LAST MINUTE

REVISION BOOK
DERMATOLOGY
by
DR. PRATIK RAJENDRA MOHTA
MD DERMATOLOGY (AIIMS DELHI),
EX MEDICINE RESIDENCY (AIIMS
DELHI)
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 BASICS IN DERMATOLOGY
# Skin = 16% of total body weight Primary skin lesions (1ST skin lesion to appear)
# Total area of skin in body = 1.7 sqm 1. Macule in primary school WE say MNOP
Melanocytes = like painters who paint bricks 2. Papule (rest all are 20)
# in S. basale 3. Plaque
# origin = neural crest 4. Nodule
# contain pigment melanin in melanosomes 5. Vesicle (O = shape of vesicle/bulla)
# 1 painter for 36 bricks - - - - > 1 M for 36 K = 1 : 36 6. Bulla
# Markers = HMB 45, S 100, Melan A 7. Pustule
Langerhans cell (LC) 8. Purpura
# are dendritic cells 9. Petechiae
located in S. spinosum 10. Ecchymoses
# origin = bone marrow 11. Wheal
# contain BIRBECK
GRANULES (tennis - flat lesion < 1 cm = macule, > 1 cm = patch
racquet shaped) - raised palpable lesion > 1 cm = papule
# Markers : CD 1a, S 100, - raised palpable lesion >0.5 cm + depth = nodule
CD 207 (Langerin) +ve
Merkel cells Lichenification – hyperpigmentation +
# site = S. basale of rete - increased skin marking +
ridges - skin thickening
# origin = ectoderm >
neural crest (controversial) Poikiloderma (ATP)
# Mechanoreceptor - -- > for touch - -> slow adapting - Atrophy
# concentrated in fingertips - Telangiectasia
# Marker = CK 20 (cytokeratin) - Pigmentary change (hypo/hyper)
❖ Stratum spinosum – abundant desmosomes
❖ Stratum basale does not contain --> Langerhans cell ❖ Most abundant collagen in dermis = Type 1
❖ MALPHIGIAN LAYER = S. spinosum + S. basale ❖ Type 1 : 3 collagen = 3:1
(Pigeon is a Sweet Bird)

Plaque of psoriasis – primary lesion

Silvery scale – sec. skin lesion Nodule – primary skin lesion Fissure – sec. skin lesion

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 APPROACHING IMMUNOBULLOUS DISORDERS IN MCQ
If only clinical information is given without any histology finding

Flaccid bulla Shallow erosions & Tense bulla Tense vesicles

Oral ulcers crusts Itching, urticaria String of pearls/
Acantholytic cells No oral ulcer No oral cluster of Jewels
Seborrheic distribution No acantholytic cell
Acantholytic cells

Linear IgA disease

Pemphigus vulgaris Pemphigus foliaceous Bullous pemphigoid
(adult)
(Desmoglein 3 > 1) (Desmoglein 1)
(If pregnant think of
pemphigoid gestationis) Chronic bullous
disease of childhood
(child)

Papulovesicular lesions
Severe itching
Elbows, knees
Gluten enteropathy

Dermatitis herpetiformis

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If histological findings are given, use it as a clue

Gap inside epidermis Gap between epidermis and dermis

(Subepidermal cleft)

Pemphig If we have 2 options mentioning

us pemphigus then look for

Subcorneal cleft Suprabasal cleft 1. Bullous pemphigoid Neutrophil abscess in

Row of Tombstone dermal papilla
2. Pemphigoid
gestationis

3. LINEAR Ig A/ CBDC

Pemphigus Pemphigus Dermatitis

foliaceous vulgaris herpetiformis

Mnemonic for [Link]

DONALD duck Fishing

Dsg antibody

Oral ulcer

Nikolsky sign +ve

Acantholytic cells

Lower age

Death stone - Row of Tombstone

Fish net pattern on DIF

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 Direct immunofluorescence findings to diagnose Immunobullous disorders

FISH NET Pattern LINEAR PATTERN along DEJ Granular pattern along DEJ
(Epidermis highlighted) (DEJ highlighted) (Dermal papilla highlighted)

Pemphigus VULGARIS Bullous pemphigoid Dermatitis herpetiformis

Pemphigoid gestationis
Pemphigus FOLIACEOUS Ig A deposits
LAD/CBDC
All 3 will have linear deposits
along DEJ
BP & PG => Ig G and C3
LAD/ CBDC => Ig A

