Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Um ok, so we'll get started just so that we don't run over time. Um So welcome to the teaching session on skin rashes and it's presented by myself and by Shray. Uh we're both leads for teaching things itself. So if anyone also has any feedback for teaching things in general, please let us know um just so we can improve for future sessions. Um So if you're new to teaching things a little bit about it, it's run by medical students for medical students across the UK and internationally as well. Uh We have doctors who review our teaching slides um to ensure accuracy and yeah, it's weekly tutorials. Uh So if there are any topics that we haven't already covered, uh so far this year, if anyone wants something done, then just please let us know. Um and we can try and fit in in the future. Um We also have a lot of teaching sessions coming up in the new Year as well uh for both fourth years and for 50 years. Um so today's session is going to be on uh skin rashes. So when we think about dermatology quite broadly, there's a lot of skin conditions and um it can be quite confusing with them. A lot of it is just actually being able to spot what something is by just looking at it. If we think about it quite broadly, we can actually split it up into kind of different sections. So uh inflammatory skin diseases are infections or neoplasias or our cancers, things about hair and then the systemic ones. So this is what we usually see uh in other specialties, basically, which overlaps with dermatology and then burns, which is quite a small um area which is not generally covered that much by med schools. Um So today, we're going to be mostly focusing on our inflammatory skin diseases. So these are the very common conditions that are seen um generally by DERM but also within GP um with emergencies as well in A&E as well. So this is eczema psoriasis and acne. Um OK. So uh why is this not just to begin with terminology is a very key component of dermatology? So, um it comes up quite commonly within Aussies. So with our ay last year, we had a station which required us to essentially look at a picture of um of a skin condition um and be able to describe it. And so we have to use the correct terminology um which is a key component of DERM. So in the chart, if anyone can just say what this picture here represents, so it's a lesion, a flat lesion, which is less than 10 millimeters and it's non palpable. So if you just type it in the chart, we'll go through these quite quickly. Yep. Good, perfect, good. And this one here so similar again, so flat lesion, nonpalpable, but it's more than 10 millimeters. Yeah, perfect pouch. Thank you. And here we have a distinct raised lesion. It's less than 10 millimeters. Thank you. Thanks. Um Perfect pap. And lastly, uh lastly now, one more actually after this, so elevated solid lesion well circumscribed and it's more than 1010 millimeters. So this is quite a common one that I usually see. We'll go over this condition later as well. Yeah, thank you. Perfect. And then this is the last one here. So less than 10 millimeters inflamed and pus filled lesion, anyone. OK, recur. So this is a pustule. So this is essentially where a papula becomes very inflamed even more inflamed than it already is. Um You get pus and it becomes filled with pus. Basically, the reason I'm going over this terminology is because it will come up throughout the sbs that we use today and especially when we're looking at ACNE. Um these, these terminology is quite important because it's relevant for the questions we're actually going to go, there we go acne, we're going to go straight into an SBA here. Um I will set up the pole. Um So as a 14 year old boy presents to GP complaining about recent skin changes on examination. He has diffuse papules, pustules and comedo on the face and this is affecting his self esteem and he's keen to start treatment. What is the most appropriate initial management? And I will set up a home, stop it. There we go, try and get a few more answers. And we've got one so far. Oh, there we go. Five. See. How many do we have in this? We have 14 people. OK. OK. We'll go with that. OK. So mostly people have gone for topical Adaline and benzoyl peroxide, which is the right answer. Um So we'll go over why the other ones are wrong first. So, um it OK. So in terms of the key components within this question itself, so the papules, pustules and comedones these, these kind of characteristics of this presentation is what we'd called moderate acne. Um And I'll explain through a bit more about acne in a little bit just after this question. Um So in terms of this presentation, the, the, the acne itself is affecting his self esteem, which is a very common thing to happen with people with acne. A lot of people suffer from self esteem issues and also just anxiety with the skin. Um and he says that he's keen to start treatment. So, ideally, we would want to be starting him on something um especially because it is moderate acne. Um So here, the correct answer was topical Adaline and Benzyl peroxide. Other lines of treatments that we could also go through for this. Um for this presentation would be tretinoin and topical tretinoin and Clindamycin or Benzyl peroxide and Clindamycin. The reason the other ones are wrong. So, an oral retinoid, we'd use that usually with more severe acne. Um it so be more if the other ones don't work, we'd go to that basically uh topical benzyl peroxide. So this is what we call just a single treatment. So we're just giving him topical benzoyl peroxide. We wouldn't really be giving it for something for something like this just because it is a bit more severe than just if he had comedones. Um, we'd be going for more of a combination treatment which is why, uh D is the right answer here in terms of the oral doxy and topical topical clindamycin. So these are two antibiotics. One is oral and one's topical. We don't tend to combine, um, oral and topical antibiotics, which is why, um, with this answer with D is the right answer because it's like a mix of both an antibiotic and, or something