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Hi guys, I'm Jade. I'm an F One X Imperial. I'm currently doing my S FP in the West Midlands. Can you hear? AC? Ok. Yeah. Ok. Uh So I'm living the dermatology tutorial today. Um I know dermatology is one of those smaller topics that come up in finals. I know a lot of people kind of focus on the bigger specialties like cardiology, rest and so on. But the thing with dermatology is that even though it might not be one of the bigger specialties, it's those questions that really help differentiate um getting very, doing very well versus just passing in your exams. I've in the tutorial, I'm going to cover all the conditions that come up in your MLA um learning outcomes. And I put that at the end of the slide just to show you kind of how I've mapped everything together. Um So hopefully it should be reduced for tutorial and it's SB based. So I hope you guys can help contribute to the me teeth. So starting off just briefly, I'm going to go over the layers of the skin. So starting with the epidermis, that's the outermost layer of the skin, the skin, the layer of the skin that provides protection, protection. This is where you find cells like melanin, you'll find like the L cells which um help with immu with immunity. Um And there's some waterproof layer that helps protect your skin within the epidermis. You have the stratum corneum, stratum, laid, stratum granulosum, stratum spinosum, the stratum basal, I'm not sure to what degree you need to know how much about each layer of the skin. However, it is useful relatively to just know the order of them and to know that the epidermis is the outer most layer, the dermis is the middle layer and the hypodermis layer is the innermost layer where you'll find the fat in the muscle and the nerve endings, the epidermis, like I said will have the bein and the immune cells and then the dermis as well. You'll find like oil, um hair follicles and like oil glands and sweat glands and so on. So, if you're looking at a condition like eczema, for example, that's going to affect the epidermis because that's the surface of the skin. But some conditions like folliculitis which is inflammation, the hair follicle will be found at the dermis because that's where the hair follicle originates from. Uh moving on to my 1st 1st SBA. If you can please join Menting, that's the code on the slide. Just check that before with it. OK. Yeah, I can see someone's already tried answering. Thank you. Um So yeah, this is the case. So this um Mn Af because you guys will be sitting down next year. So a 17 year old female presents with facial papules, pustules or condoms worsening over six months, especially around her forehead and cheeks. What is the most likely diagnosis? Um I'll give you around 20 seconds to answer, I think. Yeah, two of you guys have answered it already. So I think that's everyone is here today. All the amount of today. Yeah. Um So yeah, it's acne vulgaris. Um So what is acne vulgaris? So it's caused by sebaceous gland hyperplasia and extra semen production, which leads to a differentiation and colonization by bacteria. It's a combination of both inflammation and immune responses and can be due to endocrine disorders can be genetics and family history. Some medications can exacerbate acne. So things like the combined pill, for example, and it could be environmental. So like obviously personal hygiene will come into play some um things might irritate the skin. So someone with like a more sensitive type of skin is more likely to develop acne with someone who's not um key features. So there's down. So these are these types of papules that you can see at this kind of pic picture here and then you have sorry that you have papules or pustules. So you can see kind of this diagram that shows you the difference between papules and pustules. Um pustules essentially have a white head papules don't have a white head, both or essentially in the dermis layer of the skin as you can see in this diagram for the management of acne. So, oh and then these are different images showing you different types of how les and pustules and cysts can look on a face for the management. So if they've just got the calone, which are these kind of white heads over here, topical retinoids are tend to be the first line. And then, so um and you can add in topical benzoyl peroxide as a second line. If topical retinoids don't work on. So, topical retinoid are things like tretinoin. Um Adapine is like one of them, but I would just know tretinoin. I don't think you need to know more than one. If it's acne with inflammatory p uh papules and pustules, you can add in a topical, you can add in a topical antibiotic. So that can be things like Clindamycin, Erythromycin Minocycline. And then if it's severe acne, then you would move on to the oral retinoids. So things like eyes or retinoid um if it's a child, so Children over 12 years of age, you'd give 0.10 0.5 to 1 mg per kilogram daily, orally given in two doses. If it's an adult at 0.5 to 2 mg per kg daily, given in two doses. Um when women are put on retinoids, they have to be on some form of contraception or at least there has to be a conversation about um what they're doing about reducing the chances of getting pregnant because as I'm sure you might know is retinoma and oral re are associated like fetal abnormalities. Um And then in the UK that like they had to categorize women before they put them on is in and have that conversation actually legal before they prescribe it for them. Um If it's hormonal acne related. So for example, that's something you in the history. So if they're coming in saying that the acne is worse, worse around their period, then you can consider adding in the combined contraceptive pill. Um As well. If everyone have, if anyone has any questions, feel free to just send a message in the chat and I'm happy to answer throughout. Um moving on to the next case. So a 36 year old female presents with dry inflamed patches of skin, particularly on the hands and the back of the knees. What is the most likely diagnosis? No fix? Yeah. So I think you guys have got your eczema um eczema and are two of the most common dermatological conditions are the ones that are most likely to come up in your exam. Um Like I mentioned earlier, eczema is in the epidermis. So the outer area of the skin which is responsible for like that protection against like um just general protection, but also that waterproof barrier and eczema can be due to genetics. So if there's a family history of it, it could be used due to immune system dysregulation. So if someone already has an autoimmune disease, they might be more likely to develop eczema and it could be environmental um for the diagnosis criteria. So the way they uh to, to have a diagnosis of eczema is a clinical diagnosis, a person has to present with itchiness and then three or more of the following. So