Topics covered in Weekend Practical Meeting

Lectures on 
1. Skin diagnosis
2. The common skin diseases, Acne, Eczema, Psoriasis, Skin Infections
3. Contact dermatitis and Patch Testing
4. Dermatoscopy
5. Common skin cancers
6. Use of medications and PDT for treating non melanoma skin cancer
7 Wound management and dressings
8 Advising patients commencing Cosmetic procedures, Phototherapy for Psoriasis, Laser therapy, Acne drug side effects

Practical Instruction
1. Patch testing
2. Carrying out Phototherapy nb UVB
3. Carrying out PDT treatments
4. Skin biopsies and suturing wounds
5. Total Body Photography

Stream 1 General Dermatology - The Common Skin Diseases

Topics to be covered in the Certificate Course

Psoriasis,
 Atopic eczema ,
 Tinea,
 Acne,
 Rosacea
Seborrhoeic Dermatitis

Below is a sample of how we present material in  the Certificate course for Nurses. It looks at Atopic Eczema.

Atopic Eczema

Atopic dermatitis is the commonest form of endogenous dermatitis that you will see. Note that I said endogenous meaning coming from within. An exogenous dermatitis coming from outside would be perhaps an irritant dermatitis or an allergic contact dermatitis from something that you have handled or a plant contact dermatitis. You are born with a genetic tendency to atopic dermatitis.

The essential morphological feature of atopic dermatitis is a red scaly rash with breaks in the surface often with weeping.  It is an extremely itchy disorder. In fact most of the rash is caused by scratching the skin. If you scratch skin excessively it will thicken, this is known as lichenification. Children with atopic eczema have an increased incidence of asthma and hayfever. The genes that cause these conditions are all on the same chromosome.

Atopic dermatitis is probably a disorder of barrier function rather than an immune disease. They can be irritated by soaps and detergents but also by wool, grass and sand. Atopics have skin that is much dryer than normal and hyperirritable. People who have the condition do not make good doctors or nurses because they cannot handle the hand washing and detergent exposure. Similarly they are not good hairdressers either.

Q 1: What is atopy? A 1: Clinically it is the combination of eczema, asthma and hay fever in an individual or their family

Q 2: What is the main superficial feature of eczema? A 2: Small breaks or fissures in the red scaly skin.They may or may not weep.

