ATLAS OF BASIC DERMATOLOGY DIAGNOSIS AND TREATMENT For healthcare staff at the first stage of medical attention.
Dr. Roberto A. Estrada Castañón Dra. María de Guadalupe Chávez López Dra. Guadalupe E. Estrada Chávez
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Edition: M&N Medical Solutrad S.A. de C.V. Layout: M&N Medical Solutrad S.A. de C.V. Cover design: David A. RamĂrez Printing: PENDING
ATLAS OF BASIC DERMATOLOGY, DIAGNOSIS AND TREATMENT For healthcare staff at the first stage of medical attention. This Atlas offers a simplified vision for a prompt detection of the ailments most frequently encountered in dermatology consultation. In this pages readers will find essential basic knowledge that will help them recognize and handle the main dermatological conditions that any health professional -regardless of their category- must have, because no doubt they will encounter them at least once during consultation. This guide includes color photographies which clearly illustrate dermatological illnesses. This greatly aids clinicians, particularly those who give valuable service in remote and isolated areas. Putting this Atlas together has been possible thanks to the support of the Secretary of Health, the Integral Family Development, DIF Estatal (Desarrollo Integral de la Familia) and the Faculty of Medicine at the Universidad Autonoma de Guerrero (UAGro), as well as the interest and constant aid from international organisms such as the International League of Dermatological Societies, the American Academy of Dermatology, the Skin Pact Award-Galderma and in Mexico, the Fundacion Mexicana para la Dermatologia (Mexican Foundation for Dermatology).
Copyright (C. P. Art. 270) It is a crime to reproduce, plagiarize, distribute or communicate publicly, partially or entirely, for profit and to the detriment of third parties, a literary, artistic or scientific work, in any type of analogue or digital support, without the authorization of the autors of the corresponding copyright Intellectual or its assignees. All rights reserved. Copyright Š 2019 Author Registration Number: 03-2019-050713035200-01
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P R E F A CE
Close to half of the population of numerous countries has some type of skin lesion. Thus, skin diseases are the first or second reason for medical consultation in many communities. This creates a heavy workload that puts the personnel´s capacities and resources to test and has a significant and negative impact on individuals, families and the overall quality of life in their communities. In a lot of cases the treatments are based on incorrect diagnosis, recommending expensive meds that sometimes are hard to get. As a result there´s an unacceptable amount of cases of failure in handling skin lesions. From a dermatological perspective, an inefficient treatment leads to the worsening of many of these conditions, rendering them harder to treat and compromising a huge amount of communities’ financial resources that should go towards food, education and other basic needs. To solve this situation, there needs to be a development of resources for handling and diagnosing skin problems through the proper training of health care personnel, the supervision of their diagnosis and the search for therapeutic options even at the most remote locations. There´s a need for specialized staff that can accurately detect from the simplest of conditions, to the early detection of more serious illnesses with a high morbidity or even fatal or incurable ones. One of the first initiatives to implement effective teaching and training in handling skin diseases, was developed by the Community Dermatology program in the state of Guerrero, Mexico. This program was initially focused on customized tuition in remote communities, based on knowledge of the most prevalent dermatoses at a regional level and then expanding to a large-scale training of health care staff in detection and handling of skin problems on a daily basis. In addition, the program focuses on detecting and treating serious conditions such as leprosy, cancer and mycosis with a deep impact on the cutaneous organ. Detecting these diseases promptly improves health and saves lives, while encouraging others to implement similar initiatives. This program has progressively developed a strategy to make sure appropriate training resources are available. The present Atlas constitutes a determining and critical resource when training health care staff in the most remote and poor communities.
Prof. Roderick J. Hay
International Foundation for Dermatology (IFD)
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INTRODUCTION This manual has been edited with resources and support from the International League of Dermatological Societies (ILDS), the International Foundation for Dermatology, the American Dermatology Academy, the “Skin Pact Award” (SPA and the Mexican Foundation for Dermatology.
• The objective of the present work is to help identify the most frequent skin conditions in a prompt manner, and to teach clearly and concisely how to diagnose and treat them. • We expect the educational material to be useful in remote communities, to detect and remedy the dermatological issues at the first level of attention. • For more serious clinical cases, it is recommended to carry out a consultation with a specialist through TELEDERMATOLOGY on the web sites provided at the end of this atlas. • We recommend to read the instructive on how to make a TELECONSULTATION.
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PYODERMA Skin infections mainly caused by staphylococcus aureus and hemolytic streptococcus. Most frequent clinical forms: • mpeti o • Folliculitis and furuncles • rysipelas • cthyma Triggering factors: • ad hy iene • alnutrition • espiratory tract infections • cratchin or previous injuries • ontact with dirty water, dust or soil
Fig. 1 Common impetigo
Common Impetigo Fre uent in children, mostly on the face, around the nose and mouth areas. (fig.1) It spreads quickly to areas with erythema, pustules or blisters which form burn like yellow scabs when they burst (fig.2) they can present themselves as conse uences of other dermatosis that cause itchin secondary impetigo).
Fig. 2 Impetigo blisters
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PYODERMA Folliculitis
Pustules on the hair follicles, with reddening at the base (fig.3), they can be painful, depending on the severity of the lesions. It is associated with shaving with contaminated razors. Fig. 3 Folliculitis injuries
Furunculosis
Deep lesions known as boils, which are painful, with erythema and voluminous (fig.4); sometimes accompanied with fever and physical discomfort. In obese or diabetic people, lesions can appear in the skin´s creases, caused by excessive perspiration, humidity or bad hygiene. Fig. 4 Furunculosis
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PYODERMA
Fig. 5 Erysipelas injuries
Fig. 6 Ecthyma injuries
Erysipelas
Ecthyma
Caused by streptococcus. It’s characterized by intense reddening and inflammation (fig.5). It appears most frequently on the legs and is preceded by fever and muscular pain, followed by superficial blisters or purpuric injuries.