visi visible flexural eczema involving the skin creases. So for example, that would be um bend at the elbows like it was in this case or behind the knees. If it's in a child under 18 months or younger, it could also be like on, you could add in the cheeks and extensor areas, but in the adults flex flexors, um if they've got a personal history of flexor or eczema or eczema on the cheeks again or on the extensor areas as a child, personal history of dry skin in the last 12 months, personal history of atypia or allergic rhinitis and then onset of symptoms before the age of two. And that's usually in Children. So it's not really benefit in adults um for the management. So there's obviously the psychological aspect of um eczema. They use what they call the easy score to determine the degree to how much eczema is affecting like um the quality of life of patients because unfortunately, eczema is one of those conditions that doesn't really have a cure. So the treatment is mainly focused on the management and you guys might have heard the phrase of like eczema far. So like if a patient is like stressed or going through something, they're more likely to have their eczema worsened um to the E score kind of helps support, keep in mind the psychological aspects of see if any extra support is needed. And that's also relevant when you get to kind of further line of treatment. So for example, so moving on to treatment and management, you start off with conservative um obviously, that would be avoiding anything that could worsen skin, so harsh soaps and detergents and then using things like a more to rehydrate and improve the barrier function of the skin. So 3 to 4 times a day and they can use topical steroids in severe flares. So they start with the weakest effective steroids for seven days. So the weakest steroid would be something like hydrocortisone and then they'll move up the um steroid la ladder as kind of um as time goes on depending on kind of how the patient responding, responding to treatment. Um If those two systems, if those, if e and topical steroids aren't helping, then you'd move on to things like topical calcineurin inhibitors. So that could be things like um sorry, I'm really bad at pronouncing drugs but things like Tachina or like pin um if indicated. So this is where things like the easy score become more and more relevant because in the NHS, if you want to put patients on these like third or fourth line of drugs, especially in the top and especially like dermatology, doctors have to apply for funding. Um And so it's important to show how much symptoms are affecting the patient's life, uh day to day life and then moving, if the topical carin inhibitors don't work, then you can add in systemic treatments. So that would be things like azaTHIOprine cycloSPORINE and methotrexate, very severe disease. And and um you could also add in, sorry, I forgot to mention oral antibiotics. So, oral antibiotics though, they'd only be really indicated if there's evidence of infection on top of the eczema. So things like cellulitis and vertigo or like um eczema like um or the eczema is itching like you see like weeping or any just signs of infection, then you would add in the oral antibiotic. Otherwise, then you just move up to systemic treatment. Like I said earlier. Um phototherapy can also be considered and for itching. They recommend a sedating um antihistamine at night or something like hydrOXYzine um to help manage any itching. If anyone has any questions or if I speaking too quickly, please do let me know. Um otherwise I'll move on to the next condition. So a 35 year old female presents with raised red plaques covered in sary scales on her elbows and knees. Um These have been getting worse over the past six months. And what is the most likely diagnosis? Ok. I think, yeah, you guys have got on this one and psoriasis also relatively common. Um it's come from dermatology. So, psoriasis is a chronic inflammatory skin disease. It's not unclear what's the most common cause that causes it, but it could be genetic. So there's a 50% risk for example of someone developing psoriasis if both parents haven't, um it can be triggered by things like stress. So like I mentioned earlier, eczema can flare up because of stress. So, psoriasis could as well but also trauma could worsen psoriasis. So if a patient does have a history of psoriasis and they have a surgery that scar can actually get psoriasis developed on top of it. And things like infection can also worsen psoriasis and they're more likely to also get scarring, which is a form of scarring. If they do have psoriasis, some drugs can uh make the patient more likely to develop psoriasis. So things like lithium uner and beta blockers, I have had that on the slide because it comes a bit lower down kind of a list of causes. Um And then yeah, if so, um psoriasis also obviously has a lead to psoriatic arthritis which is might be more might be related to the joint swelling or pain. Um psoriasis also affects the epidermis. So it's the reason why it happens is because you get the hyperproliferation of the epidermis and proliferation and dilation of blood vessels in the dermis, which then leads to inflammation of the inflamma inflammatory cells and the symptoms associated with psoriasis, which were quite difficult in this case. Um Both words that you're likely to see in exams um would be like silvery white scale knee circus PPIs and plaques. Um If you see silvery and white nine out of 10 times, it's probably going to be psoriasis. Um It will often affect the elbows, knees, extensor limbs and scalps, extensor limbs. So that means please of the elbow back up. Um There is an association with psoriatic arthritis like I told you guys and about that would be in about 30% of patients. There are different types of psoriasis, but the most common one is chronic psoriasis and it could be a clinical diagnosis. And so how there is what they call an easy score for determining the psychological effect of eczema. There's what they call a pea score for psoriasis uh for the management. So again, it is similar in the sense that you always start with avoidance because they tend to be more gentle on the skin and avoiding exacerbating like chemicals or detergents and so on. 2nd 1st line therapy is usually a topical course of a steroid plus Vitamin D So again, talking about steroids, you always start with weaker steroids and move up the steroid ladder. Phototherapy can work for some patients. It doesn't work for others. So the and evidence on that is a bit kind of not as strong as some of the other options mentioned on the slide. Um If this topical corticosteroid and Vitamin D and the phototherapy isn't working, then you move into nonbiological drugs. So the methotrexate cycloSPORINE and, and acid tre and then if that doesn't work, then you move on to the biologics which require funding and um can be a bit more