College of Medicine, Al-Ahsa

DEPARTMENT OF MEDICINE
5TH YEAR

DERMATOLOGY
LOG BOOK

Student's name: Qasim Hussain Al-Haleimi

Academic number: 207002113

 Round 1

King Fahad Hospital dermatology clinic - Date: Saturday 14-05-2011 AD

Discussion:

Hirsutism:

Case # 1: a 40 year Saudi female patient admitted to the hospital complaining of excessive male pattern of hair growth
and was diagnosed to have (Hirsutism) that was reffered for OB/Gyne clinic for an associated Polycystic ovarian
syndrome, & to endocrinologist for an associated endocrinal abnormality.

Definition:

Hirsutism, defined as excessive male-pattern hair growth, affects approximately 10% of women. It usually represents a
variation of normal hair growth, but rarely it is a harbinger of a serious underlying condition. Hirsutism is often
idiopathic but may be caused by conditions associated with androgen excess, such as polycystic ovarian syndrome
(PCOS) or congenital adrenal hyperplasia (CAH)

Notes:

 Hair can be categorized as either vellus (fine, soft, and not pigmented) or terminal (long, coarse, and
pigmented).

 Androgens are necessary for terminal hair and sebaceous gland development and mediate differentiation of
pilosebaceous units (PSUs) into either a terminal hair follicle or a sebaceous gland.

 There are three phases in the cycle of hair growth: (1) anagen (growth phase), (2) catagen (involution phase),
and (3) telogen (rest phase). Depending on the body site, hormonal regulation may play an important role in
the hair growth cycle.

 The eyebrows, eyelashes, and vellus hairs are androgen-insensitive, whereas the axillary and pubic areas are
sensitive to low levels of androgens.

Causes of Hirsutism:

Clinical Evaluation:
Degree of Hirsutism:
Treatment:

Treatment of hirsutism may be accomplished pharmacologically or by mechanical means of hair removal.

Nonpharmacologic treatments should be considered in all patients, either as the only treatment or as an adjunct to drug
therapy.

Non-pharmacology:

(1) bleaching; (2) depilatory (removal from the skin surface) such as shaving and chemical treatments; or (3) epilatory
(removal of the hair including the root) such as plucking, waxing, electrolysis, and laser therapy. Electrolysis is
effective for more permanent hair removal, particularly in the hands of a skilled electrologist.

Pharmacology:

Pharmacologic therapy is directed at interrupting one or more of the steps in the pathway of androgen synthesis and
action: (1) suppression of adrenal and/or ovarian androgen production; (2) enhancement of androgen-binding to
plasma-binding proteins, particularly SHBG; (3) impairment of the peripheral conversion of androgen precursors to
active androgen; and (4) inhibition of androgen action at the target tissue level.

----------------
Case # 2 Lichen Plauns

Lichen planus (LP) is a chronic inflammatory disease affecting skin, oral or genital mucosae, nails and/or the scalp. Cutaneous LP
is typically a pruritic eruption of shiny, violaceous, flat, polygonal papules mainly localised on the front of the wrists, the lumbar
region and around the ankles. The most frequent oral presentation is asymptomatic reticular LP, but painful erosive or ulcerative
areas may appear.
Prognosis:
Spontaneous remission of cutaneous LP after 1 year occurs in two-thirds of cases. Patients mainly complain of pruritus. The spontaneous
remission of oral LP is much rarer and may occur in approximately 5% of patients
Diagnosis:
Hisopathology:
showing a dermoepidermal papule with hyperkeratosis, hypergranulosis and acanthosis, a basal cell vacuolisation and a band-like inflammatory
infiltrate in the superficial dermis.
Tratment:
aim of treatment is to reduce pruritus and time to resolution, without inducing severe side-effects.

Case # 3 Granuloma anulare

Case # 4 Acne vulgaris was removed earlier & scar develop so patient complain of that scar that was schedule for
treatment.