Also caused by streptococcus; it begins as impetigo, with thick, yellowish scabs that form ulcers varying in size. It is associated with malnutrition and deficient hygiene, appears predominantly on the legs. Symptoms: General discomfort, fever, muscle pain. Development: Subacute or chronic.
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TREATMENT Impetigo and folliculitis Topical: • Wash and scrape with soap and rinse abundantly. • isinfect with compresses of libour water after washin . • pply lio uinol hydrocortisone cream or mupirocin ointment on lesions. Oral: • ntibiotics icloxacillin or cephalexin. • hildren under years old m four times a day. • hildren over years old m four times a day. • dults m four times a day.
Erysipelas or ecthyma
• rocaine enicillin, day days • fter en athine enicillin, , one dose per week for three months to eradicate the streptococcus. • nti in ammatories s every hours in case of pain, fever or eneral discomfort.
For those allergic to penicillin and derivatives: • rythromycin cipro oxacin
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m or m .
Recommendations: • estin • alanced iet • Thorou h y iene • esearch on similar illnesses such as pediculosis, malnutrition and anemia.
VIRAL INFECTIONS
Viral Warts
Fig. 7 Viral warts
Fig. 8 Peringual warts
Fig. 9 Flat warts
Viral Warts
Periungual Warts
Flat Warts
Common Warts: Caused by Human Papillomavirus (HPV), serotypes 2 and 4 and associated with contact with infected objects. Lesions vary in size and appearance (fig.7); they’re more frequent in children, but can appear at any age; they are often related to micro traumatisms or poor hygiene.
Periungual warts grow around nails and toes and can cause partial or total deformity of the nail bed (fig.8); they are recurrent and hard to treat, depending on their degree.
They are skin-colored with small variations in tone, mildly elevated and numerous (fig. 9). They can be mistaken for acne on the face or lichen at the extremities. If they´re touched or hit, the lesions can spread.
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VIRAL INFECTIONS
Fig. 10 Plantart wart
Fig. 11 Acuminated condyloma
Fig. 12 Oral Papilloma
Plantar Wart:
Genital Warts or acuminated condyloma
Oral Warts or oral papilloma (Heck´s disease)
They look like “crests”, and are usually caused by sexual contact. They affect men and women equally and can appear in the anus. They´re skin-colored (fig. 11), humid and can present a bad odor. They generate through specific sub types 16 and 18 of HPV. They can stimulate the appearance of cervical-uterine cancer and squamous cell carcinomas, which is why is so important to carry out a Pap smear to rule it out. Differential diagnosis. Pearly penile papules which don’t require treatment.
Reddish in color, these lesions are associated with deficient oral hygiene (fig.12), plaque or the presence of sharp dental pieces. The treatment isn´t very effective, which is why a specialist must be consulted.
Also known as fisheye, they cause pain when pressed, they usually appear on the palms of the hands and the soles of the feet; they are keratotic, thick and sometimes bleed a little at their center (fig.10).
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TREATMENT Common, flat and plantar warts • lastic collodion with lactic and salicylic acid every day. pply with a toothpick in a small amount, let it dry and cover with paper or fabric tape. • ryotherapy with li uid nitro en. • lectro ful uration. oth have to be done by a specialist.
Acuminated Condyloma odophyllin applied by a physician since there is burning risk. eave it for hours and wash with soap and water. f there s no in ammation, reapply every week on remainin lesions. They will fall by themselves in a few days.
Recommendations When cuminated condyloma is present, is important to carry out a ap smear every six months to rule out in the cervix wall and lower the risk of cervical cancer.
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VIRAL INFECTIONS (Cause by Herpes virus)
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Fig. 13 Common Herpes
Fig. 14 Zorter Herpes
Fig. 15 Genital Herpes
Common Herpes
Zoster Herpes
Genital Herpes
Caused by type 1 herpes virus, also known as “cold sore”. Erythematous vesicles around the mouth are observed (fig.13), frequently after a fever or a drop in the body’s defense mechanism. It is self-limiting, it lasts from 7-12 days and reappears periodically since it doesn’t leave immunity.
Also known as “Shingles”; burning pain followed by erythematous vesicles (fig.14). The rash is unilateral and doesn’t cross the mid-line of the body. The lesions appear as a cluster. It’s generally a unique outbreak which sometimes may lead to post herpetic neuralgia and can last for several months or even years in adults and seniors.
It affects both genders, it’s caused by type 2 herpes virus (fig. 15). It spreads through sexual contact; it’s recurrent which often causes personal and relationship issues. It’s hard to eradicate.
TREATMENT Antivirals • cyclovir m five times a day. Must be combined with analgesics/anti-inflammatories • etorolac, ibuprofen every 12 hours. Topical • cyclovir cream.
Recomendaciones Guardar reposo para evitar el dolor de neuralgia posherpética, que puede durar meses. En herpes del nervio facial o rama oftálmica, solicitar valoración oftalmológica para prevenir la aparición de úlceras corneales y ceguera permanente.
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MOLLUSCUM CONTAGIOSUM Causative agent: Pox virus More frequent in children, it’s associated with sweating or water sports and people with sensitive skin. Transmitted through direct contact or autoinoculation when scratching or existing lesions. It can be transmitted through sexual contact in adults. The lesions are 1-5 mm, smooth, sunk at the middle (fig.16). In HIV positive patients they can be more numerous and bigger (fig. 17).
