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FINALS REVISION SERIES 23/24 Dermatology recording



This medical teaching session, led by Nilo, an internal medicine trainee at the Royal Brompton Hospital, provides an in-depth exploration of about 30 common health conditions that medical students are likely to encounter in their finals. Particularly focusing on dermatological emergencies and skin cancers, Nilo uses an interactive tool, mentee, to engage the participants and assess their level of understanding. Amidst engaging discussions and visual examples to aid learning, Nilo discusses a range of topics including the diagnosis and treatment of eczema, psoriasis, guttate psoriasis, and scabies, among others. Despite not being a dermatologist, Nilo's passion for the subject and commitment to helping others understand these medical conditions shine through in this comprehensive and accessible session.
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A lecture focusing on key points in dermatology needed to pass finals.

Learning objectives

1. Identify and describe the symptoms of common dermatological conditions such as eczema, psoriasis, guttate psoriasis, pityriasis rosea, and scabies. 2. Differentiate between these various skin conditions based on patient history, symptoms, and visual cues by utilizing the process of spot diagnosis. 3. Understand the underlying pathophysiology and triggers contributing to these dermatological conditions. 4. Discuss the treatment options available for each of these conditions, with an understanding of steroid potencies, systemic treatments including DMARDs and biologics, and supportive management methods such as emollients and phototherapy. 5. Identify the importance of observational skills in the management of dermatological conditions, recognizing the potential racial differences in presentation and learning to interpret associated important signs, including a fir tree appearance for pityriasis rosea and burrows for scabies.
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Computer generated transcript

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

Alright, we're on, we're on nine people. There'll be more like whenever you're ready anyway. Ok, so hi everyone. Um I'm Nilo. You might remember me from my acute care lecture. I'm one of the internal medicine trainees. Um I'm currently working at the Royal Brompton and you might have seen me on the ward on fas ward. I'm currently doing CF um if any of you care um uh on my last lecture, one of the feedback you guys gave me is that you wanted mentee. So I have tried. Ok, and I've created a mentee. So let's see if it works. We haven't worked out with the book with Phil and Manish, how to get you guys to see it, but at least I can see what you've done what you've written it all. It all makes sense. After the first one, we'll trial and error. Um, worse comes to worse. We might have to go back to the chat. Um ok, so this is um what I'm going to cover. So this is gonna be I'm covering quite a lot, there's quite a lot of conditions. Uh there's about 30 conditions that I'm covering. I'm hoping that I get go through, I was hoping everything that will come up in your finals. But I think at least most things that will come up in your finals. Um, a couple of dermatological emergencies and also skin cancers. Now, what I'm, what I can't, what I haven't covered is childhood exanthems because I started it and I thought the scope of this lecture is too large. Now, let's, let's, let's sit back. But if you want me to do childhood exanthems, um let me know in the feedback at the end or let fill. Uh No, and I can at the very least send you the notes that I made back in med school. So how it's gonna work is I'm gonna ask you, um I'm gonna get show you a picture, ask you all to type out, do a sort of a spot diagnosis thing which I really loved when I was in medical school, spot diagnosing things. Um And then we'll go through the condition. I'll pick out all the buzzwords that I think that you can pick out from the MCQ. I will say as a disclaimer before we start that, I'm not a dermatologist. My dermatology experience was one single clinic in med school and one week as a taste a week. So I can't give you sort of clinical advice on dermatology, but I do love the subject. Um And I enjoy studying for it. Uh So this comprehensive, as I say, I don't expect you to stay to the end. Um But as long as it's something that you can look back on. All right, let's just take a moment to absorb this diagram and move on. OK. So this is the first um picture. So what I want you guys to do is log into this ment thing and then just type what you think the diagnosis is. I'll give you guys a second dose also. Mm Right. OK. So can you guys see what uh Manish or Phil can? What can you see on your screen now? Yeah, we can see a picture of two elbows or knees. Oh You can still see. OK. So you can't see what everyone's responded. OK. So I'm just going to tell you what most people have responded, responded. Eczema and that is indeed the answer. So eczema, the key things to know about eczema is that it's itchy, it's on the flexural surfaces. Um And often the patient that they will present will have a history of ATP. So that's other allergies such as um asthma food allergies either in themselves um or in a first degree relative. Most cases of eczema start when in kids and most people grow out of it. But we know that lots of adults have eczema. We don't really know what causes it, genetics allergens, infections, but it's basically the