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The Comprehensive Dermatology Guide: Session 2



Join Kareem, a final year medical student, as he takes you through an in-depth exploration of eczema, one of the most crucial topics for your MCQs and ACY. This session will delve into various types of eczema, such as atopic, discoid, and venous eczema. Kareem will particularly focus on atopic eczema, examining its characteristics, causes, symptoms, triggers, and complications. Additionally, get a detailed outline of the management of eczema, from creating and maintaining an artificial skin barrier to handling disease flares. Furthermore, this session will touch on other topics such as cutaneous signs of systemic disease and skin infections. Maximise your understanding and boost your scores on your MCQs by attending this interactive session.
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This is the second session of the Comprehensive dermatology Guide which will be lead by QUBDermSoc Secretary Karim. Topics include: eczema, cutaneous signs of systemic disease and skin infections.

Learning objectives

1. Understand the key clinical features of eczema, its pathophysiology, and how these manifest in different age groups. 2. Learn how to manage both acute flares and maintenance therapy for eczema, and understand the importance of skin barrier protection and maintenance. 3. Familiarize with the types of emollients and steroids used for eczema management and their applications based on the condition's severity. 4. Understand the potential complications and contributing factors to eczema and learn strategy to counsel patients and their families for the management of symptoms and triggers. 5. Develop knowledge on the associated conditions of eczema, like asthma or allergies, and understand how to approach these in a clinical history and management plan.
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Computer generated transcript

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

All right. Yeah, hello everybody. I'm, I'm Kareem. I'm uh one of the final year students. And uh today we're, we're going to go through a few topics that are uh very important for your MCQ S and also for the ACY, although though the AUS will have their own separate session in uh in two weeks time. Um So uh the topics that we're covering today are going to be eczema. Uh and then we'll, we'll, we'll, we'll mainly focus on eczema and then we'll, we'll, we'll, we'll lightly touch on cutaneous signs of systemic disease and uh skin infections. Uh So I'll, I'll give you uh just a brief outlook on these two, these two topics. Uh the, the bulk of the details stuff for you that you're going to find that in past med. OK. So cause it's just, it will be very difficult for us to cover everything in one session. It will run on for a very long time. So let's make a start. So we're starting off with eczema here. Um So eczema is a, uh it's a descriptive term uh for a group of disorders that are basically very itchy. OK. Another term for eczema is uh dermatitis. OK. Um There are many different types of eczema. OK. And they all show up on your M CQ S. OK. Um uh we'll, we'll mainly focus on atopic, eczema, seic, eczema and uh uh discoid eczema pli and, and varicose uh eczema or venous eczema. OK. So, uh whenever we get to talk about uh atopic eczema, uh basically, it's a, this is a very important topic. Uh You have to know it very well. I mean, inside and out for the A for the NSE Qs and more importantly for the Aus because in third year and maybe even in fourth year and in fourth year, I it definitely in third year and fifth year, maybe. Also in fourth year, they might ask you to counsel uh uh a AAA parents, OK, who's coming with, you know, she has a child, a mother with a child with poorly controlled, excellent, she's asking for help. So this could come under, you know, GP or under dermatology for any of the years, 34 or five. OK. Uh or pediatrics. So at atopic eczema is a chronic con uh condition where there's inflammation of the skin causing breakdown of the skin barrier. OK. And it runs a chronic relapsing and remitting course. OK. So there are periods that are characterized by having uh acute flares or what we call acute eczema that would be triggered by irritants. OK? And then you'll have periods of remission which we, you could also refer to as chronic eczema. So, acute eczema is uh uh uh is, is, as we said, characterized by severe erythema. Ok. And acute flares is, is characterized by severe erythema edema of the skin. You can also have vesicles and papules and it's very itchy, itchy and it can easily bleed and leak fluid, chronic eczema. On the other hand, it, it's, it's much drier. Ok. So what happens then is that the skin uh becomes thicker uh or what we call lignification and there'll be discoloration of the skin. OK. It, it, it gets a bit darker. OK. Uh That's also called postinflammation, hyperpigmentation. So, the pathophysiology underlying this condition is uh basically there, it's, it's multifactorial. OK. So there's an immune element to it. So there's immune dysregulation. It's, it's uh basically uh uh uh it's a type one hypersensitivity reaction with an increase in IgE antibodies. There is dysregulation of the skin barrier uh caused by mutations in, in, in genes that are coding for uh proteins that are important for skin integrity. And what happens then is uh with the, with the, with the itch wi with the scratching and the uh the itchiness. There is a breach of the skin barrier which then allows uh irritants and allergens and microbes to penetrate the skin. This then triggers an immune response which causes