Acanthosis Nigricans

Describes symmetrical, brown, velvety plaques that are often found on the neck, axilla and groin.

Causes

 type 2 diabetes mellitus

 gastrointestinal cancer
 obesity
 polycystic ovarian syndrome
 acromegaly
 Cushing's disease
 hypothyroidism
 familial
 Prader-Willi syndrome
 drugs
o combined oral contraceptive pill
o nicotinic acid

Pathophysiology

 insulin resistance → hyperinsulinemia → stimulation of keratinocytes and dermal fibroblast

proliferation via interaction with insulin-like growth factor receptor-1 (IGFR1)

Acne Vulgaris
Acne vulgaris is a common skin disorder which usually occurs in adolescence. It typically affects the
face, neck and upper trunk and is characterised by the obstruction of the pilosebaceous follicle
with keratin plugs which results in comedones, inflammation and pustules.

Epidemiology

 affects around 80-90% of teenagers, 60% of whom seek medical advice

 acne may also persist beyond adolescence, with 10-15% of females and 5% of males over
25 years old being affected

Pathophysiology is multifactorial

 follicular epidermal hyperproliferation resulting in the formation of a keratin plug. This in

turn causes obstruction of the pilosebaceous follicle. Activity of sebaceous glands may be
controlled by androgen, although levels are often normal in patients with acne
 colonisation by the anaerobic bacterium Propionibacterium acnes
 inflammation

Management
Acne vulgaris is a common skin disorder which usually occurs in adolescence. It typically affects the
face, neck and upper trunk and is characterised by the obstruction of the pilosebaceous follicles
with keratin plugs which results in comedones, inflammation and pustules.

Acne may be classified into mild, moderate or severe:

 mild: open and closed comedones with or without sparse inflammatory lesions
 moderate acne: widespread non-inflammatory lesions and numerous papules and pustules
 severe acne: extensive inflammatory lesions, which may include nodules, pitting, and
scarring

For people with mild to moderate acne: CKS

 a 12-week course of topical combination therapy should be tried first-line:

o a fixed combination of topical adapalene with topical benzoyl peroxide
o a fixed combination of topical tretinoin with topical clindamycin
o a fixed combination of topical benzoyl peroxide with topical clindamycin
 topical benzoyl peroxide may be used as monotherapy if these options are contraindicated
or the person wishes to avoid using a topical retinoid or an antibiotic

For people with moderate to severe acne: CKS

 a 12-week course of one of the following options:

o a fixed combination of topical adapalene with topical benzoyl peroxide
o a fixed combination of topical tretinoin with topical clindamycin
o a fixed combination of topical adapalene with topical benzoyl peroxide + either oral
lymecycline or oral doxycycline
o a topical azelaic acid + either oral lymecycline or oral doxycycline
 important points about oral antibiotic usage:
o tetracyclines should be avoided in pregnant or breastfeeding women and in children
younger than 12 years of age. Erythromycin may be used in pregnancy
o minocycline is now considered less appropriate due to the possibility of irreversible
pigmentation
o only continue a treatment option that includes an antibiotic (topical or oral) for more
than 6 months in exceptional circumstances
o a topical retinoid (if not contraindicated) or benzoyl peroxide should always be co-
prescribed with oral antibiotics to reduce the risk of antibiotic resistance
developing. Topical and oral antibiotics should not be used in combination
o Gram-negative folliculitis may occur as a complication of long-term antibiotic use -
high-dose oral trimethoprim is effective if this occurs
 combined oral contraceptives (COCP) are an alternative to oral antibiotics in women
o as with antibiotics, they should be used in combination with topical agents
o Dianette (co-cyprindiol) is sometimes used as it has anti-androgen properties.
However, it has an increased risk of venous thromboembolism compared to other
COCPs, therefore it should generally be used second-line, only be given for 3 months
and women should be appropriately counselled about the risks
 oral isotretinoin: only under specialist supervision
o pregnancy is a contraindication to topical and oral retinoid treatment

To reduce the risk of antibiotic resistance developing the following should not be used to treat
acne: CKS

 monotherapy with a topical antibiotic

 monotherapy with an oral antibiotic
 a combination of a topical antibiotic and an oral antibiotic

NICE referral criteria CKS

 the following patients should be referred to a dermatologist:

o patients with acne conglobate acne: a rare and severe form of acne found mostly in
men that presents with extensive inflammatory papules, suppurative nodules (that
may coalesce to form sinuses) and cysts on the trunk.
o patients with nodulo-cystic acne
 referral should be considered in the following scenarios:
o mild to moderate acne has not responded to two completed courses of treatment
o moderate to severe acne has not responded to previous treatment that includes an
oral antibiotic
o acne with scarring
o acne with persistent pigmentary changes
o acne is causing or contributing to persistent psychological distress or a mental health
disorder
Actinic Keratosis
Actinic, or solar, keratoses (AK) 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

Management options include

 prevention of further risk: e.g. sun avoidance, sun cream

 fluorouracil cream: typically a 2 to 3 week course. The skin will become red and inflamed -
sometimes topical hydrocortisone is given following fluorouracil to help settle the
inflammation
 topical diclofenac: may be used for mild AKs. Moderate efficacy but much fewer side-effects
 topical imiquimod: trials have shown good efficacy
 cryotherapy
 curettage and cautery