pathophysiology is epidermal barrier loss. And unfortunately, the treatment of eczema is management rather than cure um avoid of the things that trigger it, harsh soaps, detergents and they just have to just keep putting cream on, um, different emollients. And we all know that ba basically dermatology is emollients and steroids for, for most things. Um, and that's, uh, if the flare is severe and you can use it for up to seven days. Um, and there's other things that you can use, um, such as dmards. Um, if, if this disease is very severe, um and you can give them some antihistamines at night to stop the itch oops season. Uh This is just here to showcase um that though most of the pictures that you'll see on your exam is going to be on caucasian skin, skin conditions look different um on skin of color. Um But because that's what comes up in your exam, most pictures I'm going to show you are on caucasian skin, but this is what eczema would look like on skin of color. I made this when I was a medical student, I decided to put it on here in case it's useful for you guys. It was just the steroid ladder because I never knew what they were talking about. A lot of times they would use sort of things like um or betnovate and I didn't know what it was. So this is just uh giving you an idea of what the potencies of different steroids are and you would start in most conditions you would start with low potency and you would go down and some steroids um have things with them like antifungals, antibacterials and things. So this is more for your future reference. Um And I won't go through this today either, but just remember that topical steroids have side effects. That's why we only wanna use them uh for less than a week and these are what they are, but you can read this in your own time. OK. Second question. I don't know if this is coming up for you to put the responses down on men. So what do you guys think this condition is? Yeah, I think it is coming up. Oh Yeah, I can see it. Great. Yes, things are looking promising. Here are the answers. OK. So, but everyone who's responded has said that this is psoriasis and that is correct. Now, psoriasis, there's scaly erythematous plaques. Um I always remember psoriasis uh because Kim Kardashian has psoriasis and when things are getting really stressful and keeping up the Kardashians, um her psoriasis flares. So stress is a common trigger for psoriasis. Uh so are infections um and some drugs can cause it as well. And what happens is that it's caused by proliferation of the epidermis. Um and then dilatation of blood vessels in the dermis and then the inflammatory cells come on and cause these skin changes. Um Now, other than diagnosing eczema spot diagnosing eczema, I think what came up in my finals or at least one of my progress tests was that um psoriasis is treated with steroids plus topical Vitamin D Of course, you always use emollients and you can also use a lot of patients have really good uh response to UVA and U VV. Uh phototherapy. Then you can use again, dmards and some biologics uh are also licensed for psoriasis. Ok. Moving on in the same vein. Ok. This is a little bit of a harder one. I wonder what you guys think this is? OK. Yep. So this is the first one. I think that's caused some um diagnostic um uncertainty amongst you guys. We've got one Duno. Uh We've got three guttate psoriasis. We've got uh pityriasis, rosea, one pityriasis, versicolor. Um So what if I told you, I don't know if this helps. This patient had um some viral symptoms a couple of weeks ago. I'm not sure if that helps. OK. Right. So this is actually uh guttate psoriasis. Um And it's precipitated by streptococcal infection. So typically in an MCQ, the patient will have had a sore throat 2 to 4 weeks ago. And then they've got this all over their body and they will describe them as tear drop papules. So I always say, I always think when you're in the gutter, you produce tears. Um And that's how I remember that tear drop papules are associated with guttate psoriasis. Um And often this resolves by itself, you don't have to give the antibiotics for the streptococcal uh infection. Um If it's already resolved, it doesn't show to make a difference. You can give the topical agents you would in psoriasis and you can also give, um, phototherapy and, uh, if it's a problem, uh you might want to remove tonsils if it keeps happening because, uh, that's probably where the streptococcal infection is coming from. Ok. Next one. Oopsy. What do you guys think that this is the reason I'm laughing is cos there's somebody who keeps saying, I don't know. Um So let's say this one here. Can you guys if you guys can see my uh mouse? This one here happened first and then all of these appeared. Does that change anyone? Anyone's response? OK. So this is actually pityriasis rosea. Yes, someone got it. Um H HV six. So it's Pityriasis rosea. It's um associated with human herpes virus six and seven. And typical things you might see on MQ is the Herald patch usually on the trunk followed by oval scaly patches a couple of weeks later. And um another thing you'll see is that they'll be um described as happening in a fir tree appearance. I never knew what they meant by this. Um But I'll show you a picture uh in just a second and this has um incredibly good prognosis and self resolves after six weeks, but you can use uh you can do some symptom control with the usual derm things. Um So I find this quite hard to remember. But if you think I always think about this quite Christmas themed. So you've got the Herald patch and