TREATMENT Podophyllin 25%. Apply a minimum amount every night with a toothpick at the center of every wound, wash every morning, use talc during the day to keep the skin dry. Podophyllin must be applied by a physician due to risk of burning and permanent scars. Cryotherapy (liquid nitrogen) is very effective when handled by a specialist.
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Fig. 16 Molluscum Contagiosum
Fig. 17 Molluscum Contagiosum in a HIV patient
Recommendations •
o not scratch or pinch the lesions, the virus is easily spread. • void usin spon es when showering. • eep the skin clean and dry durin the day. • Wear cotton clothin .
DERMATOPHYTOSIS These infections are caused by fungus that affect the skin, hair and nails. They’re spread from person to person or through contact with domestic animals or contaminated objects, such as shoes, socks or clothing. They thrive in warm, humid environments, in clothing or shoes made of plastic or synthetic materials. The lesions may vary depending on their location.
Fig. 18 Tinea Capitis
Fig. 20 Tinea Pedis Fig. 19 Kerion Celsi
TINEA CAPITIS (Ringworm of the scalp) It has two types: Dry form with pseudo alopecia, short hair with mild peeling, loss of hair in circles or diffused and itching (fig. 18). Predominant in children and rare in adults. The inflammatory form presents erythema, pus and secretions which form yellowish scabs with blood (fig.19). It is painful and can leave permanent marks.
TINEA PEDIS (Athlete´s foot) and TINEA UNGUIUM (Onychomycosis) This affection is more frequent in adults. Associated with poor hygiene and the use of synthetic footwear and nylon socks. It appears between the toes (fig. 20) and can cause peeling and blebs which defines the type of tinea. It causes itching and bad odor. The toenails, deform, change color or end up being totally destroyed from the tip to the base (fig. 21).
Fig. 21 Onychomycosis
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DERMATOPHYTOSIS TINEA CORPORIS
TINEA OF THE GROIN
This infection looks like a red ring with a clearer center on the surface of the skin (fig. 22). If the lesion is scratched it can cause secondary bacterial infections. In children it’s associated to contact with infected dogs or cats. In such cases the lesions are small and numerous (fig.23).
It causes itching and a more intense pigmentation than the tinea of the body or tinea corporis (fig. 24). It can spread to the abdomen and the buttocks (fig. 25). It’s important to know if the patient has tinea pedis, sometimes the patient scratches the feet and the tinea spreads to other body areas. Both the tinea of the body and groin can spread or further complicate when using strong topic corticoids (fig. 25).
Fig. 22 Tinea Corporis
Fig. 24 Tinea of the groin
Fig. 25 Tinea buttocks spread
Fig. 23 Microsphoric tinea
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TREATMENT
Oral:
Itraconazole, 100 mg/day for 1-2 months or Terbinafine 250mg for a month.
Children over 5 years old:
Terbinafine pills, 125mg (half a pill) for a month. In case of onychomycosis, the treatment must extend up to 4-6 months. Do not use ketoconazole, its prolonged use may cause hepatotoxicity.
Topical:
Miconazole, isoconazole or clotrimazole cream, twice a day for a month.
RECOMMENDATIONS Tinea capitis: •
void sharin towels, combs or brushes, caps or hats. • void contact with domestic animals.
Tinea pedis:
• Wash and dry between the toes and the soles of the feet, avoid wearin plastic or rubber shoes. • void sharin footwear.
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TINEA VERSICOLOR (PITYRIASIS VERSICOLOR) It’s a condition caused by Malassezia fungus (fig. 26), it’s common in tropical areas since it thrives in the heat and humidity. Transpiration and skin oils favor its growth. It has the appearance of clusters of “white drops” on the skin (fig. 27). Color and shape vary according to the type of skin: white or pale 80%, reddish when in contact with sunlight (fig. 28), or hyper chromic (fig. 29). Fig. 26 Malasse zia: “spaguetti and meatballs” image like
Fig. 28. Erythematous spots
Fig. 29 Hyperchromic spots
Fig. 27 Hyperchromic spots in “drops” shape
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TREATMENT ORAL:
Itraconazole 100 mg capsules once a day for 15 days or Ketoconazole 200mg capsules once a day for 10 days.
TOPICAL:
• etocona ole shampoo or selenium disulphide to wash the hair and apply over skin marks. • icona ole, ketocona ole or isocona ole cream, solution or spray. pply over clean and dry skin once a day for a month.
RECOMMENDATIONS To avoid recurrence • void direct sunli ht or intense indirect sunli ht. • void activities that cause excessive perspiration. • Wash the skin and rinse immediately perfectly dry areas where sweat tends to accumulate, especially skin folds. • o not apply lotions, oils or any reasy products on the skin. • se cotton clothin only, avoid synthetic materials. • o not apply home remedies.
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SPOROTHRYCOSIS
Subcutaneous mycosis frequent in tropical and subtropical countries. The causal agent penetrates the skin through contact with contaminated materials (fig. 30). Common in both genders, but more frequent in men, young adults and children who work in agriculture and farming (fig. 31). It affects the skin, lymph vessels, muscles and occasionally bones. It has the appearance of lumps (fig. 32) which ulcerate and fill with scars, or form granulomatous lesions with scaring and erythema (fig. 33 y 34).
Fig. 30 Acacia thorns
Fig. 33 Sporotrichosis in children
Fig. 31 Risk group
Fig. 34 Lymphangitic sporotrichosis
Fig 32 Ulcerated lumps
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TREATMENT
Potassium iodide 3-6 g/day, (one tablespoon [5ml] every 8 hours) for 2-3 months. • ntimycotics such as itracona ole, m , twice a day for months. • f the previous aren t found, administer trimethoprim/ sulfamethoxa ole, m twice a day for months.
ote t is convenient to study these cases thorou hly. When there s a patient with this type of condition, it s recommended to call the phones or visit the web sites listed in the T T pa e, to et free information about treatments and complementary studies.
