Dermatology ebook download

It is lavishly illustrated with more than 2, top-quality, full-color photographs. The accompanying text clearly and thoroughly covers the etiology, clinical features, diagnosis and treatment of each disease.

We have uploaded a genuine PDF ebook copy of this book to our online file repository so that you can enjoy a blazing-fast and safe downloading experience. Download Link. Share this Post with your friends. Moreover Cmecde. If you feel that we have violated your copyrights, then please contact us immediately. Save my name, email, and website in this browser for the next time I comment. Notify me of follow-up comments by email. In the controlled by sympathetic adrenergic The skin also has a rich and adaptive reticular and papillary dermis there are innervation.

The apocrine glands blood supply. Arteries in the subcutis arteriovenous anastomoses which are represent a phylogenetic remnant of branch upwards, forming a superficial well innervated and concerned with the mammalian sexual scent gland. Branches extend to the The lymphatic drainage of the skin is dermal papillae Fig. Veins and assemble into larger vessels which drain from the venous side of this loop ultimately drain into the regional to form the mid-dermal and lymph nodes.

Derivatives » Sebaceous glands, associated with hair follicles, are androgen sensitive. A cross-section through Fig.

Undifferentiated cells in the basal Rate of maturation with vital functions [Table 1 including layer and the layer immediately above Kinetic studies show that, on average, the protection and homeo stasis of the divide continuously.

Half of these cells the dividing basal cells replicate every body. The resultant upwards and differentiate. In the prickle cell layer, cells to reach the stratum corneum and a Table 1 Functions of skin change from being columnar to further 14 days to be shed. The cell Presents barrier to physical agents polygonal.

Differentiating turnover time is considerably Protects against mechanical injury keratinocytes synthesize keratins shortened in keratinization disorders Prevents loss of body fluids which aggregate to form tonofilaments. Reduces penetration of UV radiation The desmosomes connecting Helps regulate body temperature keratinocytes are condensations of Acts as a sensory organ tonofilaments.

Desmosomes distribute Affords a surface for grip structural stresses throughout the Hair growth Plays a role in Vitamin D production epidermis and maintain a distance of In most mammals, hair or fur plays an Acts as an outpost for immune surveillance 20 nm between adjacent cells.

In the granular layer, enzymes the conservation of heat; this is not the induce degradation of nuclei and case in 'nude' humans. Scalp hair in organelles. Keratohyalin granules humans does function as a protection Keratinocyte maturation mature the keratin and provide an against the cancer-inducing effects of amorphous protein matrix for the ultraviolet radiation; it also protects The differentiation of basal cells into tonofilaments.

Membrane-coating against minor injury. However, the dead, but functionally important, granules attach to the cell membrane main role of hair in human society is as corneocytes is a unique feature of the and release an impervious lipid an organ of sexual attraction, and skin.

The horny layer is important in containing cement which contributes therein lies its importance to the preventing all manner of agents from to cell adhesion and to the horny layer cosmetics industry. The rate of hair growth differs microorganisms, water and particulate 4.

In the horny layer, the dead, depending on the site. For example, matter. The epidermis also prevents the flattened corneocytes have developed eyebrow hair grows faster and has a body's fluids from getting out. The hair. On average, there are about following sequence during strong disulphide bonds of the keratin hairs on the scalp, and the keratinocyte maturation Fig. However, if it individual hairs, although dries out i. The three phases of hair 5.

The corneocytes are eventually development Fig. Physiology of the skin 7 1. Anagen is the growing phase. For Fig. These are packaged into through the evaporation of sweat and scalp hair this lasts from years, but granules which are moved down by direct heat loss from the surface.

Blood flow are in anagen, and about scalp Melanin granules form a protective cap Skin temperature is highly responsive follicles switch to catagen per day.

Dilation or 2. Catagen is the resting phase and nuclei in the inner layers of the contraction of the dermal blood vessels lasts weeks.

Hair protein synthesis epidermis. Arteriovenous anastomoses 3. Telogen is the shedding phase, the skin. Each day wavelengths of to nm UVB - superficial venous plexuses Fig.

Local of hairs being in telogen at any one photo-oxidation of preformed melanin, factors, both chemical and physical, can time.

UV radiation also Sweat induces keratinocyte proliferation, The production of sweat cools the skin Melanocyte function resulting in thickening of the through evaporation. The minimum Melanocytes located in the basal layer epidermis. Maximum daily secretion is elongated, membrane-bound due not to differences in melanocyte 10 litres, with a maximum output of organelles known as melanosomes numbers, but to the number and size of about 2 litres per hour. Men sweat melanosomes produced.