else really. Um, and in terms of advising strict skin hygiene routine, this is, in this case, it's wrong but it is something that you would actually say to a patient anyway because, um, you know, they could be doing all these treatments but still going through like quite triggering habits which, um, will just continue to make the acne worse. So, key components is avoiding, over cleaning the skin. So, over washing. So some people tend to because, um, with acne, your skin can be a little bit oilier. Some people tend to over wash our skin, which actually just makes it worse in the long run using, um, Nonalkaline, uh, synthetic detergents. So that's just a normal cleanser. Basically a good cleanser avoiding oil based skin care products or things like makeup as well that are oil based. Um, and just if you are using them, just making sure that you're removing them thoroughly at the end of the day, eating a balanced and healthy diet. So there is. So there's some, some people suggest that things like sugar and dairy can make acne worse. Um I don't think there's real evidence for this. Um, but some patients do report that, you know, it does make their acne worse in which case, like avoid it, avoiding triggers. Um, is also a key component of management, but in this case, because it's affecting his self esteem and he does want to start treatment. We'd advise this, but we'd also want to actually start start him on something. Ok. So in terms of the pathos for acne, um, it's quite important to understand this because it, it determines the medications that we use really and like how the medications actually work. So, um, here we have what's called the pilosebaceous follicle. Um, and what happens is we get hyperkeratinization. So it basically becomes clogged. Um and this means that we get an excess of sebum production. So our sebaceous glands start to produce a lot of sebum, which is basically the natural oil within our skin. This basically becomes like a breeding ground for this bacteria here. So propion bacteria and acnes um and that's what causes an inflammation of the skin um and causes the presentation that we get. So uh usually comedones um is quite a common presentation for mild acne. I think I go over this actually. Yeah, there we go. So mild acne here we usually get mostly Comones. So, Comones are essentially just, um, kind of raised bumps. No, no noninflamed, raised bumps around pore openings, um, which are produced because of this excess semen production. Um, which yeah, basically doesn't, the skin doesn't like, um, when these Comones become more inflamed, we get what's called moderate acne. So we get these papules and pustules, um, that you can see in the middle or two photos here, it can get really bad sometimes. Um, and you can get what's called, uh, nodular cystic acne, uh, which is a severe case of acne. Um, and this is, it can happen quite often. Um, and you see this with patients that have a lot of scarring from acne as well. So, actually, I haven't included it in here, but does anyone know what the most common, um, kind of scarring is in acne? You can just answer in the chat I don't think I included in the presentation. Oh, yeah. Perfect. Ice pick. Um, I don't, haven't got a picture of it and I don't know if it's on, uh, you can't really see it to be fair on these. But, um, yeah, ice pick scarring just have a quick Google of that. Um, it's a very common, uh, type of scarring seen within acne, basically almost looks a bit like punched out holes within the face. Um Yeah, so in terms of management for acne, um so obviously we'd go with our conservative management first. So minimizing stress and triggers and again, don't over wash your skin, thinking about medical management. So this is the medications that we'd be using. We pretty much split it up into the type of acne. It is so mild, moderate or severe acne. Um So with mild acne, we'd actually be looking more at maybe potentially using a single treatment. So this could be a topical adapine, which is a topical um like Retinone, basically topical benzoyl peroxide or a topical clindamycin, which is the antibiotic. Um with mild to moderate some more. On the moderate side, we'd be more looking at a combination of these drugs uh of these topical medications. So which is why our answer in IPA was topical adapine and benzylperoxide usually if this doesn't work. So when we're leaning towards a more moderate severe acne, we'd add on a um antibiotic. So this tends to be um doxy So oral doxy um on top of like the combination treatment itself. So as you can see, topical daple, topical benzyl peroxide with um it, it is more oral doxy that's given. Um And if these don't work, then we'd be looking at doing oral tretinoin, um ISOtretinoin things to be aware of though is uh retinoids are teratogenic. So avoiding these in pregnant women and making sure that if um if a woman is using them, maybe thinking about contraception as well. If they are thinking about um using this. OK, a quick review of antibiotics. I only included this because um I was revising for the PSA but Clindamycin is what family of uh antibiotics just type in the drop. No, OK. I'll carry on it is macrolide and any side effects that we know of macrolides. No. OK. It so we're thinking about Long Qt syndrome P 450 inhibitors and also gi disturbances and for Doxy. 00 my God. I'm so sorry. I didn't realize you had answered. Sorry I couldn't see it. Yeah. Doxy years. Yeah. Thank you. Tetracycline and side effects two. This Yeah, perfect. So uh where is this? Yeah, so don't give him pregnancy. Um it does cause cause photosensitivity. So thinking about using sunscreen in the sunscreen in these patients uh gi disturbances. So yeah, the tooth discoloration. So in pregnancy, one of the reasons we also avoid it is it can cause um this discoloration in uh babies especially uh Yeah. So onto B2. So a 14 year old boy presents to GP complaining about recent skin changes on his face. He has several papules, pustules and comedones. What organism is thought to have a role in this condition? Let me one second. Let me uh oh, let me start po OK. None of you