the, the Herald patch followed by a fir tree appearance. So I always, and I always think about rosy cheeks in six and seven year olds around Christmas time. But I realize that that is a bit of a reach. Um And this, I don't know if you, I don't know if I can convince myself, but can I convince you that this is, this is the fir tree appearance that the general direction that this rash is going is downwards from the midline. I don't know. But, but that's what they mean when they say fir tree appearance. Next one, this patient is so, so, so itchy. What do you guys think? OK, someone said isolate them. Yeah, you guys know what this is. This is good old scabies caused um mostly in Children and young adults. Um It's an equal opportunity uh affects male and female, same. It's caused by the Sarcoptes scabies mite which burrows into your skin um laying into the stratum corneum um causing a delayed type four hypersensitivity reaction. Now, there are um there are different types of hypersensitivity reaction. You know, the type one is anaphylaxis type two and three. I can't remember this is a type four hypersensitivity reaction and that's what causes this intense, intense itch. Um And the reason I think you guys got it quick, you guys know that it's most commonly in the interdigital webs. Um, and they'll probably, they might mention that on the MC Qs. They might mention that there's burrows. I'll show you a picture of a burrow in a second and you'll see secondary, uh, skin changes, secondary to the itching. Excoriation is the, is just the flex of blood from the itching and you can get, uh, sad infections as well. This was actually a question in my finals. I remember this very well. Um They, uh they told us it was scabies and they asked us what the management was. Um, and the management is permethrin. And I always remember if you've got scabies, you want the treatment to really permeate the hence permethrin. Um, maybe that's a reach to, um, and important to know, um, you apply it to all the areas of your skin, um, and then leave it on, um, for up to sort of up to 48 hours and then you repeat the treatment after a day and important to know as well that every household and physical contact gets the treatment as well. And of course, you've got to kill the mites by laundering, ironing, tumble, drying all of your things. Um And the itchiness can unfortunately, um, persist even though you've eradicated it. Now, this is what I wanted to show you about the burrows. So this is where the mite has gone into the skin and this is how it's traveled I don't know if you guys can, I don't know how good the image quality is that you guys can see, but this is, I never really knew what they meant by burrows, but this is what they mean. OK. What do you guys think that this is? Yeah, you know this one, let's say this is a caucasian male that's just gone to Spain and he's come back and he's seen this. Ok? You guys seem I'm pretty confident on this one as well. So this is pityriasis versicolor. Um And the reason why they mention um patients going on holiday and then coming back um is because it's hypopigmented patches and that can be quite hard to see on caucasian skin. Um So if the rest of the skin gets more brown and these sort of come up, um they become more visible and it's caused by a fungus Malassezia furfur. Um And therefore it needs antifungal treatment and fungus on the skin. It needs uh topical antifungals. So you can use ketoconazole shampoo. Um And if it really doesn't respond, um then you can consider um an alternative diagnosis or you can consider uh oral antifungals. Um OK. I think that's, that's all that will come up for that. What about this? This pa this is, this patient has had this rash since they were a kid and think about what other conditions they might have as well. Mhm Yeah. The spellings are mental here. Yeah, that's right. That's right guys. So this is vitiligo. Um And you're right, this is associated with autoimmune conditions. Someone actually mentioned thyroid disease and other things that can be autoimmune, uh things like hyperthyroid type one, diabetes, Addison's, et cetera. And it's well demarcated patches of deep pigmented skin. Um and it doesn't really cause any symptoms um or any harm. So it's just cosmetic appearances. Um So that's why I highlighted camouflage. So you just basically um treat, treat the cosmetic appearance and you can use sunblock um if it's uh to prevent uh further, oh, you can uh sorry, uh use sunblock to make sure that the affected hyperpigmented areas don't get burnt. Um And vitiligo is something that exhibits cob a phenomenon. Now, a lot of the conditions that I'm going to talk about um will exhibit coona phenomena. So I just wanted to highlight what it means. So that coa phenomenon is in previously unaffected skin. So you can see uh this gentleman has basically fine skin and then you get the condition on an area of trauma if that makes sense. So here you can see he's cut the back of his neck and then he's got vitiligo around it. So that is a skin disease that exhibits the Codner phenomenon and a couple of others do uh psoriasis does um and a couple of others that we'll talk about does as well. OK. I know. I said no, no childhood exanthems, but this is a child who's come to you looking miserable. This, this picture is hot. This picture is really bad quality. I'm sorry. OK. And now that I know that you guys can give more than one answer. Can you tell me what uh what bacteria has caused this? Oh, great. You guys give all sorts of answers on this. I didn't think about