ALL DERMATOLOGY NOTES Last Updated on 28th May 2018

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 The Basics
1. Describing the Lesion
a. Location & Distribution
b. Colour
c. Type (Primary morphology)
d. Configuration (Secondary morphology)
e. Texture/secondary changes
f. Other signs
2. Location & Distribution
a. Single or multiple
b. Localised or generalised
c. Symmetrical or asymmetrical
d. Flexure or extensor
e. Body parts – scalp, face, trunk, limb etc
f. Sun-exposed or protected skin
3. Colour
a. Erythematous – inflammation/infection/vascular
b. Orange – hypercarotenaemia
c. Yellow – jaundice, xanthelesma, xanthoma
d. Purple – cutaneous haemorrhage, vasculitis, haemangiomas, dermatoyositis (heliotrope colour
around eyelid)
e. Blue, silver, grey – drug/metal deposition, ischemia, deep dermal naevi
f. Black – naevi, melanoma (melanocytic), ecshars (dead skin from infarction), arterial
insufficiency, vasculitis
g. Hyperpigmented
h. Hypopigmented
4. 4. Types (primary morphology)
a. Macules : flat, <1cm
b. Patch : flat, >1cm
c. Papule : palpable, < 0.5cm
d. Nodule : palpable, > 0.5cm
e. Plaque : palpable, flat-topped, > 1cm
f. Vesicle : fluid-filled blister, < 0.5cm
g. Bulla : vesicle > 0.5cm
h. Pustule : small collection of pus
i. Abscess : collection of pus, >1cm
j. Wheal/urticaria : transient dermal edema often surrounded by zone of erythema
k. Burrow : tunnel
l. Erosion : loss of part or all of epidermis
m. Ulcer : loss of epidermis & part of dermis
n. Petechiae : punctate foci of haemorrhage
o. Purpura/ecchymoses : larger area of haemorrhage
p. Telangiectasias : foci of small, permanently dilated blood vessels
5. Configuration (secondary morphology)
a. Linear : straight line
b. Serpiginous : linear, branch & curving elements
c. Annular : rings with central clearing
d. Target (bull’s-eye or iris) lesions : rings with central duskiness e.g. erythema multiforme
e. Discoid/nummular : circular or coin-shaped
f. Umbilicated : central indentation e.g. molluscum contagiosum
g. Grouped : e.g. herpes simplex
h. Bizzare : e.g. dermatitis artefacta
i. Herpetiform : grouped papules/vesicles
 j. Zosteriform : clustered in dermatomal distribution
6. Texture
a. Scales : keratin presents as flaking
b. Crust : dried serum and exudate
c. Atrophy : thinning, loss of normal skin markings
d. Lichenification : thickening, prominent skin markings due to repeated scratching or rubbing
e. Scarring : fibrosis replacing normal skin, may be hypertrophic, raised, keloid
f. Excoriation : scratch marks causing erosions/ulcers
g. Verrucous : irregular, pebbly, or rough surface e.g. warts and seborrheic keratoses
 URTICARIA
1. Describe
a. Multiple generalised erythematous wheals over the
forearm
2. Diagnosis
a. Urticaria
3. Causes
a. Shellfish, strawberry
b. Penicillin
c. Sweating (cholinergic)
d. Heat, water, cold, light
4. Investigation
a. Skin prick test
b. Radioallergosorbent test (RAST) - serum Antibody
5. Treatment
a. Avoid triggers
b. Antihistamine eg loratadine

1. Changes shape, disappear and reappear within hours

2. Feels firm, fluid extravasation, dermal oedema, check for
blanching or non blanching (blanchable)
3. Check for angioedema (severity)
4. RED FLAGS: If it lasts more than 24 hour, remains same shape
and at the same locality, if resolve with some
hyperpigmentation
5. Treat with antihistamines
6. Chronic urticaria if it lasts more than 6 weeks - need to do
blood investigations
“Adapted from - dermato quiz”

Dermatographism - writings after

being stroked firmly by a pointed object.
Delayed pressure urticaria
Cholinergic urticaria
 ECZEMA/DERMATITIS
1. Contact dermatitis
2. Childhood atopic dermatitis
3. Seborrhoeic dermatitis - PITYROSPORUM ORBICULARE (MALASSEZIA FURFUR)
4. Infantile seborrhoeic dermatitis
5. Napkin irritant dermatitis
6. Discoid eczema
7. Varicose eczema/static eczema
8. Pompholyx
9. Chronic hand eczema with fissuring and hyperkeratosis
10. Asteatotic eczema

1. Describe the lesion?

a. Generalized erythematous lesion of the palm with
scales and excoriations more prominent over the
fingers
2. Diagnosis?
a. Contact allergic dermatitis of the hand
3. Possible causes?
a. Soaps, detergents, shampoos
b. Nickel & cobalt (jewellery, watches)
c. Cement
d. Rubber (gloves, shoes)
e. Formaldehyde, parabens (toiletries)
 f. Corticosteroid
4. Investigation?
a. Patch testing
5. Treatment?
a. Avoid allergen eg rubber, nickel, gold, cement
b. Potent topical corticosteroids eg Clobetasol
propionate
c. Soaking in KMNO4 (drying agent) if vesicular/bullous
i. Purple in colour

ii.

1. Describe the lesion?

a. Generalised erythematous patches with crusts over
the face with sparing of the perioral and perinasal
areas
2. Diagnosis
a. Childhood atopic dermatitis/eczema
3. Causes
a. High level of IgE, Genetic
b. Chemical irritant & detergent
Childhood atopic dermatitis 4. Can be superimposed infection SA (weepy yellow
crust) or HSV (eczema herpeticum)
5. Clinical features
a. Begin in childhood <2 yo
b. Personal or FHx of atopy
c. Itchy
6. Investigation?
Atopic eczema with 2º staphylococcal a. Swab for bacterial C+S – TRO staphylococcal
infection b. Swab for viral PCR – TRO eczema herpeticum
c. Skin prick test & RAST only confirm atopy (as
urticaria)
 7. Treatment
a. Conservative
i. Avoid excessive bathing
ii. Avoid wool, sweating, rubbing - prevent
abrasion for superimposed infection
b. Topical
i. Oil base soap substitutes
ii. Emollients eg paraffin oil - to keep it moist
iii. Coal tar paste bandage – sooth itchy skin
Eczema herpaticum
iv. KMNO4 wash (drying agent)
v. Topical corticosteroids
c. Systemic/other
i. Antihistamine eg promethazine
ii. AB for staphylococcal
iii. Antiviral eg acyclovir for HSV
iv. Steroids - po prednisolone

Chronic atopic dermatitis

“Lichenification,hyperpigmented and
prominent skin creases indicates
chronicity”

1. Describe the lesion?

a. Single erythematous patch with yellow scales on the
scalp with localised hair loss, no sparing of nasolabial
folds
b. Erythematous patch over the nasal and paranasal area
with yellow scales
c. Erythematous patch at the periauricular area with
post-auricle thickening of skin
2. Diagnosis?
a. Seborrhoeic dermatitis/eczema
3. Cause?
a. Yeast Pityrosporum orbiculare (Malassezia
furfur) - also cause tinea vesicolor OR pityrosporum
ovale
b. Increased sebaceous gland activity
c. Associated with HIV
4. Other sites: nasolabial fold, eyebrows, behind ears, upper
chest, axilla, groin
5. Investigation?
a. No useful test
b. HIV serology
6. Treatment?
a. Topical antifungal eg ketoconazole
b. Topical corticosteroid eg hydrocortisone
 c. Selenium sulphide/ketoconazole shampoo
d. Keratolytics eg salicylic acid ← given when the
lesion is scaly (to soften scales to aid removal)

Infantile seborrheic dermatitis

1. 1st 3 months of life

2. Affected areas
a. Cradle cap
b. Eyebrows
c. Fold of neck, axilla, elbow, knees
d. Napkin rash
Cradle cap
3. Itching is NOT a prominent feature
4. Causes:
a. Overproduction of sebum
b. Associated with Malassezia furfur
5. Rx:
a. Skin - mild topical corticosteroids + antifungal
(ketoconazole)
b. Scalp - gentle shampooing, salicylic acid (keratolytic)
6. DDx for napkin seborrhoeic dermatitis