Red-haired more than women. Thermoregulation depends to emotion and after eating spicy food. Keratin Keratins are high-molecular-weight polypeptide chains produced by keratinocytes Fig. They are the major constituent of the stratum corneum, hair and nails. Keratin polypeptides are of different molecular weight e. Epidermal keratin Fig. The than the harder, hair keratin. Melanin Melanin is produced from tyrosine Fig. Most natural melanins are mixtures of eumelanin and phaeomelanin.

Melanins act as an energy sink and free-radical scavengers, and absorb the energy of UV radiation. Eumelanin is a high-molecular-weight polymer of complex structure formed by oxidative polymerization. The phaeomelanin polymer is synthesized from dopaquinone and cysteine via cysteinyl dopa. Collagen Collagen is synthesized by fibroblasts Fig. The main amino acids in collagen are glycine, proline and hydroxyproline.

Tropocollagen is formed from three polypetide chains which are coilded m type VIII - found in endothelial around each other in a triple helix. Assembled collagent fibrills are nm wide. In the dermis, chondroitin sulphate is the main GAG, along with dermatan sulphate and hyaluronan. GAGs often exist as high-molecular- weight polymers with a protein core. These structures are known as proteoglycans [Fig. The skin surface has a slightly acidic pH between 6 and 7.

Sebum Table 1 , sweat and the horny layer including Hormone Site of production Effects intercellular lipid contribute to the surface conditions, Vitamin D Produced in dermis from Important for the absorption precursors though the of calcium and for calcification which generally discourage microbial proliferation.

Triglyceride is broken down by lipase to give free sebum fatty acid FFA - an energy source - and glycerol Fig. Melanocyte-stimulating Pituitary gland Stimulate melanogenesis hormone MSH Adrenocorticotrophic hormone ACTH Oestrogens Adrenal cortex Stimulate melanogenesis Ovaries Epidermal growth factor Skin probably produced Receptors found on EGF at several sites in, as well keratinocytes, hair follicles, as outside, the skin] sebaceous glands and sweat duct cells Stimulates differentiation Alters calcium metabolism Cytokines and Cell membrane may be Effects on immune function, eicosanoids produced by several skin inflammation and cell cells, including keratinocytes proliferation Fig.

They form the horny layer, nails and hair. Melanin is a complex polymer synthesized from tyrosine. There are eu- and phaeo-types. Melanins absorb free radicals and energy including UV. It is synthesised byfibroblasts.

GAG makes up the ground substance of skin. They provide viscosity and hydration, andean exist as high MW polymers. Much of the original research into immunology was done using the skin as a model. Equally, the generous blood and and may be divided into Thl promote inhibits Thl cells lymphatic supplies to the dermis are inflammation, secrete IL-3, interferon- Interferon- T cells, natural inhibits Th2 cells, important channels through which gamma killer NK cells favours Thl cell gamma and tumour necrosis factor- immune cells can pass to or from their OFN--Y development beta and Th2 stimulate B cells to sites of action.

B-lymphocytes cells and macrophages Table 1. Langerhans cell Certain cytokines activate the nuclear are not found in normal skin, but are The Langerhans cells of the epidermis factor NF -kappa B cell signalling seen in some disease states.

They in inflammation. Eicosanoids are non- Mast cell are dendritic, bone-marrow-derived cells specific inflammatory mediators Mast cells which release histamine and characterized ultrastructurally by a e. Langerhans cells arachidonic acid by mast cells, macrophages. Both may be recruited to play an important role in antigen macrophages and keratinocytes. Dendritic cells are also seen in the dermis; these lack the Complement Birbeck granule but their other Keratinocyte Activation of the complement cascade characteristics suggest that they too can Keratinocytes may have an down either the classical or the present antigen.

They can alternative pathways results in produce proinflammatory cytokines molecules that have powerful effects. T lymphocyte especially interleukin-1 and express on These include opsonization, lysis, T lymphocytes circulate through their surface immune reactive molecules mast-cell degranulation, smooth normal skin.

Different types of T cell such as MHC class II antigens muscle contraction and chemotaxis for with differing functions are recognized, e. HLA-DR and intercellular neutrophils and macrophages. Adhesion molecules Functional systems The adhesion molecules, particularly Skin-associated lymphoid tissue ICAM-1, are cell-surface molecules The skin, with its afferent blood found on lymphocytes and sometimes supply, lymphatic drainage, regional on endothelial cells and keratinocytes.

