BIOSOFT HELP FILES

1)      Widespread seborrheic dermatitis – exclude HIV infection

2)      Psoriasis

1)      Pityriasis rosea

2)      Pityriasis versicolor

3)      Seborrheic dermatitis -

4)      Herpes zoster –  lesions are maculopapular, plaques, vesicles, a grouping of vesicles, vesicles initially clear fluid, later purulent, neurological symptom restricted to the dermatome include hyperesthesia, dysesthesia, hypoesthesia, lesions along a dermatome, usually thoracic nerves (chest), cervical (neck) or lumbar nerves (posterior thigh), ophthalmic nerve (facial),  Ramsay Hunt Syndrome of zoster lesions in the pinna, hearing loss, facial pain, facial paresis, loss of taste sensation, vertigo (facial nerve), Mx – Oral Acyclovir 800 mg five times a day for 7-10 days, to be started within 24-72 hrs of onset, OR Valacyclovir 1000 mg PO tid for 1 week OR Famciclovir 500 mg PO tid for 1 week, valacyclovir and famciclovir superior to acyclovir for clinical outcomes, lesions management include wet compresses of  1:20 Burow’s solution, for secondary infections systemic antibiotics

1)      Zoster lesions in multiple dermatomes – immunocompromise

2)      Zoster lesions which are hemorrhagic, gangrenous, bullous (sever heres zoster ? underlying immunosuppression)

3)      Ophthalmic zoster involving the tip of the nose (risk of zoster keratoconjunctivitis, ophthalmologist referral)

4)      Zoster not responding to acyclovir (? HIV infection)

1)      Intertrigo – red macule as a mirror image in either side of the body fold, common sites are inframammary, axillary, inguinal, umbilical, sacral, neck, between fingers, anterior elbow areas, an initial macule may progress to oozing, exudation, erosion, painful fissuring, crusting, cellulitis, satellite papules, and pustules suggest C. albicans, Mx – manage usually underlying problems like obesity, diabetes, sweatiness, wetness and maceration with low hygiene, cellulitis needs Tx if present, promote drying of the area, prevent skin apposition, aerate the body fold, steroid-antibiotic creams,

2)      Seborrheic dermatitis – well demarcated area of fine, dry scaling,erythema, itchy lesions, papules and scales are the main primary lesions, common areas are scalp, face (eye brows, eye lids, nasolabial folds, postauricular groove, moustache and beard), upper chest and interscapular region, secondary infection of the lesions can ause impetigo, folliculits in addition, chronic recurrent disease, relapses triggered by fatigue, stress, cold weather,  common in infancy and adults and not seen in between infancy and adulthood, Mx – ketoconazole cream or lotion 2%, shampoos containing 0.1% triamcinolone, 2.5% selenium shampoo (5-10 min application 2-3 times weekly), exensive lesions which are inflammatory apply a topical steroid (in ascending potency) cream, lotion or gel, thick crusts require a keratolytic like salicylic acid, crusts can also removed by application of warm mineral oil for 1-2 hrs and then washing off with a soap, topical metronidazole effective in some, widespread unresponsive cases oral antifungals (ketoconazole 200 mg daily for 2-4 weeks OR itraconazole 100 mg daily for 3 weeks OR itraconazole 200 mg daily for  week OR terbinafine 250 mg daily for 4-6 weeks), oral antibiotics for clinically obvious skin infection, dermatology referral for severe cases for isotretinoin or immunomodulator therapy which helps many patients, remissions can be maintained by (in scalp and chest disease) by prophylactic antifungals, frequent washing with soap and water,

3)      Irritant dermatitis

4)      Tinea pedis – Dermatophytoses -  fissuring, maceration, scaling in between the toes, fine scaly rash of moccasin distribution

5)      Erythrasma – mild, chronic, localized lesion, dry, smooth, scaly, brownish, well-demarcated area, in the axillary, inframammary, genitocrural folds, fissuring in severe cases, diagnosed by coral-red fluorescence under Wood’s light, Mx – keep the area clean, dry well aerated, erythromycin or tetracycline 250 mg qid for 10-21 days, topical miconazole or clotrimazole,

6)      Miliaria

1)      Impetigo – Tx – Cloxacillin 30-50 mg/kg/day in divided doses 6 hourly PO OR cephalexin 30-50 mg/kg/day in divided doses 8 hourly PO OR children with penicillin allergy 

