Skin Tumours: Types, Symptoms, and Management

Skin tumours are abnormal growths of skin cells that can be benign or malignant. Basal cell carcinomas are the most common malignant skin tumour, usually caused by excessive sun exposure in early life and previous sunburn. They often present as a slow-growing nodule or papule that forms an ulcer with a raised ‘rolled’ edge. Basal cell carcinomas grow slowly and rarely metastasise.

Low-risk basal cell carcinomas can be managed in primary care if the GP meets the requirements to perform skin surgery. A specialist referral is appropriate for most people with a suspicious skin lesion, and urgent referral is necessary if there is a concern that a delay may have a significant impact.

Squamous cell carcinomas have a crusted or ulcerated surface, while seborrhoeic warts have a warty pigmented surface appearance. Lentigo maligna is a melanoma in situ that progresses slowly and can remain non-invasive for years. In amelanotic melanoma, the colour may be pink, red, purple, or the colour of normal skin, and growth is likely to be rapid with a poor prognosis.

In conclusion, early detection and management of skin tumours are crucial for better outcomes. Regular skin checks and seeking medical advice for any suspicious skin lesion are recommended.

Understanding the Causes of Cellulitis: Streptococcus, Staphylococcus, Herpes Simplex Virus, Pseudomonas, and Varicella Zoster Virus

Cellulitis is a common skin infection that is characterized by a red, tender area of skin associated with a fever. The most common pathogen causing cellulitis is streptococcus, which can enter the body through excoriated skin. Staphylococcus can also cause cellulitis, but it is less common than streptococcus. Herpes simplex virus typically causes cold sores or genital warts, and can be inoculated into abrasions, but this would produce a vesicular rash. Pseudomonas is not a common pathogen in cellulitis, but can occur following puncture wounds or in immunocompromised people. Varicella zoster virus causes Chickenpox and shingles, but neither of these descriptions are seen in cellulitis. Understanding the different causes of cellulitis can help with proper diagnosis and treatment.

Penile Cancer, Chancroid, and Syphilis: A Comparison

Penile cancer is a rare condition in the UK, but is more commonly seen in patients from Asia and Africa. It is often associated with poor hygiene and herpes infections, and can cause difficulty in retracting the foreskin. The 5-year survival rate with lymph-node involvement is around 50%.

Chancroid, on the other hand, is characterized by a painful ulcer. Lymphadenitis is also painful, and may progress to a suppurative bubo. Multiple ulcers may be present.

In syphilis, the primary chancre typically heals within 4-8 weeks, with or without treatment.

While these conditions may have some similarities, they are distinct and require different approaches to diagnosis and treatment. It is important to seek medical attention if you suspect you may have any of these conditions.

Types of Leg Ulcers and Their Characteristics

Leg ulcers can be caused by various factors, and each type has its own distinct characteristics. Here are some of the common types of leg ulcers and their features:

Arterial Ulcers: These ulcers are usually found on the feet, heels, or toes. They are painful, especially when the legs are at rest and elevated. The borders of the ulcer have a punched-out appearance, and the feet may appear cold, white, or bluish.

Neurotrophic Ulcers: These ulcers have a deep sinus and are often located under calluses or over pressure points. They are painless, and the surrounding area may have diminished or absent sensation.

Malignant Ulcers: Ulcers that do not respond to treatment may be a sign of malignant ulceration, such as squamous cell carcinoma.

Vasculitic Ulcers: Systemic vasculitis can cause multiple leg ulcers that are necrotic and deep. There may be other vasculitic lesions elsewhere, such as nail-fold infarcts and splinter hemorrhages.

Venous Ulcers: These ulcers are located below the knee, often on the inner part of the ankle. They are relatively painless but may be associated with aching, swollen lower legs. They are surrounded by venous eczema and may be associated with lipodermatosclerosis. There may also be atrophie blanche and localised hyperpigmentation.

In conclusion, identifying the type of leg ulcer is crucial in determining the appropriate treatment and management plan.

