Dermatology clinic

In the first of a regular series, Susannah Baron tells you why dermatology is so important and how to approach clinical cases

What's in a name?

Piezogenic pedal papules: what sort of a name is that? Once you can see past the thousands of unintelligible names in dermatology you will be all right. In fact all would be fine if we still had a classical education, with a firm grounding in Latin and Greek. Dermatology is a visual specialty and the names often describe what you can see in front of you. For example, erythema nodosum simply means red lumps, and the word eczema comes from the Greek "ek" - out - and "zeein" - to boil.

Why is dermatology important?

Dermatology is a fascinating specialty and unique in that skin disease affects everyone from neonates to elderly people. A large amount of general medical disease presents first to the dermatologist, but dermatology also encompasses surgery. Depending on your surgical interests this can vary between a simple minor operating list to extensive plastic surgery with full thickness flaps and skin grafts.

There are numerous other subspecialties, including paediatric dermatology, phototherapy, contact dermatitis, skin cancer, and lasers. Skin disease is constantly on show, thus affecting self confidence and often limiting such activities as swimming and socialising. At times of stress skin disease tends to worsen. This can lead to a vicious downward spiral as people become even more stressed by their worsening disease being on show to the world. This can lead to a long lasting negative effect on self confidence and self image.

There is no reason to be intimidated by skin disease. Dermatology just needs to be approached in a fashion identical to other medical specialties: take a full history, examine the patient, and perform the relevant investigations. In fact, as dermatologists we have a definite advantage in that we can easily see and more importantly feel the problem, and that the skin is readily accessible for biopsies.

Over the next few months I am going to share with you some cases from outpatients. I will give you a case history and show you a picture, and I will want you then to formulate in your head a plan for diagnosis, investigations, and treatment. I will then go on briefly to discuss the management of each patient. Some cases will be common and some more unusual, but they should give you an idea of the great variety of dermatological disease. I hope that this will be helpful and, more importantly, make you enthusiastic about this fascinating specialty.

Case history

A mother brings her 4 month little boy to see you. She tells you that he has had a skin rash since he was 6 weeks old. His skin has worsened over the past week and now his scalp is very sore, weepy, and cracked, his skin is covered in a red raised rash, and he is scratching continuously. He is not sleeping well and has gone off his food.

Questions

• Describe the skin rash.
• What is the diagnosis?
• What investigations would you like to do?
• What treatment are you going to instigate?

Answers

• Looking at the child's face and back you can see multiple raised areas of erythematous papules in association with oedema and vesicles. His scalp also has areas of yellow pustules and crusting. His skin is extremely dry (very difficult to see this on a photograph which is why touching the skin is so important.)
• This child has atopic eczema and his scalp is secondarily infected.
• It is important to take the child's temperature to see if he has systemic infection. Swab the infected areas of skin. Ask the mother about family history of eczema, asthma, and hayfever to see if he has an atopic background. No specific investigations are needed to confirm the diagnosis of atopic eczema.
• Talk to the boy's mother about her knowledge and understanding of atopic eczema. Explain that this is a very common condition affecting 1-3% of infants in the United Kingdom. Atopic eczema often starts on the face and then usually spreads to the trunk and the flexural areas in a symmetrical pattern. It is extremely itchy and the resulting scratching and rubbing results in excoriations and lichenification. This scratching makes children prone to secondary bacterial infection, often by Staphylococcus aureus with which many patients are densely colonised. Children with atopic eczema have inherent dryness (xerosis) of their skin. Dry skin tends to be itchy and it is susceptible to irritant substances-for example, detergents. It is important to explain that the intensity of eczema tends to vary due to climatic change, episodes of infection, times of stress, and sometimes for no apparent reason. Atopic eczema tends to improve during childhood with more than half the children being disease free by the age of 13. Give the mother some printed information sheets.
• Explain that management involves control rather than cure. This child should have an emollient oil for the bath, emollient applied to all the skin twice daily, and a combination of steroid-antibiotic of moderate potency to be applied twice daily to the infected areas. A weaker topical steroid ointment should be used on the face. If the child has a temperature then systemic antibiotics (usually flucloxacillin) should be prescribed. A dermatology nurse should show the child's mother how to apply the treatments and occlusive dressings such as stockinette which prevent the baby from scratching. In general ointments not creams should be prescribed for eczema as they are greasier. The baby should be reviewed in a week's time or sooner if his eczema does not improve.