difficult for patients to access. So that would be things like Infliximab, Adalimumab and Etanercept. Um but for a patient to get to the biological drugs, the psoriasis has to be pretty severe. And if a patient kind of finds themselves approving a biological drugs, there is scope to kind of set them down and try other forms of treatment that's pretty much psoriasis covered and obviously psychological effect of the PZ score, which I told you about. So that looks at things like how and widespread is the psoriasis on the patient's body like relative to their body area? Um How many times a day does their like psoriasis bother them? How many times a day does the psoriasis um affect their day to day living and things like that and that's how they score higher and lower. Um to figure out the psychological effects of the drug and similar to eczema psoriasis isn't really curable, but it is not as treatment is about the management. So it is a condition that stays and even if a patient's psoriasis goes away, they, it could come back later on in life because of trauma, because of stress, because of any one of the reasons I have spoken about four case, um, a 32 year old male presents with itchy red and scaly rash on his hands, which happened after using a product was the most likely diagnosis. Yeah, I think it's a nice question. It's contact dermatitis. Um, I will say after using a new cleaning product is a bit of a clear kind of gives you a very clear idea of what it is. But generally that's what contact dermatitis looks like. And looking at the ma pass paper questions, they, they've got example papers on the website, you dermatology question is likely to present as a picture with a bit of a background and then they'll tell you what is the most likely diagnosis. Um So contact dermatitis is an inflammatory skin reaction triggered by direct contact with an irritant. Um There's different types. So there's irritant, contact dermatitis. So if there's like repeated exposure to something that irritates the skin, then that that's what would be, it can lead to inflammation and it can be allergic contact dermatitis. So the immune system is already sensitized to an allergen that leads to delayed hypersensitivity reaction and then they get an inflammatory response upon reexposure investigation. So the gold standard would be patch testing, as you guys might remember from pathology. Last year. And then management, conservative, conservative would be avoiding like harsh soaps and detergents. And then if they've got urgent contact iritis, then every time they come in contact with the, with the irritant they can um they would take a morning and then topical corticosteroids, um which depend on the site and the severity. And then that also differs between adults and Children. But you would still use the same concept of starting with the weakest and moving up that steroid bladder. So for example, if it's a an adult with dermatitis on their face, they might just need hydrocortisone. But then you might be able to use a stronger form of steroid on other parts of the body, like the palms of the hand or like the arms which might tolerate stronger steroids compared to the, for example, and skin around your face, an urgent contact uh dermatitis, you start with a topical corticosteroid. So you start with things like hydrocortisone, which you can use on the face like I mentioned earlier. Um medium potency, corticosteroids are things like betamethasone and like fluticasone can be used on the Toso and then other parts of the body that can tolerate kind of these stronger steroids. If that doesn't work, then you move on to topical calcium inhibitors. So um they can be used, these are very useful like thin skinned areas. Um where if you use a a steroid that may lead to like skin atrophy, IV hyperpigmentation and So on. Examples of those would be things like charius and they usually tend to be quite effective treatments and then if that doesn't work, then you can move on to photo therapy. So this is the fifth ba um 25 year old female with an itchy rash with raised red wells on her arms and torso that appeared three hours ago. She has, she has, she reports experiencing swelling in her leg and has a history of allergic reactions to shellfish was the most likely diagnosis. Ok. I think you guys got this one as well as urticaria um which can present with angioedema with or without angioedema. So uh for this one, it's an IgE mediated reaction. So usually what happens is um the immune system gets activated leading to uh cells like mast cells and basophils also getting activated. These cells are found obviously all around the body. And then once mast cells are activated, you get degranulation which leads to the release of vasoreactive um um vasoactive mediators of things like histamine. You could try and C four and prostaglandins. These then lead to vasodilation, uh vascularity and then presents as edema and pruritus and the symptoms associated with urticaria. You can also get a delayed release of cytokines which can lead to um also the inflammatory response and like the inflammatory lesions associated with urticaria. Um I think that's basically a lot of detail that covers the etiology of it. It can be caused by things like drugs, um food or insect bites, it could also be associated with like contact reactions. So things like grass, animal live and latex and it could be also associated with like immune complex diseases, like post viral and so on. Urticaria could be acute or chronic and the main thing is just the length of it. So if it episodes occur over less than six weeks, then it would be acute over six weeks would be chronic. Um, if it's acute urticaria, it's usually self limiting, usually self limiting and um results on its own. But if it's chronic, it's usually idiopathic and it can be associated with autoimmune disease. Um So management will obviously be avoiding the triggers. And then if it's acute urticaria again, depending on whether or not there's angioedema. And if there's any immediate threat to life, if there's ever the angioedema, you start with the A and you'd have to give im adrenaline IV and histamine. So you essentially treat it like, um if the airway is fine and there's, if the airway is fine and there's no kind of immediate threat to life, you could just add an antihistamine and consider a course of like predniSONE if it's chronic urticaria. So you have to screen the patient for any other autoimmune diseases, they might be having associated with it and then treat any underlying I instances you can give antihistamines and then that could be sedating if you want to give it in the evening or non sedating. If we give it the other day and you can consider H two antagonists or steroids. You could also use like cycloSPORINE, but that would be the kind of 4th, 3rd, 4th line treatment. So it's a bit further down the pad of management options. If you guys have any