Combining oral isotretinoin with tetracyclines is not recommended as it may lead to benign intracranial hypertension. Trimethoprim is not suitable for treating skin or soft tissue infections. Clindamycin, a lincomycin antibiotic, can be used for such infections, especially if the patient is allergic to penicillin. Co-amoxiclav doesn’t interact with isotretinoin, but it cannot be used in patients with penicillin allergy. Doxycycline, a tetracycline antibiotic, should be avoided when a patient is taking isotretinoin due to the risk of benign intracranial hypertension.

Understanding Isotretinoin and its Adverse Effects

Isotretinoin is a type of oral retinoid that is commonly used to treat severe acne. It has been found to be effective in providing long-term remission or cure for two-thirds of patients who undergo a course of treatment. However, it is important to note that isotretinoin also comes with several adverse effects that patients should be aware of.

One of the most significant adverse effects of isotretinoin is its teratogenicity, which means that it can cause birth defects in fetuses if taken during pregnancy. For this reason, females who are taking isotretinoin should ideally be using two forms of contraception to prevent pregnancy. Other common adverse effects of isotretinoin include dry skin, eyes, and lips/mouth, low mood, raised triglycerides, hair thinning, nosebleeds, and photosensitivity.

It is also worth noting that there is some controversy surrounding the potential link between isotretinoin and depression or other psychiatric problems. While these adverse effects are listed in the British National Formulary (BNF), further research is needed to fully understand the relationship between isotretinoin and mental health.

Overall, while isotretinoin can be an effective treatment for severe acne, patients should be aware of its potential adverse effects and discuss any concerns with their healthcare provider.

Tetracyclines are the preferred oral antibiotics for treating moderate to severe acne vulgaris. This condition is a common reason for patients to visit their GP and can significantly impact their quality of life.

To address this patient’s acne and scarring, it would be appropriate to initiate a topical treatment and prescribe an oral antibiotic. Referral to a dermatologist may also be necessary, but first-line treatment may be effective.

Tetracyclines are the recommended first-line oral antibiotics for acne vulgaris. All tetracyclines are licensed for this indication, and there is no evidence to suggest that one is more effective than another. The choice of specific tetracycline should be based on individual preference and cost.

Tetracycline and oxytetracycline are typically prescribed at a dose of 500 mg twice daily on an empty stomach. Doxycycline and lymecycline are taken once daily and can be taken with food, although doxycycline may cause photosensitivity.

Minocycline is not recommended for acne treatment, and erythromycin is a suitable alternative to tetracyclines if they are contraindicated. The usual dose for erythromycin is 500 mg twice daily.

Acne vulgaris is a common skin condition that usually affects teenagers and is characterized by the obstruction of hair follicles with keratin plugs, resulting in comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the number and type of lesions present. Treatment for acne typically involves a step-up approach, starting with single topical therapy and progressing to combination therapy or oral antibiotics if necessary. Tetracyclines are commonly used but should be avoided in certain populations, and a topical retinoid or benzoyl peroxide should always be co-prescribed to reduce the risk of antibiotic resistance. Combined oral contraceptives can also be used in women, and oral isotretinoin is reserved for severe cases under specialist supervision. Dietary modification has no role in the management of acne.

Serologic studies reveal that adults aged 60 years and above have been exposed to Chickenpox to a great extent. Hence, it is recommended that individuals within the age range of 70-79 years should receive the vaccine, irrespective of their memory of having had Chickenpox. However, the vaccine may not be as efficacious in individuals above 80 years of age.

Varicella-Zoster Vaccination: Protection Against Chickenpox and Shingles

Varicella-zoster is a herpesvirus that causes Chickenpox and shingles. There are two types of vaccines available to protect against these infections. The first type is a live attenuated vaccine that prevents primary varicella infection or Chickenpox. This vaccine is recommended for healthcare workers who are not immune to VZV and for individuals who are in close contact with immunocompromised patients.

The second type of vaccine is designed to reduce the incidence of herpes zoster or shingles caused by reactivation of VZV. This live-attenuated vaccine is given subcutaneously and is offered to patients aged 70-79 years. The vaccine is also available as a catch-up campaign for those who missed out on their vaccinations in the previous two years of the program. However, the shingles vaccine is not available on the NHS to anyone aged 80 and over because it seems to be less effective in this age group.