that. OK. Yeah. So, impetigo, correct. This happens in kids and it's caused by the um regular old skin infe the the regular skin infection. So, Staph aureus uh and strep pyogenes. Um so well done, well done. Um guys who said that um and it's highly contagious and it, it's, the diagnosis is golden crusted skin lesions that tend to occur on the face. Now, back in my day and someone did answer this. Um It, it was just fusidic acid but I think that there's new nice guide. Well, there are, I looked it up, there's new nice guidelines um saying that if they're fine and they're not systemically unwell and they're OK. Otherwise you can just use hydrogen peroxide cream. Um And that's to stop antibiotic resistance basically. Um And you can use the regular old oral antibiotics for skin diseases like flucloxacillin and sometimes randomly in MCQ, they'll ask you about school inclusion exclusion criteria, which I hated, but it's basically until all the lesions have crossed it or 48 hours after commencing antibiotic treatment. Next, I wonder if you, I wonder if you guys will get this. This is another poor quality image. I'm sorry, it looked better on my small laptop. So yeah, this, this one is a little bit harder. What if I told you that they had um some, they, they also showed you some white stuff in their mouth, in their buc in their buccal mucosa. You look at the buccal mucosa. There's also some a white lace pattern. Yeah, some of you have got it. But yeah. Yeah. The planus of lichen, OK. Um And lichen planus likes peas. So in MCQ S, it will be polygonal papular, they'll call it purple though. I don't think it's purple but they'll say purple. Um rashes on the palms, flexor surfaces of the arms and they'll have Wickham Stri eye on the surface. Um which I think is the white stuff to be, to be honest, I don't actually know what the Wickham stre are, but that will come up on the MCQ. It's another one that exhibits a co phenomenon and this is what I was, this is what I was trying to um uh hint to you guys, they'll also typically have uh might have a white lace pattern on the buccal mucosa which supports a diagnosis of lichen planus. Um And treatment is the um benzydamine mouthwash for the um oral manifestations and just topical steroids. You can give oral steroids if it's really bad. We don't know what causes it probably um probably immune mediated autoimmune can also be due to drug drug reactions. OK? Next. So this one, I've shown you an armpit. But what if I told you that this was on someone's vulva? So II overthought giving you guys an image of a vulva. Um So you get the armpit instead. I think this one is particularly hard. OK. Yeah. Yeah. Yeah. Yeah. So some of you guys have got this. This is lichen sclerosis. OK? So um II used to struggle um with lichen planus and lichen sclerosis. Um that sclerosis is, is the one that's on the vulva. I don't know how you guys would suggest remembering this. Um We don't know what causes it. Probably genetic, probably hormonal can be traumatic infectious components, mostly in women over 50. Um but it's basically on the nonhairbearing inner areas of the vulva. And I think it can be quite bad and cause adhesions and scarring and soreness. Um And therefore we use topical corticosteroids as well as all the general measures. Uh estrogen creams can help. Um You can also use tac uh topical tacrolimus and retinoids. OK. Next, this is a favorite. This is a uh this is a phd student or back in uh my university. We had people doing the grad course which is five years and four years and someone got this disease just from the stress of that. Yeah. So what, what, what causes this as well? Bonus? What, what, what's the, what actually causes this Yeah. Yeah. Yeah. Yeah. Yeah. Yeah, it is. And now tell me what a complication of it as well. So someone said the eye thing, OK. Yeah, this is shingles. This is a reactivation of the varicella zoster virus. So you can only have it reactivated if you've had it in, in the first place. So you can only get it if you've had chicken pox in the past. So what happens is the virus lies dormant in your cranial nerve, in your dorsal root or cranial nerve ganglia. Um And then things like stress illness, immunosuppression, trauma, burning basically makes it makes the virus travel back up until it gets to the skin and it causes this um uh dermatological manifestation that happens mostly in older people because probably they tend to be more immunosuppressed. It's acute unilateral, painful blistering and very importantly, it follows a dermatologic um a dermatomal sorry distribution. So you can see that right? So it doesn't cross the midline. Importantly, and you give them antivirals and in severe case, you can give them oral corticosteroids, not, not just topical, you can give them oral. Um And you need to get on their pain relief as well because this can be really painful and it's because it's a neurological pain, it's a neuropathic pain, sorry. Um You might consider giving them neuropathic agents. Um And uh uh when I asked you guys about complications, um some of the complications you can get the pain. Um even after the rash is gone, the pain might continue. So you have to manage that pain. You get herpes zoster ophthalmicus, which is the eye thing that whoever wrote the eye thing was talking about. Um And that's when it affects the ophthalmic branch. Um And you get it, I haven't actually added a picture into this presentation that you, you see pictures of the for the half of the forehead and the eye being affect in the tip of the nose. Um And this needs