have answered. We'll go with that. OK. So there is actually, yeah, so there are actually two answers for this one. I was a little bit mean with it. So it's actually both C and D Qter Acnes and also proprium bacterium acnes. Um I don't know if you saw it on the slide earlier, but basically uh cutibacterium acnes is the new name given to propion bacterium acnes. So it's the same thing essentially. Um just a new name for it. The only reason I've included this is because um it can still be referred to as either within questions. I've seen it referred to as both. Um although it tends to be, I've seen it more as proprium bacterium. Um but just to be aware of it in case it does come up in, in an SBA as cutibacterium. So you're not thrown off. Um It can be referred to as both. Uh So yeah, so Staph A is Impetigo, the other one is Rosacea and then last one was 70 which we'll go over in a little bit anyway. OK. And then SV three. So an 18 year old woman comes to GP complaining of acne weight gain, facial hair growth. She uses topical benzoyl peroxide which offers some but not complete improvement for her acne. What's the most appropriate treatment to offer her? Let me start you off. Yeah. OK. OK. OK. Quite a bit of a split answer. OK. So you're mostly going between diet or doxy and progesterone only. OK. We'll leave it at there. Is anyone else an answer? OK. So you're all mostly tools or doxy? OK. The answer is Danet. So this is a combined oral contraceptive pill. Um So the stem of the question, so the acne, the weight gain and the facial hair growth kind of makes you think more of PCOS picture. Um And so we'd be thinking more of a contraceptive oral pill, combined oral contraceptive pill for her. Um And because she's already tried this topical benzyl peroxide, um It's kind of two birds one stone in a way, the reason I was a bit mean with this one to be fair. Um I did write as Danet just because they don't tend to use brand names within SBA S but Danet is a good one to know. Um Just generally it is a very commonly used one. So it's a good one to know. Um And yeah, so the combined oral contraceptive pill is a good option for young women with acne even if they don't have PCOS. Um just because it's a, you know, one of the mechanisms is also antiandrogen is the excess androgens, um which can also lead to the excess sebum production. So, if we're kind of counteracting this, we can also help with the acne itself. Um Does that make sense? Ok. OK. And then on to the next one here. So we have a 24 year old pregnant woman since GPA picture of her face is shown over there. I hope he gets clear for you guys. Uh What is the most appropriate initial treatment? Let me just take this one. There you go. It. OK, good. So the majority have gone for topical benzyl peroxide, which is correct. So, yeah, so highlighted point here she is pregnant. Um So topical benzoyl would be our preferred option here. So we'd not be given her a diet, the combined oral contraception, she's she's pregnant uh oral doxy and uh ISOtretinoin both highly teratogenic in terms of the topical retinoid. I've seen like someone said yes to that one. It's not likely to be as teratogenic as the oral uh oral tretinoin, but it's probably not worth the risk um of, of it. I don't know how much research that actually is in terms of the topical one. It is just generally recommended not to be used though uh during pregnancy. Cool. Um Oh yeah. And here's another point as well. So uh I've seen this come big questions but if you are thinking about giving an oral uh antibiotic during pregnancy for acne Erythromycin would probably be the preferred option. Um because obviously avoiding the oral doxy. Um, well, oral uh tetracyclines cool and then on to this next one. Uh let me stop this. Ok. So 21 year old GP his face is shown here below. He's currently, he currently takes oral tetracycline, topical ISOtretinoin and topical benzyl peroxide. What's the best next management of, of this patient? Let me stop. Paul. Ok. We'll leave it at that. Perfect. Yeah. So majority of people have gone for referred to dermatology, which is the correct answer. Um Yeah. So he's on a triple treatment at the moment already with the oral antibiotics already. And he's presenting to GP, which is the key component here. Um Only dermatologist can prescribe oral ISOtretinoin. So we would be, we would be wanting to start him on the oral retinoid, but uh only Derm can do that. So the answer would be refer to dermatology to do this. Cool. So yeah, uh Dermatology have to prescribe it. Laser therapy is not treatment for acne and reassure and discharge maybe if it was mild. Um But yeah, so yeah, the some of the question here says management, not treatment. So just be aware of this. Um I honestly with, with you came there as well, you can highlight the question. So I definitely recommend this just to avoid key words which actually uh which will uh what's the word lead the the answer? Um Yeah. So there's just a few more uh side effects to oral ISOtretinoin here. So it can cause liver derangement. So, monitoring LFT S is quite a key component as well, although not commonly done really. Um as I said, it's already too as well. So avoiding pregnancy, there is some suggestion about it being um a what's the word like can cause depression? I guess. So maybe screening with a phq nine very commonly though the more commonly seen side effects is the hypersensitivity. So, photosensitivity, sorry. Um So making sure that whoever is using it is using a good sunscreen, um SPF 50 can cause headaches, dry lips and dry skin are more are very, very commonly seen within it and myalgia has occasionally seen it as well. Cool and then finally on to the next one, let me stop calling. So what's the likely cause of the presentation shown below? Uh I'll still again the OK, I'm gonna leave it 13 blood. Yeah, perfect. So this is Rosacea. So anyone know the name of what this uh sign is called, I guess. Sign. Yeah. Sign. We'll go the sign. Yeah. Yeah. Good rhinophyma. Um So yeah, this is a uh this is called rhinophyma. So this is basically, it basically translates to no swelling