questions, please just send a message in the chat and I'm happy to get back to you. So basic. So, a 55 year old man from Australia presents with a raised lesion with central ulceration on his moves that has been growing over the past year. It's painless but occasionally bleeds. What is the most likely diagnosis? Ok. I think you guys got this one as well. There's quite a lot of buzzwords for this for this case, it's basal cell carcinoma, which is the most common non melanoma associated skin care condition in the world. And it's uh caused by period potent cells in the epidermis and follicular epithelium. A lot of the buzzers on this kind of if you see these buzz words nine out of 10 times again, going to the basal cell carcinoma. Currently raised lesions, central ulceration and slowly growing are three very typical descriptions of this case. Um The biggest risk factor of everything is going to be sun exposure. So sometimes in exam questions, you might see something suggesting something like that from Australia like I did in this case. Um It could also be genetic and then people who are like immunosuppressed because of other conditions, like someone's post transplant. There were no immunosuppressants for whatever reason, they're more likely to develop a cell carcinoma. Um The key features of it, it's a very slow growing cancer that rarely metastasizes. As I told you earlier, it's a per nodule with the rolled edge, you can also be told to have angiectasia and then again, it could be scaly red clots. But I think per nodule is essentially the main buzzword. You, you would, I would expect to see in an exam question. Um Another way to be for it could be described as a nonhealing ulcer or a nonhealing sore. Um So just keep that in mind in dermatology, I think if it's cancer or just always excision, other options could be cryotherapy, curettage, and radiotherapy and photodynamic therapy. But because it doesn't really metastasize excision usually helps manage it, you know, appropriately and then they could be put on topical management on top of the lesion. Um So if there's like any margins that on healing, they can see any margins, they might give them a topical or flu to help them with the treatment and reduce recurrence. This is a spot diagnosis. Hopefully, it's quite familiar. Yes, I think you guys got this one as well. It's a melanoma. Very characteristic. I read it has pretty much all the features. So it arises from me which beyond the epidermis and then risk factors would be things like sun exposure. So all, all dermatology, cancer is the biggest risk factor is sun exposure. And then obviously, it could be genetic. And then um there's different skin types. I haven't really covered this in this presentation. So the Fitzpatrick skin types uh Fitzpatrick one type one is basically the pain of skin and then as the number is a dark of the skin tone. So um this factor type one skin is most likely to develop melanoma um for the diagnostic criteria. So it's the A to E um abbreviation that might be sorry, there's different types of Melanoma. So it can be superficial spreading and it could be not, you know, superficial. Uh Melanoma is the most common type in 55 to 60% of cases, whereas ano in 10 to 15. Um So for your superficial type, the diagnostic criteria is the ABCD E criteria. So A is asymmetrical. So as you can see in both these images, um well, this one, this is a superficial one you can see it's very clearly, it's asymmetrical, the borders are regular. Um there's kind of radiation and changes and then it's different. So it's it looks different compared to like other moles in the body. It it is changing and evolving over time and that would give you a kind of indication if there could be Melanoma. No. So that would be in this case, you see it's elevated, it's firm to touch and growing. Um If you want to assess the prognosis of melanoma, then you look at the breast the thickness. So that's the measurement of millimeters on the skin surface of the deepest part of the skin. And the larger the number, the worse the prognosis. Again, just like uh basal cell carcinoma. The treatment is why they're called excision. You do, you can include systemic therapy of this cancer, especially because it can um metastasize. So it would probably be more common to use in Melanoma. And that would be things like biomo and immune immune modulating therapy as well as radiotherapy. Again. It all this depends kind of on the stage at diagnosis, the stage um the grade of the cancer at diagnosis has it metastasized or not. Um And that helps guide any other treatments. But the main thing is just wide local position and then systemic therapy with vis if indicated eight questions. So a 70 year old male presents with a firm red nodule on his ear that has been slowly growing over the past six months. It has a scaly surface and occasionally bleeds but is painless. What is the most likely diagnosis? Ok. I think not all of you guys are answering the questions. Um It would be great if you could. Um I know some of you guys might have lost the. So I'm just gonna say the code again. It's 7118 8840. It'd be great if you guys can join. Sorry, I can't see the chart, but if someone can write you in the chart, so, so you can join. That would be great in the interest of time. Um So, yeah, a squamous cell carcinoma. Um that's the second most common nonmelanoma, non melanoma, skin cancer worldwide. Secondary to basal cell carcinoma, it arises from keratinocytes. And um again, the big biggest risk factor is similar to all the other cancers we've spoken about is sun exposure, genetic Fitzpatrick type one skin and then immunosuppressant for whatever reason for the monitor. Uh So the precursors actinic keratosis, these are skin changes that might look similar to the picture, but there are clear differences. So let me just go back. So for example, this one is being described as like like um it bleeds, but it's painless actin kosis would not bleed. It would not be a full red nodule. It would just, it would, it would just look a bit less red than this. Essentially, I should have probably put a picture of actin Kratos. Essentially, it's just skin damage. What you would when I say skin damage, what does that look like to you? That's probably actin Kratos. Um It looks like an enlarging scale, a crusty which is painful, it rarely metastasizes, but it's more likely to compared to basal cell carcinoma. And if you look at histology, you'll see squamous epithelial cells rising from the epidermis and extending into the dermis if it doesn't, um, extend. So, if it's just in the epidermis, that it would be called Bowen's disease. But Bowen's disease is a form of squamous cell carcino for the management. So, squamous cell carcinoma is a bit different in that you excise within 3 to 10 millimeters of the margin from the normal tissue around the tumor. And so, depending on the site and depending