-shaped swelling. There is usually osteoarthritis in the surrounding joint. They are more common in middle-aged women.

Dr Khaled Elmagraby

Molluscum contagiosum

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Molluscum contagiosum is caused by a pox DNA virus infection. It is typically seen in younger children and results in characteristic small, pearly, umbilicated (central dimple) lesions. Molluscum contagiosum is highly infectious. Lesions may be present for up to 12 months and usually resolve spontaneously. No treatment is recommend in the initial phase due to the benign nature of the condition. Cryotherapy, topical imiquimod and topical cantharidin. Oral cimetidine may also be attempted in some patients especially those with widespread lesions. Dr Khaled Elmagraby

Molluscum contagiosum in HIV

 Such umbilicated, pearly papules 2-5 mm in diameter are seen in patients with advanced HIV/AIDS (CD4 count less than 200 cells/mm3).  They are caused by a DNA pox virus called molluscum contagiosum virus (MCV).  They commonly occur on the face, especially near the eyelids; they also occur on genitals and trunk.  They should be treated with cryotherapy, liquid nitrogen or curettage. Dr Khaled Elmagraby

Erythrasma

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Erythrasma is a generally asymptomatic, flat, slightly scaly, pink or brown rash usually found in the groin or axillae. It is caused by an overgrowth of the diphtheroid Corynebacterium minutissimum. Examination with Wood's light fluorescence reveals a coral-red fluorescence. Topical miconazole or antibacterial are usually effective. Oral erythromycin may be used for more extensive infection. Dr Khaled Elmagraby

Pompholyx

 Pompholyx is a type of eczema which affects both the hands (cheiropompholyx) and the feet (pedopompholyx).  Features:  Small blisters on the palms and soles.  Pruritic, sometimes burning sensation.  Once blisters burst skin may become dry and crack. Dr Khaled Elmagraby  Management: 1)Cool compresses. 2)Emollients. 3)Topical steroids

Pellagra  Pellagra is a caused by nicotinic acid (niacin) deficiency (Vit B3).  The classical features are the 3 D's - Dermatitis, Diarrhoea and Dementia.  Pellagra may occur as a consequence of isoniazid therapy (isoniazid inhibits the conversion of tryptophan to niacin) and it is more common in alcoholics.  Features: 1) Dermatitis (red-brown, symmetrically scaly rash on sun-exposed sites termed Casal's necklace if around neck). 2) Diarrhoea. 3) Dementia, Depression. 4) Death if not treated.

Dr Khaled Elmagraby

Discoid lupus erythematous  Discoid lupus erythematous is a benign disorder generally seen in younger females.  It very rarely progresses to SLE (in less than 5% of cases).  It is characterised by follicular keratin plugs and is thought to be autoimmune in aetiology.  Features:  Erythematous, raised rash, sometimes scaly  May be photosensitive  More common on face, neck, ears and scalp  Lesions heal with atrophy, scarring (may cause scarring alopecia), and pigmentation.  Management: 1) Topical steroid. 2) Oral antimalarials may be used second-line e.g. hydroxychloroquine 3) Avoid sun exposure

Dr Khaled Elmagraby

Dermatomyositis (DM)

 The characteristic heliotrope rash consists of a violaceous or erythematous rash (sometimes with oedema) in a symmetrical distribution involving periorbital skin.  This is frequently subtle and may involve only a mild discolouration along the eyelid margin. Dr Khaled Elmagraby

Dermatomyositis Gottron's papules

 Gottron's papules : roughened red papules over extensor surfaces of fingers at knuckles.  Gottron's papules are found over bony prominences, particularly the metacarpophalangeal joints, the proximal interphalangeal joints, and/or the distal interphalangeal joints.  Papules may also be found overlying the elbows, knees, and/or feet.  The lesions consist of slightly elevated violaceous papules and plaques, and may be scaly.  Nailfold changes consist of periungual telangiectases and/or a characteristic cuticular change with hypertrophy of Dr Khaled Elmagraby the cuticle and small haemorrhagic infarcts with this hypertrophic area.

