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Um Hi guys. Um I think we're live now. So this is Doctor Hiba Alma. She's a specialty doctor in dermatology and she's kindly agreed to teach her. Um I'll give it positive to you, doctor. Thank you so much, doctor. It's really a pleasure to see you. Uh Thank you so much everyone for joining in the series. Um My name is Doctor He Matti. I am one of the uh speciality doctors in Dermatology in Sherwood uh forest Hospitals today. I'm pleased to present the one of the uh challenging uh sometimes challenging but most interesting subject which is the dermatology. I know some people find the dermatology altogether is a bit challenging and it's not everyone's cup of tea, but hopefully by the end of this presentation, you will gain a bit more information uh that can help you passing through this test. Um So without further ado, let's dive into the today's uh presentation. So, shall we change, please? So, I'm starting with a very familiar topic to many of you, which is the infections uh in this presentation. Of course, it's hard to get all the dermatology in such a short time. So I'm trying to be as much as examined as possible. Um Right now we're going to discuss the infections first. So the ones I marked in uh red are mostly the type of information they see in, in, in this exam. So if we are to talk about cellulitis, which is one of the most common scenarios you come across in your practice as well as in this exam. Cellulitis is mainly a gram positive bacterial infection, mostly with uh staph. Uh but we can find it with a strep infection as well. It's usually affecting the lower derms. It's a little bit deeper. So it usually manifest itself with some systemic symptoms as well. Um As it shows in as a clinical picture, it is um as you can see, I hope the photos can be a bit more uh illustrative. So it is an area of localized redness, pain, uh tenderness and it's quite swollen. It is also hot to touch. Uh mostly. And when I say to be honest, it's not mostly, it's almost always, it is unilateral. Bilateral cellulitis is very, very rare and it doesn't come except for a very immune comp immune compromised patients. But in most of the cases, it comes as a unilateral. And of course, it's the treatment is flucloxacillin. This is our preferred antibiotic in dermatology. So the answer would be flucloxacillin. Uh change, please. The second most common uh form of infection uh is Vertigo Tiger is mainly also a bacterial infection. Um It is coming usually to Children. But as you can see in the left hand in the left hand photo, it can also affect adults, but it is more common in Children. Usually the clue is the honey color crusts. So as you can see, they are, um they're very easy to be taken out. Uh It usually comes in the perioral area but still it can be in other uh areas of the uh skin, most likely the exposed skin. Uh it usually spreads by a direct contact but also with the discharge. Uh it can also spread indirectly through toys or clothings. That's why we can find it in nurseries. Sometimes it can happen as a breakout. Um The first line of treatment is topically which is fusidic acid. If um if it's am RSA, it would, we would use the person, but we always use the fusidic acid first if it's extensive. Of course, we resort to our oral flucloxacillin. Um 11 thing you need to know is that Children should be excluded from school until the lesions crossed or 48 hours. After commencing the antibiotics, they are not allowed to go to schools any time before that um change. Another type of infection is the viral infection. So now we go with the herpes simplex, simply the cold sores. So the cold sores is very common. It comes as a result of infection of herpes simplex virus. It is usually recurrent and it's following a very predictable course that starts with a prodorm, prodorm of pain and tingling. Usually after that with um fo 24 or 48 hours, it would start the eruption and the eruption usually looks as physicals filled with a clear fluid, they ulcerate, they are painful. Um And you, it's mostly affecting adults. On the other hand, we have similar entity which is the molluscum contagiosum. So the molluscum contagiosum, it is mainly affecting Children or immune compromised adults. It comes as an infection with pox virus and the very characteristic sign that the physical would be implicated. So it does have an umbilicus in its center. It usually con not contains cheesy material if squeezed. Of course, you wouldn't want to squeeze it because it's highly infectious. But the silver lining that it resolves spontaneously in about 6 to 24 months. Um In exam, if the patient is adult, you would want to choose the herpes simplex. But for a child, you would mostly think about the molluscum Conus and don't forget