Notes:

There are different types of acne. The most common acne is the type that develops during the teen years. Puberty
causes hormone levels to rise, especially testosterone. High hormones cause signal skin glands to start making more
oil (sebum). Oil releases from the pores to protect the skin and keep it moist. Acne begins when oil mixes with dead
cells and clogs the skin's pores. Bacteria can grow in this mixture. And if this mixture leaks into nearby tissues, it
causes swelling, redness, and pus. A common name for these raised bumps is pimples or comedon.

Certain medicines can cause acne to develop(Like lithium, or Steroids).. This type of acne usually clears up when you
stop taking the medicine.

It isn't just teens who are affected by acne. Sometimes newborns have acne because their mothers pass hormones to
them just before delivery. Acne can also appear when the stress of birth causes the baby's body to release hormones on
its own. Young children and older adults also may get acne.

A few conditions of the endocrine system, such as polycystic ovary syndrome and Cushing's syndrome, can lead to
outbreaks of acne.

Treatment of acne:

 Inflammatory( Comedon, plus papule, pustule, cyst, or crust): Topical keratolytic (Retinoid, or
Benzylperoxide), & Antibiotic (Systemic: Doxycycline or Azithromycin) or (Topical: Clindamycin).

 Non inflammatory (Only comedon) by topical keratolytic.

Scar formation is a natural part of the healing process after injury.

Various factors influence how your skin scars. Of course, the depth and size of the wound or incision and the location
of the injury are going to impact the scar's characteristics. But your age, heredity, even your sex or ethnicity, will all
affect how your skin reacts.

Types of scar:

These are several different types of scars including:

  Keloid scars. These scars are the result of an overly aggressive healing process. These scars extend beyond
the original injury. Over time, a keloid scar may affect mobility. Possible treatments include surgical removal,
or injections with steroids. Smaller keloids can be treated using cryotherapy(freezing therapy using liquid
nitrogen). You can also prevent keloid formation by using pressure treatment or gel pads with silicone when
you sustain an injury. Keloid scars most often occur in Blacks.

 Contracture scars. If your skin has been burned, you may have a contracture scar, which causes tightening of
skin that can impair your ability to move; additionally, this type of scar may go deeper to affect muscles and
nerves.

 Hypertrophic scars. Raised and red scars that are similar to keloids, but do not breach the boundaries of the
injury site. Possible treatments can include injections of steroids to reduce inflammation.

 Acne scars. If you've had severe acne, you probably have the scars to prove it. There are many types of acne
scars, ranging from deep pits to scars that are angular or wavelike in appearance. Possible treatments will
depend on the types of acne scars you have.

Treatment of scarring:

 prescription creams, ointments or gels

 Surgical removal

 Corticosteroid injection.

Types of Acne scar

There are four types of acne scars which are the most common. These are:

Icepick Scars:

Ice pick scars are deep, narrow scars which form pits in the skin. They are among the most common.

Rolling Scars

Rolling scars create a wave-like appearance on the skin's surface due to their wide and shallow depth.

Boxcar Scars

As one might expect from their name, boxcar scars have angular, well-defined edges usually on the temples or cheeks.
Their appearance is similar to chickenpox scars.

Hypertrophic / Keloid Scars

Hypertrophic scars are raised scars which stay within the boundary of the original wound and can reduce in size with
the passage of time. Keloid scars, on the other hand, are overgrowths of tissue which expand beyond the original
wound site. The scar is rubbery and firm and may itch. Often they form to be much larger than the original wound.

Acne scar removal methods:

 Laser Treatment

 Fractional Laser
Treatment

 Chemical Peels

 Microdermabrasion

 Punch Techniques

 Injections

 Creams

Case # 5 Vitiligo
 Round 2 Basic lesions in Dermatology

 Four basic features of a skin lesion must be noted and considered during a physical examination: the
distribution of the eruption, the types of primary and secondary lesions, the shape of individual lesions, and
the arrangement of the lesions.