seen in very severe uh rosacea. Um I've included it here. It's a, it's the, the full name of Rosacea is Acne Rosacea. It's very much a misnomer. Um So ii shouldn't really include it in this section but I did. Um, but yeah, so it's a, it's commonly seen with quite severe Rosacea. So Rosacea itself is a circular distribution, usually seen around the nose. It doesn't spare the folds, uh, which is why it can look a bit like lupus. But, uh, it's not, uh, and it can be pustular as well. So it, it, some, for some people, it does look a bit like acne but there are no comedones and it usually presents much later in life. Whereas with acne, you'll see it more in um the teenage years, early twenties as well, potentially. Um And yeah, so one of the complications is what we've just seen the rhinophyma and also posterior blepharitis as well. So I think we've got an SBA next. Oh no, we haven't. Ok. So triggers so we can kind of split up the triggers here. So, yeah, exactly. Alcohol use is good. So um yeah, so in terms of drugs, I haven't included alcohol here, but alcohol is one. So, steroids, vasodilators and alcohol is a trigger for rosacea uh weather. So the sun is a massive trigger for it. And also spicy foods. I think we have an SBA that we do. Uh So a 37 year old woman presents a GP claiming that she's developed this red bumpy skin on her face. So you can see the picture uh which is worse when she's out in the sun on examination. She has papules, pustules with a small amount of talented, talented cheese. Yeah, I can never say that. Uh what is the most appropriate initial treatment? Uh Let me start the b OK, cool. So we have a bit of a split. So, OK. So majority have gone for topical ivermectin, a couple for steroids, some of the retinoid um brimonidine gel. OK. So the correct answer here is topical ivermectin. So just going through the stem again. So we know it's Rosacea um because she has this red bumpy skin, we can see from the picture and the distribution of it. Uh it's worse in the sun, which is a common trigger that we know of and also the papules and pustules and also uh hazy as well. So, uh we'll go through why the other ones aren't right first. So topical brimonidine gel is usually used in Rosacea where there's predominantly more erythema and flushing of the skin. If a stem, if the some of the questions suggest that they have uh Tect Taia, then we think we've kind of rule this option out to be honest. So the way Brimonidine works, it's an alpha two agonist, which means that it causes constriction of the blood vessels. So, within Rosacea, you're getting a lot of dilation basically, which is why vasodilators is a trigger for it. Um So we'd be looking more, if this was less severe, we'd be using uh a as an option really. Um retinoid is not really used within rosaceous, as I said, it's used within acne vulgaris steroids. So, steroids should not be used in Rosacea. Um they can cause initial improvement and then it becomes much, much worse afterwards. So just avoid, it just don't use steroids in this. Um Although within dermatology, steroid is usually the right answer. This is one of the cases where cases where it's not and then metroNIDAZOLE, it's an alternative to ivermectin. So usually if Ivermectin is not working for a patient, then we'd give them Metro instead. Cool. And then I'm gonna hand over to trace to do the eczema bit. Cool. All right. Um So this is eczema. I'm going to go through this fairly quickly. Um Yeah. Uh And if anyone at any point has questions, just stick them in the chart. There's also AQ and a function on, on, on a metal where you can put your questions in as well if you have any, anything that you'd like to ask us. Um But yeah. Right. Let's get going. Next Rayer. Cool. All right. So, very quickly, quick overview of the pathophysiology of eczema. Basically, some people have a genetic predisposition to it. It's very familial. Um So what happens is you'll have minor, very small defects in the skin barrier. Uh And these basically let in a lot of er irritants triggers environmental things which then cause I irritation and that can become a chronic process. So, uh your uh eczema is often associated with a history of ap so things like asthma as well. Uh It's all associated with each other. All they're all kind of immune things. Um Common environmental triggers include dust, chemicals, detergents, things like that. Um It's an IgE mediated type one hypersensitivity uh involving interleukin 17 and 22 which is something for your own knowledge. Um And basically the, we, we treat it uh with generally first line emollient because it's really important to keep the skin barrier moisturized um in order to maintain that skin barrier, sorry. Uh So by, by keeping the area moisturized uh and applying creams, then we can um prevent allergens from outside going into the skin. Um But yeah, OK. Next slide, just one thing to mention with emollients as well, especially with eczema or quite severe eczema in Children doing what's called wet wrapping. So, basically layering on a lot of emollients, wrapping it up overnight just to help seal it and really moisturize the skin especially overnight. Um because some people tend to not want to use quite heavy creams or um IOL during the day because it can make your skin look a little bit more oily. Um Yeah, I haven't really included it in this part in this presentation, but we do have different types of creams. So you have your lotions, your creams and your emollients. So as you go down that list, they become much more heavier and much more thicker, which helps to protect um the loss of like fluids from your skin and help really moisturize it. Um but yeah. Ok, show your next one. Ok. I don't know where he's gone. So, ok, we'll just go into the whilst I give him a sec. So a woman brings her one year old son to GP, she says that he has dry red skin, which is most obvious uh on his back at the, he's diligently applying moisturizing cream to the affected areas but would like something stronger. What is the most appropriate treatment to advise? I'll let you carry on. Yeah, if you launch the pole for