the poorly implicated um look of it change, please. So the erythema infections, this is another vi viral infection that usually presents in Children as well. So it's very common among school Children and it has a very characteristic sign which is the slabbed cheek appearance. So it and also it spares the nasolabial folds. So it it usually you would find it limited to the cheeks and it is a result of infection with Baru B 19. Um usually it doesn't require any treatment except of course, for rest and analgesia if the child is in pain and once the rash appears, the child can go to school but not before that um change, please. So with the fungal infections, the one of the again, most common infections is the tinea capitis or the scalp ringworm. Uh many of you may have come across this and it is usually the fungal infection of the scalp that causes the alopecia, severe itchiness and dry um scales uh mostly in Children, but it still can affect adults somehow. Uh So in Children, the standard treatment is oral griseofulvin and it is the only licensed treatment in the UK for the taenia capitis in Children. As for the adults, we always resort to oral terbinafine change, please. Tia circinata again, very common scenario. Uh It is an infection with the dermatophytes and it is red scaly itchy rash. What you always look look for if you see a patient with stenia circinata is what we call the active border. So the border of the lesion would be popular would be slightly raised, would be active. Meanwhile, the center would be more subtle, more scaly. Um Usually the treatment is topical with clotrimazole cream. Sometimes we might need some systemic in some situations. But the answer you're looking for mostly in that test is the topical antifungal change, please. Um So we have these scabies. This is um a very recurrent question. Uh Usually your patient should be in a care home because it does have tendency to have breakouts in care homes with the residents. Usually the scabies is highly contagious. Um There are many types of scabies but and it comes as a result of the uh infestation of the skin by the Sarcos scabiei mite. Usually your clue for the diagnosis would be the linear tracks or the burrows. To be honest, realistically speaking, we don't always see the burrows, but we see the signs of excoriations and the severe itch involving the um the whips of the fingers or the cape side sites as we call them. So usually web spaces in the fingers or those very umbilical groin area, um uh very areolar in chest um in the axilla or flexures of the body. So this is mainly what you're looking for in clues for your um for your answer, but mostly it comes as a resident of a care home change, please. So to move to a different type of um of questions or dermatological conditions, which is the inflammatory conditions. Of course, we do have the psoriasis. Psoriasis is really and very, very um wide subject and it's a huge umbrella for many types underneath it. So what what psoriasis is mainly a chronic inflammatory skin condition as you and your patients might know that it has no cure, but it does have a treatment how to diagnose psoriasis is by the clinical look. So it comes as well demarcated red scaly plaques, usually they are covered with silvery white scales. So as you can see in these photos, these are all plaques that's um red and very sharply well defined uh the scales when being um robbed off, they have a pinpoint bleeding underneath them. And that's what we call an Auspitz sign. So Auspitz sign is mainly the pinpoint bleeding that comes after rubbing off these silvery thick white scales. Um Another interesting phenomena of the psoriasis, which is the Kepner phenomena. Uh that means a new lesions that appear at the site of trauma. So we see that commonly with patients who have surgeries and on the scar of the surgery, they tend to develop psoriatic patches. Um The psoriasis, as I said has many types. So we have generalized psoriasis. We have uh the guttate psoriasis, which I think is a common, again, common scenario. Um The guttate psoriasis, the main sign of it is the tear drop. So it is like three tear drops, usually preceded by a strict infection, but it can come with many other types of infection. But you the commonest scenario is that it comes after a period of strict infection. Um it has a tear drop that the appearance that start on the trunk and then become generalized. The psoriasis itself is more on the extensor surfaces of the skin. So on the elbows, on the knees that's when the generalized plaque psoriasis starts with the guttate. It has the form of the trea uh tear drops. It is polygenetic in nature. So it can um not necessarily passing through through generations, but it can do. The treatments are quite um various. But usually we start