1)      Acne – Tx – Local applications – Adapalene gel, cream, solution 0.1% OD, bd or every other day application, Tazarotene gel or cream 0.05-0.1% OD, Tretinoin cream 0.1%, 0.05%, 0.025%, gel 0.01%, 0.025%, solution 0.05% OD, Clindamycin gel 1%, lotion 1%, solution 1% or swab 1% bd application, Erythromycin gel 2%, solution 2%, bd application, Azelaic acid cream 20% cream bid application, Benzoyl peroxide 2.5%,5%,10% gel, 2.5%, 5%, 10% wash OD-bid application, Drugs - Doxycyline 50-100 mg daily, Tetracycline 250-500 mg qid, Minocycline 50-100 mg OD-bd, Erythromycin 250-500 mg bd.  Treatment algorithm – mild acne use topical retinoids, benzoyl peroxide, topical antibiotics in that order until improvement, moderate acne – oral antibiotics for 12/52, add benzoyl peroxide or topical antibiotic, on failure switch onto hormonal therapy, severe acne – topical antibiotic and hormonal therapy OR dermatologist referral for isotretinoin therapy, maintenance therapy – benzoyl peroxide OR topical antibiotics, -

2)      Folliculitis in the face -

3)      Rosacea – earliest features are central facial erythema and telangiectasis, next stage central facial papules (rarely pustules) with erythema, chronic stage of rhinophyma with papules and telangiectasis, never itchy, lesions only in the face, never in the chest or back, common in adults than in teen like in acne, associated flushing episodes triggered by sun exposure, cold weather, hot beverages, emotions, associated eye changes (conjunctivitis which is itchy, burning, dry, gritty conjunctivitis, episcleritis, iritis) positive,  Mx – avoidance of triggers, topical metronidazole, topical clindamycin, if no response dermatologist referral for further management with isotretinoin therapy

4)      Seborrheic dermatitis -

5)      Herpes simplex primary infection – severe pain and tenderness prior to the appearance of the mucosal lesion, tenders cervical lymphadenopathy, multiple small vesicles, clusters of vesicles, perioral areas, lesions mostly in the gum, inside the mouth causing an acute gingivostomatitis (common in children) or acute pharyngotonsillitis (common in adults), symptoms last 5-7 days, unable to eat and drink, high fever, vesicles, erosions, and maceration in the buccal mucosa, erythematous and edematous gum margin, tender submandibular lymphadenopathy, Mx – Valacyclovir 1000 mg bid for 10 days OR Acyclovir 400 mg tid for 10 days

6)      Herpes simplex recurrent infection – herpes labialis – prodrome of tingling and burning at the site of rash, usually around lips, perioral area, cheeks, nose, neck, lesion progression in the following sequence, erythema, clear fluid vesicles, purulent vesicles, crusting and healing, vesicle clustering seen, tender lymphadenopathy, Mx – Valacyclovir 2000 mg bid for 1 day OR Famciclovir 500 mg tid for 5 days OR Acyclovir 800 mg tid for 5 days AND topical 1% penciclovir cream applied every 2 hourly for 4 days.

7)      Herpes ophthalmicus –

8)      Contact dermatitis

9)      Impetigo

10)    Perioral dermatitis – 

1)      Pityriasis alba

1)      Tinea pedis – toe web maceration,

2)      Atopic eczema

3)      Non-eczematous dermatitis

4)      Pitted keratolysis

5)      Onychomycosis – nail discoloration (white, brown), usually spread from nail edge towards the lunula of the nail, advancing along the lateral edges, sometimes total white discoloration of the nail, fissure formation in the nails, brittle, friable, thick nails, subungual debris, breakdown of the nail plate, Mx – Terbinafine (for dermatophyte infection, 250 gm daily for 6/52 for finger nail and 12/52 for toe nail infections, shorter courses and pulse dosing studied now, monitoring with FBC, ALT and AST levels baseline and then monthly recommended, prescribe only for healthy individuals), Itraconazole (dermatophytes, nondermatophytes, candida infections, fatal interaction with statins, diazepam, 200 mg daily for 6/52 finger nail infections and 12/52 for toe nail infections, monitoring with AST and ALT levels baseline and monthly, prescribe only for healthy individuals), Fluconazole (widespectrum like itraconazole, finger nail infection 200-400 mg once weekly for 3/12 and 6/12 for toe nails, monitoring not necessary, prescribe only for healthy individuals), managing predisposing conditions like tinea pedis, avoid foot maceration in tight footwear, keep feet dry always, wearing cotton socks.