me. Sorry about that. Yeah. All right. We'll just wait for a few more of you to answer. Even if you, if you don't know the answer, that's completely fine and that's why we're going through it. Um Just put something down and we're gonna go through it. Um Yeah. OK. So. All right for a couple of more, but at the moment, there's a, there's a split between emollient gel and topical hydrocortisone. We've got a few more answers in. Yeah. Cool. All right. Fine. Um So the most common answer was the Emer Gel. Thank you. So, the correct answer is actually topical hydrocortisone 1%. All right. Um So the, the mother has already been applying moisturizing creams. Obviously, we need to find out which cream she's been uh applying. If it's something that's just from like AAA basic cream, that's not really uh, dermato dermatology tested. Uh, it could have things like, uh, perfumes and, and scents added, which can, uh, actually inflame, uh, the skin more. So we need to kind of have a look at which cream she's applying already. But considering that she said, let's assume that the cream that she's been using is, is, is one, is a good emollient. Uh, we need to stack that up to, to one above that, which is going to be our topical hydrocortisone 1%. So if you go to the next slide, please, we'll go through why the other ones are wrong. Um Yeah, so the emollient is just again moisturizer. So that's we, she's already tried. That hasn't worked. So we'll uh we need to up it. The clobetasol is too strong. Our hydrocortisone, I mean, oh, ok. We'll do the, yeah, the hydrocortisone 5% is also too strong. Uh And the diphenhydrAMINE uh is an antihistamine which you can tell from the ending of the name. Um and antihistamines, they're not really gonna be useful for eczema in this, in this sense because uh they're more for allergies, urticaria, things like that. This is uh hypersensitivity. So, if you go to the next side, please. So, um here's how we manage our eczema. So, um we've got our distribution of uh eczema in adults. It's more on the flexor. So within the elbows behind the knees and in Children, it's more on the extensor. So more on the outside uh our levels of management. So we'll start off with conservative management. So that's Emmons avoiding triggers. Um And if you can get to the bottom of what the trigger is, then that is obviously really, really useful, then we can move on to using some topical steroids. Um And those will often be used alongside your emmolient. Um And you need regular review, obviously using long term steroids isn't going to be good for your skin. Um So, um yeah, so you need to regularly review and only give those steroids really and flares uh and then maintain remission by maintaining that skin barrier with emollients so that those allergens can't get into the skin. Um Next one up is going to be UV phototherapy. This can sometimes help. Um Then we'll go for systemic treatments, um systemic things to calm down the immune system. Um So, yeah, and then last of all our biologics, this is all gonna be done by our specialists. So the dermatologists are going to be worrying about that stuff. All right. Um As brea mentioned, wet wrapping is really useful, uh often it can be really uncomfortable, especially at night um for Children to be completely slathered in emollient, be really, really greasy and it can be really uncomfortable going to bed. Um So that's also another way where if you've got severe eczema, wet wrapping is really good. Um because it keeps that er, emollient contained. Another thing to mention if you do have, let's say an Osk station, you need to counsel some, er, dermatology stuff and a counsel about, er, emollients, you need to make sure that when you have an emollient you're giving it in a, or it's in a pump form. So, like a hand soap dispenser form, um, rather than a tub where you dip your fingers in and, and, and take the cream out and that's because there's an increased risk of infection. Um If you're putting your hand in every day, you do get some cream out, then that cream could get bacteria, you could be applying that to your skin and causing infection. And although it doesn't sound like a massive issue for people who are already uh have a heightened immune system and, and these immune reactions um if it's severe enough that can cause some issues. Um But yeah, next slide, please. Uh One thing to mention as well. Does anyone know the side effects of the steroids and why we're gonna be avoiding using them long term? I don't think I've actually included it in the presentation. So we'll just mention it quickly now. Mhm Yeah, perfect. Thank you. Yeah. So it thins out the skin um if you're using it long term, uh which is something we'd want to avoid really because it's actually not going to uh benefit long term, especially with something like eczema can also cause skin depigmentation as well. Yeah, perfect. Um OK, I'll move on to the next slide. All right, then. So here we come to our steroid potencies. Um This is something to know and, and to learn. Um So the potency, so the mildest is going to be your hydrocortisone. Then clobetasone, uh betamethasone and clobetasol. All right. Um And they have brand names, which is, I think most people just use the brand names because they're easier to remember, to be honest. Um So hydrocortisone is hydrocortisone. That's fine. Um And Betnovate and finally, Dermovate is the most stronger steroid cream. So that acronym that we use is uh this aid memoir helps every budding dermatologist, hydrocortisone. IV. Betnovate Dermovate. All right. Um And those are our steroid potencies um in the previous class where it was where two of the options were either topical hydro cortisone 1% versus topical hydrocortisone. 