Immunogenetics Cytokines and eicosanoids The tissue type antigens of an Cytokines are soluble molecules that individual are found in the major mediate actions between cells. They are histocompatibility complex MHC , Fig.

The dendritic produced by T lymphocytes and located in man on the HLA gene Langerhans cells form a network in the epidermis. In this section, the Langerhans cells have been sometimes by other skin cells, cluster on chromosome 6. Pemphigus DRw4 10 In addition, the appearance of 4 Psoriasis B13 specific HLA genes is associated with Dw7 10 an increased likelihood of certain Cw6 12 diseases, some of which are Psoriatic arthropathy B27 10 'autoimmune' in nature Table 2.

Bw38 9 Reiter's disease B27 35 Hypersensitivity reactions and the skin Hypersensitivity is the term applied when an adaptive immune response is inappropriate or exaggerated to the degree that tissue damage results. The skin can exhibit all the main types of hypersensitivity response.

On encountering Antibodies directed against an antigen on target skin cells or structures antigen e. For example, crosslinked, producing degranulation and the release of inflammatory IgG pemphigus antibodies directed against desmoglein on the keratinocyte mediators. These include preformed mediators such as histamine and newly surface result in activation of complement, attraction of effector cells and the formed ones e.

The result in the skin is lysis of the keratinocytes. Intra-epidermal blisters result. Haemolytic anaemia urticaria, although massive histamine release can cause anaphylaxis. The and transfusion reactions are other examples of type II hypersensitivity. Some response occurs within minutes, although a delayed component is of these conditions are 'autoimmune'. Factors other than IgE can cause mast cell degranulation.

Type III immune complex disease Type IV cell-mediated or delayed Immune complexes formed by the combination of antigen and antibodies in Specifically sensitized Th lymphocytes have secondary contact with the the blood are deposited in the walls of small vessels, often those of the skin. Complement activation, platelet aggregation and the release of lysosomal Cytokine release produces T cell activation and amplifies the reaction by enzymes from polymorphs cause vascular damage.

Tissue damage results vasculitis is seen with, for example, systemic lupus erythematosus and which is maximal at hours. Allergic contact dermatitis [see p. The 'Arthus reaction' is due to immune complex formation at a of type IV reaction. The responses to skin infections such as leprosy or local site. It can be induced in the skin by an intradermal injection, and is tuberculosis are granulomatous variants of the reaction.

J Immunology « Skin provides a physical barrier to infection. T lymphocytes. They are localized by adhesion molecules. HLA-DRw4 with pemphigus. The Human Genome Project has now mapped all human genes, of which there are about 30, Genetics has been found to be more complicated than the original Mendelian concept, and common conditions such as atopy occur due to a complex interaction between multiple susceptibility genes and the environment.

Table 1 Skin conditions or characteristics with definite or probable gene localities The human chromosomes on the chromosomes The human genome comprises Chromosome Disease or characteristic 23 pairs of chromosomes which are 1 porphyria cutanea tarda: enzyme p. Divided by the 4 red hair colour, psoriasis PsorsS gene complex. The phenotype is the linkage and using probes to identify 9 tuberous sclerosis p. The 12 epidermolysis bullosa simplex: keratin 5 p. A DNA restriction enzymes at specific sites, Cp.

The two DNA strands of the a stable population. Molecular techniques can be used to: double helix are linked by hydrogen detect small amounts of DNA, e. RNA copies are made and the compare the base sequences with family members similarly affected by a order of the bases determines the amino disorder, thus mapping a specific gene polymorphism characteristic for that acid content of the final protein.

The human genome contains 30, genes. The mapping of disease- associated genes is often based on observing when two genes adjacent on a chromosome are inherited together Fig. Showing migration of DNA after cutting with enzymes, Fig. Molecular genetics and the skin 13 Forms of inheritance An individual with two different genes alleles at a particular locus is heterozygous and one who has identical alleles is homozygous.

Genes borne on chromosomes other than X and Y are autosomal whereas those on X and Y are sex-linked. Factors governing genetic penetrance are unclear. Heredity is complex and more than simply dominant or recessive: 11 Dominant: Affected individuals both sexes are heterozygous for Fig.