urgent ophthalmol referral because they, that can cause a permanent vision loss. And you can also get Ramsay Hunt Syndrome um as a complicated, that's when it affects the facial nerve and it causes the lesions in the ear, the vesicular lesions in the ear and Justin Bieber actually had this back in the day, but I don't know if you guys are too young to even remember. Um But it causes just um uh uh drooping of one side of the face as well as vesicular lesions in the ear. That's what Ramsay Hunt syndrome is. And you can also get in um encephalitis 3 to 4 days after the rash. Um And that's more common if you're immunocompromised or you get shingles in one of your cranial nerve dermatomes moving on. This is another child I'm afraid although I promise no childhood xanthe, but this one comes up all the time. It is not really causing this child any bother. Um but it mom just wonders what this is. Ok. All right. That's OK. We know what this is. This is molluscum contagiosum. So, I always remember molluscum contagiosum, umbilical lesions. I don't know if that's a reach as well. Umbilicated lesions. So, can you see in the middle of these lesions, you get a little uh dip that looks like an umbilicus and that's what an umbilicated lesion is and they're pink, pearly white papules and they're mostly in the warm moist areas. Armpits behind the knee groin. It's caused by the pox virus and it's transmitted um by contaminated circles including towels, I should say not rowels. Um And you just give, you just give people reassurance. This is self limiting. Um You can squeeze and pierce them if you want. Um But that can cause it to spread to other areas of the skin and you can give cryotherapy. That's, that's cold blasting it if you want. But that can cause um uh whitening of the skin around it. There's as well as in kids, you can also get sexual transmission in adults. Um So if you do get it in adults just uh and if, if it's um anogenital, just refer them to gum and if it's in the eye, then you need to refer to ophthalmology. Oh Crap. Giving you the answer to this. So flaky itchy scalp. Yeah. So I gave you uh the answer already. This is seborrheic dermatitis. Uh This uh is more common in males and it happens on sort of the, the sebum rich areas, the scalp around the eyes. It can happen sort of um on the eyebrow. You can commonly see it uh and uh the nasolabial folds and it's caused by the Malassezia fur of fungus. Remember that's just like uh pityriasis versicolor. So you use the same um treatment which is the topical antifungal. Um So it's a fungal infection and you can also use, you know, head and shoulders apparently because it contains zinc, parathion and t Neutrogena. Ok. Oh, you can also get blepharitis, which is sort of dryness, inflammation of the um skin around the eye and a auto externa with this. What is this, this gentleman has come to you saying why does my skin look like this? I'm too old for this. Yeah, I'll give you some more time, I guess. Yeah. So I've got half, half of you saying acne and half of you saying rosacea. So this is acne rosacea because for some reason, this was always my favorite past me M CQ. And um it affects adults, 30 to 50 years old. The person in my picture is clearly a lot older. Um but it's a acne form rush and people um 30 to 50 years. So above when you would expect to get acne vulgaris, and specifically, it causes redness, flushing and telangiectasia which can develop then into papules and particles made it, which is what gives it the name of Acne and someone said it actually on the uh ment rhinophyma, um Rhinophyma is associated with a, it's what it is. It's this a thickening of the skin of the nose. That, that's what it is. I haven't actually uh put a picture here, but if you google a picture, I mean, it's clear, um, that it's just nose thickening and it's exacerbated by sunlight as well. So you need to make sure that they're using daily sunscreen and for the symptoms of the erythema and flushing. If that's what most, if that's their um uh most pressing issue, then you can give them topical brimonidine, which is an alpha adrenergic agonist and that just reduces the red, the, the appearance of the redness. Um But if they're getting the pappies and pustules, you can give them topical ivermectin, um which is the antibiotic and then if it's really severe, then you can give them, uh as well a systemic antibiotic, Doxycycline. But remember that if they're taking Doxycycline, they really need to be using the daily sunscreen because one of the side effects of doxycycline is sensitivity to the sunlight. Um and they can get laser therapy if the above doesn't work via derm. Ok. What's this guys? I'll see if you can get it without clues first and then I'll give you clues. So there are people who, who can get it without clues. Let me what if I told you this was really painful rush. Can you tell me what? Um can you tell me what co condition this patient might have as well? Yeah. Really commonly in MC Qs. Yeah, you guys know you guys know it great. This is erythema nodosum. Um And this is not an equal opportunity rash. It's more common in women than in younger women as well. And it's painful because it's the inflammation of the subcutaneous fat. And really commonly, the reason I've just put IBD in pink is that every time I think I've seen this question in NCQ, it's been a patient with ulcerative colitis. Um but also things and these are all things that you guys um have said infections like TB, some of you said TB sarcoid, some of you said malignancy, some of you said um and