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The Comprehensive Dermatology Guide: Session 1

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Summary

This teaching session provides a comprehensive guide to dermatology, with a particular focus on psoriasis and its various subtypes: plaque, flexural, guttate, pustular, and scalp. The presenter also discusses the physical manifestations of psoriasis including nail changes and scalp thickening. The session illuminates the connections between psoriasis and other conditions such as metabolic syndrome, cardiovascular disease, and psychological disorders. Relevant anatomical imagery and an interactive Q&A session are included. Useful for medical professionals interested in dermatology or those preparing for exams, the session offers in-depth understanding of psoriasis, its causes, symptoms, and complications.
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Description

Welcome to session 1 of the the QUB DermSoc's Comprehensive Dermatology Guide. Murtaza will be covering a dermatological teaching session covering: psoriasis, non-melanocytic lesions and emergency dermatology.

Learning objectives

1. Understand the various types of psoriasis, including plaque psoriasis, flexural psoriasis, guttate psoriasis, pustular psoriasis and scalp psoriasis, and their distinguishing characteristics. 2. Be able to identify common presentation differences between basal cell carcinomas and squamous cell carcinomas and their role in emergency dermatology. 3. Recognize the associations and complications of psoriasis, including psoriatic arthritis, metabolic syndrome, cardiovascular disease, and psychological distress. 4. Comprehend the theory of Koebner Phenomenon as it pertains to psoriasis and its relevance in diagnosis. 5. Gain knowledge about dermatology emergency conditions, such as necrotizing fasciitis and Steven Johnson syndrome, and their role on the disease spectrum.
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Computer generated transcript

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

Hey, everyone. Uh I hope you guys can hear me. All right. Uh, we'll wait another 2 to 3 minutes before we start. Just, uh, give people some time to come in if they haven't already. Um, and we should be starting shortly. Uh, so, yeah, just let me know if you guys can all hear me. All right, in the chat and, uh, hopefully we'll start in the next 2 to 3 minutes. All right. Um, I think we will make a start now. Uh, just wanna make sure everyone can hear me. Ok? If anyone can just put in the chat that you can hear my audio and we can start the session, right? Wonderful. Thank you. R OK. So, um, just before we start quick disclaimer, uh, all the pictures and everything used here are not mine. Um, and, er, not from Queens, they are from, er, all credit goes to Dam Net and passed cos don't wanna get sued. But, um, just so you all know there will be a feedback form uh, that will be sent to you by the end of this lecture and if you fill that out then we will feedback a certificate to you, er, which you can use for um, whatever you would like, um, put it onto your CV. And uh you can confirm your attendance to this Comprehensive Dermatology Guide. So there's gonna be session one. we're gonna have two more sessions after this and once this session is complete, we should have a post up for an event that we're organizing in the near future, uh 27th of April um for a career in dermatology. So that would be a very interesting event for anyone who likes dermatology and is thinking about it. Um And maybe wants to specialize in it. It would be very beneficial for you. So yeah, let's get cracking. Um I am yet to break my fast and I'm sure that you all don't wanna spend your entire evenings here as well. So hopefully we can get this done as efficiently and effectively as possible. So the agenda for today is psoriasis, non melanocytic lesions, emergency dermatology. And then we'll run through some questions right at the end. Now, in regards to the psoriasis, there are many different types of psoriasis, but obviously, we can't go through all of them today. I will touch on the ones that are high yield and the ones that you should know for the upcoming exams. But mainly we're gonna focus on plaque psoriasis, which is what you'll you'll probably encounter as well. Um in hospitals and in clinic. Um in terms of the non melanocytic lesions. We're just gonna go through actinic keratosis, basal cell carcinomas and squamous cell carcinomas. The main thing that I want you all to take away from from that part of this lecture is just being able to differentiate between B CCS and S CCS. So the squamous cell and the basal cell carcinomas in terms of their presentation and even just how they look and j just be able to kind of get a bit used to uh a few spot diagnosis if you would. Um And for emergency dermatology, we'll go through a few emergency conditions, necrotizing fasciitis, uh Steven Johnson syndrome and 10, and again, I just want you to really understand mainly between S Js and TE and that they're not particularly two different um sets of, of diseases that are actually on the same spectrum. It's just that one is uh a lot worse than the other. But again, you'll, you'll, you'll get the hang of it once we get there. So to start off uh just a quick overview on psoriasis. So, psoriasis is a common chronic skin disorder and it's characterized by red scaly patches on the skin that you can see and they're very itchy, um very hard to miss uh and patients with psoriasis, um they are at an increased risk of arthritis and cardiovascular disease. That is something uh You should keep in mind uh especially in, in terms of questions. Um You'll see a lot of times there will be patients who have these uh especially arthritis will be coinciding with the psoriasis. Um And we'll touch a bit more of that, a bit more on that on the next slide as well. In terms of pathophysiology, there's not really much that um you, you, you need to keep in your mind, you should understand that it is not fully understood. There are a few genetic factors. Um If you would like to know specifically which ones um it is associated with HLA B 13 and B 17. Um And then there are