Red scaly rashesRed scaly rashes

Dr. D. Czarnecki MD MB BSDr. D. Czarnecki MD MB BS

Red Scaly RashesRed Scaly Rashes

• When someone presents with a red, scaly, itchy When someone presents with a red, scaly, itchy rashrash

1 Assume that he has dermatitis1 Assume that he has dermatitis

2 2 Look for a raised edgeLook for a raised edge

33 Look at the elbows and knees Look at the elbows and knees

• Dermatitis, psoriasis, or tinea are the most likely diagnoses Dermatitis, psoriasis, or tinea are the most likely diagnoses for 90% of patients with red, scaly, itchy rashes.for 90% of patients with red, scaly, itchy rashes.

Red Scaly RashesRed Scaly Rashes

• Dermatitis (also called eczema) is the most Dermatitis (also called eczema) is the most common skin diseasecommon skin disease

• More than two out of three will develop it at some More than two out of three will develop it at some time in their livestime in their lives

• It is more prevalent with age (as most diseases It is more prevalent with age (as most diseases are)are)

• It can vary in appearance depending on its severityIt can vary in appearance depending on its severity

Red Scaly RashesRed Scaly Rashes

• Dermatitis on the legDermatitis on the leg• There is no raised edgeThere is no raised edge• The scale is thin and The scale is thin and

delicatedelicate

• The leg is a common The leg is a common sitesite

Red Scaly RashesRed Scaly Rashes

• TineaTinea• There is a raised edge There is a raised edge

with a clearing centrewith a clearing centre

• The buttocks are not a The buttocks are not a common sitecommon site

• You must look at the You must look at the feetfeet

Red Scaly RashesRed Scaly Rashes

• PsoriasisPsoriasis• The scale is thick, The scale is thick,

silvery and easily silvery and easily comes away from the comes away from the skinskin

• The underlying skin has The underlying skin has a pink coloura pink colour

• You must look at the You must look at the elbows and kneeselbows and knees

DermatitisDermatitis

• You have made the diagnosis of dermatitisYou have made the diagnosis of dermatitis

• Begin treatment.Begin treatment.• Prescribe an Prescribe an adequate quantityadequate quantity of an of an adequate strengthadequate strength

glucocorticosteroidglucocorticosteroid• Recommend soap substitutesRecommend soap substitutes• Recommend sun exposure (if possible)Recommend sun exposure (if possible)

• Review the patient in one weekReview the patient in one week

• If the patient is not better, you have made a mistakeIf the patient is not better, you have made a mistake

Red Scaly RashesRed Scaly Rashes

• Dermatitis around the Dermatitis around the mouthmouth

• Dermatitis responds to:Dermatitis responds to:

glucocorticosteroidsglucocorticosteroids

emollientsemollients

ultraviolet lightultraviolet light

• Antihistamines are Antihistamines are seldom neededseldom needed

Fine scale, red base, itchyFine scale, red base, itchy

DermatitisDermatitis

• Glucocorticosteroids – become familiar with:Glucocorticosteroids – become familiar with:

hydrocortisone 1%hydrocortisone 1% triamcinolone 0.02%triamcinolone 0.02% betamethasone valerate 0.05%betamethasone valerate 0.05%

• Ointments are more effective than creams but patients do not Ointments are more effective than creams but patients do not like using ointments – too greasylike using ointments – too greasy

• Prescribe an adequate quantity – it takes 30 gms to cover the Prescribe an adequate quantity – it takes 30 gms to cover the body oncebody once

• Use the rule of 9 – head - 9% of the surface area; back – 18%; Use the rule of 9 – head - 9% of the surface area; back – 18%; chest – 9%; arm – 9%; thigh – 9%; leg – 9%chest – 9%; arm – 9%; thigh – 9%; leg – 9%

DermatitisDermatitis

• Glucocorticosteroids are safe when applied to the Glucocorticosteroids are safe when applied to the skin.skin.

• Little is absorbedLittle is absorbed

face – 7%face – 7% trunk or limbs – 1%trunk or limbs – 1% groin – 33%groin – 33% inflamed skin on the trunk absorbs about 5% - this inflamed skin on the trunk absorbs about 5% - this

returns to normal when the inflammation returns to normal when the inflammation disappearsdisappears

• Plastic occlusion increases absorptionPlastic occlusion increases absorption

Red Scaly RashesRed Scaly Rashes

• Review the patient in 1 Review the patient in 1 weekweek

• The skin will be much The skin will be much improvedimproved

• If the patient is no If the patient is no better, you have made a better, you have made a mistakemistake

• There are not too many There are not too many causes for failurecauses for failure

No better despite 3 weeks No better despite 3 weeks of using a of using a glucocorticosteroid creamglucocorticosteroid cream

Note the raised edgeNote the raised edge

Dermatitis- no betterDermatitis- no better

• The most common reasons for failure to improve The most common reasons for failure to improve despite using an adequate strength cream are:despite using an adequate strength cream are:

• ScabiesScabies• TineaTinea• A persistent antigenA persistent antigen

• A rare dermatosis is a less likely reasonA rare dermatosis is a less likely reason

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• Scabies causes itch Scabies causes itch and scratching causes and scratching causes dermatitisdermatitis

• Look for burrows on the Look for burrows on the hands (wrists and hands (wrists and between the fingers)between the fingers)

• Anyone else in the Anyone else in the family itchy?family itchy?