Q 3: What is the scratching pattern in atopic eczema called? A 3: The Itch Scratch cycle. History: Question What is the distribution of the rash in atopic dermatitis? Answer Distribution is really quite classic. In young children before the age of one it is often on the face particularly on the cheeks. If it is found mainly circumoral then consider a food allergen. Past the age of one it is more typically seen on the fronts of the elbows and behind the knees. In severe cases of atopic dermatitis the entire body can be affected. Occasionally though the eczema can only affect a particular area for example above the lip, eyelids, behind the ears, perhaps just the face itself or present as a hand dermatitis. Question What other factors are involved in the aetiology of atopic dermatitis? Answer Allergy is always raised as an issue. Skin prick tests where a dissolved drop of the allergen is placed in the skin and a small scratch or prick is made into the skin tend to correlate with acute skin reactions such as urticaria and generalised erythema.When scratch tests are done for atopic dermatitis dust mite sensitivity is commonly found. In fact it is found in 80% of cases. The most common foods that cause problems in children are eggs, peanuts, milk, fish, soy and wheat. These are usually included in a battery of RAST tests where allergy tests can be done on a sample of blood. It indicates specific IgE immunity. This food worsening of atopic eczema is seen in individuals with severe disease rather than mild disease. It is thought that prolonged breastfeeding can delay the onset of atopic eczema and pro biotic therapy with lactobacillus is also useful but it does not prevent the development of the disorder. Secondary staphylococcal infection is commonly seen. In fact virtually all weeping atopics will have significant secondary staph, which should be treated with either oral antibiotics or with Mupirocin or Bactroban cream topically. Passive exposure to cigarette smoking can aggravate atopic dermatitis in a child.Sweat retention is important in some areas such as the back. Exposure to drying environments also contributes.Stress is certainly a factor in adults. Sweating is common in both children and adults especially in a very humid summer. Clothing and airborne allergens and irritants have already been mentioned. Q 1: In what three conditions do patients scratch to the point of excoriation? A 1: Atopic eczema, scabies and dermatitis herpetiformis. Q 2: What percentage of the population have an atopic diathesis? A 2: Around 20% but only around 5% will exhibit eczema. History: Pityriasis alba is a mild form of atopic eczema presenting in darker skinned individuals where the eczematous process interferes with normal pigmentation. Hence they present with a pale, slightly scaly area, particularly on the face or the upper trunk. This is easily managed with moisturising and some 1% Hydrocortisone cream. Differential diagnosis. When you see a neonate with a rash on the face and chest wall and they are itchy, it may well be atopic dermatitis but you also have to consider seborrhoeic dermatitis, in which case the child may have extensive cradle cap as well. There is usually extensive flexural involvement under the armpits and in the groin, particularly under the neck fold. Atopic eczema usually spares the folds. This is best seen with the typically normal skin in the area covered by a nappy in a child with atopic eczema. Irritant dermatitis can also be a cause of eczema on the buttock skin and flexures as well as seborrhoeic eczema. In infants seborrhoeic dermatitis is also a significant differential but scabies is another important diagnosis to consider in an itchy child. Q 1: Which rash is more likely to involve the flexures, atopic or seborrhoeic eczema? A 1: Seborrhoeic eczema. History: Question How do you manage a child with atopic dermatitis? Answer You look at general measures such as avoiding irritants coming in contact with the skin namely wool, grass and excess soaps and detergents particularly bubble baths. You moisturise the skin either with an oatmeal based product such as Dermaveen or some Glycerine and Sorbolene cream or even Lanolin. You then try to suppress the dermatitis. 1% Hydrocortisone is usually quite safe in young children and can be used over extensive body areas. Creams are better than ointments for slightly weepy eczema. If there is significant weeping then there is likely to be secondary staph infection and an oral antibiotic such as Dicloxacillin has to be given or Bactroban cream can be applied. Children with extensive atopic eczema are very irritable and often do not sleep. This may mean the whole family does not sleep. In these circumstances a sedative may be given such as Phenergan or Valergan. With Phenergan it is generally 5mg to 10mg at night. Sometimes these children should be admitted to hospital for wet dressings. These are done using blue backed incontinence sheets which are wetted on the paper side, a moisturising cream and a bit of Hydrocortisone is then applied to the skin and the damp area is applied to the creamed skin and bandaged on. Oral steroids are not a good idea in children and stronger topical steroids should be avoided. Methylprednisolone or Advantan 1% is a useful alternative if the initial Hydrocortone has not been successful. Question How do you treat severe atopic eczema in an adult? Answer All the general measures indicated for children come into play but drugs such as Azathioprine, Cyclosporine and PUVA using oral psoralens and UVA light or narrow band UVB have also been effective. Cyclosporine orally can be used in children as a dose of 5mg per kilogram per day but this is tapered after a few weeks. Any relevant food allergens should be sought and avoided. Desensitisation to dust mite can be attempted but it has to be done over a two to three year period and it is really only of value if you have proven dust mite exposure is a significant factor and that does not just mean a positive RAST test Q 1: What features would suggest an eczema is infected? A 1: Weeping and yellow crusts or pustules. Skin tenderness. History: Question What advice do I give to someone with atopic dermatitis? Answer First of all I tell them not to scratch. Scratching induces a lot of the lesions that you see in atopic dermatitis. This is very difficult for small children to obey and even adults. The child should rest in a cool room. They should avoid being overheated with blankets or doonas. The room should have tiled or wooden floors to avoid any accumulation of dust mite. The surface of the mattress should be wiped clean once a week or have a dust mite protector put on it. The child should wear cotton or silk clothing and avoid any woollen blankets. Baths should be kept to a minimum. Oil can be put in the bath such as Oilatum or Alpha Keri. The water should not be too warm. The skin should be patted dry and moisturiser should be added to the skin straight away. This is usually in the form of an oatmeal moisturiser such as Aveeno or Dermaveen.  A topical steroid will help reduce inflammation. On the body I use Methylprednisolone or Advantan cream. On the face 1% Hydrocortisone with Hycor 1% eye ointment around the eyes. If the skin is weeping then secondary infection is presumed present and Bactroban cream or some Dicloxacillin or Flucloxacillin orally is given. When topical steroids are used they should be used intensively two to three times a day for three to four days and then there should be a break during which only moisturiser is applied. The moisturiser is applied first and the steroid cream is applied to the areas of eczema. Recently topical immunomodulators such as Pimecrolimus and Tacrolimus have been used. Pimecrolimus and 0.03% Tacrolimus are equivalent to 1% hydrocortisone. 0.1% Tacrolimus is equivalent to a moderate potency steroid. They are particularly useful for the face, head and neck. They will not work in the presence of infection. They are mainly a preventative rather than a treatment modality. They are there to prevent flares. Occasionally they will cause burning and stinging particularly Tacrolimus. Wet dressings have already been described for severely affected children admitted to hospital. Antihistamines orally primarily act as a sedative but have been used for years. Valergan and Phenergan are usually used. Q 1: Are immune modulating drugs used to treat acute flares of atopic eczema? A 1: No topical steroids are used to treat acute flares. Immune modulating drugs such as Pimecrolimus are used to prevent flares. History: Question What do you think about if a child’s eczema suddenly flares? Answer You consider secondary infection. You consider a contact allergen and you also consider a herpes virus involving the eczema areas. This is known as eczema herpeticum. There are crusted papules or vesicles with erosions. They are often described as being monomorphic and punched out. If there are just crusts present it is impossible to differentiate between bacteria and viruses and swabs for both have to be taken. If eczema herpeticum is diagnosed Acyclovir should be given intravenously. In some cases of early eczema herpeticum you may be able to see the classic umbilicated vesicles of the herpes virus infection. Q 1: How do you treat eczema herpeticum? A 1: Admission to hospital and intravenous acyclovir. Avoid topical steroids