environmental factors which can affect it as well. So things such as skin trauma stress is a very big one. A lot of times you'll encounter patients who um maybe their psoriasis hasn't really flared up in a long time and they've had it well under control, but then a very stressful event occurs in their life, maybe the loss of a loved one, et cetera. And then that can really uh really, really cause that psoriasis to flare up again and it could be very later on in their life as well. Um All the strep infections, er, for example, now, uh I will have more detailed notes. Um Obviously I have uh the these slides will be available to everyone and the notes underneath will also be available. So all the extra information that I'm giving er, is all available to the public once you get a hold of these slides. Now, in regards to the subtypes of psoriasis. So we have uh a few different subtypes. We have plaque psoriasis, flexural psoriasis, gutta psoriasis, which I would like to put some emphasis on that gut psoriasis is a big one that they do like to ask questions on pustular psoriasis and scalp psoriasis. So just quick differentials between these. So you can, so you can understand a bit plaque psoriasis is the most common subtype and it's the one that you've been seeing in the last few pictures. Um It is very well demarcated red scaly patches and they tend to affect the extensor surfaces. So the the, the, the front of your knees, the uh back of your elbows, you know, these extensor surfaces are what are usually affected when it comes to psoriasis. Um plaque psoriasis in terms of flexural psoriasis, as the name says, flexural, um it, it is a bit more common on the flexural aspect of your body. So, um the er near the bicep area of your, of your elbows when you're flexing um areas like that and it is very smooth in contrast to plaque psoriasis, I'll uh we, we have a few pictures as well on the next slide. So you'll get a better understanding of what I mean, but just keep in mind that flexural psoriasis, it's, it's, it's a lot, it's a lot smoother than plaque psoriasis. And in regards to gate psoriasis, which again is very high yield. Um I would say I've seen quite a few questions on gut psoriasis. Now, this is a, is a very easy um in terms of when you get a question, it's very easy to uh click in your brain that OK, this is gate because it's the, it's the only one that happens 2 to 4 weeks after a strep infection, usually a slow infection and these present very differently as well. Uh So these have small tear drop lesions er on the body, which again, will you'll get a better understanding on the picture, which will be on the next slide. So keep in mind, GTT psoriasis is 2 to 4 weeks, post strep infection and it causes tear drop lesions on your body. Pustular psoriasis tends to affect the palms and soles and scalp. Psoriasis as the name entails is basically psoriasis on your head. Um very hard to miss when you see it. Um It's just, it, it's like a very large thickening of the scalp. You can tell that there's a lot of area which is just you, it's like you're not touching the head, you're touching um uh another entity over there and it's very um it, it's very scaly and if you er brush the hair, you'll see a lot of dandruff falling off as well. Now, in regards to any complications and associations. So, uh as mentioned, er, ps psoriatic arthritis, around 10% of people will experience um uh psoriasis with uh this, this type of uh arthritis, especially if they're middle age, but it can occur at any age. Um Nail signs very important. They always like to ask about nail signs. Um So this can include things like nail pitting, nail, thickening, nail, dis discoloration, ridging. And the main one would be oncolysis that I would want everyone to really put their attention to. So, oncolysis is just separation of the nail from the nail bed itself. So it's like you can literally pop off the nail. Um And again, if you see a picture of this, it's, it just sticks in your brain, which is something I personally like about dermatology. A lot is that uh a lot of times once you get used to seeing a few of these pictures, it's just hard to get them out of your brain. Um So around 80 to 90% of patients with um psoriatic arthropathy tend to have these nail changes. So it's very important that you're able to recognize these, these types of uh intricacies. Now, um they are at an increased incidence of metabolic syndrome, cardiovascular disease and VT E um again, uh high yield, remember that VT E cardiovascular disease, these things are um they are at a high incidence of, of these condi er, of these er conditions and in terms of psychological distress, I'm sure you can imagine um yourself that there is a lot of anxiety and sometimes even depression uh that can occur because a lot of the patients who have psoriasis, uh, especially when it's affecting a large amount of their body. Um, they are not very comfortable with, for example, taking off their shirt or they're not comfortable with even, um, even just having it on their elbows, it's, it's very psychologically distressing for them and I'm sure you all can appreciate why that would be. Um, and, uh, other comorbidities that increase the risk of cardiovascular disease are associated with psoriasis, particularly obesity, hyperlipidemia, hypertension and type two diabetes. Now, right at the end, I've written, er, Kiba phenomenon because again, this is a very high yield er, topic which um universities do like to touch on. So Kiba phenomenon is basically when you get a injury or a trauma in one area and then from that area, um the psoriasis uh starts to happen over there. So let's say you get a cut on your forearm and then while the forearm cut is healing, uh you've got psoriasis that starts to um act on that area specific area where you've had the laceration. So again, uh keep that in mind, Kiba phenomenon very important. Um If you, if you would like to look it up yourself and get a better understanding of it, that would be good. There are a few other derm conditions which um also, er, are associated with a Kiba phenomenon like keloids. Um So again, I think it would be good if, if you will look that up and just saw what other dermatological conditions, um, are