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OD is much better now. So let me just try to share my screen. Hi, Steve, you'll see that. Yes, I can see that. Ok, I'll go through. Thank you for your help. You're welcome. That's fine. Uh Can everybody hear us and see us? Yeah, we can hear and see you. Yeah. Right. OK. Apologies guys. Uh So that's forward to proceed. Um So is my audio? Ok, you can stop me at any time if you can't, you can't hear my audio because that's a pain in the bum. So yes. Um to start again, I'm going to do the third session of the Comprehensive Derm Guide. Um and we're gonna just go through it quickly. It's a brief presentation on Acne Vulgaris Acne Rosacea a bit on Melanoma burns and then we'll finish off with a few common MC Qs that I think are relevant to the topic. So starting off with Acne, um I just like to go through the conditions in a logical order. So definition cause epidemiology and then any investigations or management. So starting off with Acne vulgaris, then it's a chronic condition affecting the hair follicles and pilosebaceous or sebaceous glands in the skin and what happens in acne, it leads to a blockage of the follicle and they can become inflamed as well. The cause it's multifactorial. So if there's a strong family history of acne, you're going to be at increased risk of developing it yourself. If there's a change in the hormones as well, you may be at increased risk of developing it. Um Everyone has harmless bacteria on their skin. So that's proprium bacterium. Um but when that comes clogged into the pores as well, that can cause acne, certain drugs as well, like steroids can cause acne. So a typical M CQ question would be say a patients being prescribed a course of oral drugs for s condition and they've had a flare up of acne and it will give you a list of drugs. And if steroids on there, it's most likely going to be that epidemiology. It's most prevalent in adolescents and young adults and it affects up to 85% of 18 to 16 to 18 year olds. So, you know, a large amount of our population are affected by acne. So the clinical features I'll go on to show a few photos in a minute, but they're, it's characterized by open and closed uninflamed condoms and these are blackheads and whiteheads. And then if these go on to become inflamed, it can lead into papules and pustules. And in more severe acne patients can present with nodules, pseudocysts and these can be very painful under the skin and have, you know, a psychological effect on the patients if it leads to any scarring. So onto the next slide there. Yeah. So these are just pictures of the pustules and papules. You can see the pustules or are raised bumps and they have that white and yellow center and the papules are, haven't got that yellow center and they're just more of a solid bump and then the closed condoms are your white heads and the open are your black heads there. So that's just a good few photos to memorize off on to the next slide, then classifying acne. So think about it logically in mild, moderate and severe. So if a patient is presenting with just white and black heads, they might have a few inflamed papules or pustules, but there'll be minimal scarring that's considered mild acne on to moderate patients will present with more numerous papules and pustules. They'll meet increased risk scarring as well with the moderate acne and then severe acne is classified by, you know, extensive pules and pustules. It could be on their back, it could be on their face. There'll be more inflammation and pain associated with the severe acne and there's a high risk of scarring and developing keloids as well. The top right there is a photo of nodulocystic acne and that's um part of the referral criteria on to dermatology services in secondary care. So a patient could present with really sore. Um You can see they're, they almost look like boils on the skin that can be really sore for the patient and they can be referred on to dermatology if they present with that. A few other things that are worthwhile learning off um for MC Qs, when to refer patients on to dermatology, a key one would be psychological distress. So no matter the severity of acne, if a patient is having psychological distress or experiencing any mental health issues, they should be referred on to secondary care services. Also, if they're having any scarring, because that's a long, long term effect, they can be referred on. And if they just aren't responding to any treatment in primary care. So if they've had two completed courses, they can be referred on. And also if it's not responding to oral antibiotics, they'd consider being referred. So on to the next slide, then this is just something to look out for in a patient with acne. It's basically just very severe acne. Um It's called acne fulminans and it's associated with systemic upsets. The patient will present with a fluctuating fever. They can also have painful joints, malaise loss of appetite and hospital admission is often required and they'll be given steroids there as well. And it's nearly always in adolescent males and it can be an abrupt onset as well. So just keep that in mind. So the next slide onto the treatment of acne. So I'd just like to divide it into two. Mild to moderate and moderate to severe. Starting off with mild, always think of 12 have the number 12 in your head. It's 12 weeks