with um topical steroids and I have to stress that not systemic steroid. You don't want your patient to be on a systemic steroid as quickly and rapidly it will improve. However, it comes back with a vengeance. So we can use topic, topical steroids moderately as well as Vitamin D analogs. Um We have many other options such as the phototherapy, methotrexate or immune suppression uh biologics, which a whole new era of treatment of psoriasis. Um What also um you need to let your patients know and in the exam as well that psoriasis is not contagious. So the stigma around it is not properly is not true. Um Change, please. So another common dermatological condition is the eczema. So the eczema is simply a group of itchy and inflammatory skin condition, which is usually characterized by the epidermal changes. So it's kindly superficial. Um when we, when we mention the eczema, we think of chronicity. So, but it still can manifest itself acutely. There is a first time for everything but usually the term eczema or eczematous skin, it comes with a chronicity or with a chronic cause. It does have many, many types, but the most um common types are the atopic. The atopic eczema is mainly started the child at the childhood period and it's usually affect the flexures. So the uh inside of the uh the flexural surface of the elbow behind the knees, it does have a family history. So most of the Children with uh atopic eczema, they have parents or um any of the family uh members involved. Um They, it also comes very in, in a very close association with asthma and hay fever. Um Another uh um type of the eczema is the CPO eczema. So the CPO eczema is mainly inflammation of the sebaceous glands. And usually the sebum can irritate the skin in a certain mechanism or immune mechanism and it, it um usually manifest itself as scaly uh rash that's affecting the Sebo sites. So, what are the Sebo sites? They are the sites that bearing the hair? So we can see it commonly on the scalp hair, on the eyebrows, on the chest area. Um And sometimes in the uh axillary areas, usually the dandruff is a huge sign or a huge um uh te tell off sign. Uh The treatment can involve the use of topical antifungals or even systemic antifungals. Not because it does have fungal infection element. Although some of the researchers suggested that but also because they have an effect on the s uh on the seedling gland, uh treatment of the eczema in general, a very uh common question that's asking what the first line of treatment in eczema and it is emollient and you would be surprised at what a simple emollient can do. So, the first line in treatment of the eczema is emollient. Um The second line would be the topical steroid. Remember that the atopic eczema comes in Children and you don't want steroid to be your first line of treatment. So, the first line of treatment is emollient. If you're combining emollient and steroid topically together, you would want to use the emollient first and then apply your uh topical steroid 30 minutes after. Um we can also use topical anti-inflammatories slash immunomodulators, which is the calcineurin inhibitors. Uh We can also use the light therapy. Antihistamines are not a treatment, but we can use them if it disturbs the sleep. So, antihistamines can be used for both Children and adults if disturbing the sleep, systemic steroids can be used as well as immunosuppressants or the biologics. One important thing to um to familiarize yourself with is the topical steroid ladder. As you all might be aware that the steroids vary in uh potency. So we have this letter of treatment. Um I tried to put it here in this presentation. It starts with the hydrocortisone. As we go up in the potency, we have the clobetasone which is known as va betamethasone and uh mometasone and ending with the most potent which is the clobetasol um change, please and change. So, Rosacea is another inflammatory skin condition and it's a very chronic you all uh have come across acne either in your practice or as um in, in community. So, the acne is um the rosacea is a variant of the acne. One thing you remember about the acne is that it comes as uh for mostly uh during teenage years, but there is an adult onset type of acne. But we do have another variant which is rosacea. So the rosacea is a, an older brother of the ACNE, which is predominantly affecting the nose, cheeks and forehead. Uh If you think of Rosacea, if you're familiar with the movie up, uh the um the character of the old man, he did have a rosacea. So you can see his um nose slightly bigger and that's what we call a rhinophyma. So, if you see in this photo, this gentleman here has resistant redness and telangiectasia. Um And on top of it, there comes a few papules as well and with his nose becoming slightly disfigured, that's