5%. That is a mean question. That's just AAA test of memory saying if you've done um questions and if you haven't, that's fine, just give it a read um and look at the different algorithms for it. But um yeah, yeah, sorry that was on me. But yeah, 1% is the one that we tend to go for. All right, then uh next question, you're the f one on the ward. A student nurse approaches you saying that her hands are feeling itchy and tight. She denies repeated hand washing um this morning uh because and she's been diligently wearing PPE. Uh What is the most likely diagnosis here. So someone who's not been washing their hands um and has been diligently wearing PPE sorry, this question isn't great, but it's more because I wanted to like highlight a certain point, but we'll go with that. All right. Uh ok, cool. Yeah. So the answer is, bring your next slide, please. The answer is allergic contact dermatitis that's probably from the latex in her gloves which contain PP or yeah, it's her in this case. Yeah. Um All right then. So why is it not the other things? But if you go through and reveal all the things. So, um, ok, that's fine. Leave it, leave it on the last slide. Sorry. So, um, we do patch testing to identify allergic contact dermatitis. Um What is irritant, contact dermatitis? Um It's a non immunological reaction to a substance. Uh that's damaging the skin. So, detergents, soaps, things like that, whereas allergic contact is uh caused by allergens. So that's uh immune mediated. All right. Uh So the reason I highlighted itching tight here is because quite commonly with allergic contact dermatitis, you'll see a sort of rash, especially with things like the hands, you might see a rash more. Um But it can also present as being quite itch and tighty because the skin, the skin barrier just isn't, isn't as protected. It's like a bit more damage. Um It's the same way like if I don't know if anyone else has experienced this but um if you damage your facial skin barrier with too many acts of ingredients in your skin care, it can feel very tight and uh quite itchy as well. It's the same kind of um process almost with allergic contact dermatitis. Uh which is why I've included it here. Um But yeah, apologies again. The question isn't a great one but uh I just wanted to highlight that point. Really? OK. Look like this. Cool. All right. Then another, another S pa for you. Um You're an F one on the coop border coop being care of the older pe of older people. Um The team come to see Mister Smith, a 76 year old male with suspected delirium secondary to a UTI I on a background of Parkinson's disease. Although his delirium and UTI are improving, Mister Smith contains about an intensely itchy scalp. What is the most likely diagnosis here? So if we launch thank you, launch Paul, uh put your answers in. Um And let's go through it. Cool. All right, then uh we'll go through it. Review, review. The answer is seb dermatitis. Um This is a characteristic greasy eczema. All right. So it's a little bit different to normal eczema. Usually you get it on the face and the head. Um That's not to say you can't get eczema there. But um the thing that gives it away is that Seder is a bit more greasy and oily while still being uh a bit like eczema. It's also associated with certain things which we'll go through. Now. Next slide, please. So, yeah. So in infants, er, they can get sub derm and it's called cradle cap. Um, in the elderly. It, or in anyone it can happen on a background of immunosuppression. Um, so commonly we'd be looking at something like HIV, uh, and also in neurological or psychiatric conditions. So, it's, for example, Parkinson's or depression. So, typically Parkinson's disease is associated with sero dermatitis. All right. That's a key association. You need to know it's caused by a fungus probably for you to go to next slide called um Malassezia Furfur. Um So it's an a greasy eczema caused by this fungus. Uh and we treat it with ketoconazole, just topical ketoconazole. Um We don't treat it like with steroids uh as with other types of dermatitis. Um But yeah, that's all about I done I think gave this away if you were listening just before. But um if you ever go with this question, stick it in the chart. If you know the answer, I will, I mean, II did say say yeah, good HIV. Perfect. Um Yeah, that's, that's the thing that we'll be thinking about. I know that SBI hope all these BS are useful. We're trying to expose you to questions then teach you based on. Um Let me know if this is like useful for you guys. Um Just because it felt a bit more a bit more. I know what the word is like. A bit better than just talking to you about the condition. I think it's because a lot of, um, is management. Yeah, exactly. And also just recognition of uh what they look like as well. Yeah. Ok. Uh Your own GP seeing a patient you saw last week, one year old with eczema, you gave them uh hydrocortisone 1% today being brought in with by his mum and has a new rash on the face. Um He seems to be in severe pain, refusing to eat on examination. The face is red with a large vesicular rash. What is the most appropriate management? Are you going to refer to pediatric A&E increase topical therapy to hydrocortisone? 5%. Give oral acyclovir, oral hydrocortisone or oral fluoxil, get your answers in. Um Yeah, so the correct answer is refer urgently to pediatric A&E although there was an image with it as well. Um So basically this is eczema hepaticum uh which is a pediatric and emergency regardless of whether this was eczema hepaticum or not. Uh The fact that the patient has been refusing to eat, I mean, this is coming onto Pe's territory. Um but a pediatric patient who's been feeling less than 50% or 50% or less, um I think for more than a day or so, uh you would just refer straight because that's a red flag symptom uh in a child. Um So yeah, that that, that's a red flag symptom. Also, we know that they've got eczema. This rash rapidly evolving rash is eczema hepaticum medical emergency. We're going to send them to the hospital straight away. They will receive IV, Acyclo Acyclovir. Um But that's not something that you can manage in the community. They need uh lots and lots of intervention and looking after. So, yeah, next question, please. Does anyone know what causes um eczema hepatica on, on a background of eczema itself? Like and why we're giving this uh Cyclovir? You can name the virus. Yeah. Good. HSV one especially. Um Yeah, so HSV one infection um on a background of eczema can basically cause