The main contraindication for both vaccines is immunosuppression. Side effects of the vaccines include injection site reactions, and less than 1 in 10,000 individuals may develop Chickenpox. It is important to note that vaccination is the most effective way to prevent varicella-zoster infections and their complications.

Pemphigoid: A Skin Condition Caused by Furosemide

Pemphigoid is a skin condition that typically affects elderly individuals, presenting as tense blisters on the arms and legs. In some cases, it can be caused by the use of furosemide, a diuretic medication. While other diuretics can also cause pemphigoid, it is a rarer occurrence.

A positive immunofluorescence test can confirm the diagnosis, and treatment typically involves the use of steroids. It is important to differentiate pemphigoid from pemphigus, which presents in younger age groups and causes flaccid blisters that easily erupt and leave widespread lesions.

Overall, recognizing the signs and causes of pemphigoid is crucial for proper diagnosis and treatment.

Patients who have developed rhinophyma as a result of rosacea should be referred to a dermatologist for further evaluation and treatment. Rhinophyma is a severe form of rosacea that affects the nasal soft tissues, causing nasal obstruction, disfigurement, and significant psychological distress. Only specialized care in secondary settings can provide the necessary assessment and management, which may include laser therapy, scalpel excision, electrocautery, or surgery.

Continuing with self-management measures is not recommended as the patient requires an escalation in treatment. However, lifestyle modifications remain an essential aspect of her management.

Prescribing oral doxycycline is not appropriate in this case as the patient is pregnant, and the medication is contraindicated.

Topical brimonidine is also not recommended as the manufacturer advises against its use during pregnancy due to limited information available. While it can provide temporary relief of flushing and erythema symptoms, it is not a suitable treatment option for rhinophyma.

Rosacea, also known as acne rosacea, is a skin condition that is chronic in nature and its cause is unknown. It typically affects the nose, cheeks, and forehead, and the first symptom is often flushing. Telangiectasia, which are small blood vessels that are visible on the skin, are common, and the condition can progress to persistent erythema with papules and pustules. Rhinophyma, a condition where the nose becomes enlarged and bulbous, can also occur. Ocular involvement, such as blepharitis, can also be present, and sunlight can exacerbate symptoms.

Management of rosacea depends on the severity of the symptoms. For mild symptoms, topical metronidazole may be used, while topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia. More severe cases may require systemic antibiotics such as oxytetracycline. It is recommended that patients apply a high-factor sunscreen daily and use camouflage creams to conceal redness. Laser therapy may be appropriate for patients with prominent telangiectasia, and those with rhinophyma should be referred to a dermatologist for further management.

Stevens-Johnson Syndrome: A Severe Drug Reaction

Stevens-Johnson syndrome (SJS), also known as erythema multiforme major, is a severe and extensive drug reaction that always involves mucous membranes. This condition is characterized by the presence of blisters that tend to become confluent and bullous. One of the diagnostic signs of SJS is Nikolsky’s sign, which is the extension of blisters with gentle sliding pressure.

In addition to skin lesions, patients with SJS may experience systemic symptoms such as fever, prostration, cheilitis, stomatitis, vulvovaginitis, and balanitis. These symptoms can lead to difficulties with micturition. Moreover, SJS can affect the eyes, causing conjunctivitis and keratitis, which carry a risk of scarring and permanent visual impairment.

If there are lesions in the pharynx and larynx, it is important to seek an ENT opinion. SJS is a serious condition that requires prompt medical attention.

Acne vulgaris is a common condition that can significantly impact a patient’s quality of life. The severity of acne can range from mild to severe, and in this case, the patient has moderate to severe acne. Treatment with an oral antibiotic is recommended, and a referral to a dermatologist has already been scheduled.

Tetracyclines are typically the first-line treatment for acne vulgaris, but they are contraindicated in pregnant women. This patient is pregnant, so an alternative antibiotic is needed. Oral tetracyclines should also be avoided in breastfeeding women and children under 12 years old due to the risk of deposition in developing teeth and bones.

Erythromycin is a suitable alternative to tetracyclines for the treatment of acne vulgaris in pregnancy. The usual dose is 500 mg twice a day. Some specialists may use trimethoprim, but it is unlicensed for this indication. Women of childbearing age should use effective contraception, especially if using a topical retinoid concomitantly.