Alopecia
Alopecia may be divided into scarring (destruction of hair follicle) and non-scarring (preservation
of hair follicle)

Scarring alopecia

 trauma, burns
 radiotherapy
 lichen planus
 discoid lupus
 tinea capitis*

Non-scarring alopecia

 male-pattern baldness
 drugs: cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, colchicine
 nutritional: iron and zinc deficiency
 autoimmune: alopecia areata
 telogen effluvium
o hair loss following stressful period e.g. surgery
 trichotillomania

*scarring may develop in untreated tinea capitis if a kerion develops

Alopecia Areata
Alopecia areata is a presumed autoimmune condition causing localised, well demarcated patches
of hair loss. At the edge of the hair loss, there may be small, broken 'exclamation mark' hairs

Hair will regrow in 50% of patients by 1 year, and in 80-90% eventually. Careful explanation is
therefore sufficient in many patients. Other treatment options include:

 topical or intralesional corticosteroids

 topical minoxidil
 phototherapy
 dithranol
 contact immunotherapy
 wigs

Antihistamines
Antihistamines (H1 inhibitors) are of value in the treatment of allergic rhinitis and urticaria.

Examples of sedating antihistamines

 chlorpheniramine

As well as being sedating these antihistamines have some antimuscarinic properties (e.g. urinary
retention, dry mouth).

Examples of non-sedating antihistamines

 loratidine
 cetirizine

Of the non-sedating antihistamines there is some evidence that cetirizine may cause more
drowsiness than other drugs in the class.

Basal cell carcinoma

Basal cell carcinoma (BCC) is one of the three main types of skin cancer. Lesions are also known as
rodent ulcers and are characterised by slow-growth and local invasion. Metastases are extremely
rare. BCC is the most common type of cancer in the Western world.

Features

 many types of BCC are described. The most common type is nodular BCC, which is
described here
 sun-exposed sites, especially the head and neck account for the majority of lesions
 initially a pearly, flesh-coloured papule with telangiectasia
 may later ulcerate leaving a central 'crater'

Referral

 generally, if a BCC is suspected, a routine referral should be made

Management options:

 surgical removal
 curettage
 cryotherapy
 topical cream: imiquimod, fluorouracil
 radiotherapy

Bullous pemphigoid

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
 there is stereotypically no mucosal involvement (i.e. the mouth is spared)
o in reality around 10-50% of patients have a degree of mucosal involvement. It would,
however, be unusual for an exam question to mention mucosal involvement as it is
seen as a classic differentiating feature between pemphigoid and pemphigus.
Skin biopsy

 immunofluorescence shows IgG and C3 at the dermoepidermal junction

Management

 referral to a dermatologist for biopsy and confirmation of diagnosis

 oral corticosteroids are the mainstay of treatment
 topical corticosteroids, immunosuppressants and antibiotics are also used

contact dermatitis

There are two main types of contact dermatitis

 irritant contact dermatitis: common - non-allergic reaction due to weak acids or alkalis (e.g.
detergents). Often seen on the hands. Erythema is typical, crusting and vesicles are rare
 allergic contact dermatitis: type IV hypersensitivity reaction. Uncommon - often seen on the
head following hair dyes. Presents as an acute weeping eczema which predominately affects
the margins of the hairline rather than the hairy scalp itself. Topical treatment with a potent
steroid is indicated

Cement is a frequent cause of contact dermatitis. The alkaline nature of cement may cause an
irritant contact dermatitis whilst the dichromates in cement also can cause an allergic contact
dermatitis

Dermatitis artefacta
Dermatitis artefacta is a rare psycho-dermatological condition characterised by self-inflicted skin
lesions. Patients typically deny that these are self-induced.

Epidemiology:

 It typically affects adolescence but may present at any age

 it is 4-20 times more common in females

Risk factors:

 dermatitis artefacta is strongly associated with personality disorder, dissociative disorders

and eating disorders
 the prevalence of dermatitis artefacta is up to 33% in patients with bulimia or anorexia
Clinical features:

 patients typically present with linear/geometric lesions that are well-demarcated from
normal skin. The appearance of lesions depends on the mechanism of injuries which may be
either (scratching with fingernails or other objects, burning skin with cigarettes) or chemical
(deodorant spray)
 skin lesions are typically described to appear suddenly e.g. overnight. They usually appear
whole and complete and do not evolve over time. There may be multiple lesions at various
stages of healing
 commonly affected areas are the face (especially cheeks) and the dorsum of the hands
 despite the severity of skin lesions, patients may be nonchalant, displaying 'la belle
indifference' (also known as Mona Lisa smile)
 In the history, there may be recent life events or triggers such as a marital dispute or recent
bereavement

Diagnostic approach:

 this condition is diagnosed clinically based on history and after exclusion of other
dermatological conditions
 biopsy of skin lesions is not routine but may be helpful to exclude other conditions.
Histopathological analysis of self-inflicted lesions is non-specific
 psychiatric assessment may be necessary