the term we use for the rhinophyma. Uh Usually the rosacea is exacerbated by alcohol, spicy, food and sunshine. The treatment is through the topical metroNIDAZOLE um and the tetracyclines if it's severe ISOtretinoin can work and it is the gold standard treatment for acne. Um But we might need it for some cases of the rosacea as well, especially to prevent the rhinophyma from happening. We have another inflammatory skin condition which is the pr or pitas rosea, the pitas rosea is a self-limiting type of rash. Usually it starts with a big scaly um, patch, usually on the trunk and then daughter, uh, um, daughter patches arise from that patch in a pattern that's similar to the Christmas tree and it is usually on the trunk. Uh, this is a very harmless rash and it requires no treatment change, please. So the attic area simply the urticaria is, um, an immune reaction of the skin. It's characterized by wheals. So the wheels are edematous parts of the skin. Um Usually it looks as a very pale skin swelling surrounded by areas of erythema. It lasts any anytime between just a few minutes up to 24 hours. So the urticaria is usually classified by according to the um uh the duration either to acute or chronic. The acute urticaria is less than six weeks. So multiple episodes, each of them last for up to a day. Uh but happening in less than six weeks course, but if it's more than six weeks, that means it's chronic urticaria. It does coexist sometimes with angioedema. So the angioedema is the deeper swelling in the tissues in the um either subcutaneous tissues or the mucous membranes. That's why uh the angioedema manifest can be uh manifested as the lip swelling, eye swelling or even lary laryngeal obstructions. The chronic urticaria, it can happen for different reasons. But most of the situations we can find the trigger. So we call it spontaneous or idiopathic but still it can be inducible. The most common inducers of urticaria is um aspirin, opiates, stress or even changes in the temperature. So, and in some situations, water itself, uh there is an entity that's called um uh aquagenic urticaria, which in which the urticaria is precipitated by water. The treatment usually is the non sedating antihistamines. Of course, in severe cases, you might want to give your patients II M adrenaline, especially if accompanied by angioedema. Um If your patient is pregnant, then you would choose a sedating antihistamine which is the chloropheniramine malate um change, please. So, erythemas um this is I find II used to find it um a very confusing subject. So the erythema is um mainly what's what erythema I is defined as. So it is a red skin that's caused by increased the blood supply to the skin. So mainly an area of redness. Usually it has a shape, either annular erythema polycyclic and it is the it it is categorized according to that sometimes as well as according to the type and trigger. So the types you need to know in for this test. Um The most important one would be the erythema multiforme. So, erythema multiforme is mainly a reaction um to infection either with herpes simplex virus or to mycoplasma. Usually it is um it presents as target lesion. So if you see in the f uh the upper photo that the lesion does have a center and a surrounding area uh of paler erythema and then a rim of darker erythema. So similar to the target of the darts. And this target is very cha this target lesion is very characteristic for the erythema multiforme. It might be scary because sometimes it can lead to Steven Johnson syndrome, which is a severe form of the erythema multiforme. But most situations it can resolve on its own along with the treatment of the cause. So, with the treatment of the herpes simplex virus or the mycoplasma, uh sometimes we can give patients a prophylactic course of acyclovir if it's recurrent, um the second type of erythema would be the erythema migraines. So, the erythema migrans is also linked to another infection, which is the Lyme disease and it is an infection of the skin with the porella. Usually it's not as um widespread as the erythema multiforme. It doesn't affect the mucous membranes, it is limited to the area of the infection. Um as you can see, still target lesion but not as um as generalized at the erythema multiforme. Um the erythema marginatus. So the ery erythema marginatus, it's a reactionary erythema. It usually comes um affecting Children and um usually the Children who get infected with a strict infection. Uh And the most important clue is having a rheumatic fever. So it is a reaction that comes with the rheumatic fever and it looks quite annular. Usually it is very asymptomatic. So, the treatment would be, of course, with the tr treating the rheumatic fever, the erythema nodosum, it is usually affecting the subcutaneous