inflammation, itchiness, uh redness and, and, and uh dry skin. Uh uh it, it tends to run in families and particularly it's associated with other atopic conditions such as asthma, uh uh allergic rhinitis and, and food allergies. So when you, when you're taking your history, uh it's also very important that you ask the, the patient if they have any of these other conditions. Ok. Now, the presentation in infants, it tends to uh show up on the face, ok? Tends to show up here on the face with the mouse. Wow. Lost my mouth. But yeah, the, the picture on the top there basically in infants, it, it, it tends to uh show up on the, on the, on the cheeks. OK? On the face. Whereas with, with, with Children and adults, it affects the skin flexures. So the antecubital fossa is a very common place, but it can also affect the neck as you can see and also the area behind the, the, the, the knee. OK. Uh The acute flares as you can see, it's very, it's very angry looking, OK? Uh It looks very wet and you can see that you have papules and, and vesicles all over the place. Whereas the chronic uh the chronic uh eczema basically during the the remission period, uh there's much le there's much less inflammation, it's uh much drier, you know, compared to the, to the previous picture. OK. Uh I it's very scaly and the skin thickening as you can see. And uh yeah, they recorded everything. Yeah. Uh the, the recording will be available after the session and if you want the slides, yeah, I can send that to you. I, I'll put them on, on metal. Yeah, that's fine. Um OK. Yeah, we, we, so we were also talking about postinflammation, hyperpigmentation. OK. Triggers. Uh So it could be uh in, in some cases, actually, in most cases, there isn't really a, a AAA very clear trigger. But uh so uh so that's one, it can also be caused by things like uh stress scratching, uh having had uh a recent bacterial or viral infection, heat sweat, um uh irritants such as uh wool dust, soap, uh bubble baths, uh a allergens such as pet dander or, or uh fragrances. Um So it's very important that when you're counseling, uh the mother uh that basically that she needs to make sure that she keeps her son or her child, you know, away of these uh triggers, ok. Um So the management of acute flares. So the management of uh eczema sorry is really divided or split into the management of the acute flares and then the maintenance therapy uh during the periods of remission. Ok. So when we talk about the um the the maintenance therapy, we start off with the maintenance therapy. Basically, the problem that we have with eczema is there's a breakdown of the skin barrier. Ok. And so what we need to do is build an artificial skin barrier to compensate for the, the, the defective barrier that we have and the way we do this basically is by applying a thick paraffin based emollient and, and that's what is called an ointment. Ok. Um, you need to know what are the different types of, uh, emollients that are there. So there's the paraffin based ones that are basically ointments and then there's the lighter ones as well. Uh, because it comes up on XQ S, uh, it's not enough to just know what the word emollients you need to know like the different subtypes of it. So you need to look it up in the context of eczema. Um So we created the barrier using a paraffin based emollient. OK. Um And now we have to maintain it. OK. So the way we do that is basically by avoiding activities that would break down the barrier. So for example, don't ba don't bathe your child in hot water. Um uh avoid scratching, avoid scrubbing, uh uh avoid using soap and, and, and, and, and body wash what you want to use the soap substitutes. OK. Uh When washing or showering such as lotions, OK. So lotions are diff another type of IOL. OK. So you use the paraffin based ammonium to build the barrier and then you use lotions which are another type of ammonium as a soap substitute. OK? And you want to eliminate the trigger or eliminate, triggers for the, for the uh eczema. So avoid being out in, in cold weather or uh uh being exposed to dust or uh pet dander, whatever it is that uh is it seems to be causing or triggering the the acute flares? So how do we go about managing the flares? Uh We apply a simple emollient. OK. Plus a steroid in a 10 to 1 ratio. OK. And the the amount of uh so, so that's number one, we apply the f the emmolient first and then we we wait for 30 minutes uh to apply the steroid. We use very small amounts of steroid. OK. And they're measured in fingertip units. Ok. So what is the month fingertip unit? Ok. A single fingertip unit can treat an area twice the size of an adult hand. And after that, what you want to do is lock in the moisture. So you apply a wet wrapping to lock in the moisture and you can use antihistamines uh to, to decrease the itch and improve sleep at night. Ok. Uh uh And the, the, the other point here is uh skin depigmentation is an important side effect of uh steroids uh particularly in, in the MCQ S. Uh it came up a few times whenever I was revising for finals. Uh So, yeah. So what steroid do you use? Uh we start with the weakest steroid that will control the uh patient's symptoms. Ok. And it's very important that you know, your steroid ladder. Ok. Uh I'm not gonna read, read through this uh uh this table. Um just have a look at it and um it would be good if you can, you know, know it off the top of your head. Uh And as we said, the fingertip unit is about 0.5 g and it is sufficient to treat a skin area about twice the size of an adult tent. Ok. Um Again, here, this basically tells you, you know, how much or how many fingertip in if you need, you need for uh uh each and every, you know, body