and you can give a 12 week course of a topical combined therapy as first line. So you can start off with. There's a few options here, topical tretinoin and that basically just like exfoliates the top layer of your skin to try and unclog the pores. And that can be given with topical clindamycin. You could also try topical benzoyl peroxide and topical clindamycin or topical Adaline. I hope I've not butchered that name. Um, and it's also important to note if they're not able to take any topical tre one or topical clindamycin, you can go ahead with monotherapy, topical benzoyl peroxide. If all the other ones are contraindicated. But that's the only one you should really be given as monotherapy on to moderate and severe. Then it's sort of similar, it's like a treatment ladder starting off similar to the ones I just mentioned there. So you can try first line topical tretinoin with a topical antibiotic. But if that isn't helping, you can go on to try adding an oral antibiotic like doxycycline. But if the patient is breastfeeding or pregnant, it's important to give them Erythromycin and try to avoid tetracyclines. Um, second line, then you can try a combined oral contraceptive pill in female patients. This can also be combined with topical agents. So second line, you give the pill alongside another topical agent and you can try that for three months. However, it's important to, you know, take a thorough history from the patient. Their um me, three and four criteria shouldn't be given out if there's a VT risk. Um So yes, and then third line, it's further down the line. It's ISOtretinoin also known as um Roine, but that would only be prescribed in dermatology services that wouldn't be provided in primary care. And with ISOtretinoin, that would be a good counsel station in an AK um it can have very severe side effects like really dry skin headaches. You have to get your LFT S checked. Um Is it every three or six monthly and you're also not allowed to get pregnant on it. So that's a bit more of a severe treatment that you have to get in dermatology services. So, next slide, um I'm just going to do briefly a bit on ay counseling on Acne because this is something that can really come up from year three onwards. Um And it's just um a good one to be able to counsel, especially going out into placement as well. A lot of people are coming in with Acne. So of course, introduce yourself. Do all the basics check the patient's details, gain consent and take a brief history from them as well. You know how it's affecting them, their mood if they know anything about it as well. Anyone in their family have acne, you know, just a brief history and then I like to do the pneumonic for counseling conditions. Normally, we can probably manage. So, you know what's normal, what goes wrong in a condition, the cause of the condition, the problems management and then safety net. But we'll go through that quickly now. So um this is just an example of how I would explain what's normal. So, you know, you could start off by saying, look, normally our skin is a barrier that protects our body. It contains lots of different components like glands and hair cells. And these usually produce an oily lubricant to keep our hair and skin healthy. But in acne and then go to explain like what actually happens in acne. So oily lubricants mix with dead skin cells can bulk them out or normally bacteria on our skin is harmless. And however, if it gets clogged, it can cause infection in the skin. So check with them throughout that they understand as well. But there's just a few examples of how I would go about explaining it and then explaining the cause as well. It's really important to explain to a patient. You know, it's not their fault, it's not a cleanliness or a hygiene issue. Acne is very multifactorial, it can run in families. It may be a change in hormones or certain conditions like P CS can cause it. So ask that in the history as well. If they've got any P CS or other medical conditions and then go on to explain the problems to them. So, you know, it can lead to scarring infection, pain, ask about their mood as well cause it can cause depression and mental health issues in a lot of patients and then explaining the management to them to them. So all those treatments I mentioned above above try um explain to them, you know, the topical ones are gonna help them try and exfoliate the layers of the skin and unclog the pores. And when you're using like tretinoin, use S BF and then of course, safety net, the patient tell them not to squeeze their skin and seek medical attention. If the skin is oozing. If they're feeling unwell, any fevers, ask them if they have any questions and give them an information leaflet and also direct them to the NHS website as well. Sorry cream go on two slides. Now, if that's ok. So that's acne vulgaris covered then onto acne rosacea. So here's a few photos on the right there of just a typical presentation of rosacea. So definition, it's a chronic skin condition characterized by persistent facial redness and it can come in a relapsing and remitting pattern, but the symptoms can usually be controlled quite well. So characteristically, it affects the nose, the cheeks and the forehead and the first symptoms often flushing and it's common in middle aged women as well. Telangiectasia is also present in a lot of cases of rosacea. And