associated with the Kiba phenomenon. Now, as I said, uh, the pictures that I promised now, uh, I do wanna let you guys know there are a few pictures, er, in this, which might be a bit disturbing and maybe, er, getting you feeling a bit nauseous. So, uh, if you're not good with that, I would, uh, advise you to avert your eyes. But, um, again, this is the reality. So flexural psoriasis, as you can see on the left side, um it's uh it, it's a lot smoother. You, you can't see as much of that sines. And um it, it, it does seem very different to the to the classic psoriasis we've been looking at so far um through the electric slides. Uh on the right hand side, you can see pustular psoriasis, which is affecting the hands and the, the soles of the feet. Um again, very distinct and very, very different from plaque psoriasis. And now in the middle there you have gut psoriasis. So I II hope you guys can see on the chest, the smaller the teardrop word. Honestly, I II feel like it's very descriptive of, of what it is because they are very small, teardrop, papules, small teardrop lesions. Um And as I said, they do occur 2 to 4 weeks. Um after a strep infection is when the lesions will start to appear classically, it will be a throat, uh a a sore throat which the patient will have and it is more common in Children and adolescents. So the treatment for this um for gut psoriasis is uh honestly, it resolves mostly spontaneously within 2 to 3 months. So you don't really need to do much. Um Just a bit of support would be great. But uh most of these cases do resolve spontaneously within 2 to 3 months in and of themselves. Now, this is a very big chunk. Um I would say for the exams, the main two dermatological conditions which have very extensive managements would be uh chronic plaque psoriasis and um acne vulgaris. Other things, most things in dermatology like acne rosacea or um like we just went to gate and all these things, they're either very supportive or they have one drug which is the mainstay of the management. But these two conditions, acne vulgaris and chronic plaque psoriasis. I would recommend that all of you go through them a few times and make sure that you've really cemented it in your brain. What the 1st, 2nd and 3rd line are for, for, for the management of these things. Now, in terms of plaque psoriasis, nice recommends using a potent corticosteroid once a day and a Vitamin D analog once a day, but they should be applied separately. So one in the morning and the other in the evening time. Now you wanna do this for up to four weeks for your initial treatment. Now, if there's no improvement after eight weeks, then you would wanna offer the Vitamin D analog twice a day by itself. So you wanna remove the steroid now, so you're only giving them the Vitamin D twice a day and you've gotten rid of the steroids to see if that's gonna maybe help them and that's gonna work better. Now, if again, if there's no improvement after 8 to 12 weeks after that, then you can move on to your third line, which would be getting rid of the Vitamin D analog and bringing back the potent corticosteroid and applying that twice a day for up to four weeks. Um or you could alternatively use a cold tar preparation uh applied once or twice daily and in terms of secondary care. So if none of these uh above treatments work, if um I, if it's not helping them emmolient use is also obviously very good just for just for the patients themselves to, you know, not have that kind of scaliness. But if in and of itself, none of these things are really benefiting the patient, then you would move on to your secondary care management, which would be phototherapy or the use of methotrexate in terms of systemic therapy. And this honestly really just uh I is based on the patient, what they're presenting with what type of drugs they might be on already if they have any comorbidities. Um So for example, if someone has already got an associated joint disease, then oral methotrexate would be very useful in that scenario, for example. Um but again, uh you can use phototherapy and that would be three times a week otherwise methotrexate for systemic therapy um is also uh considered first line um in terms of secondary care management. So, psoriasis management, as I said, er results spontaneously within 2 to 3 months and in terms of scalp psoriasis, uh nice does recommend the use of potent corticosteroids er once daily for four weeks. And if there's no improvement after that, then you would use a different formulation. So you would use a shampoo or a mousse or something that would just um work better with that patient and their hair and their scalp. Um And in terms of exacerbating factors, trauma, alcohol, um withdrawal of the steroids, all of these can um exacerbate your uh psoriasis and even these drugs which I mentioned here. Uh Blank, I feel like that was the best way I could make an acronym for it. Uh But beta blockers, Lehi ace inhibitors, nsaids and quiNINE. Now, I know that was a lot to take in. Uh again, these slides will be available to you. But um the, the management for psoriasis honestly is, is, is the main thing I would want you guys to, to focus on other than other than just being able to recognize the different types based on pictures. Now, we're gonna move on to the non melanocytic lesions So we're gonna start with actinic keratosis. So, on the right, you can see a picture of someone who's got actinic keratosis on the hands. Now, actinic keratosis is uh it these are scaly spots that are found on sun damaged areas or sun damaged uh areas of your skin. Um It's also known as solar keratosis. Now, obviously, you can understand why the hands would be a an ample place is because usually your hands are not covered uh whenever you're outside and they are um exposed to a lot of sunlight and um actinic keratosis. A lot of times is considered an early form of a squamous cell carcinoma. Now, it is not necessary and I'll repeat, it's not necessary that every actinic keratosis turns into an sec and every sec started off as an actinic keratosis. That is not a precursor that needs to be there. Um They can happen independently of each other. However, it is considered an early form of squamous cell carcinoma because of the