part. OK. Again, that's past me as well as the table. So it's important that you uh be familiar with this. OK? Because it can come up on the, if you and here uh the, the, the, the, the, the quantities will also be uh something that would be important for you to know. OK. Um uh So yeah, and then with regards to, so we talked about the, the, the medical or the pharmacological management of eczema. There's also other things that need to be done. So the patient requires to have uh requires to have a, you know, good education and that will be provided by the dermatology nurse who will provide education in, in, in how to, you know, apply the cream and quantities and how to apply the wet tr a clinical psychologist may be needed to, you know, help with breaking the itch scratch cycle and you could al you always, always at the end of any uh counseling station, you need to, you know, tell the patient, I'm going to that here, you here, I'm going to give you like some leaflets to read through or signpost into some websites to read through. Uh So that's also very important now, complications of uh atopic eczema. Uh It can, it, you can get AAA superimposed bacterial infection or a secondary bacterial infection and PTI where you get these yellow crusting and, and weeping over the, the uh the areas of the eczema. And we'll see a picture of that. You can get a superimposed viral infection. Uh The most important one to know here is the eczema herpeticum. Uh So, uh you get these punched out vesicles and erosions that are very painful and that's actually a very important uh uh complication to be aware of cause. Um It, it, it comes up very often on the MC QS and it's quite serious and we'll see how that is in, in a few, in a few slides. You can also get a contact allergic dermatitis, sleep deprivation due to the itchiness, uh which is, as we said, uh could be released using a sedative antihistamines in Children. Uh You can also get um you know, growth impairment due to the, you know, long term use of steroids. And uh from the eczema itself, it can affect the, the, the, the ability of the patient to, you know, put on weight. Ok. And depression and isolation. So, this is the appetite that I was talking about here. You can see that the this is an acute flare of eczema. It is very angry looking and very wet looking. But then on top of that, you also see the, the white, I'm sorry, the yellow crusting over it. So that's the the superimposed bacterial infection. OK. And then eczema herpeticum uh that is uh very important for you to be aware of uh uh stick that picture in your mind. OK. Very. It's a severe primary infection of uh caused by either HSV uh uh one or two. OK. Herpes Synthy virus, one or two. Um It presents as a sudden onset of rapidly progressive uh rash that is very painful, punched out vesicles whenever you read that in the, in the uh the MC QS. That's, that's a buzzword for uh for, for uh Eczema hepaticum. OK. So, punched out vesicles and erosions is a characteristic and diagnostic feature on examination. You have these monomorphic, punched out uh erosions, circular, depressed ulcerated lesions, usually 1 to 3 millimeters in diameter. It's potentially lifethreatening for uh in Children. And, and, and these Children should be admitted to hospital for IV as acyclovir. And uh the, the other thing is uh if you, if it's ii if, if left untreated, it can actually affect the eye, OK. Uh It can cause scarring, scarring of the eyes. So that's why you need to bring them into hospital and, and start them on I VA cyclovir immediately. So here's a small question to see if we can apply what we just learned there. So, a six year old boy is brought to the GP by his mother over the last day, he has developed an intensely itchy rash. His temperature is 37.6 on examination. The GP notes multiple arithmetic across the vesicles and punched out erosions on the face and neck. The GP saw him two years ago and prescribed uh treatment for Eryth mets itchy papules and dry ski of skin and the creases of his arms and necks in his arm and neck. This treatment can help control her son's symptoms but he has recently run out. What is the next most appropriate step in terms of management? You type it in the chart. What's the diagnosis here? Anyone? OK. Right. OK. So basically this is eczema herpeticum. OK. And it requires a same day referral to dermatology. OK. Urgently admit the patient to secondary care. OK. That's very important. OK. Uh As, as, as we said before, that's because of the severe consequences of the condition. You can get scarring, you can get eye involvement and you can get uh it can even cause death. OK? And therefore requires immediate hospital admission. Uh So then we talk about Zoric eczema. Uh This is caused by a fungal overgrowth. It has uh a, a, an infant or a child subtype and an adult uh subtype. So, uh it's as you said, it's a, it's a common, it's a common uh skin condition in, in uh, in, in, in Children. Uh It affects, in Children or in infants. It commonly affects the, the, the, the cradle cap or the top of the head. Ok. Not the areas, uh, face and limph flexures. Creed cap is an early sign which may uh develop in the first few weeks of life. It's characterized by an erith rash with poor cow scales. OK? Uh And we'll see a picture of that. The management here is uh reassurance that uh basically this doesn't really affect the baby and usually results within a few weeks. What the patient or the what the parent needs to do is basically massage a bit of a topical emollient on the top, on the scalp to loosen the scales. OK? Uh brush gently with a soft brush and wash it off with a shampoo. If it's severe or persistent, we can use um an