Dermatology
Eczemas
TYPES
Contact eczema, Allergic, ALLERGENS, Lotions, perfumes, spices, Rubber compounds, Medicines, Chlorpromazine, Antibiotic creams, Steroid creams, Metals, Cobolt, Nickel, Chrome compounds, Chromate (Cr salt) = very allergenic!, (Metallic chrome = not allergenic!), Plastics, Unhardened plastics only, Acrylics, epoxy resins, Plants, Tulips, lilies, herb extracts, Poison Ivy, PATHOGENESIS, Cellmediated, delayed hypersensitivity (Coombs type 4), No reaction at first exposure..., ...but eczema at later exposure., 1 - SENSITIZATION, Antigens (usually haptene) form Complete Antigens when covalently bound to proteins in the living layers of the skin..., Such a "Complete Antigen" may stimulate Cells of Langerhans to a immune response..., ...the activated "L cells" migrate to the lymphatic system and "teach" the T cells of the new antigen..., ...and the individual is thus SENSITIZED., 2 - ELICITATION, Later binding of antigen activates T-cells..., ...Activated T-cells generates inflammatory cytokines..., Spongiosis, Infiltration, Symtoms!, TREATMENT, Elimination of contact allergen, Reduction of skin irritating factors, Sick leave, change of work, LOCAL TREATMENT, Steroid creams, softening cream, Antibiotics if necessary, PICTURES, Contact eczema, Nickel allergy, Nonallergic, PROGRESS, Dryness & small cracks..., ...Rubor, papules, scaling..., ...often 2' infection due to barrier damage., ETIOLOGY, Traumaiterative & skin irritation, Damages barrier function, Detergents, E.g. washing detergent, Diluted alkalis, E.g. soap, soda, Organic solvents, E.g. Alcohol, acetone, OFTEN WORK RELATED!, Specific history on chemicals etc, Rubber gloves may trap mild irritants and cause excessive skin exposure
Atopical eczema, PICTURE, DIAGNOSTICS, Itching skin disease + 3 of:, Debut before age 2, History of flexural engagement, History of asthma or hay fever, History of dry skin over the last year, Visible eczema in flexure or face, INVESTIGATION, ImmunoCAP Phadiatop!, Prick testing (what allergen?), Total IgE, IgE elevated?, Then also do the RAST test for Malazessia, C. Albicans and Mites!, Some clinical signs, Generally dry skin, Patient scratches him/herself, Intolerable to wool, Keratosis pilaris, Vasoconstriction, Toddlers have..., ...itching papules/vesicles on cheeks, ...on extensor side on legs/arms, ...symtom debut when sampling new food, ...lichenification, Adults have..., ...Engagement on face, neck, upper thorax, ...Hand eczema (nonallergic), ETIOLOGY, Altered Tcell function, Excess tendency of IgE production, Psychiatric factors, Scratching, COMPLICATIONS, Contact allergy, Herpex simplex eczema, Molluscum contagiosum, Impetigo, TREATMENT, Creams, Steroids class I-III, Softeners, Kalcineurin inhibitors, (=Tacrolimus), Break the "itch circle"!, Light treatment, UVA/UVB 2-3 times/week
Nummular eczema, New node
Seborroic eczema, ETIOLOGY, Malassezia furfur (?), Inherited
Localized types, Neurodermatitis, Diaper eczema, Picture, Statis eczema
GENERAL
Eczema = Epidermotitis = Inflamed skin
All eczemas are dermatites, but..., ...not all dermatites are eczemas!
Infections
Fungal
Cryptococcus, Affects immunosuppressed patients, Pic (face of man)
Tinea corporis, (=dermatophytosis), Causes a ringworm-like lesion, Pic (scalp of baby), Spread from guinea-pigs, cows etc
Bacterial
Impetigo, Pic (Bullous I. /Back of girl), Non-bullous I, Group A Strep or Staph Aureus, Starts in skin crack, Usually face / limbs, Pustulas -> Breaks -> Honeycolored crusts, Bullous I, Always Staph Aureus!, Erupts anywhere on body, Bullae -> Breaks -> Red sores
Viral
Herpes Simplex, Pic (leg of child)
Herpes Zoster, Pic (scalp of girl)
Fifth disease, Parvovirus B19, "Slapped cheek syndrome", No treatment exists!, IV globulins to immunosuppressed, Pic (hands, 9yo girl), Pic (small boy), Pic (girl face)
Tropical
Parasites
Amoebasis, Entamoeba Histolytica, Pic (abscess /immunosuppressed), Pic (abscess 2), Pic (abscess 3), Pic (Lifecycle)
Granulomatous diseases
Sarcoidosis
Rheumatic nodules
Anular granulomas
Necrobiosis Lipoidica
Accumulative diseases
Xanthomas
Amyloidosis
Myxedema
Neoplasia
Benign
Naevi
Seborroic keratosis
Hemangioma
Fibroma
Malignant
Melanoma
Basalioma, Pic (nose of 72yo woman)
Actinic keratosis
Squamous cell cancer
Lymphoma
Venereology...
Work in progress!