Fish in dermatology

1. Fish net immunofluorescence -> Pemphigus

2. Fishy odor on adding KOH -> Whiff test in Bacterial vaginosis
3. Fish like scales -> Ichthyosis vulgaris
4. School of fish appearance -> Chancroid

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 LMR DERMATOLOGY

PAPULOSQUAMOUS DISORDERS

Examples Diseases a/w infections

My PET Snake Likes Soft Drink PepSi 1. Pityriasis rosea- HHV 7 and 6
Mycosis fungoides 2. Lichen planus – Hep C
P – Psoriasis 3. Kaposi sarcoma – HHV 8
- Pityriasis rubra pilaris 4. Oral hair leucoplakia - EBV
- Pityriasis lichenoides 5. PAN – Hep B
- Pityriasis rosea 6. Membranous GN – Hep B
E – Eczema 7. Membranoproliferative GN – Hep C
T – Tinea
Snake – Sec. syphilis Disorder Scales
Likes – Lichen planus & Lichen nitidus
Soft Drink – Seborrheic Dermatitis Pityriasis lichenoides Mica like adherent scales
PepSi = Papulo Squamous chronica

Psoriasis Silvery scales

Congenital syphilis is not papulo-squamous
P. versicolor Powdery fine scales
Histological features of LICHEN PLANUS Ichthyosis vulgaris Fish like scales
Max – Max Joseph space
Saw – Saw tooth rete ridges Seborrheic dermatitis Greasy scales
Big – Basal cell damage
Cat – Civatte bodies/
Micro Munro abscess -----> Psoriasis
Colloid bodies
Pautrier’s abscess -----> Mycosis fungoides
And got
HyPER - Hypergranulosis

Types of pustular psoriasis

Generalized Localized Pustular psoriasis Treatment of pustular psoriasis

1. Drug of choice = Acitretin
Acute generalized PP Palmo plantar PP
2. Drug of choice in pregnancy
= k/as Von Zumbusch
= Oral steroids
disease
Cutaneous disorders a/w
Impetigo Acrodermatitis
herpetiformis (PP of Continua of metabolic syndrome
Pregnancy) Hallopeau APLA
Acanthosis nigricans
Infantile PP
Psoriasis
Lichen planus
Androgenetic alopecia

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ECZEMATOUS DISORDERS

Atopic dermatitis

Infantile
Child + Adult
(2 m – 2 yrs)
Extensors
Flexors
+ Face

Clues to atopic dermatitis in MCQ

1. Onset in infancy/ childhood

2. Itchy rash over extensor/ flexures/ face

3. Chronic

4. Family or personal history of atopy – recurrent allergic rhinitis/

asthma/ atopic dermatitis Flexural rash in an

MCQ – think of
Causes of erythroderma atopic dermatitis

ID-SCALP

I - Idiopathic

D – Drugs (Phenytoin, Allopurinol)

S – Seborrheic dermatitis

C – Contact dermatitis

A – Atopic dermatitis

L – Lymphoma and leukemia

P – Psoriasis

- Pityriasis rubra pilaris

- Parthenium Dermatitis

- Pemphigus foliaceous

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 LMR DERMATOLOGY

LEPROSY and STD

Ridley Jopling classification Most common in leprosy

1. Tuberculoid tuberculoid TT ✓ Leprosy in India = BT
2. Borderline tuberculoid BT ✓ Peripheral nerve involved = Ulnar > posterior tibial
3. Borderline borderline BB ✓ Cranial nerve involved = Facial
4. Borderline lepromatous BL ✓ Nerve taken for biopsy = Radial cutaneous > Sural
5. lepromatous leprosy LL ✓ Internal organ involved = testis (male), liver
Based on 4 criteria (female)
M I C H ae L Jackson ✓ First sensation to be lost = hot and cold difference
M- microbiological / bacteriological ✓ Organs not involved in leprosy = Lungs, CNS,
(Slit Skin Smear) female reproductive system (uterus least
I – Immunological common, ovary sometimes), prostate
C – Clinical
H – Histological
L for leprosy
J Jopling