drugs such as the combined um combined oral contraceptive pill and these are really tender, but they resolve within six weeks. Um And they normally resolve without any uh without any sort of specific treatment. Obviously, if it's infect, if it's caused by infection, you need to treat the source and you might need to stop the drug that's caused it. Um But you just give them supportive management with analgesia um and you can give them systemic steroids if you need to. This is a hard, I think this is a hard one, but I'm gonna see who gets it without clues. But II don't expect you to get this without clues. So this is a really first clue is a really itchy rash. It's, it's in insanely itchy and this patient is intolerant to gluten. Yeah. So a few of you have got this now. So this is dermatitis, herpetiformis. And I don't think I've ever been asked, um, in exams to diagnose it based on a picture. It's mostly based on history. Um, and, um, it's simply the buzzwords are, they've got celiac disease, immunofluorescence shows iga deposition in the upper dermis and it's very itchy and it happens on the extensor surfaces. Um And the treatment really um is a gluten free diet and Dapsone, uh which is also used for leprosy. I was gonna ask you guys anyway, it's also used for leprosy, Sulfon uh sulfonamide antibiotic, um which can help this condition as well. OK. This is a patient who is sitting comfortably on your Jerry's ward. I once got called to see a patient who had this as an F one on call and it wasn't about this. It was about another thing that she had, I think she had another issue, but I was incredibly excited as someone who liked her. She was sitting there quite comfortably looking pretty well. Yeah. So most of you have got these bonus points if you can tell me, OK, may maybe it's too hard. Let, let's just let me just tell you what it is. So it's bullous Pemper good, which most of you told. Uh which, which is what most of you said um some of you said another condition. Yeah. So yeah, some of you said another condition which is coming up um And what it is is autoantibodies targeting the hemidesmosomal proteins. So that's what you need to remember. And I'm going to show you um I'm gonna show you an image in a second as to what uh that, that might help you remember later as to the proteins that it targets and how it works. So these are tense blisters usually around the flexor and it doesn't normally affect the mouth. I can't remember how much um how much this comes up. But if you the the skin biopsy immuno shows IgG and C three at the dermo epidermal junction that might be a bit advanced at a final stage. Um But basically you can give them um oral steroids um and or, and or immunosuppressive agents um or topical cortico cortico sur are mild, but actually these patients remain well with the condition and the blisters do usually heal without scarring and it happens in an elderly population. So what to remember, elderly population tense blisters because of um disruption of hemidesmosomal proteins. And they're relatively well, you can treat them with steroids unlike this. So what's this in the same sort of vein? Yeah, really good. So what are the auto antibody? What are the auto antibodies to in this condition? Ok. Maybe that's a bit hard. So this is pemphigus, vulgaris. Um and these are auto antibodies that target proteins found in the desmosomes. So let me just show you, let me just show you the diagram. Now. So here are the desmosomes and here are the hemidesmosomes. So, in bullous pemphigoid, the auto antibodies are to the de into the hemidesmosomes here in the basement membrane. So that's why the bliss are sort of tense and they maintain their integrity. However, emp vulgaris, they're a bit more on the surface of the skin. So the skin is more friable. Um and the blisters tend to burst and you get more, you, you lose this epidermal barrier. So the patients tend to be more unwell and they also have mucosal involvement as well. There's a younger patient that's um a younger patient population that's affected. Um the auto antibodies target the desmosomes. These are flaccid blisters because of where the desmosomes are. So they're a bit more on the surface of the skin and they're often Nikolsky positive. Now, Nico being Nikolski positive is basically, if you run your hand along the blister, it will just peel off the surface of the skin. Um and there are other conditions that are Nikolski positive that we're gonna get to uh it can happen anywhere but the oral mucosa has affected nearly all cases. So they're painful, um oral ulcerations and that's why these patients might need nutritional supplementation. Um They might need to come in because they, they basically can't swallow, they can't maintain an oral intake and these patients get uh systemic corticosteroids as well, but they need more monitoring and more treatment. And they also can commonly get secondary bacterial infections such as say I and inti um because of the breaking of that skin barrier, what do we think? I think we're over halfway through now, guys, so well done to those who have remained um think about the shape of these lesions. How, as well as the diagnosis, you can say, how would you describe, how would you describe this lesion? Yeah. So most of you have got this right. This is um erythema multiforme and these are target lesions. I mean, ii don't think I have to explain to you why um they are called this. Um and it's most commonly caused by uh herpes simplex. One virus can also be caused by drugs, um exposures disease. Um And there are