Infantile seborrheic dermatitis

- Napkin psoriasis
- Napkin irritant contact dermatitis (below)
- Napkin candidiasis with satellite lesions
Napkin seborrhoeic dermatitis
1. Describe
a. Erythematous macerated (softened) skin confined to
area of napkin, sparing the skinfold
2. Diagnosis
a. Napkin irritant/ammoniacal dermatitis
3. Cause
a. Prolonged contact with urine and feces in the napkin
4. Treatment
a. Zinc oxide ointment → Promote drying of wet, oozing
lesions
b. Frequent change of diapers

1. Describe
a. Multiple erythematosus discoid mixed of papule and
plaque over the back
2. Diagnosis
a. Discoid/nummular eczema
3. Causes
a. Triggered by
i. Minor skin trauma eg insect bites
ii. Drugs eg interferon, ribavirin
4. Investigation
a. Skin scrape TRO fungal infection
5. Treatment
a. Strong corticosteroids
b. Others same as childhood atopic

1. Describe
a. Generalised erythematous skin changes with dilated
veins and mild hyperpigmentation over the gaiter area
2. Diagnosis
a. Varicose eczema/stasis dermatitis/gravitational
eczema
3. Investigation
a. Duplex ultrasound
b. Skin scrape
4. Treatment
a. Leg elevation
b. Compressive stocking
c. Pentoxifylline - venoactive drugs
d. Surgical management - high strip, ligation,
endovascular radio/thermal ablation
1. Describe
a. Multiple vesicular erythematous skin lesion over the
palmar aspect of the left hand and fingers
2. Diagnosis
a. Pompholyx (itchy vesicle on the palm and soles)
b. aka dyshidrotic eczema
3. Investigation
a. Vesicular fluid swab for C+S
b. Skin prick test
c. Radioallergosorbent test (RAST)
d. Patch testing
4. Treatment
a. Conservative
i. Hygiene
ii. Avoid allergen
iii. Avoid rubbing, scraping
b. Topical
i. Corticosteroid
ii. KMNO4 - drying agent
iii. Coal tar - for itchiness
c. Systemic
i. Steroid
ii. Antihistamine eg loratadine, cetirizine

1. Describe
a. Dry scaly skin with yellow crust over the finger with a
linear fissure
2. Diagnosis
a. Chronic hand eczema with hyperkeratosis and
fissuring
3. Investigation and treatment: as above

1. Describe
a. Crazy paving - dry superficial fissure
b. Dry cracked and polygonal fissured skin with
irregular scarring (asteatotic)
2. Diagnosis
a. Asteatotic eczema/eczema craquele/xerotic eczema)
@ Skin is abnormally dry, itchy and cracked
3. Cause
a. Commonly found in elderly
b. Steroid usage can cause skin thinning which predisposes
to this condition
c. Worsen by winter, frequent bathing, central heating ←
caused dry skin
4. Investigation
 a. ???
5. Treatment
a. Oil-based emollients

PSORIASIS
1. Plaque
2. Erythrodermic - medical emergency
3. Pustular
4. Flexural
5. Guttate (raindrop)

Introduction 1. Clinical features

a. Skin
i. Auspitz sign - appearance of punctate
bleeding spots when psoriasis scales are
scraped off

Onycholysis

ii. Koebner’s phenomenon - skin lesions

appearing on lines of trauma (isomorphic skin
lesion on a normal skin → can progress to
develop psoriasis)

Subungual hyperkeratosis

iii.
iv. Scalp - extend beyond hair line
 v.
b. Nail
i. Onycholysis (ddx - trauma, onychomycosis,
hyperthyroidism)
ii. Subungual hyperkeratosis
iii. Yellowing of nail
Pitting iv. Pitting
c. Joint (5-10%)
i. Seronegative polyarthropathy:
ii. Symmetrical arthritis
iii. Asymmetrical arthritis
iv. DIP dominant
v. Spondylitis
vi. Arthritis mutilans
d. Eye
i. Uveitis
2. Treatment
a. Conservative
i. Reduce stress, avoid sun and skin trauma
b. Topical
i. Emollients
ii. Coal tar – plaque, guttate, scalp, flexures
iii. Keratolytic eg salicylic acid – reduce scalings
iv. Steroids – only for scalp & flexures
v. Vitamin D analogue e.g. calcipotriol –
suppress plagues, also useful in flexures
c. Phototherapy
i. Goekermann regime:
1. UVB + tar
ii. UVB – 2-3x weekly
iii. PUVA (psoralen + UVA)
iv. REPUVA (retinoids + psoralen + UVA) –
retinoids useful for abnormal keratinization
d. Systemic
i. 5-30 mg po methotrexate once/weekly –
generalized pustular psoriasis, erythroderma,
psoriatic arthropathy). SE: hepatic fibrosis
ii. Azathioprine - steroid sparing therapy
iii. Biological agents (infliximab/etanercept)
iv. Systemic steroid - but don’t stop abruptly
otherwise will cause flare up
1. Describe the lesion?
a. Single well-demarcated salmon-pink plaque with
silver scaling over the extensor surface of the elbow
2. Diagnosis?
a. Plaque psoriasis (psoriasis vulgaris)
3. Possible causes?
a. Genetic HLA-CW6
b. Trigger factors (see notes)
i. Physical trauma
ii. Infection
iii. Stress
iv. Alcohol
4. Sites of predilection: scalp, extensor surface, umbilicus
5. Investigation
a. Skin scrape - TRO fungal infection
6. Treatment
a. Refer above

1. Diagnosis
a. Flexural psoriasis (inverse psoriasis)
2. Description
a. Well demarcated pinkish glazed lesions, non-scaly
3. Affected region: axillae, groin, perianal creases, submammary
folds

1. Diagnosis
a. Guttate/Raindrop-like psoriasis
2. Describe
a. Drop-like lesions, salmon-pink papules
with fine scales
b. Explosive eruptions of small oval plaques
3. Affected area: trunk & limbs
4. Often appear 2 weeks after strep sore throat and resolves
within 4/12
1. Diagnosis
a. Pustular psoriasis
2. Affected area: palms, soles
3. Describe:
a. Well demarcated scaling + erythema
b. Yellow/green pustules

1. Diagnosis
a. Erythrodermic (confluent/brittle) psoriasis
2. Medical EMERGENCY - serious, life threatening
3. Describe
a. Plaques merge over widespread areas
4. Causes
a. Inappropriate use of Dithranol (psoriasis medication)
b. Sudden withdrawal of potent steroids
5. DDx
a. TEN, exfoliative erythroderma,
6. Complications
a. Loss of heat, water, electrolytes, iron, protein
b. Heart failure, secondary infection

ACNE
1. Acne vulgaris
2. Rosacea

1. Type of lesions found in acne vulgaris

a.
b. Comedones - open or closed
c. Papules
d. Pustules
e. Nodules
f. Cysts
g. Scars - atrophic or hypertrophic or keloid
 1. Describe the lesion?
a. Multiple polymorphic erythematous papules and
pustules on the left cheek with greasy/oily skin
2. Diagnosis?
a. Acne vulgaris (don’t confuse with “verruca vulgaris”, which
are common warts - viral HPV)
3. Causes:
a. FHx, hormonal, OCP, cosmetics, contact with oil,
weather and stress
4. Pathogenesis?
a. Hypertrophic sebaceous gland
b. Comedogenesis
c. Proliferation of propionibacterium acnes
d. Inflammation (breakdown of sebum by bacteria)
5. Affected sites:
a. face, chest, back and shoulder + upper arms

Type of acnes
1. Infantile acne: > males, clears spontaneously, but may last for some
years, in response to maternal hormone
2. Acne excoriee: young women, related to squeezing and picking
3. Acne conglobata (nodulocystic): severe form of acne characterised
by burrowing abscesses, sinuses and scarring
4. Chloracne: may be an occupational acne
5. Drug induced acne/ acne medicamentosa: steroids
(topical/systemic), lithium, androgens, and certain types of COCP
6. Acne mechanica: a “physical” type of acne eg due to occlusion at the
back of a wheelchair user or on a violinists chin
Treatment based on severity

Available drugs:

- Topical retinoids
- Topical benzoyl peroxide
- + oral AB (doxycycline) for 3-6 months
- Not suitable for pregnant women
- ++ oral isotretinoin (reduce sebum, inhibit hyperkeratosis,
anti-inflammation) for 4/12
- Not suitable for pregnant women
 - Can only be prescribed by dermatologists

1. Describe the lesion?

a. Erythematous lesion over the nose and extending
onto the cheeks, sparing the periorbital and perioral
b. **Acneiform papules**
2. Diagnosis?
a. Rosacea
3. Presentation often as atypical acne with middle age
presentation + flushing
4. DDx
a. Acne vulgaris - comedones.
b. Erysipelas - well demarcated.
c. SLE - with other systemic features.
5. Complications:
a. If affects eyes, nose (rhinophyma - red large bulbous
nose)

b.
c. Telangiectasia of the face
6. Causes
a. Rule out medications, occupational exposure
b. Worsen by spicy food and alcohol
7. Treatment
a. Topical / oral antibiotics eg metronidazole (Metrogel)
or doxycycline
b. Anti-inflammatory gel eg azelaic acid

BACTERIAL INFECTION
1. Folliculitis, Furuncle, Carbuncle
2. SSSS
3. Impetigo
4. Ecthyma
5. Erysipelas
6. Cellulitis
7. Lyme disease
1. Describe the lesion?
a. Multiple pustules with erythematous surrounding
skin in an area of rich hair distribution e.g. legs
2. Diagnosis?
a. Folliculitis
3. Causative organism → SA
4. Common sites: buttocks & thigh
5. Treatment (self limiting)
a. Topical antibiotics (fusidic acid, mupirocin)
b. **Oral flucloxacillin for SA
c. Antiseptic washes (povidone iodine, chlorhexidine)

1. Describe the lesion?

a. Single pustule with erythematous surrounding skin
2. Diagnosis?
a. Furuncle/boil (deeper folliculitis)
3. Causative organism? → SA
4. Treatment?
a. Oral antibiotics (flucoxacillin)
b. Local antiseptics
c. Large boils may need lancing (I&D)

1. Describe the lesion?

a. Single erythematous nodule with overlying
excoriation and crust over the right side of the chin
2. Diagnosis?
a. Carbuncle (deeper & more extensive follicle
involvement)
3. Causative organism? → SA
4. Risk factors: elderly, immunocompromised, diabetes,
systemic steroids
5. Treatment?
a. Systemic antibiotics (po flucloxacillin)
b. Search for underlying cause- - risk factor
modification (control DM)
c. I&D
d. Local antiseptic
1. Describe the lesion?
a. Multiple erythematous patches with desquamation
and scalded appearance
2. Diagnosis?
a. Staphylococcal scalded skin syndrome (SSSS)
3. Causative organism → SA
a. More common in infants
4. Pathogenesis?
a. Toxins produced by bacteria causes epidermis to cleave through
granular cell layer causing sheets of skin to peel away
(Nikolsky sign)
5. Treatment?
a. Parenteral antibiotics - IV flucloxacillin
b. Metabolic support - fluid resuscitation, correct
electrolyte imbalance

1. Describe the lesions?

a. (Upper) Multiple groups of (ruptured) vesicles with
underlying pink patches above and below the mouth
with skin excoriation
b. (Lower) Multiple confluent of golden honey yellow
crusted lesions with multiple excoriation and
dried bleed over the cheek extended till the auricle
and down to chin
2. Diagnosis?
a. Impetigo
3. Causative organism?
a. Staphylococcal aureus
b. Streptococcus pyogenes
4. Treatment?
a. Cleanse the skin and remove the crust using moist
soaks (saline dressing)
b. Topical antiseptic – povidone iodine, chlorhexidine
c. Topical antibiotics – fusidic acid, mupirocin
d. Systemic antibiotics (flucloxacillin) if extensive
e. Hygiene: avoid close contact with others, avoid
sharing towels, change clothes and linen daily
1. Describe the lesion?
a. Single oval shaped dirty yellowish-gray crust ulcer
with a raised border and violaceous margin and
necrotic base
b. Multiple pustules with surrounding erythema
2. Diagnosis?
a. Ecthyma ( ulcerative pyoderma of the skin, deeper
form of impetigo - dermis)
3. Causative organism?
a. Streptococcal pyogenes
b. Staphylococcus aureus
4. Common sites → Ankles, dorsa of feet, legs, thighs, buttocks
5. Treatment?
a. Hygiene measures - bactericidal soap and frequently
changing bed linens, towels, and clothing
b. Remove ecthyma crusts by soaking or using wet
compresses
c. Topical antibiotic – fusidic acid, mupirocin
d. Oral antibiotic – flucloxacillin (methicillin sensitive
penicillin)
e. Need TRO other causes of ulcer, may need skin biopsy

1. Describe the lesion?

a. Single well-demarcated, fiery red shiny
oedematous patch (or sometimes vesicles & bullae)
over the right cheek
2. Diagnosis?
a. Erysipelas
3. Layer of skin affected: dermis
4. Causative organism?
a. Streptococcus pyogenes (not SA!!)
b. GABHS
5. Common sites: face, legs
6. Clinical features?
a. Malaise, fever
b. Pruritus, burning, tenderness, swelling
c. Myalgia, arthralgia, nausea, headache
7. Treatment? → Sx tx
a. PCM for pain & fever
b. Hydration, cold compress
c. Saline wet dressing
d. Elevate & rest affected limb
e. Oral/IM penicillin, erythromycin if allergic to
penicillin
1. Describe the lesion?
a. Circumferential ill-demarcated erythematous
shiny patch with swelling over the right leg
b. May form vesicles, bullae, erosions, haemorrhage
2. Diagnosis?
a. Cellulitis
3. Layer of skin affected: dermis & subcutaneous fat
4. Causative organism?
a. Streptococcal pyogenes
b. Staphylococcus aureus
5. Symptoms → fever, chills, anorexia, malaise, pain
6. Other signs?
a. Regional lymphadenopathy
b. Signs of septicaemia
7. Treatment? → Sx tx
a. PCM for pain & fever
b. Hydration
c. Oral antibiotic (penicillin/flucoxacillin, erythromycin
if allergic) as outpatient (IV if more severe)

1. Describe the lesion?

a. Circular erythematous rash with central clearing that
slowly expands (HOW DO YOU KNOW IT
EXPANDING - it’s a static image)
b. Erythema migrans - hallmark sign
c. The rash may appear within 3-30 days, typically before
the onset of fever.
2. Diagnosis?
a. Lyme disease
3. Causative organism?
a. Borrelia burgdorferi - transmitted to humans via a
tick’s bite.
4. Clinical symptoms:

a.
5. Treatment?
a. Early treatment is a 14 to 21 day course of oral
antibiotics :
 i. Doxycycline (tetracycline) for adults
ii. Cefuroxime and amoxicillin younger
children, and women who are nursing or
breastfeeding.

VIRAL INFECTION
1. Common warts (verruca vulgaris)
2. Flat warts (verruca planae)
3. Plantar warts (verruca palmoplantar)
4. Filiform warts
5. Condyloma acuminata - HPV
6. Molluscum contagiosum - pox virus
7. Chicken pox - VZV
8. Shingles - VZV
9. Herpes zoster ophthalmicus - VZV
10. Herpes simplex labialis - HSV1/2
11. HFM disease - coxsackie virus

1. Describe the lesion?

a. Multiple hyperkeratotic, exophytic (growing outward)
dome-shaped papules over the palmar surface of the
fingers with punctate black dots representing
thrombosed capillaries
i. Differentiate from callus (not present)
2. Diagnosis?
a. Verruca vulgaris (common wart)
3. Cause?
a. HPV - 6 and 11
4. Mode of transmission?
a. Direct inoculation – skin to skin contact
b. Indirect inoculation – swimming pools, bathrooms
c. Trauma (Koebner’s phenomenon)
5. Treatment (self limiting)
a. Keratolytics – salicylic acid (biofilm)
b. Cryotherapy, electrocautery, laser ablation
1. Verruca Planae (Flat wart)
a. Skin-coloured/pink
b. Smooth surface, slightly elevated, flat topped papules
c. Dorsal hand, face, arms (exposed surfaces)