Acne vulgaris is a common skin condition that usually affects teenagers and is characterized by the obstruction of hair follicles with keratin plugs, resulting in comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the number and type of lesions present. Treatment for acne typically involves a step-up approach, starting with single topical therapy and progressing to combination therapy or oral antibiotics if necessary. Tetracyclines are commonly used but should be avoided in certain populations, and a topical retinoid or benzoyl peroxide should always be co-prescribed to reduce the risk of antibiotic resistance. Combined oral contraceptives can also be used in women, and oral isotretinoin is reserved for severe cases under specialist supervision. Dietary modification has no role in the management of acne.

The patient’s symptoms suggest acne rosacea, which is characterized by flushing, erythema, and telangiectasia on the nose, cheeks, and forehead, as well as the presence of papules and pustules. This condition is known to worsen with alcohol consumption. In contrast, acne vulgaris typically presents with comedones, papules, pustules, nodules, and/or cysts, and is less erythematous than rosacea. Erythema ab igne, on the other hand, is caused by exposure to high levels of heat or infra-red radiation, while psoriasis is characterized by a silver-scaly rash that typically appears on the knees and elbows. Although the patient’s symptoms could be mistaken for a butterfly rash, there is no evidence to suggest lupus.

Rosacea, also known as acne rosacea, is a skin condition that is chronic in nature and its cause is unknown. It typically affects the nose, cheeks, and forehead, and the first symptom is often flushing. Telangiectasia, which are small blood vessels that are visible on the skin, are common, and the condition can progress to persistent erythema with papules and pustules. Rhinophyma, a condition where the nose becomes enlarged and bulbous, can also occur. Ocular involvement, such as blepharitis, can also be present, and sunlight can exacerbate symptoms.

Management of rosacea depends on the severity of the symptoms. For mild symptoms, topical metronidazole may be used, while topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia. More severe cases may require systemic antibiotics such as oxytetracycline. It is recommended that patients apply a high-factor sunscreen daily and use camouflage creams to conceal redness. Laser therapy may be appropriate for patients with prominent telangiectasia, and those with rhinophyma should be referred to a dermatologist for further management.

NICE Guidance on Cellulitis and Erysipelas Treatment

NICE has recently updated its guidance on the treatment of cellulitis and erysipelas with NG141. According to the new guidelines, Flucloxacillin 500mg qds is the first choice treatment for people over the age of 18. The recommended course of treatment is an oral course for 5 to 7 days. However, if a person is severely unwell or unable to take oral medication, a twice daily course of the intravenous antibiotic may be necessary. Based on clinical assessment, a longer course of up to 14 days may be needed. It is important to note that skin takes time to return to normal, and full resolution at 5 to 7 days is not expected.

Topical Steroids for Eczema Treatment

Eczema is a common skin condition that causes red, itchy, and inflamed skin. Topical steroids are often used to treat eczema, but it is important to use the weakest steroid cream that effectively controls the patient’s symptoms. The potency of topical steroids varies, and the table below shows the different types of topical steroids by potency.

To determine the appropriate amount of topical steroid to use, the fingertip rule can be applied. One fingertip unit (FTU) is equivalent to 0.5 g and is sufficient to treat an area of skin about twice the size of an adult hand. The table also provides the recommended number of FTUs per dose for different areas of the body.

The British National Formulary (BNF) recommends specific quantities of topical steroids to be prescribed for a single daily application for two weeks. The recommended amounts vary depending on the area of the body being treated.

In summary, when using topical steroids for eczema treatment, it is important to use the weakest steroid cream that effectively controls symptoms and to follow the recommended amounts for each area of the body.

Patients who have developed skin changes due to varicose veins, such as pigmentation and eczema, should be referred to secondary care.

Understanding Varicose Veins

Varicose veins are enlarged and twisted veins that occur when the valves in the veins become weak or damaged, causing blood to flow backward and pool in the veins. They are most commonly found in the legs and can be caused by various factors such as age, gender, pregnancy, obesity, and genetics. While many people seek treatment for cosmetic reasons, others may experience symptoms such as aching, throbbing, and itching. In severe cases, varicose veins can lead to skin changes, bleeding, superficial thrombophlebitis, and venous ulceration.