 An ideal skin examination includes evaluation of the skin, hair, and nails as well as the mucous membranes of
the mouth, eyes, nose, nasopharynx, and anogenital region.
History:

a complete history should be obtained to emphasize the following features:

1. Evolution of lesions

a. Site of onset

b. Manner in which the eruption progressed or spread

c. Duration

d. Periods of resolution or improvement in chronic eruptions

2. Symptoms associated with the eruption

a. Itching, burning, pain, numbness

b. What, if anything, has relieved symptoms

c. Time of day when symptoms are most severe

3. Current or recent medications (prescribed as well as over-the-counter)

4. Associated systemic symptoms (e.g., malaise, fever, arthralgias)

5. Ongoing or previous illnesses

6. History of allergies

7. Presence of photosensitivity

8. Review of systems

9. Family history (particularly relevant for patients with melanoma, atopy, psoriasis, or acne)

10. Social, sexual, or travel history as relevant to the patient

Diagnostic techniques in Dermatology:

 Skin biopsy

 KOH Preparation(Smear): A potassium hydroxide (KOH) preparation is performed on scaling skin lesions
where a fungal infection is suspected.

Procedure: The edge of such a lesion is scraped gently with a no. 15 scalpel blade, and the removed scale is collected
on a glass microscope slide then treated with 1 to 2 drops of a solution of 10–20% KOH. KOH dissolves keratin and
allows easier visualization of fungal elements. When the preparation is viewed under the microscope, the refractile
hyphae will be seen more easily when the light intensity is reduced and the condenser is lowered.

 Wood’s Light

 Tzanck Smear: A Tzanck smear is a cytologic technique most often used in the diagnosis of herpesvirus
infections [herpes simplex virus (HSV) or varicella zoster virus (VZV)].

Procedure: An early vesicle, not a pustule or crusted lesion, is unroofed, and the base of the lesion is scraped gently
with a scalpel blade. The material is placed on a glass slide, air-dried, and stained with Giemsa or Wright’s stain.
Multinucleated epithelial giant cells suggest the presence of HSV or VZV; culture or immunofluorescence testing
must be performed to identify the specific virus.

 Diascopy: Diascopy is designed to assess whether a skin lesion will blanch with pressure as, for example, in
determining whether a red lesion is hemorrhagic or simply blood-filled.

Procedure: Diascopy is performed by pressing a microscope slide or magnifying lens against a lesion and noting
theamount of blanching that occurs. Granulomas often have an opaque to transparent, brown-pink “apple jelly”
appearance on diascopy.

 Patch testing
 Round 3 Case Discussion

IN The College Monday 16 – 05 – 2011 AD

Case # 1 Acne vulgaris

Basic lesion: Comedon, plus papule, & pustules in the right cheek of the face.

Treatment: Keratolytic agent(Retinoid) plus azithromycin or doxycycline.

Drugs that may cause the same lesion include lithium & steroids.

Case # 2 Alopecia

Basic lesion: round area of the scalp devoid of hair.

D.Diagnosis:

-Alopecia areata (Smooth skin without scale)

-Tenia capitus. (Scale is there) (Dermatophite fungal infection).

Investigations:

-Roll out other autoimmune diseases.

-KOH Smear.

-Microscopy

Treatment:

-Finastride

-Minoxidil

-Topical corticosteroid

-Topical irritant (such as garlic & onion)

Case # 3 Psorisis

Basic lesion: Well defined erythematous plaques with scales

Sites: tongue, scalp, & nail

Clinical signs:

-AUSPITz sign

-Candle Fax sign

Complications:

-Psoriatic osteoarthropathy

-Psoriatic pustula

-Psoriatic erythroderma
---------------

Round 4 in KFU health center with Dr.Fairoze

Case # 1 Eczema

A 20 year old Saudi male patient from veterinary college was admitted complaining of right hand itching with
erythematous plaque with scale as a single lesion. The patient was diagnosed as subacute eczema but fungal
infection was also a suspession so KOH Smear was done & it was negative.

Eczema classification:

Type Acute Subacute Chronic

Lesion Edema, erythema Erythema, & Lichenification

,oozing , vesicles, scaling (Hyperpigmentation
&crusting & thickening)

Treatment Corticosteroid Corticosteroid Corticosteroid

lotion cream ointment

Others Topical H1 Topical H1 Topical H1

antihistamine, antihistamine antihistamine, &
Antibiotic, soaks & keratolytic agent.
compresses(Saline,
or wit soaks)

Notes:

Common neurological complication after herpes infection is called postherpetic neuralgia & the drugs used for
treatment include Carbamazipine, & Gabapentin.