1. Verruca palmoplantar (Plantar wart)

a. Thick endophytic (depressed into skin) papules
b. Sole of feet
c. May accumulate a thick callus
d. May be painful on walking
e. Mosaic warts: plantar warts coalesce into large
plaques

1. Diagnosis
a. Filiform (threadlike) wart

1. Describe the lesion?

a. Multiple cauliflower-like warty masses in the perianal
region (not sure if this description is correct)
2. Diagnosis?
a. Condyloma acuminate (genital warts)
3. Cause: HPV 6, 11
4. Mode of transmission: sexual contact
5. Investigation?
a. VDRL/TPHA - TRO syphilis.
b. HIV antibody
c. Pap smear (females)
6. Treatment?
a. Cryotherapy, electrocautery, laser
b. Keratolytic ie salicylic acid (duofilm)
c. Topical imiquimod (interferon inducer)
 d. Topical podophyllin (anti-mitotic)
7. Prevention → HPV vaccine Gardasil (6, 11, 16, 18)

1. Describe the lesion?

a. Multiple pearly, dome-shaped, semi-translucent
papules with central umbilication
2. Diagnosis?
a. Molluscum contagiosum
3. Cause → Pox virus
4. Risk groups?
a. Young children with atopy
b. Sexually active
c. Immunocompromised
5. Mode of transmission?
a. Skin-to-skin
b. Fomite
c. Autoinoculation
d. Exposure to public swimming pool, baths
6. Clinical features?
a. Usually asymptomatic
b. Occur on trunk, face & pubic area
7. Treatment? (self limiting)
a. Topical keratolytic – cantharidin
b. Cryotherapy – can cause blistering, scarring, colour
change, pain
c. Curettage
1. Describe the lesion?
a. Multiple pink papules and vesicles over the face, trunk
and upper limbs
2. Diagnosis?
a. Chickenpox
3. Cause → Varicella zoster virus
4. Clinical features?
a. Incubation 14 days
b. Prodrome: fever, malaise, headache
c. Eruptions: pink papules → vesicular → pustular → crust
formation (PVPC)
d. Healing occurs within 3-4 days leaving pink macules
or depression
e. Further crops of new lesions continue to appear for
several days
f. Secondary infection results in permanent
‘pock-marks’
5. Treatment? → symptomatic treatment
a. Paracetamol for fever
b. Hydration
c. For well people → calamine lotion to relieve itch
d. Prevent scratching – keep nails short & put on socks
on hands at night. Can spread
e. Antiviral (acyclovir: T. acyclovir 800mg 5x/day x 1/52
and immunoglobulin (VZIg) for pregnant women,
newborn & immunocompromised
f. Isolation
g. Hygiene

1. Describe the lesion?

a. Multiple groups of vesicles on an erythematous base
over the T2 dermatome (dermatomal distribution)
2. Diagnosis?
a. Herpes zoster (shingles)
3. Cause → reactivation of VZV present in the dorsal nerve
ganglion
4. Clinical features?
a. Pain (may occur before eruption)
b. Eruption of papules → vesiculopustular → crusted
c. Crops of lesions continue to erupt for a few days
following the dermatome
5. Complications?
a. Ocular damage (ophthalmic division)
b. Temporary VII nerve palsy (Ramsay Hunt syndrome)
i. Vesicles on the hard palate, anterior ⅔ of tongue and ear.
c. Post-herpetic neuralgia
6. Treatment?
 a. Oral acyclovir: T. acyclovir 800mg 5x/day x 1/52
b. Analgesics – PCM or ibuprofen
c. For post herpetic neuralgia - give po gabapentin
d. Topical antibiotics if secondary infection

1. Describe the lesion?

a. Multiple vesicular lesion around the V1 of trigeminal
nerve
b. Hutchinson sign - vesicle at the tip of nose - classical
sign of HZ ophthalmicus (precede)
2. Diagnosis?
a. Herpes zoster ophthalmicus
3. Treatment?
a. Acyclovir PO
b. Refer ophthalmologist
4. Complications:
a. Uveitis
b. Conjunctivitis
c. Keratitis

1. Describe the lesion?

a. Multiple groups of vesicles over an erythematous base
around the perioral region with crust formation
below the lip
2. Diagnosis?
a. Herpes simplex labialis
3. Cause → HSV1 or HSV2
4. Other sites?
a. Genital area (HSV2)
b. Fingers (herpetic whitlow)
c. Eye
5. How do children present?
a. Gingivostomatitis → Inflammation of gum and oral
mucosa
b. High fever, anorexia, listlessness (tak bermaya),
 gingivitis, vesicles on oral mucosa, tongue, lips;
tender regional lymphadenopathy
6. Investigation?
a. Vesicular fluid for Giemsa stain
b. HSV IgG antibody ← serology
c. Direct fluorescent antibody to differentiate HSV1 &
HSV2
7. Treatment?
HS labialis
a. Oral acyclovir 200 mg 5x/day x 5/7
b. Cold compress
c. Lubricants
d. Analgesics

Herpetic whitlow

1. Describe the lesion?

a. Multiple vesicles with erythematous base over the
mouth, oral mucosa, palm and sole
2. Diagnosis?
a. Hand-foot-mouth disease
3. Cause?
a. Coxsackievirus
4. Clinical features:
a. Fever
b. LOA
c. Cough
d. Sore throat
e. Abdominal pain
5. Treatment? → Sx tx
a. Paracetamol or ibuprofen – fever & pain
b. Hydration
c. Soft food, avoid hot, spicy, acidic food & drinks
d. Isolation: from nursery/ school
e. Notification to DHO
6. Prevention?
a. Hand hygiene
b. Disinfect dirty surfaces and soiled items
c. Avoid close contact such as kissing, hugging, or
sharing eating utensils or cups with infected people
 FUNGAL INFECTIONS (DERMATOPHYTES)
1. Tinea pedis - TRICHOPHYTON RUBRUM
2. Tinea corporis
3. Tinea capitis
4. Tinea unguium (onychomycosis)
5. Tinea incognito
6. Kerion

Types

1. Describe the lesion?

a. Erythematous, scaling plaques on the plantar surface
of the foot and between the toes with maceration
2. Diagnosis?
a. Tinea pedis
3. Cause?
a. Trichophyton rubrum commonest cause
4. Mode of spread?
a. Public shower, gym
5. Subtypes?
a. Interdigital – scaling & redness between the toes with maceration
b. Moccasin – chronic hyperkeratotic type, sharply marginated scales
distributed along the lateral border of feet, heel and soles; “one hand two
feet” syndrome; onychomycosis
c. Vesiculobullous – grouped, 2-3 mm vesicles on the arch or instep; may be
itchy or painful
6. Investigation?
a. KOH (potassium hydroxide) microscopy to visualize
hyphae
b. Skin scraping to confirm dermatophytes and candida
albicans
7. Treatment?
a. Hygiene - Dry the area after bathing, change socks
daily, wear open shoes, use antifungal foot powder
b. Talcum powder - JBJ (keep area dry)
 c. Antifungal
i. 1st line is fungistatic: clotrimazole/miconazole
cream bd x 4-6/52;
ii. 2nd line fungicidal: terbinafine gel/cream bd
4-6/52

1. Describe the lesion?

a. Erythematous annular plaque with well-defined
margin, scaling at the edges and central clearing over
the trunk/limb
2. Diagnosis?
a. Tinea corporis
b. DDx: Erythema migrans (lice)
3. Clinical features
a. Itch and tinea elsewhere eg groin and feet
4. Investigation?
a. KOH microscopy (from the margin – the active area)
to visualize hyphae in skin scraping
b. Fungal culture
5. Treatment?
a. Hygiene
b. Talcum powder
c. Boil all the T-shirt and fomites (put in a bag and keep
it for 3 days)
d. Avoid sharing
e. Antifungal
i. 1st line is fungistatic: Clotrimazole/miconazole
cream bd x 4-6/52;
ii. 2nd line fungicidal: terbinafine gel/cream bd
4-6/52
f. Oral antifungal if poor response to topical. Oral
terbinafine 10-14 days, check LFT if >7 days
1. Diagnosis
a. Tinea capitis
2. Clinical features + alopecia
a. Begins as a small erythematous papule around a hair shaft on the scalp,
eyebrows, or eyelashes.
b. Red papule becomes paler and scaly, and the hairs appear discolored,
lusterless, and brittle → scaly alopecia ← unlike alopecia
areata
c. Lesion spreads, forming numerous papules in a typical ring form
d. Pruritus
e. Deep boggy red areas characterized by a severe acute inflammatory
infiltrate with pustule formation are termed kerions
3. Investigation
a. Wood’s Lamp Examination → Fungus will glow

b.
4. Treatment
a. PO griseofulvin 20-25 mg/kg/day x4-6 week
Alternative: oral itraconazole/terbinafine
b. Selenium sulfide shampoo to reduce spread of spores
1. Describe
a. Opaque, thickened, brittle nails
2. Diagnosis
a. Tinea unguium (onychomycosis)
3. Treatment
a. Topical clotrimazole or terbinafine
b. PO antifungal eg itraconazole/terbinafine