on the size of the tumor, you might need a skin graft or a skin flap. Um If it's a low risk tumor on the trunk and limbs, you could shave it. But usually excision is the first and most effective form of treatment. Cryotherapy works for small or low risk tumors. And again, you can use mo microscopic surgery for like facial lesions because mos is less likely to have it is mo is more likely to have a more forgiving cosmetic um effect, which is quite relevant. Dermatology. Radiotherapy can be used if the patient is like in inoperable or it could be used as an adjuvant. But like I said, Metastasin is quite rare and usually excision doesn't work quite well. Um You would only add radio radiotherapy if it's indicated for the reasons I've listed on the slide. So this is nine, a 30 year old male presented with multiple light brown, slightly scaly patches on his upper chest and back. Um The itching is worse after sweating but he denies any other symptoms. Sorry, this is not the right picture. It might be on my mentee. There you go. The right picture is all the mentee. Um Hopefully you guys can see it. If not, I'll share the screen, we can't see it. Yeah, let me share it with you just a second. I'll share that screen. Mhm. Ok. That's the right picture. I oh uh OK. If you guys can please it for all right, it's been a while since I've moved too. Is it not working? Can you guys not? I see I'm just gonna show back the uh slide. So in this one, the diagnosis is pretty clear on the picture is quite typical but I think the history is not perhaps not really clear as much. Um I think you guys got it but it's to your eyes as fury color. So um but for cutaneous fungal infection, so when I was looking at the m conditions that you need to know, they haven't actually me in this now that you need to know cutaneous fungal infections, that essentially is what this is. And then there's another condition that I'll go into in a bit. So PSIS versicolor is a fungal infection caused by Melas Fervor. It diagnosis is by hyperpigmented brown pink lesions on this trunk. Um You might have heard of it looking like a reverse, I think you have a condition. Um but it's more noticeable after a suntan and it can have a mild, mild pruritus. The management is ketoconazole and topical antifungals. If it fails to respond, then you can consider um sending shavings and using oral antifungals. If a patient is going to be on oral anti fungals, you might want to include um N FT S in your management plan. Um That's another picture. That's a picture for you. And then Seborrhoic dermatitis is actually another um technically uh cutaneous fungal infection. It's an inflammatory reaction associated with the same fungal infection associated with um pityriasis and it's associated with HIV of Parkinson's. Its diagnosis is by eczematous lesions on se rich areas. So that would be on the face, especially around like the periorbital fall fall. So around the cheek, the periorbital area as well as the knees and ele fall. So around the cheeks, around the nose, the scalp and then they can get other symptoms. So, blepharitis. So that's like dryness around the eye eyelids or a tight external. So that would be within the ear. Again, the management is pretty much the same thing. It would be ketoconazole shampoo. You could include over the counter pre uh pre over the counter preparations. So like zinc pyro, that's like has the shoulders basically and t is like Neutrogena and like other skin care brands that you can find in the pharmacies. Um you could include like topical corticosteroids for short periods of time. But generally speaking, ketoconazole is the management. So if you do get a condition in and that's the picture of it if you do get a condition in your exam and it sounds, you know, you know, it's a fungal infection. A safe bet would be to put ketoconazole as the management even if you're not familiar with the condition. Uh because it's usually a very effective treatment in patients with fungal infections, especially in dermatology. Um So a 24 year old male presents with small rough flesh color, fleshy colored growths on his fingers in the back of his hand. They're painless. Um So what is the most likely diagnosis? Ok. So this one's got a bit more of a range of answers. So I think just to recap. So, squamous cell carcinoma would be the nodular lesions that I spoke about, especially in um sun exposed areas. Um actinic keratosis is skin da sun damage. So, II should have put a picture of it in the sides, but I'm happy to show you guys a picture of it at the end of the presentation if you guys want. Um Again, if it's a condition like squamous carcinoma or keratosis, you would expect this lesion to be in an area that's heavily exposed to skin. So that would be something like the back of the neck, the scalp, the face, the back of the hands. I think the palm of the hands wouldn't be as common. Um And then warts, which is the right case. Uh right diagnosis in this case would be flesh colored growth which you can see in the picture commonly kind of at the base of the feet and the palms of the hand um moving on the management. So, yeah, in this case, it'd be a wart and I've put another picture of it on a different skin tone because I think in dermatology, there is a pattern sometimes with people with conditions being familiar of some skin tones more than others. Um So it's caused by the human of of a virus infection. And risk factors would be water immersion like swimming. Um You might to give like in your a a hint about like these lesions showed up after swimming in like a communal swimming pool, the ocean stuff like swimming pools, um occupations hand like meat or fish. So again, it might be like an as a hint, nail biting and it's more common in like Children than adults and immunocompromised. Um diagnosis would be these elevated round high. These skin papules, the lesions tend to be quite slow growing. So I do appreciate why it can be confused with squamous cell carcinoma. But I think the same squamous cell carcinoma, you're looking at something that um s skin sun exposed areas, you're looking at like firm nodules as opposed to a papule, which is this case, I think I might have mixed up earlier. I said squamous cells, a papule. So squamous cell is a nodule and this is a papule. Um You might see tiny black dots on the surface of the lesion. And it's usually a clinical diagnosis as dermatology, to be honest, except the cancers and the management is usually conservative. So, swing away or they just put d tape over them if it's a, if they, um, medical treatment is indicated and they just divide it and then just put something like salicylic acid cryotherapy or silver nitrate. You can include local immuno therapy. But that's only if it's an immunosuppressed patient. So they wouldn't really give it to like global, they wouldn't really give it to patients otherwise, if it's severe and it's not