Consanguinity subtly distinct cells. In the skin, this i Autosomal Darier's disease p. Recessive is revealed by the developmental dominant Dysplastic naevus syndrome [p. There is a growth pattern of Blaschko's lines Ichthyosis vulgaris [p.

Certain dermatoses e. A dermatomal distribution erythroderma p. Phenylketonuria p. The somatic post- from the father or the mother. It may X-linked Incontinentia pigmenti p. These tend p. Psoriasis may be inherited polygenically or by an autosomal dominant gene with incomplete penetrance. Paternal heredity seems more important than Gene therapy maternal.

In contrast, in atopic eczema Antenatal diagnosis is possible in maternal genes may have a certain genodermatoses p. An atopy gene is Recessive disorders in which there is a located on chromosome Inheritance single gene defect, e. Streaks and clearer Table 2. Epidermolysis bullosa ichthyosis or recessive epidermolysis whorls follow the lines of Blaschko. It Some dermatoses are associated with remains to be seen whether this will polymorphisms in the HLA complex work in practice.

I Molecular genetics and the skin » The human genome of 23 chromosomes karyotype 46XY or 46XX contains 30, genes, all of which have now been mapped. Rather than follow appear in Blaschko's lines. Blaschko's lines this occurs in a dermatomal » Gene therapy should be possible for some recessive single gene disorders.

A lesion is a general term for an ulceration. An eruption or rash is a more Below is a selection of other commonly encountered widespread skin involvement normally composed of several dermatological terms. Macules the skin, generally denned as less than greater than 5 mm in diameter , can be hypopigmented, as in vitiligo; 5 mm in diameter. Papules may be flat- nodules can involve any layer of the pigmented, as in a freckle a ; or topped, as in lichen planus; skin and can be oedematous or solid.

A bulla is similar to a vesicle but larger: A vesicle is a small blister less than greater than 5 mm in diameter. The 5 mm in diameter consisting of clear blisters of bullous pemphigoid a and fluid accumulated within or below the pemphigus vulgaris p. Vesicles may be grouped as examples.

Intra-epidermal vesicles are shown in the Figure left b. Glossary of Other Dermatological Terms Abscess: A localized collection of pus formed by Comedo: A plug of sebum and keratin in the dilated necrosis of tissue. Alopecia: Absence of hair from a normally hairy area. Crust: Dried exudate normally serum, blood or pus on Atrophy: Loss of epidermis, dermis or both.

Atrophic the skin surface. Erosion: A superficial break in the epidermis, not Callus: Local hyperplasia of the horny layer, often of the extending into the dermis, which heals without scarring. Erythema: Redness of the skin due to vascular Carbuncle: A collection of boils furuncles causing dilatation. Excoriation: A superficial abrasion, often linear, which Cellulitis: A purulent inflammation of the skin and is due to scratching. Terminology of skin lesions 15 Pustule Cyst: Wheal A pustule is a visible collection of free A cyst is a nodule consisting of an A wheal is a transitory, compressible pus in a blister.

Pustules may indicate epithelial-lined cavity filled with fluid papule or plaque of dermal oedema, infection e. An epidermal red or white in colour and usually always, as pustules seen in psoriasis, 'sebaceous' cyst is shown below. Olaque Seale Ulcer Ulcer A plaque is a palpable, plateau-like A scale is an accumulation of An ulcer is a circumscribed area of skin elevation of skin, usually more than thickened, horny layer keratin in the loss extending through the epidermis 2 cm in diameter.

Plaques are rarely form of readily detached fragments. Ulcers are usually the more than 5 mm in height and can be Scales usually indicate inflammatory result of impairment of the vascular or considered as extended papules. They may be fine, as in peripheral arterial disease. Fissure: A linear split in the epidermis, often just Papilloma: A nipple-like projection from the skin extending into the dermis.

Folliculitis: An inflammation of the hair follicles. Petechia: A haemorrhagic punctuate spot measuring Freckle: A macular area in which there is increased mm in diameter. Poikiloderma: A combination of hyperpigmentation, Furuncle: A pyogenic infection localized in a hair follicle. Hypertrichosis: Excessive hair growth in a Purpura: Extravasation of blood resulting in red nonandrogenic pattern. Keloid: An elevated and progressive scar not showing Scar: The replacement of normal tissue by fibrous regression.

Keratosis: A horn-like thickening of the skin. Stria: An atrophic linear band in the skin - white, pink Lichenification: Chronic thickening of the skin with or purple in colour. The result of connective tissue increased skin markings, a result of rubbing or changes. Telangiectasia: Dilated dermal blood vessels giving rise Milium: A small white cyst containing keratin. The time needed to take a history depends on the History taking in dermatology can be divided into four complaint.