1. Describe
2. Diagnosis
a. Tinea incognito (unrecognised tinea infection due to
modification with corticosteroid treatment)
3. Clinical features
a. Which leads to skin atrophy, purpura and telangiectasia
b. Lesions are enlarging and persistent
c. Common sites: Groins, hands, face
d. Compared to tinea corporis:
○ Less raised margin, less scaly
○ More pustular, extensive and irritable
4. Investigations
a. Skin scrapings for microscopy and culture (few days
after stopping all creams)
b. Skin biopsy (to find out causative organism)
5. Treatment
a. Symptomatic relief of itching (mild calamine lotion)
b. Stop topical steroid or calcineurin inhibitor
c. Topical ketoconazole

1. Describe
a. Multiple boggy-looking pustules encircled by
erythematous well-circumscribed patches on the scalp
2. Diagnosis
a. Kerion
3. Clinical Features
a. Presents as an abscess, tender and fluctuant with marked
inflammation
b. Common sites: Scalp, face (beard area), limbs
c. If fungal cause: Hairs plucked out easily and no pain
d. If bacterial cause: Hair is stuck and painful to pluck
e. Regional lymphadenopathy
f. Can get unwell
g. May be followed by widespread itchy eczema-like rash
(dermatophytid)
 h. Contagious!
4. Investigations
a. Scalp scrapings and hair sample for microscopy and
fungal culture
b. Bacterial swab (Secondary bacterial infection common
5. Treatment
a. Oral ketoconazole 6-8/52
b. Ketoconazole shampoo to reduce risk of spread to
others
c. Abx if bacterial infection

FUNGAL INFECTION (YEAST)

1. Tinea versicolor - MEATBALL & SPAGHETTI APPEARANCE
2. Candida intertrigo

1. Describe the lesion?

a. Multiple well-demarcated hypopigmented (can be
hyperpigmented) macules & patches across the back
2. Diagnosis?
a. Tinea versicolor/pityriasis versicolor
3. Cause?
a. Malassezia furfur (lipophilic yeast)
4. Risk factors?
a. High humidity, DM, Cushing’s prolonged steroid
5. Clinical features?
a. Well-demarcated tan, salmon, hyper/hypopigmented patches
most commonly on the trunk & arms
b. Macules will grow and coalesce
c. Scales seen when rubbed with finger/scalpel blade
6. Investigation?
a. Skin scraping
b. KOH microscopy – meatball & spaghetti appearance
(short hyphae & small round spores)

c.
d. Fungal culture
7. Treatment?
a. Topical is 1st line -clotrimazole/ketoconazole cream
daily for 1-4 weeks
b. Selenium sulphide 2% shampoo (or ketoconazole or
zinc pyrithione) – apply daily, wait 10 mins and rinse,
1-4 weeks
c. Oral medications – fluconazole, itraconazole – causes
 hepatotoxicity, drug interactions, GI side effects, CCF
d. If relapse, maintenance by using shampoo 1-2x per
week

1. Describe the lesion?

a. Well-defined erythematous plaques involving skin
folds with satellite lesions
2. Diagnosis?
a. Candida intertrigo
b. Intertrigo = inflammation of large skin folds –
inframammary, gluteal cleft, inguinal creases, folds
under pannus (abdomen)
3. Clinical features?
a. Burn > itch
b. Satellite macules/papules/pustules
4. Investigation?
a. Fungal culture more specific
b. Skin scrape - KOH microscopy - hyphae with buds of
yeast cells.
5. Treatment?
a. Keep intertriginous areas clean, dry, cool
b. Wear loose clothing made of cotton (prevent/absorb
sweating)
c. Topical antifungal – clotrimazole/miconazole cream,
nystatin cream (only works for candida). Note
terbinafine/naftifene not effective for candida
d. Topical anti-inflammatory to reduce burn/itch –
desonide ointment or 1% hydrocortisone bd x1-2/52
 INFESTATIONS
1. Cutaneous larvae migrans
2. Pediculosis capitis - pediculus humanus
3. Pediculosis corporis
4. Pediculosis pubis
5. Scabies - sarcoptes scabiei

1. Describe?
a. There is a cutaneous serpiginous erythematous lesion
seen over the sole
2. Diagnosis?
a. Cutaneous larvae migrans
3. Investigation
a. Clinical diagnosis
4. Treatment
a. po albendazole 400 mg BD for 3 days

Parasite of hookworm family

(nematodes)
1. Describe the lesion?
a. Multiple nits (egg of lice) present on the hair shafts
2. Diagnosis?
a. Pediculosis capitis (lice)
3. Cause → Pediculus humanus (var capitis)
4. Other areas affected by the species?
a. Body (pediculus humanus var corporis)
b. Pubic area (Phthirus pubis)
5. Mode of transmission?
a. Close physical contact with infestated individual
b. Fomites (combs, helmets, hats, bedding)
6. Clinical features?
a. Nits cemented to the hair shaft (hair cast moves freely) mostly on the
occipital and post-auricular region
b. Adult louse moves away from light source
c. Scalp pruritus
d. Cervical lymphadenopathy
e. Dermatitis on the posterior neck
f. Secondary staphylococcal infection
7. Treatment?
a. Permethrin 1% lotion or OTC pyrethrins – apply to
clean dry hair for 10 mins. Re-treat on day 9 to kill
newly hatched lice
b. Malathion 0.5% lotion – apply to dry clean hair for
8-12H, repeat after 7 days
c. Nit combing
d. Treat household members
e. Wash beddings and clothings and dry in hot dryer/sun
f. Brushes, combs and hair care items placed in hot
water >60°C for 10 mins
g. Non-washable items placed in sealed plastic bag for
3/7
h. Children stay away from school (isolation)

1. Pediculosis corporis (Body-louse)

a. Overcrowded conditions
b. Lives in seams of clothing
c. Feeds on blood of the wearer
d. Itching, scratch marks
e. Secondary bacterial infections common
1. Pediculosis pubis (Pubic-louse)
a. Sexually active young adults
b. Lice in the pubic hair, lower abdomen or inner thighs
c. Itching/blood spots on underwear & clothing

1. Describe the lesion?

a. Multiple erythematous polymorphous papules with
linear marking (burrow) over the wrist
b. (2nd picture) erythematous papules and exudative
lesions in the scalp, face, groins and axillae for one
month with vesicular lesions on the palms
2. Diagnosis?
a. Scabies
3. Cause → sarcoptes scabiei
4. Risk groups?
a. All ages & socio-economic class
b. Women & children
c. Immunocompromised
d. Crowded living area
5. Clinical features?
a. Symptoms start 3-4 weeks from infestation. Once sensitised, symptoms
1-2 days after infestation
b. Papules involving axilla, breast, umbilicus, penis,
scrotum, wrist, finger webs (circle of Hebra)
c. Scalp & head more frequently involved in infants, elderly &
Immunocompromised
d. Itching at night – hallmark
6. Burrows (linear markings in the skin) – pathognomonic
7. Immunosuppressed individuals develop crusted scabies
(hyperkeratotic/Norwegian scabies)
8. Investigation?
a. Skin scraping (mineral oil preparation) to visualize
scabies mites, eggs or faeces (scybala)
9. Treatment?
a. Conservative
b. Wash cloth and linens with hot water and non
washable item sealed in plastic bag for 3 days
c. Avoid close contact
d. Maintain good hygiene
e. Topical
f. Emulsion benzoyl benzoate 12.5% from neck
downwards for 3/7. Treat all family
 g. 1% lindane
h. 6% sulphur in calamine lotion BD for 1 week in <2 yo →
stains clothing, greasy, strong odour
i. 5% permethrin cream (insecticide to kill the newly
hatched lice) (preferable in children because ???) – for 1
night
j. Other scabicide – 0.5% malathion (insecticide too)
k. Oral ivermectin for immunocompromised/ outbreak
l. Oral antihistamine for pruritus – diphenhydramine
HCl (Benadryl)