association it does have with it. Now, it is very easy to clinically diagnose. And the main concern in terms of actinic keratosis is just again, your increased risk of developing that sec. So if you are working in a hospital and you would see something like this, your first thing would be um to understand whether or not this is actin keratosis. And then you would want to really be focused on the fact that this person could then later um have an sec develop. Now the features, as I said, the small crusty or scaly lesions, they can be pink, brown red uh or they can even be the same color as the skin. So the reason I put this picture as the second one is because I feel the first picture is a lot easier to um to see the, the lesions and the er, and the actin and keratosis here. But in the second picture, it's a lot less, it's, it's a lot more red. Um There are areas where you can see it a bit better, so closer up to the wrist, maybe on the sides of the fingers. But it is um it is less telling than the last picture. Now, usually it does present as multiple lesions as well. Um And the very common sites are again exposed areas to the sun. So the back of the hands and the face, um they affect the ears, the nose, cheeks, upper lip, um temple, forehead, uh if you're bald in your scalp, um and in terms of management, you just wanna prevent further risk. That would be your mainstay. So, what you would want to do is obviously give him sunscreen and just tell them to avoid the sun in especially those types of areas. Hopefully cover them up. You would give him fluorouracil cream typically a 2 to 3 week course and the skin does tend to become more uh red and inflamed. Um So sometimes typical hydrocortisone is given following fluorouracil to kind of help settle that inflammation, topical diclofenac is also uh available for use. Um It can be used for people with mild A KSM moderate efficacy um but there's a much fewer side effects. Um and then yes, you do have options like er imiquimod and cryotherapy as well as ridge and core. Now, in terms of squamous cell carcinomas, now, squamous cell carcinomas are a common type of keratinocyte cancer or non melanoma skin cancer. So, as you can tell, keratinocyte cancer is made up of keratin. So it's the same protein that makes of our skin and our hair and our nails. Now, it, it, it is uh most cases of SEC are associated with uh DNA mutation. Um and again, ii don't wanna get, get too into it. But uh if you, if you want, you can always look at the notes, the mutations are usually in the p 53 tumor suppressor gene and are caused again by exposure to ultraviolet radiation, especially UVB. So a lot of sunlight again. Oh, sorry for that. Uh a lot of sunlight again can um really precipitate this uh squamous cell carcinoma and the features they usually present as enlarging scaly or crusted lumps and they tend to grow over weeks or months. So that's something that you would wanna keep in mind that they do grow over weeks and months. They don't stay the same size they may alter it. Uh They tend to be pretty painful and uh they can have a cauliflower like appearance. You'll understand that a bit more on the next slide here. Um But again, just uh o other sorts of risk factors would be um apart from the exposure to the sun and actinic keratosis, um any individual who maybe is immunosuppressed. So they just had a renal transplant, um or they have HIV individuals with more fat skin, blue eyes, um blonde or red hair, um people who smoke, et cetera. Now, these are a few pictures of squamous cell carcinomas just so you guys have a better understanding of what it really looks like. So you can see that they all, they, they do look very ulcerated. Um They do look like they would be painful and again, they're on those sun exposed areas and that's very, that's very telling that they're happening on the cheek and the ear and the, the bottom of the lip is a, is a very classic area for smokers, especially for them to develop an SCC. So if you do have a patient in uh maybe a question who is smoking and he's now got this growing lesion on his bottom lip and a squamous cell carcinoma is something that your brain shoulder kind of point you towards. Now again, the risk factors, the excessive exposure to sunlight, um actinic keratosis and Bowens disease. Now, Bowen's disease is not something that I'll be able to cover today, but I do believe that you should look it up, uh, after this lecture. If you get the time, just, uh, quickly go on past me A or DM Met and look at Bowens disease, uh, get an idea of what that looks like and exactly how it can be associated as a risk factor for S ECs, immunosuppression smoking. Um, longstanding leg ulcers, uh, genetic conditions like albinism and again, that fair skin, blue eyes, just things that would really um let that sun damage get to you. And uh in terms of treatment, you would do a surgical excision with four millimeter margins if the lesion is less than 20 millimeters in diameter. So again, it's the, it's the size that really matters. And I think a good way to remember that is the fact that it is a growing lesion. So since it is growing the amount that it has grown would obviously uh in one way or another affect the type of excision that we wanna do and the margins that we wanna do on it. So, if the tumor is more than 20 millimeters and the margins uh go up to six millimeter margins, and you can use mo micrographic surgery um for patients who are at high risk. Uh and if it's in a cosmetically important area, now, this is a very nice small picture um that I found it's uh it just kind of puts it into place what a good or poor prognosis would be for someone who presents with a squamous cell carcinoma. So, again, if it's well differentiated, less than 20 millimeters, less than two millimeters deep, and there's no associated diseases that would be a great prognosis. But um if it's a poorly differentiated tumor, more than 20 millimeters, more than four millimeters in depth, and there's any sort of immunosuppression that would be more of a poor prognosis. So I think that's a, that's a nice little picture for you guys to kind of snapshot on your brains. And um again, look over when you are revising these slides. Now, we're gonna move on