two types major which has mucose involvement. It's um it's sort of one mucosal area is how they describe it, I believe. And then mine of us is no mucosal involvement. Um So just on the skin. Um and the thing to note here is that these patients are normally quite well and it is how you differentiate it from what we're gonna go on to. Um and it's just symptom management and treating the cause. Um And if the mucosal disease is severe, so if they get really bad ulcers in the mouth, same as pemphigus vulgaris, they might need support for, for oral intake. Ok. So we're moving on to dermatological emergencies. Oops, what do we think of this? And what sign is? What sign is positive here? Yeah. Really good. So, this is Steven Johnson syndrome or um uh 10, this is more common. This is most commonly drug associated. Um So, Sceptrin or Cotrimoxasole is a common drug that causes, it can also be caused by nsaids. And the difference between sjs and TE is that SJS is less than 10% skin involvement and TN is over 30% skin involvement. Um And there, it's, it's NS oh And if, by the way, if it's 10 to 30% skin involvement, then it's sort of sjs, tn. Um And these patients are clinically unwell, I will say as well. Oops. Um Yeah. So these patients need to come in basically and they need supportive care on it because if you're the, the skin acts as a barrier um preventing epidermal water loss. But if you've lost your skin barrier like this and by the way, yes, it was Nikolsky positive. Um So if, if you run your finger along the skin that's going to shed. Um So if you're losing that skin barrier, you're also losing water and electrolytes. So these patients uh need IV fluids um and they need uh support and you can also give them um uh immunosuppressive agents as well and stop whatever drug has caused this. Uh as well. So it's most common drug can be common drug infection and these patients are clinically unwell. Um, and they need intensive support. Next, this is a little harder. I was wondering whether I should include this one. Cos I've never actually seen it come up. Um, in MC Qs. Bye. Someone's got it. I do find that um, dermatological emergencies come up less in MC Qs. Um And the common conditions come up more. So. Yeah, this is erythroderma. Um And it's basically widespread Redding of the skin due to inflammatory skin disease and it's, it causes sort of an exfoliative dermatis. The skin is very rough to touch and it's also um associated with drug eruption, same as SJS T and um and other things often associated with preexisting skin disease such as psoriasis, dermatitis. Um and things like HIV graph host and it's the same really um as the Steven Johnson's and TN high. They lose a lot of heat because their barrier is disrupted and they lead to, it leads to fluid loss and electrolyte abnormalities, dehydration. Um And you, it's, it's the same treatment you need to retain the skin moisture, monitor fluid balance, et cetera. But I don't think this, I don't think this commonly comes up so I won't spend too much time. All right. Last little chunk. What do we think that this is? Yeah, really? Well done. Can't even describe it if we were in person. I'd ask you to describe most of these. Yeah, you guys know. So this is a basal cell carcinoma and it's most prevalent um in sort of elderly Caucasian males who spend a long time outside in the sun. Um because it's most commonly caused by UV exposure and it's pearly rolled edge, um uh no nodules with overly telangiectases and smooth raised edges. Um And the important thing about basal cell carcinomas is metas is quite rare and it's almost always sort of local invasion. Um And the risk factors same with all skin cancers really sun exposure, repeated sunburn, previous skin cancers. Um but they can grow and we do excise them. Um I always remember you guys know all of the uh you, you guys know the uh descriptive uh words, but I always remember pearly rolled edge, uh smooth raised edges. I always, these are sort of nice words and that's how I remember the, the basal cell carcinoma. Um me doesn't metastasize it is not so dangerous, but it does invade locally. So you do need to excise them and you can also use other things. Cryotherapy. That's the cold blast and curettage where you just shave it off. Um and radiotherapy and things. What is this do you think? Mm. So there's multiple of them. So here's one, here's one, here's one, here's one, the little teeny tiny flakes not really causing them much, much harm. Mhm So, yeah, most of you have got this, I think about 60% of you have got this. Um It's actinic keratosis. It's not so obvious to be honest. And skin cancers, actually, I think even having done my derm taste a week, I do think that they're quite hard to differentiate from each other. Um which is, which is why I'm not going into them in too much detail. Um It's just, you just need to know the keywords for the MCQ. There are small crusty scaly lesions, sun exposed area and histology will show atypical keratinocytes. Um and you need to manage them because they can be a precursor to the next condition to um yeah, to the next condition that they will talk about and you need to advise them to protect themselves from the sun to prevent um the lesions from growing or from any further ones developing. And you can give them a fluorouracil cream and the same things as the other one, cryotherapy curettage and some topical um treatments fluoro excuse me, fluorouracil um can be quite uh harsh on the skin and it can cause redness that uh needs to be managed with hydrocortisone that