DERMATOLOGICAL EMERGENCIES
1. Toxic shock syndrome
2. Angioedema
3. Exfoliative erythroderma
4. Necrotising fasciitis
5. Meningococcemia
6. SJS

1. Describe the lesion?

a. Diffuse erythematous, (non-prutitic), maculopapular
rash with desquamation
2. Diagnosis?
a. Toxic shock syndrome
3. Cause?
a. Endotoxins from Staph aureus /Strep pyogenes
superantigen which induce massive cytokine
secretion by T cells
b. Tampon or foreign stuff left in the vagina
4. Risk factors?
a. Use of tampons, barrier contraceptives, surgical and
postpartum wound infections, burns, cutaneous
lesions, osteomyelitis, and arthritis
5. Clinical features
a. 2-3 days of malaise prodrome
b. Fever, chills, nausea, abdominal pain
c. Followed by rash (as above) initially on the trunk & spreads peripherally to
palms and soles
d. Hypotension
e. Multisystemic – arrhythmias, liver failure, renal
 failure, DIC, ARDS
6. Treatment?
a. Aggressive supportive treatment – fluid replacement,
vasopressor
b. Remove inciting factor eg tampon, condom
c. Empirical antibiotics – IV clindamycin + vancomycin
d. Specific antibiotics after C+S
i. MSSA: IV clindamycin + oxacillin
ii. MRSA: IV clindamycin + vancomycin/linezolid

1. Describe the lesion?

a. Well-circumscribed oedema of the face especially the
mouth
2. Diagnosis?
a. Angioedema
3. Cause?
a. Idiopathic, hereditary
b. Medications – ACEi, penicillin, NSAIDs, radiographic
contrast
c. Food – nuts, shellfish, milk
d. Physical agents – cold, vibration
e. C1 esterase inhibitor deficiency - ACEi avoid
4. Clinical features?
a. Swelling of the face, extremities, genitalia due to
increased vascular permeability
b. Involves skin, GIT, respiratory tracts
c. + urticaria
d. Fatal if upper airway compromised
5. Treatment?
a. Ensure airway patency
b. Cool/moist compress
c. Oral/IV antihistamine – cetirizine, diphenhydramine
d. Oral/IV corticosteroids
e. Subcutaneous adrenaline in severe cases
f. Investigation of the cause by allergy specialist
g. Avoidance of known triggers
h. Avoid ACEi in C1INH deficiency
i. Danazol & stanozolol for prevention of hereditary
angioedema
1. Describe the lesion?
a. Generalized scaly erythematous skin eruption
involving >90% skin surface
2. Diagnosis?
a. Exfoliative erythroderma
i. DDx? erythrodermic psoriasis.
3. Cause?
a. Idiopathic
b. Eczema, psoriasis
c. Drug reaction – allopurinol, CCB, anticonvulsants,
lithium
d. Cutaneous T-cell lymphoma, leukaemia,
paraneoplastic syndrome
4. Clinical features?
a. Pruritus
b. Fever, malaise (excessive vasodilatation)
c. Fluid & protein loss through the skin can be
life-threatening → hypotension, electrolyte
imbalance, CCF, enteropathy
5. Management?
a. Determine the cause, stop causative medication
b. Skin biopsy may be needed
c. Supportive – admit, hydration, nutrition, electrolyte,
cardiac monitoring, temperature support
d. Skin care – emollients, compresses, topical
corticosteroids
e. Antihistamine for pruritus
f. Antibiotics if infection develop

1. Describe the lesion?

a. Diffuse erythematous skin changes over the lower mid
calf with patches of necrotic tissue
b. Multiple gangrenous wet patches with surrounding
mixed erythematous-purplish patches, with
desquamation.
c. Skin breakdown with purple patches and frank
cutaneous gangrene
2. Diagnosis?
a. Necrotising fasciitis/ flesh eating bacteria
3. Cause?
a. Rapidly spreading infection of the deep fascia causing
necrosis of the subcutaneous tissue
b. Type I - Anaerobes, Gram –ve, enterococci
c. Type II - group A strep (MOST COMMON)
4. Risk factors: DM, PVD, immunosuppression
5. Clinical features?
a. Skin trauma/insect bite
b. Intense pain, fever, tachycardia
 c.
Diffuse swelling of affected skin area
d.
Development of bullae, frank cutaneous gangrene
e.
Shock
f.
Signs – indurated oedema, skin hyperesthesia,
crepitation, muscle weakness, foul-smelling exudate
6. Treatment?
a. Aggressive supportive treatment – fluids, nutrition
b. Empirical antibiotic should cover Gram +, gram -,
anaerobes – imipenem + clindamycin + vancomycin
c. Hyperbaric O2
d. Surgical debridement of necrotic tissue, may need
amputation

1. Describe the lesion?

a. Multiple (non-blanching) red/purple/brownish
petechiae (or purpura) over the left leg of a child
2. Diagnosis?
a. Meningococcemia
3. Cause: Neisseria meningitidis
4. Risk factors: young children peak at age of 6-12 months
5. Clinical features?
a. Abrupt onset of maculopapular/petechial rash
b. Fever, chills, malaise, disorientation, headache,
photophobia, neck stiffness, myalgia, vomiting
c. May rapidly progress to purpura, DIVC, shock, death
6. Treatment?
a. Aggressive supportive treatment – fluids, nutrition,
ICU
b. Third-generation cephalosporins such as ceftriaxone
(2 g IV q24h) or cefotaxime (2 g IV q4-6h) are the
preferred antibiotics

1. Describe the lesion?

a. Erythema
b. Epidermal necrosis
c. Desquamation (10% SJS)
2. Diagnosis?
a. Steven-Johnson syndrome (a form of toxic epidermal
necrolysis)
3. Cause?
a. Idiopathic
b. Drug-induced – sulphonamides, anticonvulsants ie
carbamazepine, allopurinol, NSAIDs
4. Risk factors: Genetic susceptibility HLA B1502 - Han Chinese
and Malay
5. Clinical features?
a. Rash develops 1-3 weeks after drug administration
b. Fever, stinging eyes, dysphagia
 c. Development of dusky erythematous macules that progress to
flaccid blisters
d. 2 or more mucous membrane involved – erythema & erosions of
buccal,genital, ocular mucosa
e. Severe ophthalmic involvement → scarring & blindness
f. Epidermal detachment → massive fluid loss, electrolyte imbalance,
high risk of bacterial/fungal infection
6. Treatment?
a. Aggressive supportive treatment – ICU, fluids &
electrolytes, nutrition, temperature
b. Ophthalmic assessment
c. Removal of offending medication
d. Skin care – proper wound dressing, oral hygiene
(chlorhexidine rinses)
e. Pruritus - antihistamine, corticosteroid
f. Antibiotics, antifungal – secondary infections

HYPERPIGMENTATION
1. Melasma

1. Describe
a. Hyperpigmentation over the face sparing the
nasolabial fold
2. Diagnosis?
a. Melasma (overstimulation of melanocytes by female
sex hormone to produce melanin in response to sun
exposure)
b. May be exacerbated by pregnancy
3. Investigation
a. Wood lamp examination - can see excess melanin
4. Treatment
a. Prevent sun exposure: sunblock (reapply 2 hourly and
wide brim hat)
b. Rule out post-inflammatory hyperpigmentation
 MISCELLANEOUS
1. Basal cell carcinoma
2. Lichen planus
3. Alopecia areata
4. Strawberry naevus
5. Erythema Nodosum
6. Pityriasis (alba, rosea, versicolor, capitis)
7. Vitiligo
8. Sunburn
9. Dermatomyositis
10. HSP
11. Oral hairy leukoplakia
12. Porphyria
13. Bullous pemphigoid