----------------

Day Wednesday, & Saturday are self learning.

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Day Sunday For colleagues presentation:

Topics:

 Acne:

Acne vulgaris is a common inflammatory pilosebaceous disease; it is so common that it is often referred to as a
physiological condition.

Basic lesion:

whiteheads, blackheads, and inflamed red growths(Papule, pustule, & cysts)

Types:
-Inflammatory: only comedons

-Non-inflammatory:comedon, papules, pustules, cysts, or nodules.

Epidemiology:

Acne is a very common facial rash occurring in over 85% of adolescents and frequently continuing into early and
midadult life.

Common in male & female, with high inceidence in puberty age.

Pathophysiology:

polygenic and multi-factorial main factors include:

1. Sebaceous gland hyperplasia and excess sebum production.

2. Abnormal follicular differentiation.

3. Propionibacterium acnes colonisation.

4. Inflammation and immune response.

Riskfactors:

• Mechanical trauma, cosmetics, topical corticosteroids, and oral medicines (corticosteroids, lithium, iodides,
some antiepileptics).

• Endocrine disorders resulting in hyperandrogenism may also predispose patients to developing acne.

Agravating Factors:

• Change in sebaceous activity and hormonal level (e.g. before or during premenstrual cycle)

• High humidity conditions

• Local irritation or friction

• Rough or occlusive clothing

• Cosmetics( having greasy base)

• Diet; chocolate, fats colas, or carbohydrates.

• Oils greases , or dyes in hair product.

Classification:
Cardinal features :

1. Open comedones (blackheads) or closed comedones (whiteheads)

2. Inflammatory papules

3. Pustules

Diagnosis: by clinical setting

Treatment : mentioned before.

 Tenia Capitus:

Tinea capitis is a disease caused by superficial fungal infection of the skin of the scalp, eyebrows, and eyelashes, with
a propensity for attacking hair shafts and follicles.

Presentation:

Clinical presentation of tinea capitis varies from a scaly noninflamed dermatosis resembling seborrheic dermatitis to
an inflammatory disease with scaly erythematous lesions and hair loss or alopecia that may progress to severely
inflamed deep abscesses termed kerion, with the potential for scarring and permanent alopecia.
See & compare……

Differential Diagnosis:

Alopecia areata.

Pathology:

Tinea capitis is caused by fungi of species of genera Trichophyton and Microsporum.

Three type of invasion:

-Endothrix: development of arthroconidia within the hair shaft only. Infected hairs do not fluoresce under a Wood
lamp ultraviolet light.

-Ectothrix: development of arthroconidia on the exterior of the hair shaft.usually fluoresce a bright greenish-yellow
color under a Wood lamp ultraviolet light.

-Favus: usually caused by T schoenleinii.

Differential Diagnosis:

• Alopecia Areata

• Atopic Dermatitis

• Drug Eruptions

• Id Reaction (Autoeczematization)

• Impetigo

• Lupus Erythematosus, Subacute Cutaneous

• Psoriasis, Plaque

• Psoriasis, Pustular

• Seborrheic Dermatitis

• Syphilis
 • Trichotillomania

Treatment:

Systemic administration of griseofulvin.

 Viral warts

Viral warts(My presentation):

Definition: Warts (verrucae) are common and benign Epidermal neoplastic growth due to infection of epidermal
cells with HPV. More than 100 serotype have been described. Each type has certain body preference. Affect the skin
& the mucous membranes.

Etiology: HPV, a DNA papovavirus that multiplies in the nuclei of infected epithelial cells. Types 6, 11 most common
causing genital type, while types,1,2,& 4 are common causing common warts. Types 16, 18, 31, and 33 are strongly
associated with genital dysplasia and carcinoma.

Pathology:

• The virus infects by direct inoculation.

• The epidermis is thickened and hyperkeratotic usually with rough(Verrucus) surface.