antifungal. So a topical i imidazole cream can be tried. Uh Sear dermatitis in Children tends to resolve spontaneously by around eight months of age. OK. You can see here, this is the rate of c so the the yellow crusting on the, the baby's head there. OK. And you can also see in the picture in the middle that it's also affecting skin flexures. Uh the not skin area is also quite red, OK? Um And in the picture on the far on the far right there as well. You can see how it's affecting the skin flexures and how the head or the face of the baby is just quite yellow, it's quite red. And if you look closely up, uh, on the top of the forehead, you can see a bit of the, the cradle cap as well as in the middle. You can see the cradle cap. Ok. The adult form of it, uh, I is a chronic dermatitis that uh it's thought to be caused by uh a fungus called Malia furfur. Ok. It is uh uh basically the, the, the, the what happens to you is it the way it presents is that you have these eczematous lesions on the sebum rich areas. So the scalp, uh the periorbital area, the auricular, the auricular area and the nasolabial folds or what we call the T area. You can see a picture of that. Ok. It can also affect uh uh complications of, of, of seb dermatitis in adults is that it can cause otitis externa and blepharitis or uh inflammation within the, the eyelids. Ok. So this is the T zone. This is the common area on the face where you got Sebo dermatitis in adults. So the for the, the, the sebum rich areas so that the forehead, the nose and uh the, the nasal A FS OK. And it can also affect the hair. So you can get uh like dandruff. Ok? It's important to know what conditions? So, yeah, so we, when we talked about eczema, severe eczema in infants, we said it's, it's a, it's a benign condition just requires, you know, uh some topical treatments. Ok. In adults though, uh you're not really supposed to be getting this stuff. Ok? Because Mysia furfur is a normal skin inhabitant. It's a normal, uh you know, organism that lives on your skin. Ok? But for it to get a chance to grow like this and, and, and be, and, and invade the, the skin in this way, this means that your immune system is messed up. And so there are uh this, so sebar dermatitis in, in adults is, is, is highly associated with things like HIV and Parkinson's disease and this commonly comes up on the MS. OK. Um mhm So, in terms of the management, uh uh as we said, for the, so for the scalp disease in the adults, it's a ketoconazole shampoo. Uh uh that first line, second line would be things that contain zinc. So head and shoulders. Uh uh and you have things like selenium sulfide. But most commonly, what you, what, what you should really know is basically the 1st and 2nd line. Um you know, managements uh wouldn't go any further than that in terms of uh uh you know, the, if, if it's affecting the face and the body, it's a topical antifungal. So it's like uh ketoconazole, OK. But again, it's a topical cream. It's not a shampoo. So don't get that mixed up. OK. Uh topical steroids can be used for short periods of time. Um It's difficult to treat. OK. And so recurrences can happen. So the next form of the, of eczema that we're going to talk about is discoid, eczema. OK. Uh So you have these well-defined round uh eczematous patches uh often involving the limbs. OK? They're very itchy. Treatment requires strong steroids. OK? You need some uh potent topical steroids to use here. OK. And the differential for it is uh for, for, for such circular lesion, uh lesions are things like bones, disease or artena or psoriasis. But of course, I mean, if uh psoriasis doesn't, I mean, yes, it's a um um it's a different, I mean, for a differential, that's what you're going to say, but different psoriasis doesn't tend to affect, you know, the shins, uh bones will be, you know, one or two lesions max, you won't have all of these lesions. Uh and it probably would be uh you know, unilateral, not bilateral. OK. Um So yeah, and then the next form of eczema that we need to talk about is complex eczema and basically this affects the hands and the feet. Ok. It's much more common in, in young adults uh and more common in females than males. OK. And it's precipitated by humidity or sweating and high temperatures. Uh it features, you know, having small blisters on the palms and the soles, it's intensely itchy. Uh, and once the blister, uh, bursts the skin may become, uh, dry and cracked. Management involves cool compresses, emollients and topical steroids. Varicose eczema is another one that need to be aware of, uh, again, both for osteo more. Yeah. Third year and final year os, uh, because it's, it's, it's, it ti it ties very well with, with, with vascular surgery. So, with regards to like, um, chronic venous insufficiency. Ok. So very common form and can be mistaken for cellulitis. Ok. But the way you tell the difference between it and cellulitis is the fact that here changes are going to be bilateral. You have a chronic history, ok? You have a history of chronic venous insufficiency. Uh patient may also have things like DVT or, or uh varicose veins, OK. The hemosiderin deposition that you can see here in the picture and you can also have venous ulcers associated with it. Ok. The main investigation for it is uh abpi brachial pressure pressure index. OK. It's important nonhealing ulcers uh just as for poor arterial flow which uh could impair healing management. Here really is compression bandaging. OK. Four layers. Uh that's the only treatment that you know, if you're, if you're given a list of um uh treatments in the MCQ S. Uh The main one that works with you, the one that has the most evidence is the compression