• Treat for scabiesTreat for scabies

A scabies burrow A scabies burrow

A fine, silvery trackA fine, silvery track

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• Tinea has the raised Tinea has the raised edgeedge

• The patient will tell you The patient will tell you that the rash is that the rash is spreadingspreading

• You must look at the feetYou must look at the feet

• Take scrapings for Take scrapings for fungal culture before fungal culture before antifungal agentsantifungal agents

Tinea of the face Tinea of the face

Spreading despite treatment with a Spreading despite treatment with a glucocorticosteroid creamglucocorticosteroid cream

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• Acute dermatitisAcute dermatitis

• Weeping has caused Weeping has caused crusts – dried serumcrusts – dried serum

• This was caused by This was caused by applying an antibiotic-applying an antibiotic-glucocorticosteroid glucocorticosteroid combinationcombination

• He was allergic to the He was allergic to the antibioticantibiotic

An example of a persistent An example of a persistent antigen preventing healingantigen preventing healing

Red Scaly RashesRed Scaly Rashes

• Acute dermatitis that did not Acute dermatitis that did not clear despite oral clear despite oral prednisolone. He also had prednisolone. He also had rhinitis and blocked earsrhinitis and blocked ears

• It improved when he was off It improved when he was off workwork

• He polished black woodHe polished black wood

• He was allergic black wood He was allergic black wood and leaving work led to and leaving work led to clearance of his skin, nose clearance of his skin, nose and ears.and ears.

He was continuously He was continuously exposed to an antigenexposed to an antigen

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• A rarer dermatosisA rarer dermatosis

• Granuloma annulareGranuloma annulare

• There is no scaling There is no scaling therefore no epidermal therefore no epidermal componentcomponent

• A punch biopsy will A punch biopsy will confirm the diagnosisconfirm the diagnosis

An annular dermal eruption An annular dermal eruption The surface is smoothThe surface is smooth

Assume that the rash is dermatitisAssume that the rash is dermatitis

Look for a Look for a raised edgeraised edge

Present? - look at Present? - look at the feetthe feet

Take scrapings for Take scrapings for fungal culturefungal culture

Prescribe cortisone of Prescribe cortisone of adequate strengthadequate strength

Review in one weekReview in one week

No better? – you No better? – you have made a mistakehave made a mistake

Look at the Look at the elbows and kneeselbows and knees

Present? - Present? - psoriasispsoriasis

Scabies?Scabies?

A persistent allergen? A persistent allergen?

A rarer dermatosis?A rarer dermatosis?

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• Some cases are followingSome cases are following

• Look at the slideLook at the slide

• Follow the flow chartFollow the flow chart

• Write down your answers to the questions before Write down your answers to the questions before proceeding and see how well you do. proceeding and see how well you do.

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• A cortisone cream of A cortisone cream of adequate strength was adequate strength was appliedapplied

• Why is the rash no Why is the rash no better?better?

• She said that it was She said that it was increasing in sizeincreasing in size

• Write down your Write down your answers before you answers before you look at the next slidelook at the next slide

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• TineaTinea

• There is a raised edgeThere is a raised edge

• The centre has papules The centre has papules because a cortisone cream because a cortisone cream was used. This has was used. This has suppressed the immune suppressed the immune system and the fungus has system and the fungus has persistedpersisted

• You must look at the feet to You must look at the feet to see if there is a focus of see if there is a focus of infectioninfection

Red Scaly RashesRed Scaly Rashes

• He is no better despite He is no better despite oral and topical oral and topical cortisonecortisone

• What could be the What could be the cause(s)?cause(s)?

• Write down your Write down your answers before you answers before you look at the next slidelook at the next slide

Red Scaly RashesRed Scaly Rashes

• ScabiesScabies

• He has excoriated papules He has excoriated papules that are very itchythat are very itchy

• Papules around the anus Papules around the anus and genitalia are usually due and genitalia are usually due to scabiesto scabies

• This is worse that is usual This is worse that is usual because of the use of because of the use of cortisonecortisone

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• The same patientThe same patient

• He has excoriated papules He has excoriated papules on the penison the penis

• Papules on the penis and Papules on the penis and scrotum are scabies until scrotum are scabies until proved otherwiseproved otherwise

• His rash cleared with anti-His rash cleared with anti-scabetic therapy but the scabetic therapy but the papules took longer to clearpapules took longer to clear

Acute dermatitis – it is moist, Acute dermatitis – it is moist, there is no raised edgethere is no raised edge

Tinea – the raised edge is obviousTinea – the raised edge is obvious

Scabies – nodules, the mite was seen on the wristScabies – nodules, the mite was seen on the wrist