For example, the history in a patient with hand basic investigations: the presenting complaint, past medical warts can usually be completed quickly, but more time and history, social and family history, and drug history. Presenting complaint Prior to any diagnosis, it is essential to find out when, where and how the Case history 1 problem started, what the initial An year-old male bank clerk developed a lesions looked like and how they scaly erythematous plaque on the left elbow evolved and extended.

Symptoms, Fig. It spread to involve particularly itching, must be recorded the other elbow and both knees, but was not along with any aggravating or itchy. He developed scaliness in the scalp exacerbating factors, such as sunlight. His mother once had a similar rash. Diagnosis: psoriasis [p.

Past medical history Patients must be asked about any previous skin disease or atopic Case history 2 symptoms, such as hay fever, asthma A year-old woman was referred from the or childhood eczema.

Internal medical department of respiratory medicine where disorders may be relevant; these can she had recently been diagnosed as having involve the skin directly or may be pulmonary sarcoidosis.

Three weeks associated with certain skin diseases. She was on no medication. An incisional biopsy confirmed the clinical impression. Diagnosis: erythema nodosum p. Social history Many social factors can cause or drugs is being considered , as well as influence a patient's skin complaint.

Living or travelling in Occupational factors can induce warm climates potentially exposes an contact dermatitis or other skin individual to a wide range of tropical changes, and it is often necessary to and subtropical infections, and to ask the patient to explain exactly what strong sunlight. If the eruption improves when the patient is away from work, occupational factors should be suspected.

Hobbies also may involve Case history 3 contact with objects or chemicals that A year-old male printer engineer gave a produce contact dermatitis. A Knowledge of the patient's living few months previously he had started to use conditions and home background can the solvent trichloroethylene in his job. Patch be helpful in understanding a problem testing was negative. On substituting a and deciding on a treatment. Alcohol different solvent the eruption cleared. Some Diagnosis: von Recklinghausen's disorders with prominent skin signs neurofibromatosis NF p.

Others such as psoriasis or atopic eczema have a strong hereditary component. In Case history 5 addition to genetic syndromes, a family A year-old female shop assistant history may reveal that other family complained of brownish macules over her members have had a recent onset of an back [Fig. During her It is sometimes also necessary to teens, she had developed several soft enquire about sexual contacts.

Her father had developed a few similar nodules in later life, and one of her two brothers had brown patches on his skin. Case history 4 A year-old schoolboy gave a three-month history of an intensely itchy papular eruption Table 1 Itchy eruption: diagnosis affecting the hands, wrists and penis Table 1].

Symptom Intensely itchy eruption Several lesions were excoriated [Fig. Possible diagnosis Scabies Treatment with a potent topical steroid was of Lichen planus little benefit. His mother and sister had also Dermatitis herpetiformis recently developed itchy lesions.

Close examination showed burrows in the skin. Urticaria Eczema Diagnosis: scabies p. Insect bites Fig. Drug history Both prescribed and self-administered medicaments can result in a 'drug Case history 7 eruption'.

Almost all patients try an An year-old female secretary was given over-the-counter topical preparation griseofulvin for a fungal infection. She went [or a friend or relative's ointment on sun-bathing and 12 hours later developed an rashes, and many have had a variety of eruption with a distribution in light-exposed treatments prescribed which may be areas Fig. It is important to quiz the patient about all medicament use, including use of over-the-counter tablets or creams which the patient may well not think relevant.

Cosmetics and moisturizing creams Fig. Case history 6 « Identify any factors in the social or family A year-old woman had a minor irritating history that may be relevant.

It may be eruption on her forehead. She applied an necessary to ask specifically about a antihistamine-containing cream which she history of eczema or psoriasis in relatives.

Within 24 hours of » Record the recent use of any drugs and applying it, her face became severely swollen medications, including topical agents. Patch testing carried out later « Ask about use of cosmetics and in showed an allergic reaction to the cream. Diagnosis: medicament dermatitis p. Palpation Looking at the whole skin often reveals diagnostic lesions reveals the consistency of a lesion that the patient is unaware of or may think unimportant.

It is important to: Distribution Stand back from the patient and e. Is it limited to sun- groin or axilla, will suggest certain observe the pattern of the eruption exposed areas? Is it linear? Determine whether it is Dermatomal patterns are also seen.