To diagnose varicose veins, a venous duplex ultrasound is typically performed to detect retrograde venous flow. Treatment options vary depending on the severity of the condition. Conservative treatments such as leg elevation, weight loss, regular exercise, and compression stockings may be recommended for mild cases. However, patients with significant or troublesome symptoms, skin changes, or a history of bleeding or ulcers may require referral to a specialist for further evaluation and treatment. Possible treatments include endothermal ablation, foam sclerotherapy, or surgery.

In summary, varicose veins are a common condition that can cause discomfort and cosmetic concerns. While many cases do not require intervention, it is important to seek medical attention if symptoms or complications arise. With proper diagnosis and treatment, patients can manage their condition and improve their quality of life.

Erythrodermic Psoriasis: A Dermatological Emergency

Erythrodermic psoriasis is a severe form of psoriasis that requires immediate medical attention. It is characterized by widespread whole body erythema and systemic unwellness, which can lead to complications such as hypothermia and heart failure. This condition can also be caused by other dermatological conditions or medications such as lithium or anti-malarials.

Injudicious use of steroids with rapid withdrawal can also trigger erythroderma. Therefore, it is crucial to seek medical attention as soon as possible to prevent skin failure. The correct course of action is immediate hospital admission for supervised treatment. Dermatologists recommend close monitoring and management of erythrodermic psoriasis to avoid life-threatening complications.

Treatment Options for Scabies and Head Lice

Scabies is a skin condition characterized by intense itching and visible burrows in the finger webs. The first-line treatment for scabies is permethrin 5%, which should be applied to all household members and followed by washing of bedding and towels. If permethrin cannot be used due to allergy, malathion 0.5% aqueous solution can be used as a second-line treatment. Benzyl benzoate 25% emulsion is an older treatment for scabies and has been replaced by more effective methods.

On the other hand, head lice can be treated with permethrin 1%, which is not strong enough for scabies treatment. It is important to note that ivermectin 200 µg/kg orally is only used for crusted scabies, which causes a generalized rash with lots of scale. Topical permethrin remains the ideal treatment for scabies.

Juvenile spring eruption (JSE) is a skin condition that typically affects boys aged 5-14 years during the spring season. It is caused by sun exposure and appears as a blistering rash on the ears, causing discomfort and itchiness. The recent holiday to Tenerife suggests a possible risk factor for this condition. Treatment involves using emollients and antihistamines, and symptoms usually resolve within a week.

The rash associated with Chickenpox starts as red macules that become raised, blister, and crust over time. It is often accompanied by cold-like symptoms and fever and tends to be more widespread, affecting the trunk and limbs. This rash typically lasts for 4-10 days. However, since the patient has a 2-day history of a blistering rash isolated to the ears, Chickenpox is an unlikely diagnosis.

Given the patient’s short history, the characteristic rash, and the absence of any relevant medical history, eczema is an unlikely possibility.

Chondrodermatitis nodularis is a skin condition that is commonly seen in middle-aged or elderly patients. It is characterized by small skin-colored nodules that typically appear on the helix of the ear.

Understanding Juvenile Spring Eruption

Juvenile spring eruption is a skin condition that occurs as a result of sun exposure. It is a type of polymorphic light eruption (PLE) that causes itchy red bumps on the light-exposed parts of the ears, which can turn into blisters and crusts. This condition is more common in boys aged between 5-14 years, and it is less common in females due to increased amounts of hair covering the ears.

The main cause of juvenile spring eruption is sun-induced allergy rash, which is more likely to occur in the springtime. Some patients may also have PLE elsewhere on the body, and there is an increased incidence in cold weather. The diagnosis of this condition is usually made based on clinical presentation, and no clinical tests are required in most cases. However, in aggressive cases, lupus should be ruled out by ANA and ENA blood tests.

The management of juvenile spring eruption involves providing patient education on sun exposure and the use of sunscreen and hats. Topical treatments such as emollients or calamine lotion can be used to provide relief, and antihistamines can help with itch relief at night-time. In more serious cases, oral steroids such as prednisolone can be used, as well as immune-system suppressants.