bandaging. OK. Peripheral vasodilators and, and, and hydrochol dressings and flavonoids they might be helpful, they might be useful. But the main, the main treatment really is compression bandaging. Ok. Um, so we're ta, so that's eczema done. Ok. Um, contact, uh, dermatitis is again something you need to look, uh, look up. It's, it's, it's pretty simple. Uh, past medicine will be good enough for that. Ok. And then we'll, here, we, we'll, we'll tightly, we, we'll, we'll lightly touch on, on, on, on skin infections. OK. Uh So we'll start off with impetigo. So we've already visited the impetigo earlier. It's a superficial bacterial infection that is caused by uh staph or strep pyogenes. OK. It can be a primary infection on its own or can be superimposed on uh other uh lesions or other other skin conditions, things like eczema, uh scabies or insect bites. OK. It's very common in Children. Ok. Uh especially during warm weather, the, the lesions typically appear on the face, the flexures and uncovered limbs. It spreads through direct contact with discharge uh from infected lesions with bacteria, entering through a minor abrasions and, and, and spreading via scratching. OK. Transmission mainly happens to hand to hand contact but can also happen indirectly to toys and, and clothing and, and, and, and uh the environment, the incubation period is about 4 to 10 days. So the way it presents for you, as you can see here is you have these golden crusted lesions around the mouth or around the area that is affected and it's highly contagious. So the management really first line is hydrogen peroxide, 1% cream. Second line, if the hydrogen peroxide is not working is use topical antibiotics for things like fusidic acid. Uh and morine if, if there's a uh resistance to the fusidic acid and also if uh if the uh the uh organism that is cultured, uh uh uh turns out to be an MRSA if you have severe or widespread disease or again, it's treatment resistant. The next step would be uh going for oral antibiotics. Ok. So fluoxil or penicillin allergic would go for Clarithromycin school. Uh Exclusion is very important to consider. Here comes up on the, so the, the students, as her Children should be excluded from school until the lesions are crossed over and healed. Uh or, or 48 hours after commencing uh antibiotic treatment. The next thing we're going to talk about is cellulitis and erysipelas. Ok. It's very, it, it, it can get a bit tricky to try to figure out which is which on the MCQ S. Ok. Uh Tripped me up. Uh It took me a bit of time to figure out the difference. They're both skin infections and the most common organism involved in both are, are, are, are, is basically uh strep pyogenes. The second most common would be stor both would result in eryth mets and edematous uh uh and warm skin. Ok. And both would most commonly affect the lower extremities and in terms of the risk factors for both. It's the same. Ok. Anything that causes a break in the skin. So, trauma or any other skin condition or infection, any inflammatory condition, edema from venous insufficiency or impaired lymphatic drainage, immunosuppression and uh obesity. So, ok. So these are the similarities. How, how are they different? Let's start off with, with cellulitis, cellulitis, the skin infection extends down deep into the dermis and into the subcutaneous tissue. Ok. So it's a very deep infection. It's uh very slow in its onset. You may have some regional lymphadenopathy. It usually has localized symptoms. So you will rarely have systemic features. So things like fever and malaise and things like that. So it's mainly confined to wherever the infection is. So, mainly confined to the leg, for instance, the affected area would be raised. Ok. Uh but the lesions themselves are not raised. So basically there is swelling. Um sorry, the the there's a bit of a um a bit of a typo here, the lesions are raised. So the actual area that is inflamed would be uh raised. Ok. And uh uh there will be swelling of the affected limb. Ok. Uh It may be diffused or or well demarcated, most commonly affects the shins and severe disease may have blisters and uh uh bullae OK. As well as uh systemic features. But that's not very common with cellulitis. Ok. It's much more common with uh with, with, with ery syphilis. Um it could be purulent uh caused by a beta hemolytic strep or nonpurulent. So it could be no. Uh it could be uh perent caused by beta hemolytic strep or nonpurulent caused by Storia. So, as you can see here, II, it's, it's very red. Ok. And swollen. Ok. Uh But the lesions themselves are not raised. Uh So the, the leg itself might be swollen but the, the lesion itself is not raised. Ok. That's, that's the main point here with ery syphilis, the skin infection, I it's a skin infection involving the epidermis and the upper dermis only. Ok. So it's, it's just the upper area of the skin, acute onset of symptoms. So within 48 hours and you'll have severe systemic features. If you have fever chills, malaise, you don't see that often with, with, with cellulitis. The affected area here will be erythematous but will also be clearly demarcated and raised. The actual lesion itself will be raised. Ok. Uh So with cellulitis, what you'll have is the leg might be swollen. Ok. And the area that is affected by the ce by the cellulitis is red, but the actual lesion, the actual cellulitis is not raised. Ok. Whereas here with erysipelas, it's clearly demarcated and clearly raised compared to the rest of the skin. Erysipelas of the face would have a butterfly shape on the cheeks and the nose. Uh a a butterfly shape basically affecting the cheeks on the nose and severe cases will, may also have like