to basal cell carcinomas. Now, um these lesions are known as rodent ulcers and they're characterized again by slow growth and local invasions. They are the most common type of cancer in the, in the western world and the most common type of BCC is a nodular BCC. Now, there are different types of basal cell carcinomas. Again, I urge you guys to look at them and look at the slight differences between them. Um Some of them are a, a lot faster growing than others, a lot more aggressive than others. So, um it would be a quick read. It wouldn't take you too long, but it would be nice to know the different types of basal cell carcinomas and um what they entail the different subtypes. So if su if suspected a routine referral should be made and we're gonna show you a few pictures after this on the next slide of exactly what it looks like and the features of it are again, sun exposed sites. So mainly your head and your neck and the, the idea of, of. So a lot of times you're not really gonna get the pictures. Uh A lot of times you're just gonna get a presentation and a bunch of words. So you're gonna have to paint a picture in your head off them. So I think a description of a pearly flesh colored papule, which has a central crater, especially when I show you the next picture you'll understand, but it's very rounded off from the sides, basal cell carcinomas and they tend to have this um central crater and depression right in the middle. Um And the management for them would be uh surgical uh removal, er curetage er cryotherapy. Um You can use topical creams, radiotherapy, but again, surgical removal would be um the, the first go to and again, if ABCC is suspected, remember a routine referral should be made, do not forget that. Now, this is what a basal cell carcinoma tends to look like. So, as I said, um I don't know if you guys can see my mouse, I don't think you can. But um if you just look at the left side, the left side, I would say is the best description of that rounded rolling edges that you can see. And they're very pearly and you can see how, um, they really are rolled compared to the squamous cell carcinomas. Um, and on the picture in the middle you can see that um, crater that we were talking about again, you can see that pearly rolled edge on the side and then inside you can see that it's a severe depression, it's, it's a crater in the middle and honestly very hard to miss again happening on similar sides. So, er, areas, er, of the, er, near the eyes on the side of the nose, on the right picture. And now just for you guys to get a good understanding of a spot diagnosis, so you guys can see the difference. Um I have the picture of the sec again right here. So again, squamous cell carcinomas here, you can see how they look a lot different. Um They don't have that central depression, they don't have that crater and the edges are not that rolled off. And then you have over here the basal cell carcinoma, the edges are very rolled off and they have that central crater which is very hard to miss. No, we're gonna move on to our emergency dermatology section here. Now, what we're gonna be covering first is necrotizing fasciitis and uh you can see that on the left hand side there in the picture. Um The picture on the right hand side is um te and we're gonna go over that um, later on Um And again, I really want you guys to focus um, after the neck fash, when we, when we talk about Steven Johnson syndrome and 10, I want you guys to really understand that these two are not separate conditions, they are on the same spectrum of condition. It's just that one is worse than the other. And we'll talk about exactly how you can, you, you can tell which is which now necrotizing fasciitis is a very serious bacterial infection of the soft tissue and fascia. Uh The the most common sites affected is the perineum, which is known as fornia gangrene and the lower legs as we saw in the picture below. Now, the bacteria, they, they multiply, they release toxins and enzymes and that results in thrombosis in the blood vessels. Again, uh all of this is written on the notes if you guys wanna go very in depth into what it is, I would say something to remember would be the three types of neck fash if you, if you could remember them. So type one is just polymicrobial. So that just means that there's more than one bacteria that is involved. Type two is usually due to a humility group, a strep. So, streptococcus pyogenes written there um and then type three is a gas gangrene which is usually due to er clostridium. And I'll show you guys a picture of gas gangrene. So it's a pretty disgusting picture, but you, I'll make sure you guys, don't forget it. Um Try to pick out the most memorable picture I could. So that would be on the next slide. Um And in terms of risk factors, any sort of uh recent trauma to the skin, so any burns uh or any um again trauma or even soft tissue infections, uh can be a risk factor for neck fash. Um diabetes mellitis um is the most common preexisting medical condition specifically in patients who are treated with SGL T two inhibitors. So, if you can keep that in mind as well, that would be very important. So again, a patient who has diabetes and they are taking an SGLT two inhibitor and now they've got um this serious like really bad infection over the lower leg. You should be thinking, ok, this could be uh necrotizing fasciitis, intravenous drug use is also a prominent risk factor as well as immunosuppression. II. Think so far you guys can tell that immunosuppression is an ongoing theme here uh in terms of risk factors. And uh again, if you could remember that the the most common side that is affected is the perineum and the lower legs, foria gangrene. It it is something that they have asked in the past. So I thought I would just remind you one more time now in terms of features. So uh necrotizing fasciitis, it comes on very acutely. Uh the pain swelling, erythema at the affected site. It often presents uh as rapidly worsening cellulitis. So you might think it's cellulitis and it's getting progressively worse and, um, it's extremely tender over the infected, er, er, tissue area and then there's hypoesthesia to light touch. And again, that's, that's also very important. So it, it