I'll happily receive all and any feedback, suggestions, copyright violations or error reports: danielnygren@gmail.com Got a better idea of how to structure this map? Tell me! Thank you! Daniel Nygren Junior MD / AT-läkare Höglandssjukhuset Hospital Eksjö, Sweden
Hair, nails, adnex organs
Acne
Rosacea
Perioral dermatitis
BASIC KNOWLEDGE OF:
Hidradenitis suppurativa
Hirsutism, Hypertrichosis of women, Relative to culture!, (What's generally not accepted)
Hypertrichosis
Hyperhidrosis
Alopecia
A. Areata
Androgenic A.
Traction A.
Paronychias
Infections of nail bed, Pic (toe), Pic (finger)
Acute: usually bacterial, Treat with antibiotics, (topical or oral)
Chronic: usually fungal (Candida), Treat with antifungal cream
NAIL CHANGES...
2' to Skin diseases
2´to Melanomas
2' to trauma, Nail dystrophy (biting), Pic (9yo boy)
Pigment conditions
Dark skin
Pigmental abberations
Speckled nevus, Pic (forehead of woman)
Hereditary conditions
MORE SEVERE
Ichthyosis, Ectodermal symptom, Hyperkeratosis, dry, scaly skin, TYPES:, I. vulgaris, Appears months after birth, Mostly on the shins, Worse in winter., Cause: Mutated profilaggrin-gene →, No filaggrin →, No water-binding filaggrin residues →, Defected Keratohyaline granules →, No Stratum Granulosum →, Dry skin, Picture (palm), Lamellary I., Symptoms at birth, "collodion baby", Many babies do not survive., Prevalence: 1 to 100.000., Cause: Mutated transglutaminase →, Defected horny cells →, Thick scales throughout body, (sometimes) Ectropion, Pic (hands of 10yo boy), Pic (collodion baby), Pic (baby / adult), Bullous I., =Epidermiolytic hyperkeratosis, Prevalence 1:500.000, Causes large blisters, Worst at birth, improves with age, Scaling is lifelong, Infection causes new blisters, X-linked recessive I., Only affects men. Prevalence 1:3000, Appears soon after birth. More severe than the Vulgaris type., Cause: Lack of steroid sulphatase →, Cholesterol accumulation in the horny layer and blood, Malfunctioning steroid synthesis, ...which may affect placenta, TREATMENT, The common types are helped by, Summer sun, Salty baths, Water-retentive creams, In severe cases: retinoids
Neurofibromatosis, =Recklinghausen disease, TWO TYPES:, NF-1, Most common type. Starts during puberty with "cafe-au-lait spots", Causes:, Light mental or psychiatric conditions of about 50% of sufferers, Neurofibromas, =LOTS of small spherical skin tumors, Can grow to extreme sizes, NF-2, Causes tumors:, Bilateral acoustic neuromas →, Deafness!, Vestibular nerve tumors →, Poor balance & Vertigo, Other brain/spinal tumors, TREATMENT, None exists.
Ehler-Danlos syndrome, (=cutis hyperelastica), Rare, mesodermal. Dominant., Defected collagen →, Extremely pliable skin!, Fragile skin, easily bleeds, Joint hyperextension → damage
Epidermolysis bullosa, Blisters form at the slightest touch, TYPES, Simplex, Dominant dystrophic, Herlitz junctional type, Fatal during 1st year, ETIOLOGY, Defected dermal-to-BM anchoring proteins, TREATMENT, Sterile blister punctioning, Sterile covering, Liberal antibiotics for open wounds
LESS SEVERE
Keratosis pilaris, Autosomal dominant. Common., Cause: unknown!, Follicular bumps, Mainly on thighs and arms., TREATMENT:, Softening cream if necessary., Severe? Retinoid cream!
Keratodermia Palmoplantaris, Dominant. Cause unknown., More common in northern sweden!, Also acquired as rare paramalignant side effect of Lung cancer!, Hyperkeratosis on palms & soles, Fungal infections common., Sharp border between healty skin and hyperkeratosis!, TREATMENT, Softening & keratolytic creams, Severe cases: Oral retinoids
Darier disease, Autosomal dominant., Cause: Mutated Ca2+-ATPase →, Defected keratinocyte maturation, (Sometimes) Mild CNS symtoms, Brownish, moist, follicular keratoses, Smelly due to 2´ infections, Worsened by hot moist weather., Debuts in puberty, DIFFERENTIAL:, Seborroic eczema, TREATMENT, 5% urea cream, 1% chlorhexidine cream against smell
Keratodermia climacteria, Similar to K. Palmoplantaris, but..., only occurs in menopausal women
INTRODUCTION
Diagnostics
BASIS, Patient history, Clinical examination, Lab results, Blood, Urine, Microbiology, Fungal culture, Bacterial culture, If therapy resistant, Virological examination, Commonly done by PCR, Histopathology, Biopsy!, Possible Malignant Melanoma?, Always remove entire lesion!