improving, you could excise the warts and the problem with warts is that they show up in clusters and you could give um topical equipment for F four whites. So f or four warts look like kind of like skin tags almost. Um, uh This picture is showing you kind of wore the P type for which are more common. So, SB 11, um, a 30 year old female presents a small red bumps and pustules around hair follicles on her thighs, which she developed after shaving. Um, what is the most likely diagnosis? Again? I put two pictures. Um, here just to show you what this looks like a different, different skin tones and I'll just change. Yeah. So this one is quite straightforward. It's folliculitis. I think the shaving kind of gives it away if it's not the shave, you can very clearly see that all this like inflammation is like where the hair is coming out. So, you know, it's likely to be a folliculitis which is inflammation of the hair infection and inflammation of the hair follicles. Um called, like I said earlier, uh shaving is a big one, diabetes and immunosuppression risk factors. Um it's a clinical diagnosis, but if it's really bad, you could do a skin swab or take skin screen thing to set for a culture um to help guide management. But most of the time it's usually staph auras that causes it and its areas of bal hair growth, like the head, the neck, axilla and the groin. So um where it's more likely to develop if it's um for the anti like antibacterial soaps, I mean, because it's stuff or you can, you can, you tend to use CPS. Um and the most common used antibiotic used in this case would be something like Kela. Um if you want to add an oral antibiotic and then obviously you, you'd say antibacterial. So, so wear loose clothing and then Benzoyl peroxide as a topical management as well. So the oral antibiotics like hylax, you'd already really include if all these measures aren't working and it has to be quite for that. Um There's no picture for this one but a seven year old girl presents with itching on her scalp, uh particularly behind the ears and the need of her neck. Her mother reports similar symptoms with other Children at school. What is the most likely diagnosis? Ok. I can see some of you guys have answered it. So I think a all you guys knew it wasn't an allergic reaction. Happy to see. Um some of you have put headly and some of you have put scabies. Um although both kind of are common conditions in young Children and they're very kind of um infectious. The reason why this is more likely to be headlight is because of looking at the stent of the question, it's itching on her scalp. So scabies tends to be kind of in the in between the finger. I like the um like the and the web is between the finger to some of the flexor aspects of the wrist. Um So it's more the location in this case that makes it more likely to present to be seen as headlight as opposed to scabies. Um So yeah, in this case, it's head lice. Um it's, but I can appreciate that kind of both of those conditions do have a lot of similar features. So in the case that they're itching, it's in younger Children, they're both, you know, contact with an infected individual is just the location in this case that tells you it's head lice as opposed to scabies because scabies would be a different part of the body um and poor hygiene cause a common association as well. It's a clinical diagnosis um clear made clear by um itching of the scalp, you might actually see the lights and there might be some red papules or like just some red light dots around the hairline of the, of the neck management. So you always, always treat contacts if, if someone's under two months old, usually just mechanical removal. But if it's over two months, it's a single dose of me. And then um you repeat that if um repeat that in 7 to 10 days. So they just have one dose and they have another dose in 7 to 10 days and you have to treat all contacts. So any family members will also have to be treated um on the same regimen. So one dose of probe and then another dose is 7 to 10 days. Um A five year old boy presents with crested honey cutter, sorry if I'm moving too fast, I can't see the chart, but if there is anything shot, sure, you can just let me know and I'm happy to, to them at the end of this um end of the presentation. So a five year old boy presents with crested honey colored lesions around his mouth that have been worsening over the last three days. Um His mother reports that they started as small blisters and then ruptured and formed into a crust. What is the most likely diagnosis? Ok. So again, I think that this one there has been a bit range. Um So I'm just gonna start with the eczema, her her the eczema option. Um In fact, if a patient is presenting with that, they're more likely to kind of have a history of having like eczema of having herpes of having a preexisting skin condition. And that will also be presented in the stem. So you'll be told um this is a patient that has had eczema that's like resistant to treatment. For example, they've recently come in contact with another patient who reports feeling unwell, something along those lines. You'd have something to stem of them already having eczema already having dry skin. Um Even if it's not an official diagnosis of eczema, there will be something say that they've got dry skin as opposed it would be the child. Um If it's eczema her as well, I don't have a picture on the slide, but it does look like it tends to be in other parts of the body as opposed to the face. So it's more likely to be like on the torso, the arm and the legs, the face. Whereas in this one, the lesions being around the mouth is very typical of the vertigo and the honey crusting lesion is very typical of ti if it's something like uh eczema herpetic, it would be something like red, it would just be, you know, red spots actually around the body as opposed to these honey crested lesions, which would be very difficult to ati. Um So he is a S oh and um Eczema Herpes is caused by an H phh P in. Um I don't, it wasn't on the list of topics you need to know for the MN A but honestly, they might throw in is like a wild card because you have to, you have presentations and conditions you need to know. So they might put it in. But um it would, it wouldn't present with the honey quested lesions. So Hepati is a superficial bacterial infections caused by staph aureus, which genes most common cause is staph aureus. It's more common in younger Children, overcrowding, contact with the affected individual and poor hygiene is very, very infectious. It's clinical diagnosis and like I said, the golden crested lesions around the mouth are very, very common. Uh very characteristic of this condition and management is hydrogen peroxide cream. So the reason I think that it used to be talk about initially, but they've moved to hydrogen peroxide probably to dropped out, like to reduce the taxes of like, you