Dermatomyositis heliotrope

The classic purple (heliotrope) rash is seen on sun-exposed areas, especially the eyelids, nose, cheeks, forehead, knees, knuckles and around the nail beds. The rash may be pruritic. Dr Khaled Elmagraby

Chickenpox & Varicella pneumonia

The slide shows the typical rash of chickenpox. Varicella pneumonia occurs in up to 20% of adults with chickenpox, appearing 3 to 5 days into the course of the illness. About 30 young adults die each year from varicella pneumonia. They are best managed on a high-dependency unit. In adults with pneumonitis, treatment with IV Acyclovir is warranted. Dr Khaled Elmagraby

Hereditary haemorrhagic telangiectasia (HHT) (Osler-Weber-Rendu syndrome) (OWR)

 The condition is inherited as an autosomal dominant trait; sporadic cases also occur.  Patients typically present early in adult life with anaemia due to occult bleeding from gastrointestinal telangiectasiae.  Lesions commonly occur in the mouth and on the face. Dr Khaled Elmagraby  Complications of the disease include haemoptysis and pulmonary haemorrhage.

Necrobiosis Lipodica

Dr Khaled Elmagraby

Necrolytic Migratory Erythema (NME)

Dr Khaled Elmagraby

Acanthosis nigricans

It has a characteristic hyper pigmented, velvety surface. It frequently occurs in the axillae, groins and in the skin fold of the neck and occasionally on the dorsum of the hand. Acanthosis nigricans is associated with:  Endocrine disease (insulin resistant DM, acromegaly, Cushing's syndrome).  Polycystic ovary syndrome, and Dr Khaled Elmagraby  Paraneoplastic phenomenon (usually tumours of the GIT, especially adenocarcinoma of the stomach).

Erysipelas Streptococcus pyogenes infection of the deep dermis and subcutis

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TTT: IV antibiotics such as benzylpenicillin and erythromycin. In a penicillin allergic patient a macrolide is the drug of choice. There is a 10% cross allergy between cephalosporins and penicillins. Dr Khaled Elmagraby Complications include sepsis, cerebral abscess and venous sinus thrombosis.

Cutaneous tuberculosis (lupus vulgaris)

 It is usually occurs due to spread from an endogenous source; more than 80% of cases occur on the face and neck.  Lesions begin as papules and coalesce to form a plaque. The centre of the lesion consists of scar tissue while the lesion extends from the periphery.  Apple-jelly nodules are classically described at the margins of the lesions. Dr Khaled Elmagraby

Porphyria cutanea tarda (PCT) A 45-year-old dockyard worker presented with symptoms of fatigue and general malaise, especially after working outside. He also reported developing ulcers on his hands after minor trauma.

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PCT is associated with deficiency of hepatic uroporphyrinogen (URO) decarboxylase. Cutaneous photosensitivity is the predominant clinical finding, blistering rash on the dorsum of the hand. Bullae develop on sun-exposed areas and lesions heal slowly, leaving scars. Excess alcohol, iron and oestrogen are common precipitants. TTT:  Withdrawal of the precipitant.  Venesection is effective (450 ml/week) untilDrHb is 120 g/L. Khaled Elmagraby  Chloroquine may also be effective because it promotes porphyrin excretion.

Ancylostoma braziliense cutaneous larva migrans (creeping eruption).

 The infection is acquired by direct contact with dog or cat faeces - often acquired when sunbathing on contaminated sand, etc. The larvae burrow in the dermo-epidermal junction.  Symptoms include pruritus and a raised, serpiginous erythematous rash that migrates at a rate of up to 1 cm/day.  Treatment: Oral ivermectin in a single dose of 200 µg/kg body weight is the main treatment  Other ttt: with topical thiabendazole or oral albendazole.  Acute infection with the human nematodes Strongyloides stercoralis, Necator americanus and Ancylostoma duodenale, Dr Khaled Elmagraby may produce a similar appearance.

Kaposi's sarcoma (KS) in HIV

 It is induced by human herpes virus 8 (HHV-8) infection in patients with HIV.  This patient may have contracted HIV on his travels and a full sexual history would be indicated, followed by appropriate counselling and an HIV test. Khaled Elmagraby  Kaposi's is on the decline due to the advent of highlyDractive antiretroviral therapy.