tissue. So it is tender nodules mostly on the chins, on the shins of the legs and it is very tender. Um it usually accompanies the sarcoidosis and sometimes even can be a first manifestation of the sarcoidosis. It's also linked to the I to the IBD. So the um irritable bowel disease. Uh sorry. Um Yeah, to the irritable bowel diseases. And with the TB uh again, treatment would be just supportive and treating the cause. The last type of erythema is the erythema albinae. So the erythema abiinae again, a reactionary erythema. Um it is very interesting because it comes in not quite in an annular or circular pattern, but it comes in a reticular or linear pattern. It is usually comes as a result of the infrared radiation. We see that sometimes with um people who have the physiotherapy treatments and also with people who have their laptops on their thighs for a really long time. So it was very interesting uh to see in those types of patients um change, please. So, blistering rashes, um I would say this is really important as subject in dermatology and for this uh exam as well. So a lot of blistering rash, uh rashes are out there. But the most important types that you need to know are the pemphigus, vulgaris and the bullous pemphigoid. So both falls under the umbrella of the blistering rashes, both of them manifest itself usually in an older kind of uh age. So the pemphigus vulgaris usually in less uh in a younger um group in comparison to bullous pemphigoid. So it comes in the age of 40 to 60 but you still can see it in even uh younger or older the bullous Figo, it comes to the 70 plus. So it's mostly in older group of patients for the histology. So what happens in a blistering rash is the uh separation or the clefting of the skin layers. So it can happen either between the epiderm and the derms or it can happen in the epiderm on its own. So with the level of disc clefting or the level of separation. So once this separation happens, the skin that would result in blister if that level is in the epiderm. So if it's intraepidermal, that is um pemphigus vulgaris. But if it's underneath the epiderm or subepidermal, that's the bullous bmyo that translates itself to what we see clinically. So if the level of separation is in the epiderm, usually the blisters would be more superficial. So that means they will be flaccid and easier to uh to rupture and that leaves areas of erosions as well. So if a if superficial intraepidermal, it would be flaccid. But on the other hand, and that's the bullous vulgaris, uh BMS, vulgaris, if the, if the level of separation is subepidermal, it will be slightly deeper. So the bully would be tense and there is a good chance we see the tense bully on the patient itself. Um Usually the distribution can be anywhere. But with the pemphigus vulgaris, we see an involvement of the oral mucosa, but it can be anywhere on the skin, same for bullous pemphigoid. But it does prefer the flexural surfaces and the abdomen area. The onset of the blisters in the pemphigus, vulgaris usually comes with pain. So the patient would complain that the these sores or these blisters are very painful. While the patient of the bullous pemphigoid would think of it as more itchy. And even before the uh blister developed, the patient might have an very itchy rash. First line of treatment is mainly similar for both, which is the steroids in the pemphigus vulgaris. We like to use the oral steroid as a first line for bullous bin Figo. If it's not extensive, if it's limited, we can get away with a topical steroid. But our first line of treatment would remain the oral steroids, the mortality. Um It is not as high as many would think. Um We see that more with the pemphigus vulgaris um up to 10% 15% but it's very rare that the bullous Figo would be um would cause mortality. Us. Uh It does follow a very um benign course change, please. Um The autoimmune diseases in dermatology. Um I always thought it's very unfair to try and cover the, cover them. So I'm trying to cover the parts that usually the um the aim of the questions in for this exam. So mainly um they would prefer to ask you about the antibodies that is diagnostic for each of these types. Um to start with the again from the very common, from the most common uh types of autoimmune diseases to the ra risks. So we will start with the systemic lupus. So in lupus erythro Matos, it is, it has many types and it does have the systemic lupus erythro Matos that we all might be aware of. And it also has another type which is the discoid lupus erythematosus, which is mainly limited to skin in systemic lupus erythematosus. It in, of course, it's a systemic disease. So it does involve uh other organs. Um I have this little um numeric to do remind myself about it, which is MD brain soap. The M is for