1. Description
a. Hyperpigmented rough nodular nodular papule at the
base of the ear with contracted surrounding skin
b. aka “rodent ulcer”
c. Have a roll up/everted edge
d. Telangiectasia, pearly with ulceration
2. Sun exposure
3. Refer to dermatologist

Basal cell carcinoma

1. Describe - 5P
a. Polygonal shape
b. Pruritic - u can’t c this -> but you can see his face ‘the
cannot tahan must scratch NOW’ look.
c. Purple
d. Papule (multiple)
e. Plaques
2. Diagnosis?
a. Lichen planus - thickening prominent skin
3. Seen in the mucosa → Lacey looking white streaks-lichen striae
a. Eg of scenario: 30 year old man presents with itchy
purple papules on his wrists and fingers and in his
mouth with overlying white reticulate appearance.
4. Treatment
a. Potent steroids - methylprednisolone

1. Describe
a. Patchy, normal looking skin non scarring area of hair
loss
2. Diagnosis?
a. Alopecia areata, ddx: SLE
3. Investigate by pulling → some hair at edges come out easily
(exclamation mark broken hair)
4. Can have nail pitting, hypopigmented skin
5. Autoimmune disease
6. May treat with intralesional steroids to suppress the
autoantibodies

1. Describe
2. Diagnosis?
a. Strawberry naevus (benign tumour of blood vessels)
3. Self limiting but gets worse first before it gets better (will be
gone by 8 years old?)
4. If it gets too big, vision can be lost due to amblyopia
1. Describe the lesion?
a. Multiple symmetrical mildly erythematous (painful) ill
demarcated nodules, on the anterior lower limbs.
2. Diagnosis?
a. Erythema nodosum
3. Cause and risk factors?
a. Common: strep pharyngitis, TB and sarcoidosis, IBD,
b. Other possible causes.

c.
4. Pathophysiology
a. Inflammation of subcutaneous fat
5. Clinical features?
a. Tender nodules on bilateral shins
b. More common in women
6. Treatment?
a. Resolves without scarring after 2-8 weeks
b. Self limiting
c. NSAIDs, corticosteroids (2nd line)
7. Characteristics of different types of erythema.
 1. Describe the lesion?
a. Multiple hypopigmented well demarcated
irregularly-shaped patches on the face
2. Diagnosis?
a. Pityriasis alba (dry white patches)
3. Ddx?
a. Vitiligo
b. Tinea versicolor.
4. Cause?
a. Idiopathic
5. Risk factors:
a. Poor hygiene, sun exposure, humidity
b. Atopic dermatitis, dry skin
c. Children
d. May be associated with puberty
6. Clinical features?
a. Non-contagious and benign
b. Occuring on the cheeks
c. Does not fluorescence under Wood’s lamp
d. Not itchy
7. Treatment?
a. Self limiting
b. Moisturising cream
c. Topical steroids (hydrocortisone)
8. Prevention
a. Avoid exposure to sunlight

1. Describe the lesion?

a. Multiple oval and round erythematous well
demarcated scaly papules / plaques on the back
2. Diagnosis?
a. Pityriasis rosea
3. Cause?
a. Idiopathic
b. A viral pathology is probable.
4. Risk factors:
a. Teenage and young adult females.
Snapshot reference: 5. Clinical features?
a. An acute eruption of oval and rounded scaly papules
and plaques that begins in a single herald patch.
b. 1 or 2 weeks later the rash appears on the torso in a
‘christmas tree’ pattern.
c. Resolves spontaneously in 6 weeks.
6. Treatment?
a. Self limiting
b. Sunlight or UVB - help it disappear faster.
 1. Diagnosis?
a. Pityriasis versicolor = tinea versicolor (please refer
above)

1. Diagnosis?
a. Pityriasis capitis = seborrheic dermatitis (please refer
above)
From google:
- Seborrhoeic dermatitis is a form of pityriasis as it relates to the activities of the yeast
Pityrosporum of Malassezia (malassezia furfur, pityrosporum ovale, bottle bacilli).
- Dandruff (Pityriasis simplex capitis) is the mildest form of seborrhoeic dermatitis.

1. Describe the lesion?

a. Generalised hypopigmented, whitish, well
demarcated patches, covering..
2. Diagnosis → vitiligo
3. Ddx?
a. Pityriasis alba
b. Tinea versicolor.
4. Cause: idiopathic - may be autoimmune or viral infection.
5. Risk factors:
a. Family hx
b. Autoimmune disorder - ass with thyroid, pernicious
anemia
6. Clinical features?
a. Not curable lifelong condition and can appear
anywhere on the body
7. Treatment?
a. Takda
b. Can use PUVA or UVB.
1. Describe the lesion?
a. Generalised erythematous patches covering large
areas of the skin demarcated by sun exposed areas and
clothing attire, with multiple bullae and vesicles on
the left shoulder.
2. Diagnosis?
a. First degree sunburn (erythema), 2nd degree sunburn
(bullae)
3. Cause?
a. Sun.
b. Standing too close to barbeque.
4. Risk factors:
a. Light skinned
b. Occupational exposure.
5. Clinical features?
a. Can lead to painful erythema, scalding, bullae
b. Heal by epidermal peeling
6. Prevention?
a. Watch the sun, wear PPE
b. Sunscreen with high SPF (sun protection factor)
7. Treatment?
a. Self limiting: heal by 1 day to 1 week.
b. Aloe vera gel, soak in cold water, cold compressors
c. 1% silver sulfadiazine cream (more severe, normally
only in 2nd or 3rd degree burns, apply once or twice a
day)

1. Describe
a. Heliotrope- coloured erythema (Gottron’s papules over
the knuckles)
2. Diagnosis : dermatomyositis (pathognomonic!)
a. Diffuse, dusky red and purplish rash seen on the
upper eyelids and covering the whole face. May
become scaly and ulcerate

b.
1. Describe
a. Crops of petechiae over both legs
2. Dx
a. HSP
b. Meningococcal
3. Clinical manifestations for HSP
a. Palpable purpura without thrombocytopenia and
coagulopathy
b. Arthritis/arthralgia
c. Abdominal pain
d. Renal disease
4. Ix:
a. Skin biopsy for IgA
b. Normal PT and apTT (to differentiate this from
purpura due to thrombocytopenia or coagulopathy)
c. FBC: normochromic normocytic anaemia
d. High ESR

1. Describe : white plaques undersurface of tongue

2. Dx : oral hairy leukoplakia
3. Associated with : EBV infection , highly specific for HIV
4. Not generally associated with fever

1. Describe
a. Fluid-filled bullae on index finger, deep ulcers and
superficial erosions on the left dorsum of hand
b. Other sites: Sun-exposed areas eg face, dorsum of
feet, forearm and legs
2. Dx:
a. Porphyria cutaneous tarda
b. Porphyria - a group of disorders that result from a buildup of natural
chemicals that produce porphyrin in your body. Porphyrins are essential
for the function of hemoglobin.
3. Natural history
a. Skin fragile → formation of tense vesicles/bullae + erosion of skin
b. Associated with : alcohol abuse, DM, oestrogen, NSAID, hep C, HIV
4. Ix:
a. Urinary tests: ↑ uroporphyrinogen
i. Coral pink fluorescence under Wood’s lamp
 b. Blood tests: ↑ porphyrins, possibly abnormal LFTs
5. Tx
a. Avoid susceptibility factors and excessive sunlight
b. Phlebotomy to reduce iron
c. Hydroxychloroquine or chloroquine → Form water
soluble complexes with porphyrin which can be
excreted via kidneys

1. Describe
a. Localised multiple bullaes with surrounding
ill-defined erythema and several erythematous erosive
macules.
2. Diagnosis
a. Bullous pemphigoid
3. Causes
a. Autoimmunity against epithelial basement membrane
(IgG is produced)
4. Features
a. A prodromal stage with formation of urticarial lesions
may occur weeks to months before onset of blistering.
b. Intensely pruritic lesions, possibly hemorrhagic, heal
without scar formation
c. Distributed on palms, soles, lower legs, groin and
axillae
d. Usually 60-80 years old
e. Heals without scarring
5. Ix
a. Histology and immunochemistry:
i. Subepidermal clefting and blistering
ii. Deposition of linear IgG and C3 along the
dermoepidermal junction
 6. Tx
a. High-dose corticosteroids (prednisolone)