know, resistant bac bacteria, resistant antibiotics and so on. So, if they're not systematically unwell and they're not high risk of complications, cream will persist to help. Otherwise, then you need to topical antibiotics like fusidic acid. Um as first line, you could use Muricin but not as common at all. And if that fails, then you'd move to oral antibiotics. So things like Flo and Erythromycin and the the most important thing you need to know is um the school occlusion for 48 hours. Um until all lesions have crusted or 48 hours after starting antibiotic treatments. Um Just for the mu mu mu option, you tend to give that if it's fusidic acid resistant or if it's MRSA. Um So for this one, just no hydrogen peroxide cream is very well, otherwise topical antibiotics are, and if that doesn't work out, then you need to all antibiotics and school exclusion for 48 hours. So a 28 year old male presents with inte intense itching between his fingers and here and his wrists which isn't worsened. He has small red bumps and burrows on the skin, especially in the web spaces between the fingers. What is the most likely diagnosis? Sorry. II can't give that one away. Um Yes, escape. Um So like escapees is an infection caused by a mite. They burrow into the skin and they egg and cornea so that the epidermis um similar to all the other infectious conditions that I've spoken about. Very common in younger Children overcrowding contact with an infected individual of poor hygiene. The main thing you need to just remember the burrows. If you see the, if the stem of the question mentioned any form of burrows, you know, it's probably going to be babies very common to be found in between the fingers. Like I mentioned earlier, you can have secondary features like scratching and widespread pruritis and it's caused by a delayed type four hypersensitivity reaction to the mind. Um for the management again, you have to treat all um physical contact. So it's permethrin 5%. 1st line, if that doesn't work, then it's a s just a single dose I just give of permethrin 5%. Um And then you repeat in seven days. Um If that is second line treatment would be malathion again, whatever you give, you just have to give it again after seven days and treat all household contacts. You need to wash all bedding towels and clothing because like I said, it's very infectious and just be aware that the symptoms can last at 4 to 6 weeks after um, initial symptoms appear. Um So I know I said, I said that it is quite common to happen in the fingers, digital webs and flexion aspects of the wrist. In infants, it can also affect the face of the scalp. Um But infants, I'm talking like under two years old. Otherwise it is more likely to be in the between the fingers. So I can understand why I think some of you guys thought it might be similar to head mice earlier. Um because they can both present similarly. And I think maybe the picture could be clear, differentiating factor. But again, with scabies, the buzzword that always tends to come up is the liar burrows. So a 40 year old female presents with the swollen and red and warm and painful area on her foot, which has worsened over the past two days, she reports minor trauma to the area. What is the most likely diagnosis? Yeah, I think this is a very clear again, this is one of those conditions that you need to be able to identify immediately is ulit which is an infection of the deep dermis and subcutaneous tissue. More common with those are diabetes, venous insufficiency. So you might see something in the some of the questions that like they've got a history of coronary heart, peripheral vascular disease, um infections, any systemic infection or any infection of the wound. Uh that's more likely in patients with eczema. Um just because like I mentioned earlier, eczema is kind of due to the barrier of the skin having dysfunction. And so if the barrier of the skin is not working as well, bacteria and viruses and so on are more like bacteria is more likely to be egg. Um It's a clinical diagnosis and it isn't medical kind of one of those medical things that you just need, need to be able to spot immediately due to the classic characteristic features of redness and swelling, heat and tenderness. If it's associated with the break of the skin, then you do swab, swab the patient and takes cultures, cultures and need to do blood tests. So like that would improve a full blood count. CRP. Um People usually use CRP could throw S as well because you want to put them on antibiotics and check liver function. Um You have to initiate the local sepsis protocol because for a patient to have cellulitis, they have to be very unwell. So that would, that could include the sepsis six, especially if you're considering hospital admission. Usually for cellulitis, you would reduce hospital admission. I don't, I think very few doctors would feel comfortable sending a patient who ii don't think any doctor really would feel comfortable sending the patient home without hospital admission. Um So start them on broad broad spectrum antibiotics until cultures come back. So that would be things like flip flop or Clarithromycin and penicillin allergic. And then once cultures come back, you tailor the antibiotic depending on sensitivities, um supportive care and analgesia um nearing the end of the presentation. So um a 78 year old male confined to a wheelchair presents with a painful open sore in his sacral area. The wound is red with a small amount of necrotic tissue and there is some surrounding redness and warmth. What is the most likely diagnosis? This one? It's quite clear cut, it's a pressure sore. Um So that's localized damage, damage to the skin and underlying soft tissue. So it starts in the epidermis and then obviously, depending on how severe the pressure sore is, it can move down the dermis and so on. Um It most commonly occurs on like burning prominences, but it can develop on any part of the body, including mucosal surfaces. A very common area is like pressure areas. So it could be, some people might call it a pressure sore as well. So that could be like in the sacrum in a patient who is not mobilizing as much or like the buttock as well as also. So buttock back of the thigh, those are quite common areas. Um Risk factors are things like immobility. So in this case, you had it like they were patient in a wheelchair, diabetes, obesity and older age. Um clinical diagnosis, like I said earlier, most commonly occurs over bony prominences and can be superficial or deep. Um It can for example, like just be superficial wound of the epidermis or it can be something like fro tissue that goes deep into the dermis. Uh management would be pressure reducing aids, like cushions or repositioning, hygiene, cleansing and dressing for any special open sores because they are a source of infection. Analgesia can consider antibiotics or swabbing the area at least to check for any signs