that's basically just the small, broken capillaries down on the bottom right there. That's telangiectasia there. And it can also persist into erythema and papules and pustules can be associated with acne rosacea and can also affect the eyelids and cause inflammation of them as well. Another typical M CQ thing to look out for is say, the patients presenting with typical features of rosacea and it's worsened by sunlight. That's usually a good, um, alarm bell that should be going off in your head. That thinking if a rash is getting worse with sunlight, it could be acne rosacea. So on to the management, then next slide, um, it's important to start off with simple measures because it can get worse with sunlight. It's important to use daily S VF you know, greater than SPF um 50. Really, the patient should be advised to use and then dependent on the predominant symptom that the patient is presenting with. There's lots of different treatment options. So if a patient is coming in with mostly erythema and flushing, you'd start off with a topical ramot gel. And it's been basically just an alpha adrenergic that can be used just as they need it as required, which will help temporarily reduce the redness and it usually reduces it within 60 minutes. But after about six hours, the effect wears off and they might have to keep reapplying it onto mild to moderate papules and pustules. If they're presenting with papules or pustules, you should be giving them topical ivermectin or additionally. Um As an alternative, you can give like topical metroNIDAZOLE. There's just a few options there, but the key one to learn off is ivermectin. I feel like that's came up in past med quite a lot. Um And then if they're coming in with or moderate to severe papules and pustules, you can try the topical ivermectin but add on a tetracycline like doxycycline, an oral antibiotic there. And then the referral criteria for Acne rosacea. It's basically just if they're not responding to any treatment in primary care, they can get referred on to dermatology or also if the patients presenting with rhinophyma and that's just that bottom right foot there. It's basically a skin condition affecting the nose and the skin can become really thick and the spacious glands just become really enlarged and cause that enlarged nose that you can see there in the bottom. Right. So yes, next slide, then that's acne rosacea and acne vulgaris covered there. If there's any questions, you can just text in the chat or email me at the end. So melanoma, then go on to that. So there's lots of different types of melanoma, there's superficial spreading, nodular lentigo maligna or an acral melanoma as well. And if a patient is coming in with a suspicious lesion, there's some diagnostic features that you should be really looking out for that might be suggestive suggestive of Melanoma. So these might be a change in shape, size and color. If a patient is coming in with a suspicious lesion, tell them to be keeping an eye on it. If it has changed over time or say it's on their back or in an awkward place, ask them for their partner or someone they feel comfortable with to keep an eye on it for them other secondary features that might be suggestive of Melanoma is a diameter greater than seven millimeters. If there's inflammation around the area of the lesion, oozing or bleeding associated with it or altered sensation over the lesion as well onto the next slide there. So the treatment of Melanoma. So if it is a suspicious lesion meeting the criteria that I just mentioned there, they usually excise, the B, excise, the lesion and send it off for a biopsy. And another typical N CQ question is the measurement used in staging is the Breslow thickness. So they could give you a list of five say different screening tools or staging um tools. And if that's in there, that's, that's the one used for Melanoma. And depending on the Breslow thickness, then um it gives you an idea of how much to excise from the lesion. And then, so say, for example, it's 1 to 2 millimeters thick, you're gonna excise 1 to 2 centimeters um in diameter from the lesion. So, yep, next slide there. So just going on to the different types and how to recognize them, quickly superficial spreading. That's the most common one. It's in 70% of cases. It's usually on the arms, the legs, the back or the chest. And it's usually in young people as well. So you can see there in the right there, the top right there. It's a typical Melanoma. Um, there's lots of different colors there. You know, there in that one to the left hand side, it's pink, there's brown, a bit of skin colored. It's very asymmetrical. And you can see against the tape measure. It's greater than seven millimeters nodular. Then it's the second most common, but it's also the most aggressive. It's most common in sun exposed skin. And a patient can present with these red black lumps that can bleed and ooze and it's typically in middle aged patients as well. And sorry, I forgot to mention as well. Like you see the superficial spreading one, it tends to grow across the skin rather than growing deep into it. So on to the next slide there, the lentigo maligna, this is less common, but we'll just go over them briefly. It's common in chronic exposed skin um to the sun and it can be slow growing and it's usually found in older people as well. There is a picture of it on the