Approaching diagnosis of leprosy in MCQ

Single lesion Few lesion (large) Multiple lesions Multiple lesions Multiple lesions/
Hypo-aesthetic Hypo-aesthetic (10-30) (>30) diffuse infiltration/
Single thick Inverted saucer Normo-aesthetic nodules
Satellite lesions
nerve Almost Symmetric Norm-aesthetic
lesions/ punched
Well defined Few asymmetrical
out/ annular lesions Multiple B/L thick Symmetric lesions
borders nerves
nerves Symmetric B/L
AFB +
No AFB No AFB
AFB +++ nerve thickening
Glove and stocking
Tuberculoid Borderline Borderline Borderline
anesthesia
tuberculoid tuberculoid borderline lepromatous
Ear lobe infiltration
Immunoprophylaxis in Leprosy AFB ++++
-> close family contacts and high risk groups
Lepromatous
-> can also be given with MDT to decrease bacilli load
leprosy
-> Vaccines used:
1. Mw vaccine (MIP vaccine Mycobacterium Indicus ❖ Only nerves, no skin lesions = Pure neuritic
Pranii) leprosy
-> Pranii = Dr Pran (Pra) founder of National ❖ Single ill defined hypopigmented macule in
Immunology Institute (Nii) child, no sensory loss, no nerve =
2. BCG vaccine Indeterminate leprosy
3. BCG + Killed M. Leprae vaccine ( = Convit vaccine)
4. Indian Cancer Research Institute (ICRC) vaccine
- Mycobacterium Vaccae vaccine

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Newer guideline for treatment (2018 WHO) U-MDT = Uniform multidrug therapy -> means 3 drug
regimen will be common to PB and MB
For adults

Paucibacillary Multibacillary
Dapsone 100 mg daily All for 6 months All for 12 months
Clofazimine 50 mg daily
300 mg once a month
Rifampicin 600 mg once a month
In older guidelines,

For PB cases -> 2 drug regimen of Dapsone + Rifampicin was given

For MB cases -> same 3 drug regimen as now was given ❖ Fastest drug in leprosy – Rifampicin
❖ Dose of Dapsone – 2 mg/kg
Adult MB-MDT blister pack (now used for both PB and MB)
❖ Most common side effect of Clofazimine =
pigmentation of skin
❖ Follow up yearly for
2 yrs in PB leprosy
5 yrs in MB leprosy
❖ Investigation in case of pure neuritic
Hansen = Radial cut. N biopsy > Sural N.
biopsy

Tuberculoid leprosy - Single

large hypopigmented Satellite lesions – BT leprosy

hypoasthetic macule
Lepromatous leprosy – B/L
symmetrical

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Sexually transmitted disorders

Causes of genital ulcer Causes of urethral discharge

SCHOOL of Ulcers MiTHUN Chakra
a. Syphilis M - Mycoplasma
b. Chancroid T - Trichomonas vaginalis
c. Herpes H - Herpes simplex
d. DOnOvanosis U - Ureaplasma
e. LGV N - N. gonorrhea
Not caused by => Gonorrhea, Chlamydia C - C. Trachomatis

Syphilis ulcer is like Single Stone Chancroid – H. ducreyi

Ducreyi are like ducks
Single, Hard, painless, Swim in groups (multiple ulcer)
non-bleeding Pretty (painful)
Soft to feel (soft)
Can swim under water (undermined)
Bleed when cut (bleed easily)
Catch fish (School of fish appearance on stain)
LymphoGranulomaVenerum
Is like a Groom DoNOvanosis
Happy transiently during marriage No – No pain in ulcer
(transient painless ulcer) No pain in lymphadenopathy
Pianful Life later Safety pin appearance
(painful Lymphadenopathy
in later stage) Herpes genitalis – patient is pissed due to pain
- pain + polycyclic margins
- multinucleate giant cells + acantholytic cell on tzanck

Syphilis Genital warts Gram neg diplococci Gonorrhea

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How to make diagnosis in MCQ on genital ulcer? ---> look for PAIN in ulcer

Painful ulcers Painless ulcers

Think of
Think of
Chancroid Herpes genitalis Primary syphilis Donovanosis
LGV

Both have painful inguinal LN

Look for inguinal lymphadenopathy

Painless No
Painful lymphadenopathy
Don’t forget - Syphilis Smiles (no pain), Chancroid cries (all painful)

Most common in the world Investigation of choice

❖ STD = genital herpes (HSV2) ➢ Primary syphilis = DGI from ulcer

❖ Bacterial STD = Chlamydia trachomatis ➢ Sec. syphilis = VDRL/RPR

❖ Protozoal STD = Trichomonas ➢ Neurosyphilis = CSF VDRL

Drug of choice Genital warts – caused by HPV 6, 11

Inj Benzathine penicillin G 2.4 M.U. i.m. HPV vaccine

➢ Single dose – Primary, Sec. syphilis Cervarix – HPV 16, 18 (high risk)

➢ Once weekly for 3 weeks - Tertiary syphilis Gardasil – HPV 6, 11, 16, 18 (LOW + HIGH)