might need to be managed with some topical steroids. So, what's this do we think? Given what I've just told you? Yeah. So really good. This is a squamous cell carcinoma. Um And it's the most common the same in elderly males with chronic UV exposure. Um And it happens due to numerous DNA mutations that's caused by UV exposure, um enlarging, scaly crusted lumps are usually arising within the actinic keratosis that's already there. Um Or another carcinoma on sun exposed sites and they grow and they can be, they can alter it and they can be painful metasis are also rare, but they can occur in squamous cell carcinomas. So they really need to be excised with a margin of 3 to 10 millimeters. And the how you choose the margin is, is based on how big the tumor is itself. I don't think you need to know the exact rules. They might need a flap or skin graft depending on where it is. Um If it's a low risk one on an area with lots of soft tissue surrounding it, you can shave it or use curettage, uh sort of like burning it off and if it's very small, you can just use cryotherapy. That's the cold blasting. Um Now I've highlighted Mohs micrographic surgery um because um this was something that I didn't really understand. I was a medical issue. I don't fully understand it. Now, to be honest, but um from reading about it. So for large lesions with indistinct margins, uh or on places that or recurrent tumors or sites that are cosmetically important. Um mo surgery is a procedure in which they go in, they excise it. Then at the same time they look at the histology and they excise the exact margins. So in excision, you excise it and then you close it, but in most, I believe you excise it, you leave it open, you see whether you've got the margins or not. And if you haven't and you go again, now I've never seen this be performed. So I think that's the extent to which I can explain it. Um But I never knew what this was as a medical issue and I kept seeing it come up. So hopefully that gives you a little bit of light and you can also use a radiotherapy um in the meantime to stop recurrence or as an adjuvant therapy. What's this? This is a, this is a passed favorite actually, to me, it looks like a volcano and that's how I remember the name. Yeah. OK. So this is a um keratoacanthoma. This always comes up in pass me. So I thought I'd include it. Um And it's a solitary dome shaped nodule with a central keratin filled crater and, and I just think about it as a volcano, Keratocan. It sounds like a volcano name to me. I don't know why. Um But the difference is, and it's all the same risk factors as the other cancers. But the difference is is that this one just resolves by itself. However, I don't think it's very often that they let it resolve by itself because it can be mistaken for a squamous cell carcinoma. So it's normally surgically excised. This is the last one guys. And can you give me some descriptive factors, huh? Yeah, someone knows, someone knows the two people know the approach. Yeah. So you're all right. This is a good old Melanoma. Um, oops. And actually some of you have mentioned Breslow thickness, which I haven't put in this, um, in these slides. Um, what I've put, um, is the diagnosis. So you use the ABCD E for the superficial Melanomas to differentiate them from just a wart basically. And asymmetry border regularity, color variation. So here, it's not symmetrical. It's different. The border here is different to the border here. Um color here is different to the color here. Different formally diameter. So changing, evolving um and modular nodular which is here is elevated, firm to touch and growing. Um So it's in particular, this is something that is doesn't look quite right and it's also growing. Um And yep. So it's caused by the uncontrolled peripheral of the um melanocytic stem cells. Um And you can have it either inherited from your parents uh or sporadic which is acquired. Um And the treatment is wide local excision. So you leave wide margins and you also might need a systemic therapy. Uh And yeah, Breslow thickness is a histological thing um that will then guide further management. Do this patient need um A CT to look for um uh to, to look for metastases. This, this one is the most dangerous type of skin cancer most commonly metastasizes. OK. Guys, we've reached the end of this slog. How long did it take? It took an hour, which is less than I expected. Where can I find the chat? So thank you all for listening and thank you all for responding. Um Let me know if you have any questions. Um And I would really appreciate it if you uh give me some feedback and if I ever stood behind you watching you do an ABG, then it's the right thing to do. Giving feedback is the right thing to do. But thank you all. Oh, thank you so much. That was really good. Um That I don't know about everyone else, but that was much a much better way of learning than just like looking at pictures and trying to work stuff out. It was really good. Um Guys, can you make sure you fill out the feedback because Neil has, you know, gone out of her way to make this um presentation and ment meter. Um So it's really important for sorry about the men. Oh, great. We did, we did our best. Yeah. All right. Yeah. And if anyone has questions, just pop them in the chart or you can ask. Now, I wonder. Yeah. All right. You can let me know you can ask Bill who can ask me and I can send out emails all the best. Best of luck. Thank you very much, Neil and thanks everyone for coming. Thank you. Bye. Thank you so much. Thank you guys. Nice to see you bye.