Maller flush. Um um ma malar rash. Uh D is for the discoid lesions which is the um the lupus itself. The rash uh B is for blood. So the antibodies or hematological disorders uh R is for renal A is for the autoimmune antibodies or other autoimmune uh diseases and as well as A N A. Uh I uh sorry, I, is it for the immune uh disorders. M is for neuro uh S seroi serositis. Uh O is for the oral and A is for arthritis, P is for photosensitivity. So that's the systemic lupus, the dla or the discoid lupus doesn't have the systemic manifestations. Most important thing to find out or to know for this test is knowing the antibodies. So the most antibodies that's diagnostic to the SL E is the A N A anti double stranded DNA and anti Smith antibody. It's important to memorize all of these. Um the, the drug induced lupus, which the commonest drug would be the hydrALAZINE that's causing the lupus. And it is um the antihistone antibody is the most diagnostic one for it. Systemic sclerosis. The systemic sclerosis is an autoimmune um disorder that affects the skin, the vascular system as well as the internal organs. And the most diagnostic um antibody is the anti S CL 70. The CRS is another type of the systemic sclerosis. A limited type of systemic sclero sclerosis that does have uh calcinosis raynaud's esophageal dysmotility, sclerodactyly and telangiectasia. Um And the most diagnostic antibody antibody is the anti centromere. JRN is another autoimmune disorder which mainly affects the exocrine gland. It can come as a primary or it can accompany other um autoimmune disorders. And the most important antibody for the diagnosis is the anti rule. And antila dermatomyositis is the dis the autoimmune disease that affects the skin as well as the muscles. So it can have some form of muscle weakness as well as skin manifestations such as a rash. Uh what we call a heliotrope rash which is mainly around the eyes, um bluish discoloration of the nails. Uh It can also cause ragged cuticles. Um and usually we find uh elevation of the CK levels in those patients. And um the most important antibody is the anti one. The dermatitis herpetiformis, I did include that in the autoimmune be, although it's not entirely an autoimmune, it's more of a blistering rash, but only so you can remember an important antibody which is the anti T TG. So the dermatitis herpetiformis, it is um a blistering rash that usually occurs in uh crops and it's a very recurrent and itchy uh form of rash that accompanies the gluten insensitivity. So we can find it with in patients who has, who are celiac or has the celiac disease. Dermatitis. Herpetiformis is very common um as opposite to what my people think is that it's a disease of younger population. But we see first presentation in 40 50 60 year olds. Um Usually, as I mentioned, it comes with the gluten insensitivity, but you might want to involve the gi team in treating those patients because they are at a very high risk of lymphomas main. And uh gi uh so uh and gi um uh cancers, uh the most important antibody is anti TG as, as we have mentioned as well as the antigliadin and anti endomet change, please. So, oral dermatology um again, very um big topic, but the most important uh conditions you need to know would be the oral candidiasis. So, the oral candidiasis is mainly just membranous marks or membranous. Um uh lesions white in the color. Uh The most important sign is that you can drop them out. You can reme remove those membranes. Usually it's an immunosuppression, immunosuppressed patients, diabetic patients, patients who use um corticosteroid inhalers and it's very painful and the treatment of course, would be oral fluconazole for patients. As many of you might know that patients with um corticosteroid inhalers, they would need to rinse their mouth with um water or salt or, or saline when they use their inhalers because the steroid would predisposed to uh candidiasis. Sorry. So the leukoplakia leukoplakia is similar to the oral candidiasis except that it is not as spreading as the oral candidiasis usually comes in patients who smoke and it shows as a well-defined whitish black. The most um important thing you need to know that it can predispose to cancer and usually is um it predisposed to squamous cell carcinoma. So, it's very important to recognize and treat as early as possible. Your clue that it does not get robbed out. You can't remove that uh plaque from the patients. Uh oral mucosa, usually it is on the sides of the tongues, but it can happen on the inner side of the lips or even in the buccal mucosa. The oral lichen planus is another um oral uh um condition. However, it is mostly a skin condition. So the like the lichen planus is in fact a skin condition but it does have oral manifestations. The lichen planus is um again a