Kaposi's sarcoma (KS) in HIV (on the hard palate)

 The picture shows characteristic purple lesions of Kaposi's sarcoma (KS) on the hard palate.  The disease was originally described by Kaposi as a rare tumour in elderly men of Mediterranean origin ('classical Kaposi's sarcoma') in whom KS was usually found on the lower legs and feet. Dr Khaled Elmagraby

Kaposi's sarcoma (KS) of the eye. This 28-year-old man presented with a painful red eye. He had previously been well. He reported having two episodes of shingles in the past two years.

 A typical KS lesion is visible on the left side of his forehead.  Shingles is uncommon in individuals under 35 years of age; a history of shingles under this age, especially recurrent episodes, is highly suggestive of HIV infection. Dr Khaled Elmagraby

Herpes zoster rash in HIV

TTT: Aciclovir

Dr Khaled Elmagraby

Eosinophilic folliculitis (EF) in HIV

 There are three main variants of EF: 1) Classic EF 2) Immunosuppression-related EF (mostly HIV-associated) and 3) Infancy-associated EF.

Dr Khaled Elmagraby

 Classic EF, also known as Ofuji disease (eosinophilic pustular folliculitis), is more common in individuals of Japanese descent, although anyone can be affected. The clinical presentations of EF vary slightly, but histologically the forms are identical.  Immunosuppression-EF: it is The most common type of EF, it differs from the classical form in that the eruption is exquisitely pruritic. It also tends to present with erythematous, almost oedematous, papules with few pustules (whereas the classic form tends to have clusters of pustules). Because the eruption is so pruritic the lesions are often excoriated on presentation, making identification of a primary lesion difficult. The lesions are found primarily on the face and upper trunk (from the waist up). Histologic examination of a papule shows an acute and chronic infiltrate of eosinophils and lymphocytes focused at the level of the follicular isthmus that can rarely progress to complete follicular destruction.  Men seem to be more commonly affected than women. The patient's CD4+ cell count is often below 250/µL and patients may have a peripheral eosinophilia and lymphopenia.  Cases of immunosuppression-EF may worsen 3 to 6 months after the initiation of antiretroviral therapy as part of the immune restoration syndrome and even after the CD4+ cell count rises above 200/µL. The reason for this development is unknown, but may represent a previously quiescent immune system now reacting to antigens.

Dr Khaled Elmagraby

Cutaneous anthrax caused by Bacillus anthracis

 Cutaneous disease is the commonest form of the infection in humans and is usually due to contact with infected animals or animal products. Anthrax is endemic to herd animals in some parts of the world.  Following exposure, the skin lesion evolves over a period of ~2 weeks into a papule, pustule, vesicle and eventually forms an ulcer with a central black eschar. The surrounding skin is usually boggy and oedematous. Lesions are usually painless with tender regional lymph nodes.  Lesions heal spontaneously in 80-90% of cases; 10-20% of patients progress and become bacteraemic – associated with a Dr Khaled Elmagraby high mortality. Penicillin is effective in treating the infection.

Mycosis fungoides, (Cutaneous T cell lymphoma)

 The disease presents as a pruritic eczematous rash (the pre-malignant stage) and develops telangiectasias and areas of 'cigarette paper' atrophy.  As malignancy develops, nodular lesions appear and proceed to become necrotic. Dr Khaled Elmagraby

HZV Herpes Zoster Virus

 This patient has grouped vesicles and blisters over an erythematous base in a dermatomal distribution.  The lesions are also typically painful.  Herpes zoster is caused by varicella-zoster virus. Dr Khaled Elmagraby

Henoch-Schönlein purpura (HSP)

 It occurs commonly in children and young adults, Although commonly idiopathic, it can occur after prior infections.  Patients present with signs and symptoms affecting:  The skin (vasculitis)  Joints (arthralgia and arthritis)  Gastrointestinal (GI) tract (intussusceptions, GI bleeding, perforation) and  Genito-urinary tract (haematuria, proteinuria).  Immunofluorescence studies will reveal IgA deposits within blood vessel walls.  The disease is usually self-limiting. Dr Khaled Elmagraby