For example, guttate psoriasis and localized e. If the latter, determine if commonest example of this, but some trunk, whereas lichen planus often the eruption is symmetrical and, if so, naevi also appear in this guise or occurs around the wrists, and contact peripheral or central.

Note whether it follow Blaschko's lines p. Regional dermatitis frequently affects the face or involves the flexures e. Examining the skin 19 Case history 1 Individual lesion morphology An 8-year-old girl gave a month history of A hand lens is often helpful in looking an itchy eruption affecting the antecubital at individual lesions. Palpation [often and popliteal fossae [Fig. Her mother had neglected by medical students is also Table 1 Configuration of lesions a similar rash as a child.

The pattern and the important to determine the consistency, Configuration Condition morphology were characteristic. Definitions of lesions Linear Psoriasis, lichen striatus, linear Diagnosis: atopic eczema [p.

There may also be Annular Tinea corporis ringworm , mycosis secondary changes on top of primary fungoides, urticaria, granuloma lesions. The local configuration of annulare, annular erythemas lesions is often of diagnostic help Koebner Lichen planus, psoriasis, [Table 1.

Determine whether the phenomenon viral warts, molluscum contagiosum, lesions are grouped, linear or annular, sarcoidosis or if they show the Koebner phenomenon [p.

Nails, hair and mucous membranes The nails, scalp and hair frequently show diagnostic and even pathognomonic Case history 2 signs [p. With any unusual or atypical eruption, the mucous membranes of the mouth and genitalia may show important changes, such as oral involvement Six weeks ago a year-old man developed by Wickham's striae in lichen planus, oral lesions in Kaposi's sarcoma, or vulval a slightly itchy linear area running down the involvement with lichen sclerosus.

Dermatological conditions giving a linear eruption include lichen planus, morphoea, psoriasis and linear epidermal naevus. General examination Diagnosis: lichen striatus, a self-limiting Palpation of lymph nodes is important in patients with skin malignancy. In inflammatory dermatitis of unknown origin. Palpation of pedal pulses is vital in patients with leg ulcers. Special techniques Clinical diagnoses of many skin conditions can be verified by a number of special techniques.

Use of Wood's lamp, which emits ultraviolet radiation, will cause hair and, to a lesser extent, the skin to fluoresce in certain fungal infections. It may also be used to show up vitiligo, or hypopigmented macules in tuberous sclerosis. Viewing skin scrapings [treated with a potassium hydroxide solution under a light microscope can be helpful in confirming the presence of fungal hyphae.

In scabies, the acarus can be extracted using a needle and viewed under the Examining the skin microscope. Examine the entire skin surface.

Surgery can be Use a hand lens and adequate used either to excise lesions as a illumination. Look at the nails, hair and mucous Other important ancillary techniques membranes. Topical therapy Table 1 An overview of topical medicaments Drug Indications Pharmacology Topical treatment has the advantage of Corticosteroids Eczemas, psoriasis, lichen planus, Mode of action is through vasoconstrictive, direct delivery and reduced systemic discoid lupus erythematosus, sunburn, anti-inflammatory and anti-proliferative effects; toxicity.

It consists of a vehicle or base pityriasis rosea, mycosis fungoides, medication is available in different strengths; photodermatoses, lichen sclerosus side-effects need to be considered which often contains an active Antiseptics Skin sepsis, leg ulcers, infected eczema Chlorhexidine, benzalkonium chloride, silver nitrate ingredient Table 1.

A liquid vehicle, often impetigo, infected eczema polymixin, sodium fusidate, and mupirocin are available; aqueous or alcohol-based, which resistance and sensitization are potential problems. Metronidazole is used for rosacea may contain a salt in solution. A Antifungals Fungal infections of the skin, Nystatin, clotrimazole, miconazole, econazole, terbinafine, shake lotion contains an insoluble Candida albicans infections ketoconazole, sulconazole and amorolfine are available powder e.

A semi-solid emulsion of oil- Parasiticidals Scabies, lice Benzyl benzoate, permethrin and malathion for scabies; in-water; contains an emulsifier for malathion. A transparent semi-solid, non- ointments greasy emulsion. A semi-solid grease or analogues and promote differentiation; creams and ointments oil, containing little or no water but available sometimes with added powder.

No Keratolytics Acne, scaly eczemas Salicylic acid, benzoyl peroxide and tretinoin preservative is usually needed. The Retinoids Acne, psoriasis Isotretinoin [acne , tazarotene psoriasis active ingredient is suspended rather than dissolved. An ointment base with a high proportion of powder starch or be applied to the terminal phalanx of zinc oxide producing a stiff the index finger Fig.