Differential diagnosis:

 other dermatological conditions e.g. cutaneous T-cell lymphoma, pyoderma gangrenosum,

basal cell carcinoma, lichen planus, psoriasis
 other factitious disorders e.g. Munchausen syndrome (self-inflicting is not limited to the
skin), malingering (self-inflicting for secondary gain e.g. to avoid work or to gain
compensation)

Management:

 good rapport is key

 direct confrontation is unhelpful and in fact, may isolate patients and discourage them from
seeking medical help
 patients should be co-managed by dermatologists, psychologists and psychiatrists
 dermatological care includes providing occlusive dressing, topical antibiotics (if necessary)
and bland emollient
 selective serotonin reuptake inhibitor (SSRI) and cognitive behavioural therapy may be
helpful, albeit evidence is limited
Dermatitis herpetiformis
Dermatitis herpetiformis is an autoimmune blistering skin disorder associated with coeliac disease.
It is caused by deposition of IgA in the dermis. More than 90% of patients exhibit small bowel
biopsy findings consistent with some degree of gluten-sensitive enteropathy.

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
 dapsone

Eczema herpeticum

Eczema herpeticum describes a severe primary infection of the skin by herpes simplex virus 1 or 2.

It is more commonly seen in children with atopic eczema and often presents as a rapidly
progressing painful rash.

On examination, monomorphic punched-out erosions (circular, depressed, ulcerated lesions)

usually 1–3 mm in diameter are typically seen.

As it is potentially life-threatening children should be admitted for IV aciclovir.

Eczema: Topical Steroids

Use the weakest steroid cream which controls patient's symptoms

The table below shows topical steroids by potency

Mild Moderate Po
Betamethasone valerate 0.025% (Betnovate RD) Fluticasone propionate 0.
Hydrocortisone 0.5-2.5%
Clobetasone butyrate 0.05% (Eumovate) Betamethasone valerate 0

Finger tip rule

 1 finger tip unit (FTU) = 0.5 g, sufficient to treat a skin area about twice that of the flat of an
adult hand
Topical steroid doses for eczema in adults

Area of skin
Hand and fingers (front and back) 1.0
A foot (all over) 2.0
Front of chest and abdomen 7.0
Back and buttocks 7.0
Face and neck 2.5
An entire arm and hand 4.0
An entire leg and foot 8.0

The BNF makes recommendation on the quantity of topical steroids that should be prescribed for
an adult for a single daily application for 2 weeks:

Area
Face and neck
Both hands
Scalp
Both arms
Both legs
Trunk
Groin and genitalia

Erythema ab igne

Erythema ab igne is a skin disorder caused by over exposure to infrared radiation. Characteristic
features include reticulated, erythematous patches with hyperpigmentation and telangiectasia. A
typical history would be an elderly women who always sits next to an open fire.

If the cause is not treated then patients may go on to develop squamous cell skin cancer.

© Image used on license from DermNet

NZ
Erythema ab igne
Squamous Cell Carcinoma of The Skin
Squamous cell carcinoma is a common variant of skin cancer. Metastases are rare but may occur in
2-5% of patients.

Risk factors include:

 excessive exposure to sunlight / psoralen UVA therapy
 actinic keratoses and Bowen's disease
 immunosuppression e.g. following renal transplant, HIV
 smoking
 long-standing leg ulcers (Marjolin's ulcer)
 genetic conditions e.g., xeroderma pigmentosum, oculocutaneous albinism

Features
 typically, on sun-exposed sites such as the head and neck or dorsum of the hands and arms
 rapidly expanding painless, ulcerate nodules
 may have a cauliflower-like appearance
 there may be areas of bleeding

Image gallery

Treatment
 Surgical excision with 4mm margins if lesion <20mm in diameter.
 If tumour >20mm then margins should be 6mm.
 Mohs micrographic surgery may be used in high-risk patients and in cosmetically important
sites (e.g., face). Mohs surgery is designed to minimise scarring at the outset, by creating
the smallest post-surgical wound possible.
 Cryotherapy is used for some early squamous cell cancers, especially in people who cannot
have surgery. Superficial, in situ, or SCC less and equal to 1 cm has been successfully treated
with cryosurgery with results comparable to traditional surgical excision.

Prognosis
Good Prognosis Poor prognosis
Well differentiated tumours Poorly differentiated tumours
<20mm diameter >20mm in diameter
<2mm deep >4mm deep
No associated diseases Immunosupression for whatever reason

Erythrasma
Erythrasma is a generally asymptomatic, flat, slightly scaly, pink or brown rash with fine scaling and
superficial fissures usually found in the groin or axillae. It is caused by an overgrowth of the
diphtheroid Corynebacterium minutissimum.

Examination with Wood's light reveals a coral-red fluorescence.

Differentials: Candida intertrigo although can affect intertriginous areas like the groin, it usually presents as
erythematous, macerated plaques with satellite pustules and is often associated with pruritus.

Topical miconazole or antibacterial are usually effective. Oral erythromycin may be used for more
extensive infection.