Diagnosis of Skin Diseases
 Heroes of Dermatology
 High Probability Dermatoses 
Atopic Dermatitis

 The video below covers the topics listed above in that order. You can download the video and then move the cursor at the base along to any subsection that you wish to view again.

 

Stream 1 General Dermatology - Common rashes in children

Topics to be covered in the Certificate Course.

Rubella
 Measles
 Enteroviruses
 Cocksackie virus infections
 Unusual childhood exanthems

When you are a child you get exposed to multiple viruses and you can contract a variety of viral skin rashes. These rashes are known as the childhood viral exanthems. They are numbered one to six but I think that this is a terribly unromantic way of describing these diseases. Many of them have been vaccinated out of existence but you still need to know about them. Most people have a childhood exanthem and get over it without any nasty sequelae but each of these viruses can have some dramatic sequelae associated with them and we will expand on these later. 

Many of these diseases are more aggressive if you get them as an adult rather than as a child. Some such as German measles (or Rubella) are a problem if you are female and get them when you are pregnant because of the effect of the virus on the developing foetus. 

Scarlet Fever is classified as a childhood exanthem but obviously it is not a viral exanthem. It is a streptococcal infection. It is still a big problem particularly in aboriginal children in Australia where it leads to heart and kidney disease. 

Erythema infectiosum is not a particularly dangerous disease if you are a child but if a pregnant women gets it then the foetus can develop a condition called Hydrops. 

The Gianotti Crosti syndrome is sometimes known as the papular acral located rash! That name describes the nature and location of the rash and the fact that the trunk and abdomen are usually clear. Generally the child is well. The exanthem follows on from a variety of preceding viral infections and can take several weeks to resolve. Causes parental anxiety!

Stream 1 General Dermatology - Infestations and Bites

Topics to be covered in the Certificate Course.

Scabies
Papular urticaria
Swimmer's itch and Seabather's eruption

Scabies

You should spend some time in this section because at some stage in your life you are going to either get scabies or pubic lice from a close encounter of the sexual kind or your children are going to come home with nits in their hair. Scabies is the king of infestations. If you get two people in a family itchy at the same time it is scabies until proven otherwise. You diagnose scabies on the basis of the distribution of the rash and hopefully finding a small scabetic burrow in the skin. Sometimes the only way that you can convince people that they have scabies is to deroof a burrow and show the scabetic mite under a microscope on a slide. If you have a dermatoscope then this is an excellent way to show the burrow.

Question

How will scabies present to you?

Answer

A patient will come in and they will be complaining of itch. They will say that it is all over but if you ask them if it involves the face and head they will say no. When you examine them you will find the skin is excoriated and scratched and it can be quite difficult to find a burrow. If you are looking for a burrow the main areas to look are as follows:

Ø      The web spaces between the fingers.

Ø      The wrist especially the ulna surface.

Ø      Around the point of the elbow.

Ø      The anterior axillary fold.

Ø      The periumbilical area.

Ø      And also the genital skin especially in males.

Look for post scabetic nodules. These are areas of hypersensitivity to the scabies mite in the skin and they are particularly seen on scrotal skin and in the axillae.

Stream 1 General Dermatology - Selected Infections

Topics to be covered in the Certificate Course.