In conclusion, understanding juvenile spring eruption is important for proper diagnosis and management. By taking preventative measures and seeking appropriate treatment, patients can manage their symptoms and improve their quality of life.

Stevens-Johnson Syndrome: A Serious Skin Reaction

Stevens-Johnson syndrome is a rare but serious skin reaction that can be fatal. It is considered to be part of a disease spectrum that includes erythema multiforme and toxic epidermal necrolysis. However, some experts believe that erythema multiforme should not be classified as part of the same spectrum as it is associated with infections while SJS and TEN are reactions to certain drugs.

The most common drugs implicated in SJS are sulphonamides, but other medications such as penicillins, antifungals, and anticonvulsants can also cause the reaction. Less than 10% of the epidermis sloughs off in SJS, compared to over 30% in TEN.

Management involves stopping the suspected causative drugs as soon as possible and immediate admission to an intensive care or burns unit. The prognosis is better if the drugs are stopped within 24 hours of bullae appearing.

Staphylococcal scalded-skin syndrome is a differential diagnosis that can be mistaken for SJS. It is caused by a bacterial infection and tends to occur in young children.

Herpes simplex virus can cause erythema multiforme, but this rash is not the same as SJS. Shingles, caused by varicella-zoster virus, is another condition with a painful blistering rash that is confined to a dermatome.

Acne vulgaris is a common skin condition that usually affects teenagers and is characterized by the obstruction of hair follicles with keratin plugs, resulting in comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the number and type of lesions present. Treatment for acne typically involves a step-up approach, starting with single topical therapy and progressing to combination therapy or oral antibiotics if necessary. Tetracyclines are commonly used but should be avoided in certain populations, and a topical retinoid or benzoyl peroxide should always be co-prescribed to reduce the risk of antibiotic resistance. Combined oral contraceptives can also be used in women, and oral isotretinoin is reserved for severe cases under specialist supervision. Dietary modification has no role in the management of acne.

Topical Treatments for Facial Psoriasis

When it comes to treating facial psoriasis, it’s important to use the right topical treatments to avoid skin irritation and adverse effects. The National Institute for Health and Care Excellence (NICE) recommends using a mild or moderately potent steroid for two weeks, along with emollients. Calcipotriol can be used intermittently if topical corticosteroids aren’t effective enough. However, betamethasone, a potent steroid, should not be used on the face. Coal-tar solution is also not recommended for facial psoriasis. Tacrolimus ointment can be used intermittently if other treatments aren’t working. By using the appropriate topical treatments, patients can manage their facial psoriasis effectively.

Molluscum Contagiosum: Symptoms, Treatment, and Underlying Causes

Molluscum contagiosum is a viral skin infection caused by a DNA pox virus. It is characterized by small, dome-shaped papules with a central punctum that may appear umbilicated. Squeezing the lesions can release a cheesy material. While the infection usually resolves on its own within 12-18 months, patients may opt for treatment if they find the rash unsightly. Squeezing the lesions can speed up resolution.

However, if a patient presents with hundreds of widespread lesions, it is important to investigate any underlying immunodeficiency problems. This may include conditions such as HIV/AIDS. Further investigation is necessary to determine the cause of the extensive rash.

Treatment Options for Mild-to-Moderate Comedonal Acne

Comedonal acne, characterized by blackheads and whiteheads, can be effectively treated with topical preparations. The first-line treatment is topical retinoids such as adapalene, tretinoin, or isotretinoin, followed by azelaic acid or benzoyl peroxide. While some initial redness and skin peeling may occur, this typically subsides over time. If excessive irritation occurs, treatment should be reduced or suspended until the reaction subsides. Adapalene is the preferred option due to its low irritation potential. Treatment should be applied once daily to all affected areas and continued until no new lesions appear. Topical retinoids are not recommended during pregnancy, and women of childbearing age should use effective contraception.