blistering or uh you can't get uh cellulitis in. Yeah, that's ano another very important point. You can't get cellulitis in the ear as you don't have subcutaneous tissue in the ear. Therefore, if there's anything that looks on like cellulitis on the ear, that's actually erysipelas, it's not cellulitis. Ok. So you can see a bit of blistering do down there. Ok. Um And uh so the, the you can see how the lesions are, are quite raised compared to the rest of the skin. OK. So again, there's a small table to compare cellulitis and erysipelas. Cellulitis is a deep dermis infection. Erysipelas is an upper dermis infection. Uh cellulitis affects uh uh uh the subcutaneous adipose tissue. You, you don't have that with ery syphilis. You may have some superficial lymphatic involvement, acute onset for erysipelas, uh indolent course or a uh uh AAA slow course. A slow, a slow, a slow onset for cellulitis. Systemic features with erysipelas, localized features with cellulitis. OK. So there was a bit of um uh sorry, there was a bit of a uh a title here when I'm talking about raised lesions here and cellulitis. So again, just to re I and I'm going to fix this before I put the slides on. So for cellulitis, the actual limb might be swollen but the, the, the lesion itself is not swollen or is it, it's not raised? Ok. It's not raised. Whereas with Erysipelas as you can see here, the lesions are quite demarcated and quite trace compared to the rest of the skin. Ok. So management of cellulitis, uh it's a clinical diagnosis. Ok. Uh If there's evidence of sepsis, ok. Uh Or if the patient is admitted, maybe, then you might, might try to do some bloods and some cultures. Ok. But you don't usually do that if it's not uh you know, uh severe and you can manage it in the primary care. What's also very important to know is the classification because that comes up quite a bit on the NC Qs. OK. So class one is basically, so this is how we classify cellulitis. So with the basically on class one or stage one, there are no signs of systemic toxicity. OK. Class two is where the person is either systemically unwell or systemically well, but with a comorbidity, OK. So pa or chronic venous insufficiency or morbidly obese. Class three is basically where the patient has significant, significant systemic upset. OK. Um significant systemic upset. Uh uh such as acute uh basically evidence of, of, of significant uh you know, sepsis, uh acute confusion, tachycardia, tachypnea, hypertension. OK. Uh If there is a a stage four is basically if there is any evidence of any life threating infection. So like necrotizing fasciitis, OK. So the following, for, for the following uh you know, groups of patients we need to admit them for antibiotics. That's the recommendation. So that's basically people with class three or four. So anybody with e evidence of sepsis or necrotizing fasciitis or evidence of shock. Ok. Or there's a, a limb threatening infection or vascular compromise, you need to bring them in. Ok? Anyone who's rapidly deteriorating with their cellulitis. Ok? If the person is very young or very frail, uh if they're immunocompromised, if they have significant lymphedema and if they have facial cellulitis, ok, unless it's very mild or preorbital cellulitis, you're on class one. it's basically oral management. So, oral flucloxacillin, that's the best thing for, for uh the skin infections if they are uh if they're, they're allergic to penicillin in these things like Clarithromycin and Erythromycin in pregnancy or Doxycycline. Of course, no doxycycline in pregnancy in class two. admission may be necessary if the uh I mean, if the, if the expertise is there. Ok. Uh it may not sorry, it may not be sorry for ear in class two, you can manage them in the community if you have the ability to. Ok. But different regions uh have different guidelines for class three and four, you need to admit the patient and you need to start them on either uh oral IV antibiotics. Ok. Uh Tam ICF Clindamycin or IV uh Keim or cefTRIAXone. Uh And um for um ok. Yeah. So for necrotizing fasciitis, that's the next condition that we're going to talk about. Um Necci facci is a medical emergency that is challenging to recognize. OK. And um in the early stages, it's, it's very difficult to recognize in the early stages. But it can be classified into two subtypes based on the causative organism. Type. One is caused by mixed anaerobes and aer robes. Ok. Often occurs postsurgery in diabetic patients. And the second type is what's caused by uh strep pyogenes. These factors include recent trauma, burns, uh soft tissue infections, uh diabetes mellitus, especially if a patient is on an TL D2 inhibitor because SGL T two inhibitors, basically what they make you do is pee sugar out. So this provides a very rich environment for bugs to grow. And IV drug use and immunosuppression. Fournier's gangrene is the most commonly affects the perineum. So neck neck fash in the and the and the and the perineum is called fournier's gangrene and it's the most commonly affected side. Ok. Uh It, it, it's it in terms of its presentation is really of acute onset, uh severe pain, severe pain. That is uh uh is out of context of the actual presentation or the actual inflammation that is present with the, with the, with the infe with the lesion or the the site of the infection. Ok. Swelling and erythema. Um And as we said, oftenly presents as rapidly worsening cellulitis with disproportionate pain. In fact, the tissue is extremely tender with decreased sensation to light touch. You may have skin necrosis or gas gangrene. Uh but that's a very late sign. Uh you know, you don't necessarily have to have fever or tachycardia. Ok. Management