RECOMMENDATIONS lon with the treatment the followin measures are suggested: • lean the lesions they don’t spread from person to person) • pply warm compresses twice a day (thermotherapy) • void home remedies
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MYCETOMA Slow evolving subcutaneous infection, caused by 2 types of agents: actinomycetes (bacteria) and eumycetes (fungi) (fig. 35). More frequent in males, country folk and young men, but it can affect both genders at any age. It has a slow progression with very few symptoms; when it over infects due to combination with other bacteria it can present a fetid odor and pain. Mycetoma by fungi is bigger in volume, presents skin thickening, numerous fistulas with pus and inflammation (fig. 36). Eumycetoma are less inflammatory, they evolve slowly and aren’t contagious. They may have sequels and lead to disability.
TREATMENT Actinomycetes
Fig. 37 Abdominal mycetoma
Eumycetoma
Fig. 38 Mycetoma perianal region
Fig. 39 Back injuries
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Terbinafine, 500mg/day; itraconazole, 300mg/day. • t s recommended to monitor it for a long period of time • ur ery is contraindicated for mycetoma; they should be assessed by a specialist. Note: It is convenient to study these cases thoroughly. When there’s a patient with this type of condition, it’s recommended to call the phones or visit the web sites listed in the TELEDERMATOLOGY page, to get free information about treatments and complementary studies.
Fig. 35 Nocardia grain SP microscope
Fig. 36 Typical appearance of mycetoma foot.
Dapsone 100mg/day; trimethoprim/sulfamethoxazol e, total dose 160/800 mg every 12hrs for 8-12 months. To avoid recurrence the treatment must be finished even if the lesions seem to have disappeared.
PARASITISM (SCABIES OR MANGE)
Caused by the human type Sarcoptes scabiei mite (fig.40). It’s transmitted through direct contact with the skin for more than 5-8 minutes. It’s not spread by having contact with dogs. It is common that entire families are affected simultaneously, especially those who interact closely. Itching starts after 3-4 weeks after contagion, when the skin becomes sensitive to the presence of the parasite. Fig. 40 Scabies mite
Fig. 43 Starry sky sign
Fig. 41 Interdigital injuries
Fig. 44 Genital injuries
Fig. 42 Wrists injuries
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CLINICAL PROFILE
General measures:
It’s common to find papules, scabs, erythema, and lichenification (thickening of the skin) on hands (fig. 41 and fig. 42), abdomen (fig.43), genitals (fig.44), or from neck to knee (threads). Scratching can leave marks. The most affected areas are penis, nipples (in women) and soles of the feet in babies, abdomen, elbows and underarms in general patients.
DIAGNOSIS
• veryone livin in close proximity must follow the treatment simultaneously, whether they present itching and lesions or not. • tchin doesn t o away until weeks after finishing the treatment, which must not be repeated. • The risk of a second conta ion is high, so it’s important to avoid skin to skin contact with other people and small children.
The triad for diagnosis includes: 1. Typical topography: Affected areas and characteristic lesions in the body. 2. Itching is more intense during the night. 3. Several or all members of the family present contagion.
Recommendations:
TREATMENT Oral: • vermectin, m k of wei ht. Adults, 1 unique dose of two tablets. • ntihistamines if there s itchiness. Topical: • en yl ben oate dilute to with baby oil, since it may cause intense irritation) • ulfur petrolatum aseline . • ub from neck to feet in adults and all over the body for children, only for three nights.
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•
aily shower before applyin treatment and changing clothes and bed linens every morning. • The whole family must receive treatment even if they don’t present symptoms. • o not repeat treatment before three weeks have passed. • n bi families, investi ate if there s anyone else affected. • f there are complications such as impetigo or dermatitis, these should be treated first.
PEDICULOSIS (lice) These are parasites located in the scalp and they feed on blood (fig.45). Transmitted by head to head contact between family members or schoolmates (fig. 46). They cause intense itching and can easily lead to impetigo and folliculitis. To the naked eye, nits are easier to observe than lice (fig. 47). Do not apply insecticide under any circumstance, since its high toxicity can cause total alopecia or bone marrow suppression. Body lice is more frequent in cold climates and affects people with poor hygiene who don’t change or wash clothes. Pubic lice (crabs) (fig. 48) is mostly transmitted through sexual intercourse and its body is thicker than the head lice´s; if present in children, it adheres to the eye lashes (fig. 49) and is accompanied by intense itching and regional nodes growth.
Fig. 45 Scalp lice
Fig 48 Pubic lice (courtesy of Dr. Adán Fuentes)
Fig. 46 School transmition
Fig. 47 Nit
Fig. 49 Lices in eyelashes
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TREATMENT Oral: Ivermectin tablets 200 mg/kg, unique dose. Repeat every three weeks, if needed. Topical: Permethrin Topical, phenothrin and dimethicone shampoo or cream, single application.
Recommendations • heck everyone in the household and treat at the same time. • chool campai ns have to be addressed to the families of the affected children. • f there are any other complications, those should be treated first.
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LICHENS
Inflammatory skin reaction of unknown origin. It can be related to stress, medicine, climate, dust or sun. Between 40 to 60% of patients present pharynx issues. Lesions are accompanied by itching of different intensity. Non-contagious violet multifaceted papules; its multiple varieties make it seem like different illnesses (fig. 50 to fig. 53). Lichen simplex chronic (LSC) also known as neurodermatitis and the hypertrophic lichen are the most common forms of this condition.