Topical retinoids work by normalizing follicular keratinization, promoting comedone drainage, and inhibiting new comedone formation. They are also effective at treating inflammation by inhibiting microcomedone formation, as supported by evidence from placebo-controlled trials. In severe cases, manual extraction of sebum using a comedone extractor may be necessary, along with benzoyl peroxide for inflamed lesions. Topical antibiotics are ineffective against non-inflamed lesions, while systemic antibiotics are used for inflamed lesions and systemic retinoids for severe acne or treatment failures.

Managing Comedonal Acne: Topical Treatment Options and Considerations

The ABCDEF Checklist for Assessing Suspicious Pigmented Lesions

The ABCDEF checklist is a useful tool for assessing suspicious pigmented lesions, particularly for identifying potential melanomas. The checklist includes six criteria: asymmetry, irregular border, irregular colour, dark or diameter greater than 6 mm, evolutionary change, and funny looking.

Asymmetry refers to a lack of mirror image in any of the quadrants when the lesion is divided into four quadrants. Irregular border and irregular colour are self-explanatory, with irregular colour indicating at least two different colours in the lesion and lack of even pigmentation throughout the lesion being particularly suspicious. Dark or diameter greater than 6 mm refers to the size and colour of the lesion, with blue or black colour being particularly concerning. Evolutionary change refers to changes in size, colour, shape, or elevation.

The presence of any one of these criteria should raise suspicion of melanoma and prompt urgent referral to a dermatologist. Additionally, the funny looking criterion, also known as the ugly duckling sign, should be considered. This refers to a mole that appears different from the rest, even if ABCD and E criteria are absent.

Overall, the ABCDEF checklist is a valuable tool for identifying potentially cancerous pigmented lesions and ensuring prompt referral for specialist assessment.

Hyperhidrosis is typically treated with topical preparations containing aluminium chloride as the first-line option.

Managing Hyperhidrosis

Hyperhidrosis is a condition characterized by excessive sweating. To manage this condition, there are several options available. The first-line treatment is the use of topical aluminium chloride preparations, which can cause skin irritation as a side effect. Another option is iontophoresis, which is particularly useful for patients with palmar, plantar, and axillary hyperhidrosis. Botulinum toxin is also licensed for axillary symptoms. Surgery, such as endoscopic transthoracic sympathectomy, is another option, but patients should be informed of the risk of compensatory sweating. Overall, there are several management options available for hyperhidrosis, and patients should work with their healthcare provider to determine the best course of treatment for their individual needs.

If simple analgesia and neuropathic analgesia are not effective in treating refractory pain in shingles, corticosteroids such as prednisolone can be used, but only for acute shingles. This is according to the NICE CKS guideline, which recommends considering oral corticosteroids in the first 2 weeks following rash onset in immunocompetent adults with localized shingles if the pain is severe, but only in combination with antiviral treatment. In the case of a patient who has been on antiviral treatment for seven days and has tried several analgesics without relief, a course of prednisolone would be an appropriate treatment option. Chlorphenamine, an antihistamine medication, may help alleviate itching symptoms but is not the most appropriate treatment option for severe pain. Flucloxacillin, an antibiotic, is not necessary unless there is evidence of co-existing cellulitis. Fluoxetine, a selective serotonin reuptake inhibitor, has no role in shingles management. Morphine, an opioid medication, may be considered if the pain doesn’t respond to corticosteroids.

Shingles is a painful blistering rash caused by reactivation of the varicella-zoster virus. It is more common in older individuals and those with immunosuppressive conditions. The diagnosis is usually clinical and management includes analgesia, antivirals, and reminding patients they are potentially infectious. Complications include post-herpetic neuralgia, herpes zoster ophthalmicus, and herpes zoster oticus. Antivirals should be used within 72 hours to reduce the incidence of post-herpetic neuralgia.

Treatment Options for Chronic Plaque Psoriasis

Chronic plaque psoriasis is a skin condition that can be exacerbated by beta-blockers. Therefore, it is important to discontinue the use of beta-blockers and explore alternative prophylactic drugs for migraine in patients with psoriasis. In addition, regular use of emollients is recommended.