is very sore, it is very tender. But if you, if you lightly touch that area, there is uh, a sense of hyperesthesia where they don't really feel too much. Um, and skin necrosis, gas gangrene. Um These things are, are more later signs that you would see um as the necrotizing fasciitis uh progresses, um fever and tachycardia, they, they may be absent. Um they could occur later in the presentation. Um And in terms of management, just urgent referral. Uh you wanna urgently surgical uh surgically refer them for debridement. Um So you can um act on it as soon as possible and IV antibiotics uh given the fact that it is a um bacterial infection and the prognosis is an average mortality of 20%. Um You, it, it's not necessary for you to know that I don't want to throw too much information to you guys and make you think that there's a lot. Um I would say if you can um get the, the main idea of what neck fash is, what it usually affects what the risk factors and, and, and how it presents uh along with the management, I think that that should be fine. Um And just a few pictures here for you guys to really get an understanding. So that picture right in the middle is the gas gangrene that I was talking about. It looks like someone pumped it up with gas. Uh So hopefully you won't forget that. Um But yeah, you can see it, it, it does present differently. Some of these like the right picture doesn't look um subjectively as bad as the picture in the middle and that doesn't look as off as the picture on the left and the picture on the left and the middle and the right, they all look very different as well. But all of these are, are are necrotizing fasciitis and you need to understand it is very quick, it is very acute and it progresses rapidly as well. So you can understand why some stages look a bit less worse than other stages. Now, we're moving on to Steven Johnson syndrome, uh just stick with me for uh hopefully another 15 to 20 minutes guys and we should have everything wrapped up. Now, Steven Johnson syndrome is a severe systemic reaction that affects the skin and mucosa and it's almost always caused by a drug reaction. So usually these patients will be on some sort of drug and then they will get um this this kind of very severe reaction of their skin. A lot of times the mucosa is involved as well. And previously, it was thought that Steven Johnson syndrome was a severe form of Erythema Multiforme. Again, erythema Multiforme is very high yield. I'm not gonna be touching it on this lecture um in the lectures to come. Uh we will be talking about it. But again, if you guys could, from everything I've told you guys to look at, this is probably the biggest one. If you could. Just after this lecture, take a look at erythema multiforme, look at it and you can understand um exactly what it looks like and why this Steven Johnson syndrome was considered a severe form of Ery erythema multiforme. It was actually called erythema multiforme major, but now it is considered separate entity. So again, erythema multiforme is very high yield. I would suggest to all of you to give it a look. Uh after this, if you can just a quick read. Now, as I said, uh it is almost always caused by a drug reaction. So the the drugs are listed here. Penicillins, sulfonamides, lamoTRIgine, carBAMazepine phenytoin allopurinol. Um So uh nsaids, oral contraceptive pill, um a lot of times you'll maybe have a patient who has gout and they're on allopurinol and now they've got a uh systemic reaction that's really um it, it's really affecting their skin and you know, you, you can really see the, the features of it are very telling. Um So the rash itself is maculopapular and it's got those target lesions which again, why I'm saying to look up erythema multiforme really puts everything together because erythema multiforme is um it is known for its target lesion appearance. And then this rash can develop into these vesicles or bullet. And then eventually you get something known as a positive Nikolsky sign. I hope I'm saying that right. But um a positive Nikolsky sign is, is extremely telling a lot of times they'll even just give it to you in the question that they have a positive Nikolsky sign. So if you see a positive Nikolsky sign, think Steven Johnson syndrome and this is basically imagine if you put your arm out in front of you right now and you imagine just that area of your, of your forearm had this er systemic reaction. You had Steven Johnson syndrome on that, on that area and you just lightly gently rub that area. It's like the skin just begins to peel off and, and, and it starts to erode and that is what a positive Nikolsky sign is. Again, the pictures will be shown. But even if I can just go back to this on the right, you can see that all that skin at the, at the back of the patient, it's, you can see that it looks like it's peeling off and that's what a positive Nikolsky sign is. Um It's just that gentle rubbing can cause the erosion of all these um skin blisters and, and, and skin itself. Now, there is mucosal involvement and um fever and arthralgia are um common. Uh And in terms of management, hospital admission is required for supportive treatment because this is an uh an emergency condition. So you, you need them to go to the hospital and you need to admit them so that they can take care of this in the most effective way possible. Now, in terms of toxic epidermal necrolysis 1010. Um as I said, Steven Johnson syndrome and toxic epidermal necrolysis are a spectrum of the same pathology where a disproportionate immune response causes the epidermal necrosis. So again, it's a disproportionate immune response which is causing the necrosis, uh which is resulting in all the blistering and all the shedding of the top layer of your skin. And that is the reason why S Js and T and both happen. So they are of the same pathology. They're just on a spectrum. Now, the difference is that generally Steven Johnson syndrome tends to affect less than 10% of the body surface area, whereas 10 affects more than 10% of the body service area. So that picture that we saw over here. Oh, let me see if I can find it right here. So that picture would, would strike you as more of at en than an S Js. Why? Because it's his entire back