kind of inflammatory itchy condition of the skin that famous for its four peas. So the four peas are pruritic papular polygonal and purple. And usually it is a rash on the skin that can affect um anywhere of the skin pref preferring the most dependent part. Um but it can involve the oral mucosa and given us the look of a whitish lazy streaks, um usually at the inner side of the buccal mucosa. Um It it is it it it is linked to uh hepatitis C virus and it can sometimes even uh a clue for diagnosis for it. Uh change please the pregnancy, dermatosis. So again, many disorders can happen in pregnancy. But there is two important topics which is exclusive in pregnancies, which is the uh P or the polymorphic eruption of pregnancy and the bnhi gestations. Yes. So the uh pop or the polymorphic eruption of pregnancy, it's also called pruritic urticarial papules and plaques of pregnancy. It usually comes in the last trimester. It is as from the name, it is pruritic, high itchy urticarial. So it is edema and swelling of the skin papules and plaques. So just um areas of elevations of the skin, mainly it can start in the stretch marks, but it can involve anywhere but it tends to spare the umbilicus it is not quite common to reoccur in the um, uh, next pregnancies still can, but it unlikely to, to do that. And it's very harm, uh, it's very harmless to the, uh, to the infants as well. Uh, sorry to the, um, newborn as well. The Bengo gestations, it's um, a form of immune reaction that comes in the 2nd and 3rd trimester of the pregnancy, but it can occur immediately after giving birth in the postpartum period. It is, it can reoccur in the other pregnancies. Your different, your def def uh designed to differentiate from the pop is the umbilical involvement. So the pop tends not to involve the umbilicus but the um lymph gestations, uh it can involve the um very umbilical area and it does form blisters. So change, please. Um very important topic is the skin lesions. So the skin lesions, um that's mainly either the benign or the malignant lesions of the skin. We do have the benign ones. That's the most important ones are the seb ks or Sebo keratosis, Sebo keratosis. They are basically the aging spots. You can see them in almost any patient, any elderly patient that you meet, they are harmless water, uh papules that has a very uh rough surface and they appear during the adult life. They start appearing from the age of 30 in some patients and normally no treatment is needed for them unless they are irritated or they are problematic, which we can use cryo or cure at those pa those lesions but they are very harm, harm harmless and they are very benign the Ancyla Asma. So the Zyla Asma is mainly associated with the increased uh high uh with the increased cholesterol levels. Although it still can occur with normal lipids too, but it is quietly associated with the familial hyper chloro type two and the hyperlipoproteinemia, uh it's, they are usually small and yellowish papules around the eyelids. That's the most common um site of predilection for them. And again, they are very harmless. But if they are problematic, they can be treated either with um lasers or with curetting them. Um Mongolian spots. This is, it's an old uh name for the lumbosacral dermal melanocytosis. This is a very benign birthmark. Usually it comes as a, a blue gray uh patch of uh skin that's affecting the lower back and the buttock region, it follows very stable course. And again, a benign behavior. So no treatment would be required for them. Um Change, please malignant skin lesions. Uh This is really important either for this exam or for your daily practice. Um It's important to recognize these types for from skin cancers. So we have the nonpigmented ones, which is the B CCS and SCC and the malignant melanoma as a pigmented type. The BCC was previously known as rodent ulcer. This is the most common nonpigmented skin cancer, the most, it has many types. So it has a superficial type. It has a more fake type, but the most common type of the B CCS is the nodular type and it is it uh it is also the uh commonest um clinical presentation of them. So it it usually follows a very slowly and gradually cause of grow of growth. So it may take years for it to fully manifest itself. It is the most common on the sun exposed areas and it's a very linked to sun to excess of sun exposure. Um clinically, it looks as a skin colored or erythematous papule that does have pearly appearance. So you can see, um you can see it shi with a shiny surface. Usually this tends to ulcerate. Um and you can, if it's still not ulcerated, if it's just a shiny burly papule, you might see Teia usually crossing the middle of this papule. Of course, the treatment is to excise it. Um topical treatment in case of superficial