For active therapy, potent corticosteroids, vitamin D analogues, dithranol, and tar preparations are all acceptable first-line options. However, corticosteroids and topical vitamin D analogues are typically preferred due to their ease of application and cosmetic acceptability. A Cochrane review found that combining a potent corticosteroid with a vitamin D analogue was the most effective treatment, with a lower incidence of local adverse events. Dovobet®, which combines betamethasone 0.1% with calcipotriol, is one such option. Calcipotriol used alone is also an acceptable alternative treatment.

For psoriasis of the face, flexures, and genitalia, calcineurin inhibitors such as tacrolimus and pimecrolimus are second-line options after moderately potent corticosteroids.

Managing Chronic Plaque Psoriasis: Treatment Options and Considerations

Notalgia paraesthetica is a condition that causes chronic itching or tingling on the medial border of the scapula. This can lead to the development of post-inflammatory hyperpigmentation due to repeated rubbing and scratching of the affected area. The exact cause of this sensory neuropathy is not fully understood.

Causes of Pruritus

Pruritus, commonly known as itching, can be caused by various underlying conditions. Liver disease, often associated with a history of alcohol excess, can present with stigmata of chronic liver disease such as spider naevi, bruising, palmar erythema, and gynaecomastia. Evidence of decompensation such as ascites, jaundice, and encephalopathy may also be present. Iron deficiency anaemia can cause pallor and other signs such as koilonychia, atrophic glossitis, post-cricoid webs, and angular stomatitis. Pruritus after a warm bath and a ruddy complexion may indicate polycythaemia. Gout and peptic ulcer disease can also cause itching. Chronic kidney disease may present with lethargy, pallor, oedema, weight gain, hypertension, lymphadenopathy, splenomegaly, hepatomegaly, and fatigue. Other causes of pruritus include hyper- and hypothyroidism, diabetes, pregnancy, senile pruritus, urticaria, and skin disorders such as eczema, scabies, psoriasis, and pityriasis rosea. It is important to identify the underlying cause of pruritus in order to provide appropriate treatment.

NICE Guidance on Assessing Pigmented Skin Lesions

NICE guidance on Suspected cancer: recognition and referral (NG12) recommends using the ‘7-point weighted checklist’ to evaluate pigmented skin lesions. This checklist includes major and minor features of lesions, with major features scoring 2 points each and minor features scoring 1 point each. Lesions scoring 3 or more points are considered suspicious and should be referred for further evaluation, even if the score is less than 3 and the clinician strongly suspects cancer.

For example, if a patient has a pigmented skin lesion that has changed in size and has an irregular shape, they would score 2 points for each major feature. Additionally, if the lesion has a diameter of 8 mm or more, it would score a single point for a minor feature. Therefore, the overall score for this lesion would be 5, indicating that it is suspicious and requires further evaluation.

It is important for clinicians to use this checklist when assessing pigmented skin lesions to ensure that potential cases of skin cancer are not missed.

Fungal Nail Infections: Causes, Symptoms, and Treatment

Fungal nail infections, also known as onychomycosis, can affect any part of the nail or the entire nail unit. However, toenails are more susceptible to infection than fingernails. The primary cause of fungal nail infections is dermatophytes, with Trichophyton rubrum being the most common. Yeasts, such as Candida, and non-dermatophyte molds can also cause fungal nail infections. Risk factors for developing a fungal nail infection include increasing age, diabetes mellitus, psoriasis, and repeated nail trauma.

The most common symptom of a fungal nail infection is thickened, rough, and opaque nails. Patients may present with unsightly nails, which can be a source of embarrassment. Differential diagnoses include psoriasis, repeated trauma, lichen planus, and yellow nail syndrome. To confirm a fungal nail infection, nail clippings or scrapings of the affected nail should be examined under a microscope and cultured. However, the false-negative rate for cultures is around 30%, so repeat samples may be necessary if clinical suspicion is high.

Asymptomatic fungal nail infections do not require treatment unless the patient is bothered by the appearance. Topical treatment with amorolfine 5% nail lacquer is recommended for limited involvement, while oral terbinafine is the first-line treatment for more extensive involvement due to a dermatophyte infection. Fingernail infections require 6 weeks to 3 months of therapy, while toenails should be treated for 3 to 6 months. Oral itraconazole is recommended for more extensive involvement due to a Candida infection, with pulsed weekly therapy being the preferred method.