One FTU equals consistency. The safe maximum amount varies Therapeutic properties of the with the strength of the steroid, the age vehicle of the patient and the length of Lotions evaporate and cool the skin treatment. Ointments are best for dry which are used once daily. They rehydrate and occlude, but being Pharmacokinetics greasy are difficult to wash off and are The ability of a drug to penetrate the epidermis depends on several factors. These less acceptable to patients than creams.

Quantities required One application to the whole body Emollients requires g of ointment. The adult Emollients help dry-skin conditions such as eczema and ichthyosis by face or neck requires 1 g, trunk each re-establishing the surface lipid layer and enhancing rehydration of the side 3 g, arm I g, hand ljz g, leg 3 g epidermis. Common emollients include emulsifying ointment, aqueous cream, and foot 1 g. Oils added to bath water can also help e.

If outpatient man- Desoximethasone 0. Dressings, Potent Betamethasone valerate 0. These Fluticasone propionate 0. Hydrocortisone butyrate 0. Very potent Clobetasol propionate 0. Many types of paraffin gauze, hydrocolloid and alginate dressings are now available for leg ulcers p. Systemic therapy Systemic treatments are used particularly for the more Topical steroids serious conditions and for infections.

Details are given in A summary of the indications for topical treatment with Table 3. The relative potencies of the more commonly prescribed preparations are shown in Table 2. Other treatments Side-effects of topical steroid therapy A wide variety of other, more specialized treatments exists The use of topical steroids carries the potential for harmful for specific skin conditions.

Corticosteroids are sometimes side-effects. These include: injected directly into lesions e. Certain s atrophy of the skin - thinning, erythema, telangiectasia, disorders are responsive to ultraviolet B or purpura and striae [p. There are now viral infections may be potentiated very few indications for X-ray treatment of non-malignant m allergic contact dermatitis due to a component of the disease, although irradiation is of great value in several types preparation or to the steroid itself of skin tumour.

Corticosteroids Prednisolone usually Bullous disorders, connective tissue disease, vasculitis » When using topical steroids: Cytotoxics Methotrexate Psoriasis, sarcoidosis Hydroxyurea Psoriasis - use the lowest potency that is effective Azathioprine Bullous disorders, chronic actinic dermatitis, atopic eczema - look out for side-effects, especially Immunosuppressants Ciclosporin Psoriasis, atopic eczema, pyoderma gangrenosum atrophy Gold Bullous disorders, lupus erythematosus - emollients can help reduce the steroid Immunomodulators Inosine pranobex Viral warts genital , herpes simplex genital requirement.

Retinoids Acitretin Psoriasis, other keratinization disorders » Explain the treatment to the patient and Isotretinoin Acne preferably give a written handout; this Antifungals Griseofulvin, terbinafine Fungal infection helps compliance. The fingertip unit is a Ketoconazole Fungal infection C. Antihistamines H 1 blockers Urticaria, eczema » Prescribe adequate amounts.

Patients are Antiandrogens Cyproterone Acne females only often given too little, 'run out' of their Antimalarials Hydroxychloroquine Lupus erythematosus, porphyria cutanea tarda creams, and return to clinic no better as Antileprotic Dapsone Dermatitis herpetiformis, leprosy, vasculitis the treatment has been inadequate. Skin commonest complaints Fig. Only a minority seek disease is also economically significant; it is a major medical advice.

Demographic studies may experiencing the disorder within a stated period of time reveal a trend; e. Patients seen in a specialist dermatology clinic are a selected The type, prevalence and incidence of skin disease all population Fig. In some countries, e. Referral patterns vary between different regions, depending on Skin disease in the general population local facilities, interests and customs.

In the early s, a quarter of all new referrals require a minor surgical procedure. Socio-economic factors Improvements in the standard of living poorer standards of living are a cause For example, the habit of sun bathing resulting from the 19th century of this.

Occupational in the incidence of malignant of most infectious diseases and a dermatitis is quite common in melanoma in the s and s. Increased the numerous articles and programmes conditions and the introduction of sophistication in Western countries on the potential problems associated hygienic measures are thought to have also means that patients now want with a change in pigmented naevi have been important.

Most forms of something done about disorders or produced a flood of referrals of worried infectious disease, including those of minor imperfections that would not patients seeking reassurance about their the skin, are now more common in the have bothered past generations.