TREATMENT
Fig. 52 Linear striated lichen
1. If the lesions are too itchy, apply hydrocortisone or desonide at night for 2-3 weeks. Gradually reduce the amount after the first week. 2. Antihistamines such as loratadine, when itching is present. 1 tablet every 12 hrs. 3. Oral antioxidants such as vitamin A have a placebo effect. Take 1 every morning.
Fig. 53 Hypertrophic lichen
Fig. 50 Lichen planus papules
Fig. 51 Pigmented lichen
Recommendations: • emind the patient that this is a beni n ailment. • o not scrub or scratch the skin or the condition may worsen. • t s not conta ious • t doesn t re uire special diets • o not use home remedies • o not apply potent corticoids like betamethasone, they may cause stretch marks and skin thinning.
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ATOPIC DERMATITIS It’s one of the most frequent dermatosis in children within urban environments. It’s caused by family history of asthma, hives, or allergic rhinitis. In children it appears on cheeks and torso (fig. 54). In preadolescents there are lesions on creases (fig. 55), which can easily worsen (fig. 56) due to external factors. In adults there are isolated plaques on the neck (fig.57), hands, genitals and ankles. Intense itching is a characteristic of this ailment and it can lead to bacterial infections from scratching the lesions (fig. 58).
Fig. 54 Infants Injuries
Fig. 57 Adult injuries
Fig. 55 Eczema in skin folds
Fig. 58 Heavy scratch impetigo
Fig. 56 Worsening stage
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TREATMENT Oral: • ntihistamines such as loratadine and chlorpheniramine, every hrs. Topical: • inc oxide twice a day to protect the skin. In case of severe cases: • inc oxide paste with hydrocortisone cream, for days only. • Tacrolimus ointment or pimecrolimus cream. • ubricate with emollient cream as cold cream. • o not use oral corticoids or stron lotions such as betamethasone .
Recommendations: • f there s bacterial infections, treat those first. • o not use body wash, it can cause irritation. • Wear cotton clothin only, avoid deter ents and softeners. • o not scrub the skin when showerin . • dentify products that cause reactions perfumes, food, fabrics, animals, plants, etc., and avoid contact with them. • se moisturi in lotions with no perfume.
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SEBORRHEIC DERMATITIS Predominant in oily skin areas like scalp, face, chest, shoulders and back. It can appear at any age. In infants it looks like thick scales known as “cradle cap” or “milk crust” (fig. 59), it can cause itching. It affects the center of the face, it has the appearance of dry plaques which fall off (fig. 60) or accumulation of fat in cheeks and folds (fig. 61). When it appears on the eyelids it causes irritation (seborrheic blepharitis, fig. 62).
Fig. 62 Seborrheic blepharitis
TREATMENT Fig. 60 Seborrheic facial dermatitis
Ketoconazole, zinc pyrithione or coal tar base shampoo. Sulfur and salicylic acid soaps. In high inflammation cases, mix hydrocortisone and clioquinol and apply every night for 10-15 days.
Fig. 61 Severe seborrhea
Fig. 59 Milk crust
Recommendations: • •
void prolon ed exposure to sunli ht. o not use lotions, commercial products or oils on face or hair. • void food that mi ht irritate your stomach and alcoholic beverages. Control stress causing factors, since these favor the appearance of dermatitis. • Wash the face times a day and hair every day.
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CONTACT DERMATITIS Caused by contact with inflammatory substances. It can be:
Irritant contact dermatitis •
cid hydrochloric, sulfuric and nitric. • lkalis austic soda • lants oison ivy or other skin-burning species • nimals worms, spiders, jellyfish.
Clinical profile: ry skin, lichenified thick . When the skin has been irritated for a lon time it is found erythematous, with papules, scratchin traces, peelin (fig. 66) and itching.
Clinical profile: rritated, sweaty skin, vesicular skin lesions, yellow scabs (fig. 63), itching and burning. Fig. 65 Photoallergic dermatitis
Allergic contact dermatitis Caused by substances that sensitize the skin: • edicine enicillin, sulfa medication and analgesics. • ousehold products arlic, lime, deter ents, insecticides. • osmetics erfumes, deodorants, lipstick, make up. • ewelry arrin s, necklaces, metal watches. • ther elt buckles (fig. 64), rubber shoes. • ome topical meds can make the skin more sensitive to sunlight (fig. 65).
Fig. 63 Severe dermatitis
Fig. 66 Chronic dermatitis Fig. 64 Belt buckle dermatitis
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TREATMENT Acute contact dermatitis 1. Mouth rinses with Alibour´s water 2. Zinc oxide paste and hydrocortisone twice a day for a week. 3. Loratadine pills, 10 mg every 12 hrs. If there’s itching.
Chronic contact dermatitis
4. Zinc oxide paste and hydrocortisone twice a day for a week, only zinc oxide after. 5. Loratadine once or twice a day. 6. Cold cream for dry skin after 10 days.
Recommendations: Avoid sunlight exposure and sweating; it’s very important to cease contact with the material or substance which started the inflammation.
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PSORIASIS
TREATMENT
Chronic dermatosis of unknown causes. It has the appearance of red, dry plaques of scaly skin, varying in number (fig. 67 a 73). • t may have a enetic background. • t s not conta ious. • t s more common in adults. • ccasionally it affects the joints 30% of cases are linked to diabetes, arthritis and other illnesses. • t s enerally a beni n disease.
Fig. 69 Drop psoriasis
• alcitriol, calcipotriol and topical tacalcitol. • oal tar shampoo. • Topical betamethasone for no longer than three weeks. Avoid applying in body folds and face. • alicylic aseline by itself and mixed with betamethasone, depending on the inflammation.