Epidemiology:

• Age :Young, & sexually active adults.

• Transmission :Contagious, nonsexually and sexually transmitted.

• Infants and children, may acquire during delivery (Vertical transmission).

• Incidence Increased manyfold during the past two decades.

• Prevalence of HPV infection in women ranges from 3 % to 28 %, depending on the population studied.

• Risk factors:
 • Immunosuppression(HIV, Post transplantation).

• Occupational risk (Meat handler)

• Barefoot activities (Swimming in public showers or practicing sports).

• In infants and children, genital warts may be a marker for sexual abuse

Clinical presentation:

• Cutaneous :

1. Common wart 70%

2. Plantar wart 30%

3. Flat(Plane, verruca plana) wart 4%

• Mucosal:

1. Genital wart(Anogenital).

Cutaneous:

1-Common warts : dome-shaped papules or nodules with a papilliferous (Verrucus) surface , usually multiple, and
are commonest on the hands or feet but also affect the face and genitalia. Their surface interrupts skin lines. Some
facial warts are 'filiform' with fine digit-like projections.(See the picture of warts in the fingers)

2-Plane warts: smooth flat-topped papules, often slightly brown in colour, and commonest on the face and dorsal
aspects of the hands , usually multiple and resist treatment, but resolve spontaneously.
3-Plantar warts : seen in children and adolescents on the soles of the feet; pressure causes them to grow into the
dermis. They are painful and covered by callus, which, when pared, reveals dark punctate spots (thrombosed
capillaries).

Other specific forms:

 Mosaic warts are plaques on the soles which comprise multiple individual warts.

 Filiform or digitate wart, a thread- or finger-like wart, most common on the face, especially near the eyelids
and lips.

 Periungual wart, a cauliflower-like cluster of warts that occurs around the nails.

Mucosal:

1-Genital warts:

In males these affect the penis, and in homosexuals, the perianal area.

In females, the vulva, perineum and vagina may be involved. The warts may be small, or may coalesce into large
cauliflower-like 'condylomata acuminata'.
Proctoscopy (if perianal warts are present) and colposcopy (for female genital warts) are needed to identify and treat
any rectal or cervical warts because of the risk of neoplastic change. Sexual partners need to be examined.

Diagnosis:

Usually no investigation is needed to diagnose warts clinical exam is sufficent.but in certain situation were multiple
warts are their some investigation can be used to exclude any cause of immunosuppresion:

-HIV antibodies, & antigens.

-Transplantation rejection.

-Long course of corticosteroid use.

Differential diagnosis:

• Corn (On the sole or the hand)

• Molluscum contagiosum.

For Viral wart under finger,& toe nail:

• Amelanotic malignant melanoma

• Periungual fibroma (of tuberous sclerosis)

 • Bony subungual exostosis.

For Genital wart:

• condyloma lata of secondary syphilis.

Management:

• 30-50% of common warts disappear spontaneously within 6 months.

• Keratolysis, of dead surface skin cells usually using salicylic acid, blistering agents, immune system modifiers
("immunomodulators"), or formaldehyde, often with mechanical paring of the wart with a pumice stone.

• Cryotherapy with liquid nitrogen & compliance to keratolytic agent (SA).

• Surgical removal(Currettage & cautery)

• Vaccination(HPV Vaccine is avalible)

Resources:

• Dermatology 3rd ed An illustrated colored text book by David J. Gawkrodger.

• COLOR ATLAS AND SYNOPSIS OF CLINICAL DERMATOLOGY By Thomas B. Fitzpatrick, R Johnson, K

Wolff, Machiel K. Polano, Dick Suurmond (COMMON AND SERIOUS DISEASES) MC Graw Hill 1997.

Day Monday For colleagues presentation:

Topics:

 Pitryasis rosea

Pityriasis rosea (PR) is a common benign papulosquamous disease. Characterized by pinkish erythematous macule
with papules in the periphry(Collorette) of the lesion that is termed as herald patch.
Epidemiology:

 account for 2% of dermatologic outpatient visits.

 common in the spring and summer.

 commonly develops in children and young adults

Pathology: today pitryiasis rosea is said to be caused by viral infection (HHV-7).