However, it is still true that Third World than in Western Changes in social fashion have also many people with minor skin problems countries, and it would seem that the brought about changes in skin disease. Epidemiology of skin disease 23 Geographic factors Humid conditions found in hot countries predispose to fungal and bacterial infections, and to other conditions such as 'prickly heat' an itchy eruption due to blocked sweat ducts.

Ultraviolet radiation in sunny climes will obviously result in actinic damage and malignant change in the skin of non-pigmented migrants to the area. Figure 4 shows a comparison between some common complaints in different geographic locations. The rates for bacterial and fungal infections show variation, and skin cancers are more common in Australia. However, Fig. Racial and cultural factors Quite apart from the obvious differences in pigmentation, Africans, whereas mongoloid skin has a tendency to become the skin structure varies between the different races p.

Vitiligo appears to For example, hair is often spiral in black Africans but have a similar incidence in all races, but is more straight in mongoloids. In Caucasians, hair is more variable conspicuous in those with a dark skin. Skin tumours and Cultural factors may bring problems. For example, tight actinic damage are seen more in Caucasians than in black braiding of the hair, practiced by some Afro-Caribbeans, Africans, with mongoloids showing an intermediate may result in alopecia, while the use of certain traditional incidence.

Keloids and hair problems, such as oils or cosmetics can produce a dermatitis or a change in pseudofolliculitis p. Age and sex prevalence of dermatoses Different disorders are associated with encountered in defined age-groups. For decades of life. Certain disorders tend different times of life [Table 1. Some example, atopic eczema is most to appear in middle age, for example, disorders occur throughout life but are common in infants, acne is mainly pemphigus and malignant melanoma.

Thus the age structure of the population will influence the type of dermatology Table 1 Age-related onset of selected skin disorders practiced. Age Disorder Some conditions are more common Childhood Port-wine stain and strawberry naevi, ichthyosis, erythropoietic protoporphyria, epidermolysis to a specific gender Table 2.

Skin diseases can thus states. Many dermatologists believe of skin outpatients suffer make patients into 'social lepers' who that psychological factors can, for 'psychological distress' from their feel that their social lives are restricted example, make eczema and psoriasis condition. Backed by the expertise of more than world-renowned contributors, it is the reference of choice for clinicians, students, and educators.

Fitzpatrick's skillful blending of science and clinical medicine is matched only by its scope, level of detail, and quality of presentation. The Ninth Edition continues this tradition of excellence with sweeping changes designed to make it even more relevant to today's practice and education. The ALL-NEW Fitzpatrick's: New editors diverse in expertise and international in location of practice have endeavored to build on the achievements of previous editions, while providing fresh insight into the content and new thinking regarding optimal structure of the book Reorganized and updated content - important general basic science concepts are extensively covered in dedicated chapters appearing at the beginning of the book, allowing subsequent clinical chapters to focus on relevant disease-specific pathophysiology, in addition to clinical features, diagnosis, clinical course, and management Unmatched visual presentation includes more than 3, illustrations, including more than 2, full-color photographs; all tables and At-a-Glance boxes are either new or completely revised An improved index to speed you to the information you require about a concept, condition, or therapy Call Number: AccessMedicine unlimited simultaneous users.

Textbook of Pediatric Dermatology by Peter H. Hoeger Editor ; Alan D. Irvine; Albert C. Yan Editor The third edition of this highly regarded text continues to provide a comprehensive resource for pediatric dermatologists.

The book offers evidence-based diagnosis and treatment recommendations and covers both common and rare conditions, including emerging conditions and research, especially at the genetic level. A refreshing new text design makes the book more accessible, and new editors and contributors bring a distinctly international perspective to the work.

Johnston, MD, provides a superb overview of key diagnoses in dermatopathology and is ideal for quickly looking up practical problems in the recognition and diagnosis of skin lesions both clinically and histologically. Thousands of illustrations, an accessible format, and cross references to the encyclopedic and authoritative Weedon's Skin Pathology, 4th Edition, make this a must-have reference for pathologists and dermatologists in practice and in training.

More than 3, color histopathologic and clinical images provide complete visual coverage of key diagnostic points for dermatological entities Numerous summary tables and diagnostic algorithms guide you to the most likely diagnosis and set of differential diagnoses for numerous inflammatory and neoplastic skin conditions.

Outline format and bullet point style make essential information for any given lesion easy to find and review.