involves urgent surgical referral for debridement and IV antibiotics. Uh It's a very serious condition and mortality is uh about 20%. The next thing we want to talk about here is pr uh p uh parisis rosa rosea. And the reason why I wanted to put this is because there's another condition that kind of presents similar to it uh with regards to like the MC Qs. And it's, it's very important that, you know, you know, which, which is, which. So here with, with Patrias rosea, basically, it's an acute self-limiting rash, uh primarily affecting young adults. It's, it's caused by the uh uh her herpes, uh hominis virus seven. It doesn't have very much of a prodrome. OK. But some patients might cause talk about having, uh, report having a recent viral infection. OK. The rash typically begins with a single larger lesion known as a Herald patch, which is usually located on the trunk and it usually follows what we call, uh, the lines of LAN. OK? Which are basically, it's something in surgery. Basically, it's the lines, uh where you would have them where or if you basically, if you were, were to make an incision along that line, you're much less likely to have a, you know, a very big scar or very proin scar. Ok. Uh Following the Herald patch, you get these. So it starts with a small rash or one single lesion on the ch on the trunk. And then after that, you get, it explodes basically. And you get these multiple arithmetic oval and scaly patches that appear uh basically uh all over the trunk and it can affect the limbs as well and has a very characteristic distribution that I'll show you in a second. Ok. Basically, the, the, the, the fir tree or the, the Christmas tree like pattern. So these are the lights of longer basically. And this is the Herald patch. So it starts off with one lesion or one bit that is uh uh quite arithmetic. OK. And as we said, it occurs along along the lines of longer and then it explodes and it, it, it follows the lines of langer basically. So you can see here how um I don't have them if I sorry, if, if you can see here, see, you see how the lines are going are, are all flowing in a, in a particular direction. OK. Uh From top to bottom. And then if you were to look here, you see how you have the same pattern again with, with these lesions, OK. They're all following the same pattern. OK. So the following the lines of longer and it also looks like a uh uh a Christmas tree. OK. And this, this um um uh th this picture I found on Google uh kind of really, well, uh it summarizes the condition really Well, so you get, you get an acute eruption of a single lesion, OK. The Herald patch and then 1 to 2 weeks later, um you had the Christmas tree, ok. It's a viral etiology. HS HS V seven. OK. Um Sunlight can help, OK. The condition itself results within six weeks and it's mainly seen in teenagers and in young adults, young adult females. The other condition that I wanted you that kind of presents similar to it is gap psoriasis. And so there's this table and past medicine that is also very good. And in questions, it's, it's sometimes a bit difficult if you don't know what you're looking for to differentiate between the two. So with the gap psoriasis, what happens is there's classically, it's preceded by a vi by a strept with stroke, uh sore throat, uh 2 to 4 weeks with Beris rosea, they may or may not ta talk about having a viral infection. So either way, if you can't really tell much of a difference, you can't really tell them apart by, you know, looking at the history in the weeks before the rash, ok? Because both can kind of present with again, a sore throat of some sort. Ok. But what really helps you to tell the difference is how the rash develops. So I think that the last time he talked about the tear drop, uh scaly papules on the trunk and the limbs for the TP. OK. So there is there isn't a preliminary single lesion that appears and then everything sort of blows up from there. It, it, it, it all starts and it starts uh a after the, the, the, the infection right away, 2 to 4 weeks after the infection. And you have these eye drop or uh these tear drop uh uh lesions. Whereas with, with, with Patrias rosea, you start off with having the Herald patch 1 to 2 weeks. Uh and then 1 to 2 weeks later, it explodes into this Christmas tree pattern that we talked about. OK. Uh But try Rozea is uh self limiting. Most cases for gat will res will resolve spontaneously within 2 to 3 months. But you can also use topical agents for asper psoriasis and also for uh you can also use ultraviolet for uh uh ultraviolet B uh uh phototherapy. Now, there's a lot more for like skin infections. OK. That you need to be aware of past medicine is very good. Uh The dermatology section is zero to finals in under pediatrics is also very good. And ultimately, I think what the the most important bit really is not just reading stuff is doing the questions because the questions really help you apply the knowledge. OK. Um So yeah, so they will lightly touch on cutaneous signs of systemic disease. We can't cover them all. OK. Passed and SMED would be very good for them. We will mainly touch on erythema, nodosum and uh Pyoderma pyoderma, gangrenosum and purpura. OK. These five are probably the most high yield. Ok. Uh So I would focus on these, but if you have time, of course, you need to, you know, look over the uh the other ones on, on pace meth and pasmed as well. Ok. So erythema nodosum, basically what happens here is you have uh inflammation of the subcutaneous tissue or subcutaneous fat. It typically manifests as uh tender, arithmetic, nodular lesions commonly occurs on the shins, but may also affect other areas such as the forearms and