Fig. 70 Placques psoriasis
Recommendations:
Fig. 67 Erythematosus psoriasis
Fig. 71 Nail psoriasis
Fig. 72 Lesions Fig. 68 Affected areas may include: head, sacral region, elbows and knees.
• ontrol concomitant ailments such as diabetes, obesity or infections. • se an emollient wash to eliminate excessive peeling. • ome patients improve with sunlight exposure, but others worsen. Act depending on the reaction. • void alcoholic bevera es since they generally aggravate the condition. • o not use lotion, commercial products or oils on face or hair. • tress may exacerbate the condition.
Fig. 73 Palmoplantar psoriasis
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SWEAT ALTERATIONS
Cutaneous conditions caused by heat and humidity. They appear when the sweat glands become obstructed , these glands are more numerous on forehead, chest, back, hands and feet. People who suffer from obesity, children with overweight, people who practice sports and those who are exposed to heat are affected more frequently.
Crystalline surface
Fig. 76 Rubra miliaria (rash)
Media M. rubra
Most frequent varieties: Miliaria Crystalline Small blister like lesions that appear when sweat obstructs the stratum corneum, the most
Sweat gland
(fig. 75) Miliaria Rubra Common rash; sweat obstructs the middle of the sweat conduct. (fig. 76)
Fig. 74 Sweat duct affection levels
Miliaria Profunda The obstruction occurs deep in the sweat gland. (fig. 77) Miliaria Pustulosa The rash becomes pustules due Fig. 75 Crystalline miliaria
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Fig. 77 Deep miliaria
SWEAT ALTERATIONS Secondary Anhidrosis The sweat gland’s obstruction causes dehydration in the surface of the skin, which becomes red and dry, peels off and hypochromic. There’s intense itchiness due to the sweat trapped under the skin (fig. 78). Intertrigo This condition appears when sweat accumulates between skin folds due to humidity and cellular detritus. It’s more frequent in male genitalia and skin folds in obese people. It causes itchiness and burning sensation (fig. 79).
Fig. 78 Anhidrosis
Dyshidrosis Usually found in areas where skin is thicker, such as palms of the hands and soles of the feet. Here, sweat accumulates and causes itchy blisters (fig. 80). Leukoderma Usually, after the irritation phase of sweat alterations, the skin shows residual hypochromic marks that sometimes are taken for other ailments such as anemia or fungal infections (fig. 81).
Fig. 80 Dyshidrosis
Fig. 81 Leukoderma
Fig. 79 Intertrigo
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TREATMENT • oap substitutes • olloidal baths • ryin powders inc oxide and talc powder durin the day to diminish sweatin • old cream and hydrocortisone on dry areas for days only • ntihistamines to help with the itchiness
Recommendations: To prevent relapse it is recommended to • void intense activities • Wash the skin after sweatin profusely • se cotton clothin only, avoid synthetic materials • o not et exposed to sunli ht • void hot and humid places • void other sources of heat • o not use home remedies
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PITIRYASIS ALBA The main characteristic of this dermatitis is hypochromic patches on the skin. It’s frequent in children after prolonged exposure to sunlight. More noticeable on darker skin types. It’s also associated with dry climates and atopic skin. It isn’t related to anemia, parasites, virus or fungi. CHARACTERISTICS: • ypochromic patches on exposed areas, such as face, arms, chest and the back of the neck (fig. 82 y 83). • ry surface, there may be fine papules and mild peeling. • aries in si e, sin le or multiple patches (fig. 84 y 85). • li ht itchin . • t s commonly confused with other dermatosis, which is why is convenient to use the hypochromic patch algorithm (page 39).
TREATMENT • Wash with neutral soap or baby soap. • oisturi e skin with non-fragrance lotions and emollient cream. • unscreen if affordable. • The patient can also use inc oxide as sunscreen during the day. • lio uinol cream at ni ht. Fig. 83 Hypochromic V neck
RECOMMENDATIONS Fig. 84 Slight peeling on the surface
• rotect the skin from sunlight, use hats, umbrellas, caps, long sleeves and pants. • void scrubbin the skin when showering. • at healthy and nutritious food. Fig. 85 Fine papules
Fig. 82 Pitiryasis alba
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VITILIGO It’s an alteration of the skin tone due to diminishment or destruction of pigmentation cells (melanocytes). White patches of varying intensity appear (fig. 86), these are more evident in darker skins. 30% of patients have family history of the condition. It may be associated with intense emotional factors or with thyroid issues. The areas where it appears most are, lips, back of the head (fig. 87), armpits, genitals, eyelids and hands. This discoloration of the skin is a frequent source of social rejection and anguish. It’s generally asymptomatic although in some cases there’s moderate itching. Segmental Vitiligo is unilateral and affects only a specific area (fig. 88), it can appear around moles (Halo Nevus or Sutton Nevus) (fig. 89), affect the scalp or even hair (poliosis; fig. 90). With appropriate treatment the color can reappear (fig. 91).
Fig. 89 Sutton Nevus
Fig. 86 Extensive vitiligo
Fig. 90 Poliosis
Fig 87 Neck involvement
Fig. 91 Repigmentation
Fig. 88 Segmental vitiligo
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TREATMENT • Topical Tacrolimus . , combine with cream hydrocortisone avoid wide areas and body folds, such as armpits and roins . • o not use oral corticoids or stron topical solutions, the may cause atrophy. • n cases of extended duration, use sunscreen and filters since the skin is easily burnt.
RECOMMENDATIONS • eassure the patient about the possibility of recovery. • e realistic. o not promise fast or complete results. Follow up with the patient s pro ress. • There s nothin more harmful than tellin a patient that their condition is oin to worsen or can t be cured.