uh types of skin cancer with emi commode uh and radiotherapy. Um You can reassure your patient as this type of uh skin cancer. So the BCC is we call it locally malignant. It um does have a very low chance of spreading or metastasizing. So it is, well, it is a kind of a friendly cancer if we can put it that way, another type of nonpigmented skin cancers would be the squamous cell carcinoma or the SCC. Um The SCC is more aggressive compared to the PCC because it does, it does um follow a very uh rapidly growing course and it tends to invade the skin. It can metastasize either to the lymph nodes or to distant organs. Um Usually it comes on top of um chronic ulcers, but it's not exclusive to that. It can happen in any areas of the skin. Any chronic irritation may uh predispose to uh sec um linked to leukoplakia, as we mentioned earlier. Um It does tend to follow this uh aggressive course. That's why we treat it with ex excision in uh almost all situations. The malignant melanoma is um a skin cancer very aggressive and um life-threatening, it arise from the melanocytes. So it is a pigmented form of skin cancers. I'm sure you've all heard of the ABCD E which are the basic diagnostic clues for the malignant melanoma or at least raising your suspicion for a malignant melanoma. A stands for the um uh um asymmetry, which means that the LA which if the mole is asymmetric, that raises your suspicion, uh B is for the border. If the border is irregular, again, raising your suspicion uh color, uh mainly we're talking about the color variation um as you can see more uh of m more than two or three shades of uh brown in the same mole or darkening of the mole itself. Uh the standing for the diameter, it's not quite um uh not quite accurate as we could see. Melanomas even in four or five millimeter. Uh the diameter that is more than six millimeter raises your suspicion and e stands for the evolution. That means the mold is changing. Morphologically, all of these clues is uh is raising your suspicion for a Melanoma. Um and it needs to be recognized and treated as early as possible. Uh change, please. A few miscellaneous uh subjects that I just wanted to mention, which has been um a a topic of question before. So the bruising, uh the bruising as they are very simple, but some people may mistake them for something else. So just usually they can have a photo similar to that one and asking what could be the diagnosis, which is mainly a blunt trauma. So the bruise, what you need to know is the bruise can take any shape, usually the shape of the tr of the traumatizing agent itself and it can be anywhere. Um You might find the patient has um something uh has AAA um a coagulation disorder which can predispose more to bruises. It can come in a ques in the question just like that. Um The chicken pox and the measles, they have been a bit confusing to um to many doctors. The chicken pox is um an infection of the uh an infection of the skin usually in Children and it is an infection of the primary infection of the variceal varicella zoster. If it's a secondary infection, it becomes shingles. Um And it is uh very contagious. And um your clue is that it does have systemic manifestations. So the child can be feverish. Uh They can have lymph node enlargement. Uh The rash itself is polymorphic. That means you can find all the stages of the rash. So you can find a papule, you can find a physical and you can find a cross in the same patient. It does have an interesting uh look of a dew drops on a rose petal side. So it's quite similar to that. However, the measles can be sometimes confusing but it does have the prodrome as well, um which is usually starts a few days before the actual eruption. And um once the fever subsiding, you can find the Klix spots, the K spots, it's important to know because they are a gray marks papules on the buccal mucosa of the child. And within a few days, the morbi form or the mono formic uh eruption, that means it's all similar starts to erupt and you also your clue is that it spreads downwards um change, please. So we get to the end of this presentation. I hope I cracked a little bit of the mysteries of dermatology. I know it can be a bit confusing uh but I am sure all of you can really do it and can get through this exam. My only advice is do not panic. Um If you don't know a question, just leave it and the answer will definitely come to you. Um I hope I wasn't boring you. Um And I'm happy to receive any questions uh through my email. Uh I think doctor an will um will help me with that. So, thank you all. Thank you. Thank you so much, Doctor. Thank you for that. That was a great presentation. Um I'll just uh yeah. Uh CJ has send in the feedback form, so I'll send it to you later. Thank you so much. All right, good luck, everyone.