the thighs. Lesions usually resolve within about six weeks and they heal without scarring. Ok. Causes uh there are many different causes. Ok. So it could be due to infections, it could be due to systemic conditions. So uh it could be a AAA um like an uh like uh a um or, or how do you say uh uh for, for, for conditions like IBD? Basically, we're talking here about the extraintestinal manifestations of the disease. Ok. Uh So erythema, it could be a sign of the patient having IBD. OK. Having some forms of vasculitis such as Bess syndrome. Ok. Uh malignancies, uh uh uh lymphoma, OK. Drugs, penicillin, Suam, uh co ps and pregnancy. The diagnosis is clinically made. Ok? And it's based on the characteristic appearance of the and symptom and associated symptoms. Ok. Treatment often involves just addressing the underlying cause. And uh if, if, if it's identified and supportive measures, such as rest, pain relief and corticosteroids for severe cases. So, this is what we're talking about. So, basically, this is inflammation of the subcutaneous tissue that affects the, the low uh the shins. Ok. Uh OK. Very good. Uh Pyoderma gangrenosum is a rare noninfectious skin. Uh no run noninfectious inflammation disorder, inflammatory disorder, uh affects uh cau causing painful skin ulcerations, commonly affecting lower limbs. Ok. Uh Classified as uh a neutrophilic dermatosis. Ok. And it's characterized by having dense neutrophil, uh infiltrations in affected tissue, uh often seen on biopsies. That's also very important cause. There are a few histology questions about it where they basically describe it to you with, with, you know, a lesion that is full of neutrophils. And they, they, they describe to you where they got, got where they got the, the biopsy from and the diagnosis there is is is pyoderma gangrenosum. So causes it could be idiopathic, it could be associated with things like IBD, ulcerative colitis Crohn's uh rheumatological conditions. So, uh rheumatoid arthritis, sl e um hematological conditions. So, minor minor proliferative disorders, lymphoma, myeloid leukemias and monoclonal uh dermopathies. Ok. Uh could be also associated with uh primary biliary cirrhosis and uh granulomatosis with polyangiitis, it typically affects the lower limbs. Ok. Often associated with, with, with, with pathergy or pathy, which is basically it basically if you were to hurt yourself or you know, if you were to have a skin prick or um any form of laceration of the skin. Uh and it's a minor injury, basically, if you have any minor minor injury to the skin, it becomes exaggerated and it, it, it becomes much more severe. So if you were to have a needle stick injury in a few weeks time, instead of it healing you, you end up with this like big ulcer in your hand. Ok. So it starts off as uh small papules, red bumps and blood blister or blood blisters. And then later on these would sort of Colace and then they would uh uh uh develop into an ulcer that is painful. Uh It's usually purple in color. Ok. Uh and has deep necrosis, maybe deep and has ne necrosis or necrotic. Ok? Will have systemic features such as fever and myalgia. Ok. Uh It's made based on characteristic appearance. Uh diagnosis is made based on the characteristic appearance, ok. Uh associated with other conditions and the presence of paar uh histology and exclusion of other forms of ulcers management really here in both steroid use due to high potential of rapid progression. And also uh there are other immu immuno immunosuppressive therapies such as cycloSPORINE and infliximab that can be used in difficult cases. Surgery is postponed until the condition itself is controlled. Ok. Uh uh or immunosuppression. And that's again to avoid the worsening. Basically, the pathology. So, ii mean, imagine if you were to have a small ne needle stick injury and you end up with a big ulcer, let alone if you were to actually use a proper scalpel and try to, you know, uh do uh do any form of debridement, it will cause a lot more damage. So, as you can see here, these lesions are very angry looking. You can see the, the uh the purple or violet color in them. You can see how it's uh uh um quite ulcer, uh very wet. Ok. Uh and mainly affects the lower limbs. The last one that I really want to talk to you about today is uh purpura, the main thing I want you to get out of this is basically when you see a purpuric or a nonblanching rash in a child. Ok. So if you were to have a child who presents with a sudden onset of a uh a purpuric rash, ok. This is a an emergency, ok. Child with a new purpuric rash should be a admitted immediately for investigation as it may be a sign of meningococcal septicemia or acute lymphoblastic leukemia. This comes up quite often on the MCQ, ok. Uh And you need to give them parenteral antibiotics before you transfer them. Ok. So that's, that's very important. Um Yeah, that's, that's basically what I really wanted to tell you about this because this comes up quite a lot on the MCQ. Ok. So yeah. Um I think that's pretty much me. Uh apologies for some of the Typos. I was a bit rushed when I was making this, um I didn't really get a chance to revise it. So for cellulitis and erysipelas again, don't, don't get them mixed up. Uh For cellulitis, we said that the actual limb can be swollen but the, the red bit, the actual lesion is not. Ok. Whereas for erysipelas, the lesion itself will be well demarcated and raised. Ok. Uh I'll fix that in the slides before II II uh put it on metal. So, yeah, that's, that's pretty much me done. Um Do you have any questions? Can you guys hear me? Ok. Um Right. Ok. So we'll, we'll, we'll, we'll, we'll leave it there and thank you very much. Ok. Thank you.