this presentation. So these monomorphic vesicles that you can see on this uh child here um is uh especially on a background of eczema is what's pointing us towards the uh eczema hepaticum and very sick child as well. All right, next, please. Cool. Uh Well, back to Pria to talk about psoriasis. We'll try and uh go quickly so that we can end on time. What I'll do is I'll send the feedback form in the chart. If you do need to head off them, please please make sure that you fill in the feedback form um before leaving because that is we, we really require feed um just help us improve for future sessions as well. And again, if there are any sessions that people want to see, let us know. So we can plan for the future ones next time. OK. So going on, I'm going to keep this fairly quick, I'd say um there's not too much left. So, uh so going over the path of, of psoriasis itself, um I'm not a lie. This slide is kind of confusing and show, made the slide. But essentially what happens is um you're getting immune dysregulation, uh the keratinocytes which uh form your skin cells basically become way overreact, overactive. Um And so you get uh a load of keratin build up which causes these plaque formations that you can see in the picture here. Um Sorry, sorry for you. Um OK. Uh Next slide. OK. So uh we have a 42 year old man comes to GP complaining of red itchy skin on examination. He has multiple red scaly raised well demarcated regions which are visible on the trunk. What is the most likely diagnosis? Uh Let me start the whole. Yeah. OK. I'm just gonna keep going just for the sake of time. Uh But the right answer here is plaque psoriasis. So, plaque psoriasis is the most typical form of psoriasis. Uh Good. We'll go over it in a little bit as well. Uh generalized psoriasis is actually quite a rare form of psoriasis, which is why it's not the right answer I can get why people answered it as generalized though just from the presentation. But yeah, plaque psoriasis. So the in the summer of the questions uh as, as I mentioned earlier, when we were going through the technology, these uh areas which are the uh more than 10 millimeters uh of raised lesions really uh are what we call plaques. And yeah, psoriasis is a condition itself that is presenting in the ses the session is still on. Yes. OK. Um Going on to the next b an 18 year old man comes to GP complaining of an outbreak of dry scaly patches of skin. He has no medical history other than a sore throat last week, what is the most likely diagnosis? Uh Let me start the SBA. OK. Where is the 13? There we go. Ok. Get a few more ounces. Good. There we are. So, yeah, the right answer is the majority of you. Have you have gone for psoriasis, which is correct. I don't know. Have I included? Yeah, I have included a picture. So good. Psoriasis is usually following strep throat. Um So you can see here um If I can convince you these look like tear drops, it's generally described as tear drop uh plaques basically, uh which is a very commonly seen within go to psoriasis um management for this is very much just conservative management. Like obviously, if they're feeling like their skin is quite dry then using emollients. Um but you don't actually need to give them anything in the same way that we would for normal psoriasis. Um Yeah, so post drop, tear drop, scaly rash, clear spontaneously. Um So just yeah, conservative manage, conservatively, manage them. Uh Yeah. So one of your patients, a 50 year old man has ischemic heart disease and psoriasis. Three weeks ago, his medications were changed over the past two weeks. He has significant worsening of his psoriasis. What is the most likely causative drug? Uh, at least still. Ok. Ok. It looks like we're split between amLODIPine and Atenolol. So I am more. OK, we'll move forward. So the right answer is B is Atenolol. So it's beta blockers. Um So there are certain medications which do cause flare ups of psoriasis. Um If I convince you, so, psoriasis causes white uh plaques or blank in French. Um So way I remember is beta blockers, lithium alcohol and ace inhibitors, nsaids and then queens. So antimalarials um is a good way of just kind of memorizing um which drugs can cause flare ups for psoriasis. Um Just a little mnemonic there that I saw in past I thought was quite good. Um Yeah, so I'm gonna move forwards. So a 40 year old man comes to GP complaining of red itchy skin on examination. He has multiple red scaly raised, well demarcated regions which are visible on his trunk. What is the most appropriate initial treatment? Let me stop home. OK. I can get a few months in. Ok. So we're a little bit mostly gone for topical Vitamin D and uh betamethasone. A bit of a split with just the single treatments. OK, we'll go for. So the correct answer is uh is e so it's topical Vitamin D and um betamethasone. So the combination treatment. So, whereas with most dermatological conditions, we're looking more starting with single treatments before we want to double treatment. Uh psoriasis is one where we'd be giving both basically, um especially with a flare up. So uh giving both topical Vitamin D and um a steroid as well. So, um in terms of, I can't remember the exact reason for why Vitamin D helps the psoriasis because I know with psoriasis, you tend to see an improvement when patients are out in the sun. And I think they realized from that, that Vitamin D is a component which is why we use Vitamin D topically for psoriasis um in terms of these medications. So you use them separately. So one in the morning, one in the evening. Although um I think they do now come in a combined single, single cream, I guess, uh which means that you don't need to separate it, but just in case people do use them separately, they do need to be given at different times of the day just because they disrupt each other's absorption. Ok. And talking about steroids. So a 40 year old, 42 year old man, blah, blah, blah with um with psoriasis has been fully compliant with his treatment and has found good relief from eight weeks of daily topical betnovate. How long should he wait before another course of topical