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HYPOCHROMIC PATCHES- ALGORYTHM Topography
Exposed areas
+
Apparition
More frequent in children
Sensitivity
Normal
+
History/Background Wood light
Arter exposure to sunlight
Opaque glare
+
(-)
Diagnosis
Pityriasis alba
Fig. 92
On the feet
Mostly in adults
Normal
+
+
+
Frequent use of plastic Accentuated footwear glare
+
Dyschromia
(+)
Fig. 93
Any area
Any age
Normal
Previous inflammation or trauma
+
+
+
+
Opaque glare
Residual Leukoderma
(-)
Fig. 94
Any area
More frequent in children and young people
+
+
Altered
Look for family history of the condition
Opaque glare
+
+
(-)
Undertemined Leprosy
Fig. 95
Usual areas
Young adults
+
+
Normal
Other family members are affected or not
Characteristic glow
+
+
(+)
Vitiligo
Fig. 96
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MELASMA (Chloasma) Hyperpigmentation that appears in areas exposed to sun rays; face mostly. It’s commonly known as “sun spots”. The color of these patches varies depending on the patient’s skin tone, degree of sensitivity and the frequency and intensity of the exposure to sunlight. It tends to appear after intense sun or heat exposure, combined with a sensitizing factor such as: pregnancy, oral birth control, perfumed cosmetics, medication and home remedies containing lime and garlic. It’s asymptomatic although sometimes there’s a slight burning sensation or redness, besides the aesthetic discomfort. Intense heat (kitchen, car, metal roof homes, etc.) can favor this condition’s appearance or persistence despite treatment. There’s 3 types of melasma: superficial or epidermal (fig.97), dermal (fig. 98) and mixed forms, all of which depend on how deep pigmentation is.
TREATMENT
Fig. 97 Epidermal melasma
2 or 4 % Hydroquinone based depigmentation treatment or azelaic acid for night use only, they can cause more damage if used during the day. Sunblock with UV protection factor 30+ or 50+ every 4hrs immediately after sunscreen or zinc oxide (prescription must be assessed carefully since they tend to be expensive). These tend to give a white tone to the skin which isn't aesthetic
Fig. 98 Dermal melasma
RECOMMENDATIONS No treatment is effective if the patient doesn't avoid sunlight, direct or indirect or intense heat. As a matter of fact a "setback or bounce back" comes after the initial improvement, even if there's only a light exposure to sun, heat or light sun reflection.
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SOLAR DERMATITIS Lesions on skin areas that are exposed to sun rays, direct or indirectly. Its evolutions is chronical and comes with intense itching, mostly during the afternoon or following sun exposure. More frequent in women and it can start during childhood. Typically affected areas can be: cheekbones, nose and above the lips on the face (fig. 99); forearms, arms (fig. 100), neckline and legs on the body. Lesions tend to disappear on areas covered by clothing. Clinical profile: Erythema, papules, scabs, excoriation and lichenification. It may be accompanied by conjunctivitis and pterygium formation (fig. 101); on lips: eczema fissures and erosions (cheilitis) (fig. 102). It's common to acquire impetigo and dermatitis from intense scratching.
TREATMENT
Fig. 100 Forearm injuries
1. Sun filters and screens with UV protection factor of 30+ or 50+. If these aren't affordable, patients can use zinc oxide paste, although it leaves a white tone on the skin. 2. Mix equal amounts of hydrocortisone cream and zinc oxide cream and apply at night, only while the skin presents inflammation (8 to 15 days). 3. Antihistamines to diminish itching.
Fig. 101 Solar conjunctivitis
RECOMMENDATIONS
Fig. 102 Actinic Cheilitis
Fig. 99 Solar itching on the face
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• t s absolutely necessary to avoid sun exposure. Use of a hat, umbrella, long sleeves and cotton long pants. • void activities that require sun exposure or intense indirect light, including day light lamps' reflection.
ACNE It's the most frequent dermatitis in consultations at cities and third in rural areas. It appears due to inflammation and obstruction of the pilosebaceous follicles in high sebum areas of the skin; commonly known as "pimples and black heads", they appear on: face, chest and back. Their main characteristic is red papules, black and white heads and greasy skin in the non-inflammatory forms (fig. 103). Inflammatory forms include (fig. 104), pustules, reddening and abscesses which leave permanent marks on the skin (fig. 105), mostly if the patient touches or pinches it frequently. Similar lesions can appear due to inadequate use of topical betamethasone (fig. 106).
TREATMENT
Fig. 105 Post-inflammatory scars
1. Wash with Sulphur soap and salicylic acid, 2-3 times a day (for very greasy skin). 2. Benzoyl peroxide lotion or gel 1 or 2 times a day after washing. 3. Topical clindamycin in pustules twice a day. 4. Tetracycline or derivatives, 500 mg per day for a month or more, apply on inflammatory lesions.
Fig. 106 Eruptive betamethasone acne
RECOMMENDATIONS Fig. 103 Non inflammatory acne
• Wash the face times a day. • o not pinch or s uee e out in amed lesions, this leaves permanent marks. • o not use commercial products they re usually ineffective. • void betamethasone, complex and hormone vitamins, they usually stimulate acne.
Fig. 104 Inflammatory acne
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SKIN CANCER More frequent in white skinned seniors who have taken a lot of sun. Predominant in exposed areas: face, nose, cheeks and forehead, arms and forearms, although it can affect any area. It consists of neoformations of papular, nodular, ulcer or squamous form. There are three main variations. Basal cell carcinoma (BCC) It's the most frequent and less severe. It's usually located at the center of the face. It looks like a nodular or ulcerated tumor (fig. 107). In darker skin it comes with intense pigmentation which sometimes can be confused with melanoma. It doesn't usually metastasize.