of infection depending on how severe it is. So, if there is something with necrotic tissue, like I mentioned earlier, then you can look in debridement and reconstruction. Number 17. Um a 65 year old male presents with painful ulcers on his toes and feet with a history of peripheral artery disease. They have a punched out appearance with minimal bleeding and are accompanied by cold pale skin. What is the most likely diagnosis? Yeah, I think you guys had your vascular tutorials. So I think they put this under the dermatology conditions, you need to know which is why I put it in the powerpoint. Um But this like punched out appearance, even the picture of it is a very classic and the location of it is a very classic of an arterial ulcer. Um So arterial ulcers just like like venous ulcers um can be caused secondary to arterial insufficiency. And the most common um kind of indication would be someone with peripheral arterial disease. Other associated risk factors could be things like atherosclerosis and slow healing injuries. They're located in the lower legs, on the top of the feet of the toes. They've got well defined borders and like I said earlier, very punched out appearance, um they can have a necrotic base that are tend to be in areas where you're with lots of pressure. So the difference between this is and the pressure so that we spoke about earlier is location association. So that was associated with immobility. This is associated with peripheral arterial disease. And obviously, this has got more of a punch to appearance compared to that. Um to investigate a patient with arterial ulcer, you need to do a vascular exam. AV P duplex ultrasound, you could consider a CT angio and MRI angio depending on the severity of the symptoms for the management. So conservative be lifestyle changes and that lifestyle changes. Um and then medical, so you have to think about treating any underlying peripheral disease. So that could include things like using antiplatelets, like aspirin and clopidogrel and statin to reduce the risk of cardiovascular events. Um, obviously, taking, I should have added to the conservative that um taking care of the ulcers. So like um putting dressings, keeping the area clean to prevent infection. Um Other treatment could be considered a referral to a vascular surgeon for procedures like slap and bypass surgery, indicated pain management. That can be quite painful. So you can um give, you might even need to get opioids depending on severity. And if there is evidence of infection, antibiotics would be um indicated. So things like redness, running or pus and um surgery like I said, could, you know, you'd have to refer to vascular but they could have an angioplasty or bypass grafting depending on the severity of the ulcer. Um But it is important to get that early referral in any way because um you don't want to miss out on critical limb ischemia or, and non healing ulcers um should be treated as soon as possible because they can't get worse. Um Just a very quick kind of overview of arterial versus venous ulcers and venous doesn't really cover the dermatology, but I've just put this in because you found it to be use for graphic. Um So the main differentiation of things you need to know is location. So arterial tends to be under the toes, the top of the feet and near the ankle. Whereas venous tends to be in the middle part of the leg and middle and medial ankle arterial ulcers tend to have that punched out appearance that are very de deep. They might have a necrotic kind of base. Whereas the, um, venous ones tend to be a bit more swollen, they're deep pink and they're a bit more shallow. One thing that we also need to know is, uh, burns. So I haven't put in a lot about burns in this slide just and this power point just because of high constraints. Um I'm happy to answer any questions about burns if you guys have. But the main thing you should know is the formula. So determining how much um whenever a patient kind of has a burn, obviously, that's going to affect the epidermis for us, that's the most outer layer. And like I told you earlier that it's a protective layer so that layer that also like helps retain water within your body. So if you can imagine a patient has a burn, the epidermis, they grow those sort of fluids. Um So you want to initiate for fluid replacement as soon as possible within the 1st 24 hours in addition to life analgesia um having involved was in um but including antibiotics to cover for infection if indicated and so on, but there's no other formula. So when I was sitting my exam for Imperial, I made sure I just remembered the percentages. So um this is a form I need to know four mils times the body weight times to the total body surface area. And just remember the head is 4.5, torso back is 18, arms and a arms are 4.5 and legs are in the right. Um I remembered it because it was all multiples of like 4.5 and I don't know if there's any more easier way for you guys to remember it. That helps me get it more memorable for you. But this is probably just the main thing I would focus and make sure I know regarding burns uh because you might be asked to calculate the total for slow replacement that a patient would need. Um just quickly covering the MN A contacts uh content. Sorry. So these are all the conditions I've covered today, which are pretty much all the conditions you need to know for your exam. I've also structured the table. So if you guys have your own notes, feel free to just copy and paste the tables. If you guys have the feedback, copy and paste slides, uh copy and paste the tables into your note and then change the like to match what you want to know or what matches your learning needs a bit better. They have put in presentations. So things like acute rashes and bites and things which I haven't covered as much, but that would be things that might fall into like other, like, um, other specialties as well. So, like they like, um, things like, um, just off the top of my head. Like the, I can't remember it, but there's lots of different rashes. I just need to rashes and bites and things that might come up. Um, but the bull's eye appearance that might be typical and then chronic rash n abnormalities, pruritis. So we've covered quite a lot skin lesions. We've covered skin or subcutaneous lumps, we've covered and skin ulcers we've covered. So I think the main ones might just be by some things that you guys might need to be a bit more familiar with. Um because we have, I haven't covered that much today. Um Thank you for coming. It'd be really useful. You can fill in the feedback form. I do have a one more condition. I think that at the end of the powerpoint as well that you guys can have access to once you have access to the um just as extra park. But otherwise, that's the end of the presentation. If you guys do have any questions, please let me know. I'm happy to stay behind in answer.