TERMINOLOGY OF SKIN CHANGES, TISSUE GAIN, Vesicle (small blister), Liquid blister < 0,5cm, Urtica (medium bump), EXAMPLES:, Urticaria., Papule (small bump), EXAMPLES:, Eczemas. Lichen ruber., Confluent papules = A Plaque, Pustule (blister of pus), In reality a small abscess!, Many are aseptic despite their infectious apprearance., Nodule (firm bump), Larger than a papule (>0,5mm), Always firm. Synonymous to "tumor", EXAMPLES:, Dermatofibroma. Nodulous acne., Tumor (firm elevation), Well-defined solid elevation, EXAMPLES:, Basal cell cancer. Fibroma., IMPORTANT:, The term "tumor" chiefly refers to neoplasia. Use with care., Less well-defined? A nodule., A thin-walled, fluid/fat-containing body? A Cyst., Hypertrophia, Thickening of any skin layer., EXAMPLES:, Thickening of palms after hard labour, Crust, EXAMPLES:, Impetigo., Dried exsudate 2' to vital layers of epidermis (and possibly Corium), Hemorrhagic crust = dermal damage!, Bulla (blister), Liquid blister >0,5 cm, EXAMPLES:, Eczema, burn blister., Lichenification, Hypertrophia of ED & dermis by constant scratching. Coarse surface., Useful atlas here!, TISSUE LOSS, Excoriation, Mechanical Rupture, Epidermal & dermal loss, EXAMPLES:, Torn atopical eczema., Scale (epidermal fragment), Visible, coherent squamous discharge, EXAMPLES:, Psoriasis. Ichtyosis., Cicatrix, Scarring after dermal damage, EXAMPLES:, Late stage Discoid Lupus, Sclerosis, EXAMPLES:, Scleroderma., Excess collagen formation →, Thickening of skin →, Thick, smooth feel, Looks taut & stiff, Fissure, EXAMPLES:, Anal fissure. Corner-of-mouth fissure., Linear crack., Commonly mucuos membranes. Little/no substance loss., Atrophia, Thinning of both dermis & epidermis, EXAMPLES:, Age atrophia. Striae., Erosion, Defined epidermal tissue loss, 2' to burst Vesicle or Bulla, EXAMPLES:, Superficial acid damage, (others?), Ulcus (wound), EXAMPLES:, Venous shin wound., Epidermal & dermal tissue loss., NO GAIN / LOSS, Erythema (redding), EXAMPLES:, Common at inflammation., Caused by microvascular dilatation., Visible blood vessels?, =Telangiectasia, Blue-ish color?, Poor saturation / venous dilatation, Macula (spot), EXAMPLES:, Freckles. Purpura., Does not disappear with pressure.
Skin basics
Function, Protection, Sensation, Production, of Vitamin D, Signalling, Social, Sexual, Heat reduction
Layers, Epidermis (top), Barrier to the outside world, From 0.05 mm (eyelids) to >1mm (heels), Dermis, CONTAINS, Capillaries, Sebaceaous glands, Hair follicles (with one Arrector Pilii muscle each), Subcutis (bottom)
ABBREVIATIONS
Abbreviations = less clutter!
BM = Basement Membrane
ED = EpiDermis
SC = SubCutis / SubCutaneous
2' = Secondary (e.g. " 2' infection")
Papulo-squamous diseases
Psoriasis
PIC (Hands), PIC (Buttocks), PIC (legs of woman)
Pustulosis palmoplantaris
Pic (feet), Pic (hands)
Pityriasis rosea
PICTURE
Lichen ruber planus
Pic (leg), Pic (mouth), Pic (lips)
Excoriated crusted confluent purple papules
Erytrodermia
Exfoliative dermatitis
Core curriculum = BOLD
For students taking the KI dermatology course, all diseases in the Core list are written in Bold!
Urticaria etc
Urticaria
Angioedema
Anafylaxia
Toxikodermia
BASIC KNOWLEDGE OF:
Erythema multiforme, Minor, Major (Steven-Johnson syndrome), Pic (hand on 6yo Boy)
Erythema nodosum
Fysikalisk urtikaria
Contact urticaria
Leg wounds
Arterial
Venous
Anaesthetic
Purpura
BASIC KNOWLEDGE ABOUT:
Decubital wounds
Vasculitis
swe "Storkbett"
Nevus flammeus
Infantile hemangiomas
Telangiektasier, "Spider nevus"
Raynaud-fenomen
”Cherry” angioma
Pyogenic granulomas
Lymph edemas
Autoimmune- / Systemic- / Blister-dermatose- diseases
Discoid Lupus
PICTURE
Morphea
PICTURE
BASIC KNOWLEDGE OF:
SLE
Systemic sclerosis
Dermatomyositis
Pemphigus, Pic (Arm of woman), Pic (face of man), Pic (body of same man)
Pyoderma gangrenosum
Granuloma annulare
Xantelasma
Skin manifestations of DM
Bullous Pemphigoid (BP)
Chronic autoimmune disease, Antibodies against type XVII Collagen component of Hemidesmosomes, Causes skin blisters!, Rarely mucous membranes
Dermatitis Herpetiformis
PIC (leg of 2yo girl), PIC (Face of 4yo boy)
Itching
Cause
Patophysiology
Consequences
Psychiatric diseases
Trichotillomania
Urge to pull out hair
a.k.a. "Trich" or TTM