steroids. So just thinking back to the steroid slide that we went through earlier, it wasn't mentioned on here but on there. But think about how strong the steroids are, get any more. Ok. So quite a bit of a split answer was the majority have gone for four weeks. So the answer is four weeks. So um between treatments we, because it's a very strong, it's a very potent steroid. So we would be waiting four weeks between usage of it. Uh So that's to be honest, that's just something to kind of memorize and know. Um it does come up quite often in questions uh especially involving psoriasis. Cool. Uh Now on to the next one. So another of your patients has an eight week course of topical therapy. But so, so no improvement in their psoriasis. What is the best additional treatment for this patient? So, thinking beyond uh what we've already given them. OK. So majority of one for UV B therapy, some people thought the oral steroid or cycloSPORINE. OK. So the correct answer is UV B therapy. So uh typically we'd start off as initial treatment, we'd be starting off with that combination treatment of a steroid with the Vitamin D if that fails. Um Then we go on to UVB therapy. So this is a type of phototherapy basically. So usually it's either UVB phototherapy or PVA phototherapy, which is UVA A plus oral sereen. Um having said that though. So in terms of which one we'd go for. So either UVB or PUVA, um this is very much dependent on where it is and the circumstance itself. So UVB is the majority of patients will probably go through UVB, PUVA tends to be um especially with hands. So if you have quite bad psoriasis on your hands, what they can do is you can use topical sore. Um And then essential you put it under UV light. So a bit like when you get your nails done, um you'll have your topical on and on and then you'll put it under UVA light. Um And that's what PVA essentially is and it's commonly used for things like your hands um, occasionally on your face as well, I think. Um But that's just a little bit of about phototherapy on to the next one. So the poor patient is on maximum topical therapy and phototherapy to no avail. What next? So what are we going to do next? Uh Let me stop. OK. We get a few more oxygen. I realize that we're running a little bit over time, but there's like one more SB after this and then we're done. Ok. So we're 5050 so far between methotrexate and cycloSPORINE, they won't have OK, we'll leave it that. So the answer here is methotrexate. Although having said that Sarin and Acitretin are all also used as systemic therapy, but um as first line, we'd probably go for methotrexate. Um before we try any of the others onto the final one. So a 50 year old man was referred to urgently to derm outpatients. Despite maximum topical therapy and phototherapy, he has plaque psoriasis, affecting almost his entire body and he complains of arthritis which is limiting his mobility. His daughter is getting married in two weeks and he asks whether there is anything that will help with his condition, what is the appropriate treatment to advise? So this is our final SBA yes, there we have two responses anymore. Any anyone else wanna answer? OK. So it's between methotrexate and cycloSPORINE. So the answer in this question is uh cycloSPORINE. So um in the some of the questions he's talked about how his daughter is getting married in two weeks. So it suggests that you want something like a bit of a quick fix. Almost. Um cycloSPORINE can produce very rapid improvement with psoriasis. So if you want to use it very short term, have a quick um bit of uh relief from the psoriasis essentially uh just for this uh for this event, then it's a good one to use. Um cycloSPORINE can also be used in eczema as well. Uh One second, I'll answer the question. Uh cycloSPORINE can also be used in eczema as well. Uh Eczema as well as psoriasis as well for this quick rapid improvement. Uh I just seen the question. So in terms of the feedback form. Uh You could just put Pria and tray or just leave it blank if you can't remember our names. Uh Don't worry about it. Um Yeah, so that's the end of uh this teaching session. Uh If anyone has any questions, just let us know in the chat, we'll stay around for a little bit just because I know that we've gone through quite a lot. So we've gone through Acne eczema and uh psoriasis. Um There were meant to be other topics covered today, but I didn't feel like we'd have of time, but I'll be doing another session in January which will be focusing mostly on skin cancers. Um But I'll include in a couple of the um emergency reactions that you can see within derm as well uh in the January session. So, yeah, so we'll be covering everything and, um, um, but yeah, if anyone, um usually because cycle, so the question was why can't you give cycloSPORINE right away? And why is methotrexate used more? Um I think just because cycloSPORINE can't be used long term. So it's more like you use it short term, which is why methotrexate is the preferred option. Um As in it's used quite commonly. Also, I can't remember if I put in that patient had arthritis or not. Yeah. So you with arthritis as well. The methotrexate would um kind of benefit him from two aspects. Um By wait, not this question. Where is he going. Ok. I didn't include it but um yeah, so methotrexate is generally the preferred option um over Cypor because Sarin is generally just used more short term, which is why for this question here, um We use it just for the rapid response, but we wouldn't be using that over like a long period. We'd probably move back onto like methotrexate after this. Any other questions? Cool. If not just um see you in January. Uh This is our last session of this time. Um So again, in the feedback form, please fill it out. Um Trey, can you send it again? Yeah, will do thank you. Um Again, if you have any of the other, any other teaching sessions that you would like us to cover um in the new Year, then please let us know we're in the process of planning out the future events. So um yeah, please please let us know. Thank you. Thank you guys. Thanks for coming. Thank you. Bye.