Squamous cell carcinoma (SCC) Its the second most common, its aggressiveness varies according to the place it affects and its bigger in mucus membranes. It appears as ulcers or squamous cells (fig. 108) and it has the potential to metastasize to the lungs, bones or brain.
Malignant Melanoma (MM) It's the most serious and aggressive type of skin cancer, it has a high mortality rate which depends on its evolution and clinical form. In Mexico the most frequent one begins as moles on the soles of the feet or toe nails. It has a high metastatic potential within weeks or months which is why its early detection, diagnosis and treatment are vital. It often starts as pigmented moles (fig. 109).
Fig. 108 Squamous cell carcinoma
Fig. 109 Malignant melanoma
Fig. 107 Basal cell carcinoma
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Detection Tumors have different degrees of malignity, the capacity to invade and destroy other body areas and eventually cause the patient's death if they're not detected on time. The ABCDE rule must be applied to classify the type of skin cancer. A. Asymmetry: The lesion is irregular in form or one half is different than the other. B. Border: The lesion is irregular in shape, undulated or undefined. C. Color: There's tone variations within the same lesion (black, brown, blue or red). D. Diameter: It's bigger than 6mm (the size of a pencil's eraser). E. Evolution: It rapidly changes shape or color, it gets inflamed, bleeds or grows.
PREVENTION Photo protection care, use of a hat, filter or sunscreen every 4 hours. Avoid prolonged exposure to sunlight.
TREATMENT Most skin carcinomas need chirurgical intervention with a 3-5mm margin around the lesions (BCC and SCC). When the diagnosis is prompt there's a high healing rate. It's recommendable to treat melanoma cases in third level hospitals, due to the high mortality rate.
If there's suspicion of possible skin carcinoma, the best course of action is doing a biopsy; if there aren't means or material to perform it, the patient must be referred to a specialist as soon as possible.
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CORTICOSTEROID LESIONS Inadequate use of medium and high level topical and systemic corticosteroids sometimes leads to skin lesions and complications: betamethasone, fluocinolone, dexamethasone, clobetasol, fluticasone, etc. Damaging effects include: 1. Secondary infections (fungi, viruses, parasites or bacteria) due to immunosuppression from prolonged use (fig. 110). 2. Hidden infections, like tinea corporis (body ringworm): "Tinea incognito" (fig. 111). 3. Stretch marks due to damage to collagenous fibers (fig. 111). 4. Acne-like eruptions on chest and back (fig. 112). 5. Cushing syndrome, due to renal suppression, in children (fig. 113).
Fig. 110 Candida superinfection
Fig. 113 Cushing's syndrome
Fig. 111 Tinea incognita and deep stretch marks
Fig. 112 Acneiform eruption
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CORTICOSTEROID LESIONS Inadequate use of corticosteroids is favored by: 1. Wrong diagnosis. 2. Free sale, without the need of a prescription. 3. Publicity which doesn't warn about the side effects if used for more than 2 weeks. 4. Low initial cost; which escalates once complications start appearing. 5. Apparent improvement, which induces continuous rebound effects since the cause remains unsolved. 6. Irresponsible staff use when prescribing them without proper diagnosis. 7. Patients recommending their use to people with similar ailments. 8. Some forms of betamethasone combined with clotrimazole and gentamicin only conceal infectious mycotic illnesses, but don't cure them.
TREATMENT Permanent suspension of betamethasone and start of proper treatment for the observed base condition (tinea, scabies, stretch marks, acneiform eruptions, etc.)
The key to treatment is the definitive suspension of topical corticosteroid and appropriate treatment based on the correct diagnosis.
In children with Cushing syndrome, pediatric evaluation is a must. Serum cortisol test or urine test must be performed. Follow up and notifying through TELEMEDICINE-TELEDERMATOLOGY. In mild cases, suspending the medication is enough to improve the condition.
RECOMMENDATIONS • orticosteroids should only be prescribed with a certain diagnosis for psoriasis, lichen or chronic contact dermatitis. • The dama es they can cause such as atrophic stretch marks) are permanent. • s a rule, medium to hi h potency topical corticosteroids shouldn't be prescribed for more than 2 weeks. • t s important to emphasi e the suspension of the treatment and tell patients not to recommend it to others. • o no use on skin folds in children under 12 years old, due to risk of causing Cushing syndrome.
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TELEDERMATOLOGY It's the usage of distance communication means applied to dermatology; their objective is: 1. Give dermatological counseling to medical staff in remote areas. 2. Facilitate remote dermatological attention. 3. E-learning: Dermatology training through TELEMEDICINA network. 4. Referral of more complicated cases to a second or third level of attention. 5. Share updated information on procedures, medication, courses, etc. 6. Solving questions on any topic, doubts or information requests related to this field.
The next images show a teleconsultation's flux:
2
1
The patient lives in a remote area
He goes to a health center because of a skin issue
5
4
He's hesitant about leaving his home ("I have no money", "What if I get lost?", "I'm scared").
The physician sends his case through a teleconsultation.
3
He consults with the local general physician, who advises him to see a specialist
6
He receives adequate treatment and recovers.
TELEMEDICINE AT THE SERVICE OF HEALTH (Images courtesy of Mrs. María Elena Larios)
DIRECTORY DR. ADRIANA SOLÍS G. telemedicina-guerrero@hotmail.com DR. ELENA GALEANA S hga.telemedicina@yahoo.com DR. ROBERTO A. ESTRADA dermaconsulta.13@gmail.com DR. GUADALUPE CHÁVEZ chavezg13@live.com.mx DR. GUADALUPE ESTRADA estradaguadalupe@hotmail.com FACEBOOK: /DermatologiaComunitaria WEBSITE: www.dermatologiacomunitaria.org.mx 48