➢ Pregnancy with syphilis acc. to stage Gardasil 9 – HPV 6, 11, 16, 18, 31, 33, 45, 52 and 58

Aqueous crystalline penicillin

➢ Neurosyphilis

Incubation time Chancre redux is seen in Early relapsing syphilis

Syphilis → 9-90 days (Recurrence of chancre at previously healed chancre)
Chancroid → 3-10 days
LGV → 3-30 days
Gonorrhea → 2-5 days Syphilis d’ emblee
Groove sign = swollen inguinal and femoral LN with => 20 syphilis without primary chancre
middle inguinal ligament like groove = in LGV => after transfusion with infected blood

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Bacterial vaginosis Trichomoniasis is like a

Mnemonic – Talking Green Parrot eating

Big Blue Whale Fish strawberry

in a Garden Talking - Trichomonas

Big – B – Bacterial Vaginosis Green – Green-yellow discharge

Blue – Rhymes with Clue – Clue cells Parrot – Protozoa

Whale – Whiff test Strawberry – Strawberry cervix

Fish – Fishy odor Curdy white itchy vaginal discharge

Garden – m.c. cause is Gardnerella → Vulvovaginal Candidiasis by Candida albicans

Genital warts In pregnancy

Safe to use
-> Cryotherapy (Treatment of choice)
-> Trichloroacetic acid
Podophyllin contraindicated

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 MISCELLANEOUS DERMATOLOGY

Causes of non-scarring alopecia Criteria for NF 1

❖ Alopecia areata NESCAFE
❖ Trichotillomania ❖ N – Neurofibroma
❖ Tinea capitis ❖ E – Eye – Optic glioma
°
❖ 2 Syphilis ❖ S – Sphenoid dysplasia
❖ Tractional alopecia / Tibia pseudoarthrosis
❖ Alopecia totalis ❖ C – Café au lait macules
❖ Telogen effluvium ❖ A – Axillary freckles
❖ Anagen effluvium ❖ F – Family history
❖ Androgenetic alopecia ❖ E – Eye – Lisch nodules = iris hamartoma
❖ SLE Mnemonic –
❖ Thyroid disorders Anti Terrorism squad Tuberous sclerosis
Disorders starting with has non scarring -> Autosomal dominant
A/T/S are non-scarring alopecia -> Ash leaf macule
-> Shagreen patch
Alopecia areata – -> Facial angiofibroma = adenoma sebaceum
Fine nail pitting -> Koenen tumor
‘Swarm of bees’ appearance on histology
Exclamation mark hairs
Think of SLE
Causes of Flagellate pigmentation
❖ Malar rash sparing nasolabial fold
❖ Photosensitivity Bleomycin, Bendamustine, Docetaxel
❖ Alopecia
Adult onset Still’s disease
❖ Oral ulcers
❖ Fever Dermatomyositis
❖ ANA, dsDNA
Shiitake mushroom

Mnemonic - BAD Fart and Shit

Think of Dermatomyositis
❖ Heliotrope rash
Mechanism of action of antifungals
❖ Gottron papules
Acts on
❖ Shawl sign
Terbinafine ---> Squalene epoxidase
❖ V sign
Azoles ---> Lanosterol demethylase
❖ Mechanic hands
Amorolfine ---> Sterol reductase
❖ Malar rash involving nasolabial fold
Ciclopirox ---> Mitochondrial electron transport
❖ Photosensitivity
Sertaconazole ---> antipruritic and anti-inflammatory
❖ Muscle weakness (CPK)
❖ Fever

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 Traumatic inoculation Molluscum contagiosum
➢ Chromoblastomycosis - Umbilicated dome shaped papules
➢ Sporotrichosis - Pox virus
➢ Mycetoma - Intracytoplasmic inclusion bodies
➢ Phaeohyphomycosis
➢ Atypical mycobacterial infection

Chromoblastomycosis Sporotrichosis Mycetoma – grain + sinuses

- Copper penny bodies - Asteroid bodies

TINEA CAPITIS

✓ Clues in an MCQ – Child with broken hairs, alopecia patch with scaling and itching

✓ Black dot tinea capitis = Endothrix, by Trichophyton violaceum, Trichophyton tonsurans

✓ Grey patch tinea capitits = Ectothrix

✓ Favus – inflammatory tinea capitis with yellow cup shaped crust, by Trichophyton Schoenleinlii

Mnemonic - BLACK VIdow and THOR in ENDgame

My Favourite is ThanoS
Black dot
Favus
Violaceum
Trichophyton
Tonsurans
Schoenleinlii
Trichophyton

ENDothrix

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Important HLAs

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