top right there. Then acro lentus lentiginous ones. It's very rare. It can be found in the nails, palms and soles of the feet and it is more common in patients with darker pigmented skin and then next slide there. So that's melanoma covered there. Um It's worthwhile learning off how to um spot the different types because I feel like that's can come up in MC QS, differentiating the different types onto just benign melanocytic lesions. These benign melanocytic is basically just pigmented lesions involving melanin which aren't um cancerous. They can be congenital so they can be present from birth or they can be acquired. Sun exposure leads to greater number of lesions. But also you can get these where they aren't always in sun exposed areas. Management of benign lesions, they are usually just ignored because they are harmless. Sun exposure can also increase the number of lesions that you can develop and can also increase the risk of them turning or into melanoma. So, sun protection is encouraged and they can also be removed by a shave excision, which is just a short procedure under a local anesthetic, which only takes about 20 to 30 minutes really. And it can be used if they're irritating the patient. So if it's like rubbing on their clothing or catching in their comb or also if they're having for cosmetic reasons as well, if the patient's insecure about it or it's having an effect on their mental health, that could be removed onto the next slide there. So I just included a few like key benign melanocytic lesions. So the top left there is K ola macules and that can be a good feature of type one neurofibromatosis. So that can come up on MC QS quite a lot, the bottom left there. That's solar lentigo and that's quite common in patients with fairer skin or redheaded patients. Um and also freckles are considered a benign melanocytic lesion as well. And then there's your typical mole on the bottom right there. So yes, that's benign melanocytic lesions onto burns then so start off by assessing the burn. Um There, there's lots of different ways to assess the burn. But I think the one that makes the most sense to me is the Wallace's rule of nine. So there's a list here, I've added on. So head and neck, each arm, each anterior leg, I not go through them all. But those lists that list I've made there, each of those areas are worth 9% of the total body surface area. So you can work out. Um If a patient, if their total body surface area that has been burnt works up to greater than 15%. They will require IV fluids and you can work out the amount of fluids that a patient needs by timing the percentage of the body that's been burnt times by their weight and times by four and usually within the first eight hours, half of that fluid will be administered to the patient. So I think that's worthwhile learning off as well because that's something I got really confused about, but it does make sense if you think about it. Um, and then on to initial management. So, of course, you do airway breathing circulation. If a patient is coming in with a burn, there's lots of different types of burns. It might be a thermal burn, electrical burn or chemical burn. So, with the thermal burn, you should remove the patient from the source, of course, and within 20 minutes, you should cool the burn down with cool water, not iced water. Um for about 20 minutes and cover it using cling film, lay it over the burn rather than wrapping it around the burn because that can affect the circulation. Um If it's a chemical burn, just brush the powder off and don't try and irrigate it. Sorry, irrigate it with water, but don't attempt to neutralize the burn because it might make it worse. You mightn't be sure on what the chemical is. So it's best just to irrigate it with water first. So onto the next slide, then there's lots of different types of burns on dependent on what layer of the skin is affected. So, starting with the first degree burns, they're now called superficial epidermal burns. This is just like your typical, I think sunburn would be a first degree burn. You know, it's red, painful, dry, no blisters associated with it and it's treated with just analgesia and emollients for symptomatic relief. So, yeah, there's just a diagram at the bottom there to refresh your cells and the different layers of the skin. So that's just really affecting the epidermis. The first-degree burn then on the 2nd, 2nd degree burn, there's superficial dermal and deep dermal. So start with the superficial dermal. This is when a burn presents more as a pale pink color. They can have painful blisters, slow capillary, refill time and treatment would be to cleanse the wound, leave the blisters intact. Because if you're popping them, there's increased risk of infection. Non adherent dressing should be used as well and also avoid any topical creams because it could make it worse. Um, a deep dermal bone, these are appearing as white but they might have patches of non blanching, erythema as well. And the patient may often have reduced sensation but it'll be pain on deep pressure. And then finally, the third degree burn. This is just a full thickness burn affecting all areas of the skin. Fourth degree, um is something that goes on and beyond the muscles and into the muscles. But third degree um will appear as a white, waxy brown. It can also be like a leathery appearance. There'll be no