Sexually Transmitted Infections

1. Vaginitis - creamy whitish discharge
2. Trichomoniasis - strawberry cervix
3. Bacterial vaginosis (gardnerella vaginosis) - FISHY white discharge
4. Gonorrhea - purulent penile discharge
5. Chlamydia cervicitis - beefy red columnar epithelium
6. Syphilis (chancre) - painless
7. Chancroid (painful) - haemophilus ducreyi
8. Genital herpes
9. Bartholin’s abscess

1. Describe the lesion?

a. Thick, creamy/curdy white discharge around the
vaginal wall
2. Diagnosis?
a. Vaginitis
3. Cause: Candida albicans
4. Risk factors: Trauma, malnutrition, immunodeficiency (for
opportunistic infections)
5. Clinical features?
a. Vulval itching & soreness
b. Superficial dyspareunia
c. External dysuria
6. Treatment?
a. Clotrimazole vaginal pessary
b. Nystatin pessaries
c. Oral Fluconazole

1. Describe the lesion?

a. Generalised erythematous maculopapular lesions on
the cervix (ie. classical ‘strawberry cervix’) - only in 2%
2. Diagnosis?
a. Trichomoniasis
3. Cause: Trichomonas vaginalis (anaerobes)
4. Clinical features?
a. Asymptomatic in 10-50% esp in males
b. Classical frothy yellow discharge (10-30%)
c. Profuse, malodourous discharge
d. Vulval itching
e. Dysuria and dyspareunia
5. Investigations?
a. Wet mount (Motile parasites) - vaginal smear
b. Antigen detection
 c. Culture
d. Urine PCR (males)
6. Treatment?
a. Oral metronidazole 200 mg TDS 7/7 for PATIENT and
PARTNER
b. NO alcohol while on metronidazole and for 48 hours
after med (prevent disulfiram-like reaction!!!) -
Flushing, fast heartbeats, nausea, thirst, chest pain,
vertigo, and low blood pressure, metallic taste
c. Avoid sex until both partners treated

1. Describe the lesion?

a. Thin, homogenous whitish discharge from the cervix
2. Diagnosis?
a. Bacterial vaginosis (gardnerella vaginosis)
3. Cause: Overgrowth of anaerobic organisms
a. Gardnerella vaginalis
b. Prevotella sp
c. Mobilincus sp
d. Mycoplasma hominis
4. Clinical features?
a. 50% asymptomatic
b. Offensive, FISHY smelling vaginal discharge
5. Investigations?
a. Amsel criteria (At least 3 out of 4)
i. Vaginal pH >4.5
ii. Amine test, fishy odour when discharge mixed
with 10% KOH
iii. Thin, white homogenous discharge
iv. Clue cell on wet slide microscopic
examination
b. Gram stain vaginal smear
6. Treatment?
a. Oral metronidazole 400 mg BD 7/7 (Preferred)
b. Oral clindamycin 300 mg BD 7/7 (Alternative)

1. Describe the lesion

a. Picture 1: profuse and purulent penile discharge
b. Picture 3: purulent penile discharge and ulcer
2. Diagnosis
a. Gonorrhoea
b. Ddx: Chlamydia, Trichomoniasis
3. Aetiology
a. Neisseria gonorrhoeae - g- diplococci
Picture 1 4. Clinical features
a. Primary site of infection : mucous membranes or
urethra, endocervix, rectum, pharynx, conjunctiva
b. Incubation period: 2-5 days
 c. Asymptomatic in 50%
d. Mucopurulent discharge
e. Lower abdominal pain
f. Dysuria
g. Males: urethritis, epididymitis
h. Females: cervicitis, PID
i. General: septicaemia, septic arthritis
5. Investigations
a. Microscopy : gram neg intracellular diplococci
Picture 2: Gonococcal conjunctivitis

b.
c. Culture with selective media
Picture 3 6. Management
a. IM Ceftriaxone 500mg stat + oral azithromycin 1g stat
b. If PID::
IM Ceftriaxone 500mg stat +
Oral doxy 100mg bd +
Oral metronidazole 400mg tds 14 days
c. Contact tracing
d. Avoid sex until both partners complete treatment

1. Describe the lesion

a. Mucopurulent discharge and beefy red columnar
epithelium
2. Diagnosis
a. Chlamydial cervicitis
3. Aetiology
a. Chlamydia trachomatis (obligate intracellular, gram
negative bacterium)
4. Clinical features
a. Asymptomatic
b. Women
i. May present with post-coital bleed,
intermenstrual bleed; Abd pain , pelvic pain ;
Purulent vaginal discharge; Mucopurulent
cervicitis; Dysuria
ii. Types of infection: cervicitis, urethritis, PID,
proctitis
c. Men
 i. Urethritis, epididymitis , prostatitis
ii. proctitis
5. Investigations
a. NAAT gold standard but not readily available
b. Enzyme immunoassay , confirm by direct fluorescent
antibody
c. Endocervical swab
6. Management
a. Oral doxycycline 100mg bd 7 days OR
b. Oral azithromycin 1g stat
c. Screen for other STDs
d. Contact tracing
e. Abstain from sex until completed treatment
7. Complications
a. PID
b. Ectopic pregnancy
c. Chronic pelvic pain (if extend beyond cervix suspect
PID because cervicitis itself not painful)
d. Reactive arthritis

1. Describe the lesion

a. Picture 1: ulcerative penile lesion, well-defined
margin, no discharge, indurated *usually painless
b. Picture 2: generalised/diffuse maculopapular rash
over the entire trunk (secondary syphilis)
2. Diagnosis : Syphilis
3. Aetiology
a. Treponema pallidum (spirochetes)
4. Clinical features
a. Primary syphilis ( 3-4 wk after exposure)
i. Painless chancre (as opposed to chancroid
which is painful) on vulva, vagina, or cervix
painless inguinal lymphadenopathy
b. Nonspecific symptoms
i. Generalized maculopapular rash: palms, soles,
trunk, limbs
ii. Condylomata lata: anogenital, broad-based
Picture 1
fleshy grey lesions
 5. Investigations
Picture 2 a. Dark ground microscopy to look for treponema
pallidum
b. VDRL, PRP titre
6. Management
a. Syphilis
i. IM Penicillin G single dose OR
ii. IM Procaine Penicillin 600, 000 units daily for
10 days
b. Treat partners

Tertiary syphilis - later develop problem with heart, joints etc

Chancroid 1. Describe the lesion (2nd pic)

a. Single vesicular lesion on the glans with well defined
margins and a gray base
2. Diagnosis
a. Chancroid (painful)
3. Organism
a. Haemophilus ducreyi (+/- HIV)
4. Presentation
a. Men: shaft/head of penis/foreskin
b. Women: labia majora/minora
c. Painful ulcer
d. Lymphadenitis
e. Bubo formation
5. Investigation
a. Microscopy: Gram -ve coccobacilli
 b.
c. Culture from ulcer base
6. Treatment
a. Oral azithromycin 1g single dose

Herpes 1. Describe the lesion

a. Multiple vesicular lesions with erythematous bases at
the anogenital region
2. Diagnosis
a. Genital herpes
3. Organism
a. HSV2
4. Presentation
a. Fever
b. Dysuria
c. Vaginal discharge
d. Painful ulceration
e. Lymphadenitis
5. Investigation
a. Swab base for culture and PCR
b. Serology: HSV antibody
6. Treatment
a. Oral acyclovir 200mg 5 times a day
b. Saline bath
c. Analgesia 5% lignocaine

Bartholin’s abscess 1. Describe the lesion

a. Tense, erythematous, cystic swelling on the left labia
minora
2. Diagnosis
a. Bartholin’s abscess
3. Organism (anaerobes)
a. Bacteroides
b. E coli
4. Presentation
a. Bartholin gland blocked→ fluids accumulate (stasis)→
infection
b. Fever
c. Tenderness
5. Investigation
 a. Tense cystic swelling on either side of the vaginal
opening (inspection)
6. Treatment
a. I&D
b. Augmentin 625mg BD
c. Sitz bath
d. NSAIDS