that seems to be affected by this um by this immune response and this systemic reaction. So again, keep in mind it's just on the same exact spectrum of pathology. However, one of them in regards to S Js affects less than 10% of the body and 10 affects more than 10% of the body surface. Now, um in terms of courses, again, the medications, uh the, as, as we mentioned in S Js, the uh they're very similar, sorry. Um You have anti epileptics, antibiotics, allopurinol as we talked about nsaids, um and even infections. Uh if you look at derm net, uh and you read the, the, the, the, the toxic epidermal necrolysis um a page that they have over there. Uh They do mention the fact that infections such as herpes simplex, mycoplasma pneumonia, cytomegalovirus HIV can also all be a cause for toxic epidermal necrolysis. Um in my um time so far doing dermatology questions. I have yet to see um any of these. Sorry, I was just reading the chat. Uh II haven't really seen much on infections. Usually I have seen a lot of medications and again, just that positive Nikolsky sign, they'll either talk about the skin eroding itself or they'll just tell you that it has a positive Nikolsky sign. So those are usually how they want you to tho those are ways that they'll really try to push you towards this as, as a diagnosis of uh something else. So again, um in terms of the presentation, um so the, the condition itself has a spectrum of severity. So some of the cases are mild, uh others are very severe and then uh eventually a lot of them can be potentially fatal. So, um patients usually start with nonspecific symptoms of uh fever, cough, sore throat, uh a sore mouth, sore eyes, itchy skin, and then later they develop a purple or red rash and that's it, it, it spreads across the skin. And then eventually that rash starts to blister. And a few days after the blistering starts, the skin then begins to break away and shed. As we talked about the positive Nikolsky sign, leaving that raw tissue underneath. And uh in, in relation to the pain erythema blistering, shedding, it can also happen to the lips and the mucous membranes. As you uh as we mentioned earlier, this does have mucosal involvement. Um And in a few cases, the eyes can also become very inflamed and ulcerated. Um Sometimes the urinary tract can be affected internal. And so, um there are a few, a few things to just keep in mind. And as I said, this tends to affect more of your body than Steven Johnson syndrome. So that's where you could imagine why a lot of these other areas are being affected. Now, in terms of management, um S Js and 10 are medical emergencies and patient should be admitted to a suitable um it should be admitted um uh to a suitable unit for treatment. Um good supportive care is absolutely essential. Um including the nutritional care, antiseptics, analgesia, um ophthalmology input if there is uh eye involvement and the treatment options would include things like steroids, immunoglobulins, immunosuppressant medications. Um But obviously, these are all guided by a specialist and uh in terms of complications, um if you just want to keep this in your mind, obviously a secondary infection, so because there's so much of the breaking that's happening in your skin, um as we know the, the the skin in and of itself is just a protective layer for us humans. So, if the skin is being broken away by just rubbing on it, obviously, it opens it up to secondary bacterial infections which can cause cellulitis and sepsis. Uh in and of themselves, you could also have permanent skin damage. So the skin involvement can lead to scarring and damage to the skin, hair, nails, lungs and genitals, um and visual complications as well. So again, depending on the severity, if there is eye involvement, uh it can range from just sore eyes to even scarring and honestly, it it could even lead in very severe cases to blindness. So this is very serious and the management again is hospital admission um because it, it is a very serious medical emergency. Now, before I click the next arrow on my keyboard here, uh just a quick warning, there's a picture that's gonna pop up. I have put this picture here to embed in your brains. So you will never forget what 10 is. Um If you are feeling nauseous already 20 slides in, then it's better that you look away, but I'm sure most of you have the, the, the guts to see this. So this is what you should expect. Um, in regards to 10. So you never forget exactly what you're looking at. So you can see the bullet and the blistering and the, the redness of the skin and even right there in the middle um uh of oo on the, on the upper, on the upper part of the, the individual's stomach, you can see um that peeling away of that skin right over there and you can see that this is affecting the majority of, of the individual patients uh body. So this is a very serious medical emergency and always remember to hospital ad admit these patients to the hospital. It's very important. Now, um I see in the chat, uh someone asked if the slides and recording will be made available. Um, so I believe that the feedback form uh will be made available through email most probably so everyone who was signed up will be getting it. Um I could ok. Um So what we'll do is um I have a few questions here for you um during that time I will uh no problem for the warning. Um Yeah, so uh I'll, I'll let you guys answer a few of these questions here, er, rack your brains a bit. Uh I've only got three questions, so don't worry, er, it's not, it's not gonna kill you. Um, and then hopefully we should be done with the session. Um And I will see if I can get this, um, feedback form in the chat for you and I'll be able to give you a better answer in a matter of a few minutes. So you guys crack away at this question and, uh, I, I'll, I'll be right back with more information on, on the slides and how you guys can access all of them. OK. Um So just in terms of that feedback form and the slide, sorry, it, it is our first time using metal. So we're not completely um acquainted with this. Um All right, Johanna mcgugan going for SEC. Very nice. Um So I, in terms of that, we will uh the, we do have a feedback form connected to the metal. Um But if it's hard for you guys to access