1)      Proximal subungual onychomycosis (marker of immunocompromise if not due to trauma)

1)      Impetigo

2)      Pityriasis versicolor – Tinea versicolor – white, pink, or brown macules, mostly in the trunk in the adults and face in the children,  round and coalescing macules, very fine scales in the macule, hypo or hyperpigmented lesions, Mx – Ketoconazole 2% shampoo applied over the lesions kept overnight for 3 consecutive days, Ciclopirox shampoo applied over the lesions and kept for few minutes and rinsed and continue treatment for 2 weeks, any Imidazole antifungal cream applied over the lesion bid for 2 weeks.  Oral therapy includes Fluconazole single oral dose of 400 mg and a repeat dose of 200-400 mg fluconazole given 1 week later OR Itraconazole 200 mg daily for 5-7 days.

3)      Scabies – Initiallty itching localized to areas of lesions and the later becoming generalized pruritus, characteristic lesions are burrows (multiple straight or S-Shaped ridges, which appearas short, wavy, threadlike scaling lines, sometimes with a smallblack dot located at one end, representing the burrowing mite), papules, vesicles, excoriations, secondary impetigo, folliculitis or eczemaitization is not uncommon, characteristic distribution is finger webs, wrist, antecubital fossa, posterior aspect of elbow joint, nipples, umbilicus, lower abdomen, genitalia, gluteal cleft, inner thighs, in children plamoplantar and scalp lesions commoner, Mx – Permethrin 5% applied all over the body and kept overnight and washed off, a second application 1 week later if necessary, can be used even in children 2/12 and above, Gamma benzene hexachloride 10-20% lotion or cream applied all over the boy and kept for 8-12 hrs and washed off, apply well onto the areas of lesions particularly,  continue treatment for 3 consecutive days, clothes washed and dried well before using again, all close contacts should be treated at the same time.

4)      Pityriasis rosea – seen in adolescents and young adults, illness lasting 6-8 weeks, confers life-long immunity, 2-6 cm round, pink, scaly patch usually in the trunk, but can appear anywhere in the body, called ‘herald patch’, followed by a macular eruption mostly in the trunk and proximal limbs (face, hand and feet spared except in children), rarely papules too can be seen, macules are the main primary skin lesion with a collarette of fine scales (that is a rim of fines scale at the edge of the macule with free edge of the scale pointing to the center of the macule), macules number from few and sparse to many and confluent, are positioned with long axis parallel to the rib, come in crops for 7-10 days, with an overall appearance of Christmas tree-like appearance, Mx -  Depends on the severity of the disease ranging from no treatment, emollient creams, night time antihistamines, medium potency steroid creams, exposure to sunlight, oral erythromycin 250 mg qid, children 25-40 mg/kg/day in 4 divided doses, continued for 2 weeks, acyclovir 800 mg five times daily,

5)      Varicella  zoster – 1-2 days of fever, followed by the typical vesicular rash, period of infectivity lasts from day 1 of the illness to about 4-5 days after the onest of the vesicular eruption, pruritus, excoriations, secondary bacterial infections, scarring following healing if severe skin infections, lesion evolution include  erythematous maculopapules, to clear fluid vesicles with a base of areola (dew drops on a rose petal), umbilication of vesicles, vesicles turning purulent, crusting within 5 days, 3-5 crops of similar cycles within 5 days, in 1 area lesions of various stages of lesion evolution are seen, within 1-3 weeks crusts fall off and usually lesions heal without scarring, most common complication is secondary bacterial skin infection, lesions distribution mostly on the chest, abdomen and proximal part of the limbs, face and distal extremities relatively spared, Mx – Acyclovir 800 mg qid PO for 5 days from D1, symptomatic treatment with antihistamines, local antibiotics for secondary infections, systemic antibiotics if severe secondary skin infections, paracetamol for fever.  Varicella prevention without exposure adults - 2 doses with 6-week intervals, children 1-12 yrs - 1 dose, varicella prevention after exposure within 3 days for exposure - injection 1 dose, after 3 days before the onset of rash - acyclovir tx.

6)      Viral fevers and maculopapular rashes -

7)      Molluscum contagiosum -

8)      Urticaria

9)      Tinea corporis - starts as a small patch of erythematous macules and/or papules, patch enlarges with a clear demarcation border, border activity marked by vesicles and scaling, while borders enlarged center clears leaving an area of normal skin in the middle of the lesion, Mx – Econazole, Ketoconazole, Clotrimazole cream locally bid application for 4 weeks, relapse and reinfection common and continue watching for it, Fluconazole orally 150 mg/week for 4 weeks,

10)   Id reactions OR Dermatophytid reactions – grouped vesicles, pustules, or papules in a patient with tinea pedis or intertrigo.