Eczema herpeticum

 It is a cutaneous infection caused by herpes virus, seen in patients with pre-existing inflammatory skin disorders, for example, eczema, Darier's disease.  Patients present with new onset of clustered blisters and erosions over an erythematous base. The eruption can be widespread and patients may be ill. Lesions may be secondarily impetiginised with Staphylococcus infection.  Treatment requires systemic anti-virals e.g. oral aciclovir. Systemic antibiotics may be required if lesions are secondarily impetiginised.  Topical aciclovir will not be useful in this setting, as the patient requires systemic anti-virals. Khaled Elmagraby  The patient does not present with a fungal infection Dr and will not require treatment of topical or oral anti-fungals.

Lichenification

Lichenification of the skin is due to epidermal thickening characterised by visible and palpable thickening of the skin with accentuation of skin markings.

Dr Khaled Elmagraby

Lichen simplex chronicus (LSC)

 LSC presents with hyperpigmented, scaly, lichenified plaques.  Patients may volunteer a history of chronic scratching or manipulation, especially during times of stress.  The ankles are common sites for LSC.

Dr Khaled Elmagraby

Alopecia areata

 Alopecia areata is common in children as well as adults. It presents with localised patches of non-scarring hair loss. Remaining hairs have a characteristic 'exclamation mark' appearance, and are tapered towards the base. More severe involvement may present as alopecia totalis (total loss of scalp hair) or alopecia universalis (total loss of all body hair).  Androgenetic alopecia presents after puberty as a more diffuse slow hair loss with characteristic loss over the temporal regions and vertex in males.  Discoid lupus erythematosus (DLE) presents as scarring alopecia. Areas of alopecia are usually atrophic with visible loss of hair follicles. Patients may have DLE lesions elsewhere. If not treated early, hair loss is usually irreversible.  Telogen effluvium presents with diffuse hair loss and usually presents 1 to 3 months after a stressful episode, for example, viral illness, surgery, childbirth, emotional stress. Hair loss is never complete and usually stops after 3 to 5 months. Subsequent hair regrowth is usually complete.  Trichotillomania is more commonly seen in children compared to adults. Patients also present with localised hair loss but in a bizarre pattern. Hairs of differing lengths are usually seen within and at the edges of the patches. Patients may or may Dr Khaled Elmagraby not volunteer a history of hair pulling.

Discoid Lupus Erythematosus of scalp

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This patient has severe chronic discoid lupus erythematosus of the scalp. This is a form of scarring alopecia that usually presents as localised patches of hair loss. Early treatment is necessary to prevent scarring. Approximately 10% of patients may have signs of systemic lupus erythematosus.

Dr Khaled Elmagraby

Discoid Lupus Erythematosus of face

 He presents with scaly, hyperpigmented, erythematous plaques on sun-exposed areas.  This condition may lead to severe scarring.  Treatment options include:  Corticosteroids: Topical potent local, Intralesional , Oral corticosteroids.  Topical calcineurin inhibitors.  Anti-malarials. Dr Khaled Elmagraby

Neonatal lupus

 This infant has neonatal lupus. He presents with a characteristic peri-orbital 'raccoon-eyes' rash.  Other similar pink to red macules, which may have an annular configuration, may be seen on the scalp, face and extremities.  The mother is usually positive for anti-Ro or anti-La antibodies but may not have overt lupus erythematosus.  Congenital heart block is sequela that may occur in some infants with neonatal lupus, sometimes requiring pace-maker insertion. Dr Khaled Elmagraby

Angiosarcoma

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Angiosarcomas are malignant vascular tumours most commonly seen in elderly men. They most commonly occur on the scalp and forehead. They present an infiltrative vascular patch or plaque with super-imposed nodules which may bleed with minor trauma. They have a poor prognosis. Angiosarcomas can also occur in areas of chronic lymphoedema. Dr Khaled Elmagraby

Fish-tank granuloma Mycobacterium marinum

 This patient has a fish-tank granuloma, caused by the atypical mycobacterium, Mycobacterium marinum.  It is found in ornamental fish and is commonly seen in individuals who rear fish as a hobby.

Dr Khaled Elmagraby