Herpes simplex
 Herpes zoster
 Varicella
Other less common Herpes subtypes
Papilloma virus (Warts)
Impetigo and Folliculitis

The common wart is really the human papilloma virus. It is an ubiquitous infection in childhood. Luckily most individuals will develop an immune reaction within a couple of months and then the warts will disappear. However there are a considerable proportion of patients who do not develop normal immune reactions and warts can persist for two to three years. Young warts are more immunogenic than old warts. They have more surface wart markers that the immune system can recognise and mount an immune response to, so I think it is important to actually treat warts early. They can be treated with various topical irritants usually containing mixtures of salicylic acid and lactic acid such as Duofilm wart paint or they can be frozen with liquid nitrogen, again simply to cause some local inflammation and make the viral markers on the surface of the epidermal cell more obvious. Unless an immune reaction occurs the warts will not disappear.

 Note that the HPV typing has reached as high a number as 78, so theoretically you are only immune to that particular serotype when you develop an immune reaction. Luckily most of these serotypes are uncommon. Some are oncogenic and it is important to recognise this because what looks like a wart can subsequently become a squamous cell skin cancer. You do not have to know specifically what HPV types are associated with which tumours. You should just be aware there are a lot of HPV types.
 Note that wart tissue is confined to the epidermis but it expands and pushes the dermis down giving the impression that it has roots that go deep, but it really does not. Proper removal of a wart involving only epidermal tissue should not give rise to scarring. Note though that wart HPV virus extends well beyond the margins of an obvious wart, in fact sometimes up to 5mm. This is why surgical removal is so uniformly unsuccessful or should I say only has about a 20% success rate, simply because not enough tissue is removed. Plantar warts, because of pressure, tend to grow inwards, but again they do not break through the basement membrane. 
Various treatment modalities for warts will be discussed in the Certificate course.. Because there are so many treatments it means that no one is uniformly successful.

Stream 1 General Dermatology - Fungal disorders

Topics to be covered in the Certificate Course.

Variants of Candida
 Variants of Tinea
 Steroid modified tinea
Onychomycosis

Tinea corporis has a spreading scaling edge with healing in the centre. If it involves hair follicles there may be persistent red areas around the follicle and sometimes a small pustule at the edge. Tinea capitis involving the scalp will cause damage to the hair with breaking of the hair at different levels. It will also involve the scalp surface giving rise to redness and scale. These features help to differentiate it from other causes of hair loss such as alopecia areata where there is no scale and the surface is smooth and the hairs tend to come out from the base. A kerion is a peculiar type of fungal infection of the scalp usually caused by an animal fungus. It is characterised by a marked inflammatory reaction that looks like a big abscess. The word kerion is Greek for honeycomb indicating the nature of the draining pustular abscesses. This is a scarring process so it is important to diagnose it early. It needs treatment surprisingly with both oral steroids to suppress the inflammation and an oral anti fungal such as Griseofulvin to kill off the dermatophyte fungus. 

Tinea faciei is often complicated by having topical steroids applied to it. The topical steroids will reduce the inflammation but it will not get rid of the fungus and so the lesion will slowly extend in size but it may not have the typical scaly edge and it may not have the inflammatory reaction you would expect from say an animal fungus but once the topical steroid is stopped it certainly will flare up.

Tinea pedis or athlete’s foot is common in people who sweat a lot or who do not dry between their toes properly. A lot of students will have this condition. It causes fissuring and scaling in the web spaces between the toes but you can get the dryer hyperkeratotic type that affects the heels and the soles of the feet giving prominent skin markings and thickening of the epidermis and you can get the hypersensitivity type which gives small little vesicles under the skin like a pompholyx eczema.

Stream 2 Skin Cancer and Tumours - Common worrying possible skin cancers

Topics to be covered in the Certificate Course.

BCC
SCC
Keratoacanthoma
Lichenoid keratosis
Melanoma

Melanoma 

As a Dermatology Nurse you may be asked  to recognise the types of solar keratoses and the various types of basal and squamous cell skin cancers. However the most dangerous skin cancer in the body is a melanoma. (There is actually another one called a Merkel cell carcinoma that is worse but leave that for now.) Most people think these arise from pre-existing moles but only about 40% do. The other 60% arise de novo as a new black lesion on the skin. Of course as in everything in medicine, not all melanomas are black. The most dangerous melanoma of all is the amelanotic melanoma that presents as a pink nodule on the back of males. They can look very non specific like a dermal nevus and as such are usually ignored until they grow quite thick and reach the lymphatics deeper in the skin and the blood vessels and spread elsewhere before they are cut out.

As in most things in dermatology once you have seen a few images of them you will get the idea of what is normal and what is not. Various instruments have been employed to try to help in the diagnosis of melanoma and the most useful is an instrument called the dermatoscope. This gives a view of the underlying pigment distribution in a pigmented lesion and can be exceedingly useful in diagnosing melanoma and conversely noting that a pigmented lesion is a benign lesion. We will look at dermatoscopes when discussing melanomas in a later module.