Presentation:

 A solitary macule that heralds the eruption.

 A patch with a collarette of fine scale just inside the well-demarcated border.

 Bilateral and symmetric macules with a collarette scale .

 The herald patch.

 Pruritis.

 Lymphadenopathy.

Other suspected causes:

 Drug : captopril, metronidazole, penicillamine

 Certain vaccinations, such as the BCG vaccine or the diphtheria vaccine

Differential Diagnosis:

 Secondary Syphilis

 Nummular Dermatitis

 Psoriasis

 Tinea Corporis

 Lichen planus
Investigations:

Investigation usually done to exclude other causes.

-Rapid plasma reagin(RPR)

-VDRL

-Biopsy

Treatment:

Antihistamine, & topical steroid.

 Scabies

Scabies is a contagious skin infection caused by tiny parasitic mites called sarcoptes scabiei homonis.

Epidemiology:

 300 million cases of scabies are reported worldwide each year.

 Classic scabies is more common in children and in people who are sexually active.

 Crusted scabies occurs predominantly in patients who are immunocompromised, elderly or bedridden.

Complications usually secondary infection.

 Scabies is usually transmitted by skin-to-skin contact or through sexual contact.

 Spread easily through crowding

Primary lesion:

Papule, viscle, Burrows. With prurits.

Burrows are a pathognomonic sign and represent the intraepidermal tunnel created by the moving female mite.

Diagnosis:

Confirmatory diagnosis is by visualising the parasite by light microscopy.

Treatment:
Prevention is better than treatment so personal hygeine control is to be considered with use of acarside(Scabiside).

 Herpes zoster:

It is an acute, localized vesicular eruption caused by varicella zoster virus (VZV) in a person who has already had
chickenpox.

Pathophysiology:

Clinical Presentation:

• Prodromal phase: Characterized by pain, tenderness, or paresthesia within the affected dermatome that
precede cutaneous eruption by 3 to 5 days

• Acute phase: Papules (24 hours)  vesicles (48 hours)  pustules (96 hours)  crusts (7 to 10 days).

• Chronic phase (Postherpetic neuralgia): Characterized by pain lasting more than 1 month.

Complication:

 Secondary infection

 Postherpetic neuralgia

 Herpes zostar oticus

 Herpes zostar ophthalmicus

Investigation:

Tzanks smear.

Management:
Antiviral& Analgesics.

Day Tuseday with Dr.Montasser clinic at KFH:

Case # 1 Leg erusion & ulcer.

Mohammad Al-Aaid is 15 years old Saudi male patient with known neurological problem & leg deformity(Taleps
equanovarus) with sizure disorder,complaining of multiple swelling that develop ulcerations in the leg, groin
usually in the deformed areas, that was treated with: antibiotics, Antiseptic, & emollients. Because the cause of the
problem is known the patient was also instructed to continue consultation in neurology & orthopedic department.

Causes of leg Ulcer:

 Venous insufeciency

 Arterial insufeciency

 Neurological problems

 Diabetes mellitus

Case # 2

Naemah Al-hagi is a 40 year old Saudi female patient admitted to dermatology clinic complaining of papules in the
chest that was diagnosed as comedons with secondary infection the infection was treated & the papule is relieved.

Case # 3

Zahrah is 20 year old Saudi female patient complaining of excess hair fall that was treated with nezoral shampoo
containing antifungal only used one to two times per week.

Case # 4

A 20 year old Saudi male patient complaining of skin fissuring(Keratoderma) in the base of the sole that was
treated with paraffin wax, cream, vazaline use specially at night with instruction to use good shoes.

Case # 5

A 30 year old Saudi male prisoner is admitted to the dermatology clinic complaining of hair fall & pruritis with
associated knee lesion that was diagnosed as psoriasis that was treated with topical antihistamine, & nezoral
shampoo.

Case # 6

A 40 year old Saudi male patient complaining of increased skin growth in the groin diagnosed as skin tags, treated
with electrocautary with use of local keratolytic agent for removal of the smaller once.

Day Wednesday exam day