blisters, it'll be that severe and also there'll be no pain, they'll not be complaining of pain anymore due to the severity of the burn. Next slide, then onto the management of severe burns, it's important to start off with airway. It's to be secured if smoke is inhaled early intubation. If deep burns are on the face in the neck, if the patient is also presenting with Stridor as well. And then of course IV fluids should be used in severe burns, which we've talked about urinary catheter may also be um indicated if it's in the perineum area. Um or if the patient is just really unwell analgesia, of course, and then if it is a very complex burn, these will have to be transferred into the burns unit. And then also, I thought it was useful to note that antibiotic prophylaxis isn't shown to help burns. So, yeah, onto next slide then um that picture on the right there is the Wallace's rule of nine, just the different areas there. Um So referral on to secondary care, this can come up in Qs again as can everything. But um all deep dermal and full thickness burn should automatically be referred on to secondary care. Um If there's any inhalation injury as well, they should be referred on because it can affect the airways. And um any electrical or chemical burn should also just be referred on to secondary care. And if it's a young child presenting with a burn, if they're not mobile, if they're too young to be looking after themselves, you should really consider non accidental injury. It's a cigarette burn or something like that. So that should be investigated and early intubation should always be considered in deep burns around the face or the neck as well because that can lead to edema and airway airway obstruction. So, it's just important to look out, look out for the area of the burn as well. So, that's, um, all of the slides. I think we're just gonna do a few MC QS here. I think there's about five, but they're all very relevant to the talk. So, just under the first one there, I'll just read it out and you can have a few minutes to think and I'm not sure if anyone is still on this, but sure you can help me out. Um So a 35 year old woman presents to her GP with circular brown raise lesion, which is soon to be diagnosed as malignant melanoma. What um type of malignant mel melanoma is most commonly found on the legs of young patients. So I'll give these a few minutes to think about that. Ok. Ok. Ok. I'll do the next slide. So that would be superficial, spreading melanoma. It is most commonly found in young patients and particularly on the legs and the arms and the chest like I mentioned there. So, onto the next question. Um This is a good like explaining station and good for counseling. So a 16 year old is presenting to the GP with bad spots for three months and she's been diagnosed with Acne. What's the correct pathology um of Acne if you were describing it? Ok. Onto the next slide there. Yeah. The answers. B it's a disorder of the pilosebaceous follicles. So on to the next slide, the next question, three more here. So a 39 year old woman presents to her GP with a red rash over her nose and cheeks and she reports it's developed over the past few years. She said it used to come and go, but it's now persistent. There's no papules or um there's a few papules but there's no condoms present. There's erythema across her nose and cheeks. What is the most likely diagnosis there? This is an easy one. So it is say rosacea. So onto the next question, then a 53 year old presents to the GP, she's developed a red rash over her face, which is worse on sun exposure. Aside from this, the patient reports, no other symptoms and feels well. When examining her, there's a few red pules visible, visible on her forehead, cheeks and nose and eryth erythematous skin with telangiectasia. She's diagnosed with Rosacea. One of the following treatments would be most appropriate for the patient. So you're thinking they've got papules alongside the erythema. So next slide, you'd give the topical ivermectin because it's not just predominant erythema. There's also papules, you give the ivermectin and it's not severe enough. Um, it doesn't seem to add on any doxycycline at the moment. And then finally, last question. So, um a 15 year old boy presents to his GP with a new rash he complains that the rash is unsightly and would like to have it treated on examination. Um The following rash is seen below. Given the diagnosis. What's the most appropriate initial treatment? Ok. Next slide there, the answer is no. E so um yeah, you give topical retinoid with a benzoyl peroxide, topical as well. Just think about the treatment now where you can refer back to those um the summary slide I made there. So that's all the questions there. Thank you everyone for listening. And if anyone has any other questions, you can give me the email there or any questions regarding a um Please don't hesitate to give me a shout. So yes, thank you very much and sorry about all the technical difficulties. Thank you guys for, for joining us. Um Thank you very much Christy for this. This was actually excellent. Um Very well put together very, very uh clear. Uh So, apologies guys for the problems that we had at the beginning. Uh uh But the the video will be uploaded onto uh the metal and uh we'll try to get the uh the powerpoint also to be uploaded to metal. OK? So thank you very much.