that or you can't see it, we will make sure that everyone is emailed um the feedback form. And if you fill out the feedback form, you will get a certificate um once that is completed and along with the feedback form, we'll email you guys electro slides as well. So you can uh look at this for reference whenever you need or closer to exams. So Joanna Mwe and I II really wish I had a, I had a prize for you. Um But I don't because that doesn't come in the budget, but you are correct. It is an sec and the explanation is uh again, it's that renal transplant that really um makes it uh really gives you that hint that of that immunosuppression. Um uh And uh a again, the, the fact that it's, it's been a three month review and skin cancer, particularly squamous cell is the most common malignancy secondary to immunosuppression. So, uh I can see where maybe someone might be a bit confused or wondering, which could it be? But you just need to go for your best case answer. What do you think is the most probable answer? Um Because again, we're not really diagnosing these patients. These are just questions. Um But again, go for go for the the best answer um and put in the best choice and hopefully that should work out for for all of you. Now, the next question, um 78 year old man asked you to look at a lesion on the right side of the nose which has been getting slowly bigger over the past 2 to 3 months on examination. Uh You see a round raised flesh colored lesion. Uh It's three millimeters in diameter and it's got a central depression, the edges are rolled and there seems to be some telangiectasia. What is the single, most likely diagnosis? So, let's see if anyone can beat Joanna to this one. I doubt it seems like. Oh, no way, John, there's no way. Oh, Abdullah Shauna. Wow. Wonderful. Uh Ramadan Kareem brother. Um interesting. So he's going for ABCC. Uh Let's see if anyone agrees with him. Uh Ashok Kumar BCC as well. All right. Well, II again, you guys are doing great. I must be a very good lecturer because you're right. It is ABCC. Um Again, the explanation is just that the description. So I told you a lot of times they're not gonna show you pictures of, of these lesions. They're not really gonna tell you. Um they're not gonna ask you for a spot diagnosis. How of the gels? I'm sorry, you're a bit, you're a bit slow on that one, but you can get the next one, I'm sure. Um So again, the B CCS, they often present uh a slow growing flesh colored lesions. Um They have that pearly appearance to them, the rolled edges and that central depression with the presence of telangiectasia classic features. Very classic. You honestly, in, in a question, I don't think you would, you, your brain should be going anywhere else other than ABCC. It's got rolled edges. It's got a essential depression with telangiectasia and there's ap appearance. Um and it's happening on a sun exposed area. It's straight to BCC that, that's where your brain should, should immediately kick to. Now, it is the last question guys. Um You've all been great. Um I'm very excited to break my fast. So um I hope we can end it on a good note. This is a bit of a harder question. So hopefully you all were paying attention. So, a 31 year old woman, um, she's got a two month history of pain and stiffness in her hands. Uh It's worse in the morning and improves with movement. So she hasn't noticed any skin changes. Um, but she does suffer from dandruff and while she's being examined, the GP notices this appearance of her nails. Now, I'm sure you guys are pointing towards one diagnosis right now, But in regards to that diagnosis, that you're thinking, what would be the most? Hi, a complication, what complication would be at? They, they'd be at the highest risk of Hamad Dezi. Very quick, very quick on that one was cardiovascular disease. Let's see if uh I think the group agrees with you. No, Abdullah Shauna cardiovascular disease as well. Well, I, to be honest, I thought this would stump you guys a bit but very nice cardiovascular disease. So, I'm sure you guys got off that first sentence of the presentation that um it was pointing you first two sentences are pointing you towards um uh this uh arthritis and the, the nail changes should make you think of, you know, uh all the discoloration and then the dandruff should point you towards maybe they've got a bit of scalp issues. So scalp dandruff nails, arthritis sounds a lot like um er psoriasis mixed into the, the, the whole picture. Um And again, er, the, the picture itself shows the pitting um Ony is not, it's not readily seen, but I'm sure if you were seeing the patient in person, it would be a lot more um obvious. And again, patients with psoriatic arthritis, they may present without obvious skin changes. And some patients can have that scalp psoriasis, which is uh similar to dandruff and as psoriatic arthritis is the most likely diagnosis. Cardiovascular disease is the only complication listed that this patient is at a greater risk of. So I hope that was beneficial to you all. Again. Uh I'm just gonna repeat. Thank you. That's my name. That's my title. Um I'm just gonna repeat. Um We do have an event for careers in dermatology that will be coming up on the 27th hopefully of April and that should be on our Instagram page um by today or tomorrow at the latest. Um So you guys can sign up for that. That would be very useful if you are looking into a career in dermatology. Um Other than that, we do have two other sessions um which are gonna be teaching sessions for this comprehensive guide. This is only session one and that will be conducted by Kaim and Christie and I can guarantee you they'll do a wonderful job. So I hope you all er learnt a bit from this and again, the feedback forms if you cannot find it on the medal, do not worry, we're gonna email them out to you and hopefully, once you're done with that. We will give you the presentations as well and we will give you the certificate of completion and you can put that in your CV and show everyone that you're very interested in dermatology. So, thank you guys very much. I'm gonna go and break my fast and I hope you all have a great evening and yeah, take care and give me some good feedback. Thank you all very much and goodbye.