1: Sunburn

2: Lipoma

3: Multiple skin lesions in a Queensland family: (AMC Condition 051)

4: Squamous Cell Carcinoma

5: Marjolin Ulcer (Squamous Cell Carcinoma)

6: Suspicious Lesion (Malignant Melanoma)

7: Psoriasis in a 30yo man (Condition 92)

8: Cellulitis

9: Alopecia Areata

10: Skin Rash (Fungal)

1:

Patient in your GP practice in a small country town comes to you because she has

this rash on shoulder.

Task

o Take history

o Diagnosis

o Management

DDx:

o Sunburn

o Drug (photosensitivity) eg. amiodorone

o Contact dermatitis

o SLE Discoid eczema

Hx:

o Since when have you had this rash (1-2days)?

o Is the rash anywhere else or just here? Is it getting worse or is it the

same (its peeling now?)?

o Is it hot/painful? (yes)

o Do you think anything started it? Did you go out in the sun? (yes

went to beach)

o Did you apply sunscreen? When did you apply it?

(In the morning)

o Whats the SPF? (SPF15) sun protection factor

o Have you taken any new drugs recently? (No)

o Have you changed any cosmetics? Perfumes (no)

o Any fever? Do you think you are feverish?

o Any other general symptoms?

o Tiredness? Pain in joints?

o Family History and personal history: of skin cancers, allergies,

eczema/dermatitis, autoimmune disease ?

Dx and Mx

o Most likely it looks like sunburn. Sunburn is caused by ultraviolet B

rays which penetrates the epidermis and superficial dermis which

causes skin damage. Unfortunately it increases the risk of developing

skin cancer.

o Minor: If mild erythema and minimal discomfort.

o Moderate: red hot and painful. Desquamations.

o Severe: If the patient also develops vesicles and bullae formation.

Headache and nausea. Admit the patient if severely dehydrated.

o At this stage Ill give you steroid ointment (hydrocortisone 1%). It

should be used often 2-3 hours. If its painful give Panadol. Oil in the

water baths or bicarbonate of soda paste may help. If its really hot

gently apply cold compresses. Avoid using soap because it might

cause irritation. Drink lots of water because you are probably

dehydrated. Can use calamine lotion. Keep out of the sun until every

last sign of sunburn has gone.

o Doctor but its peeling off.

Its the bodys way to get rid of the dead skin.

o Next time you need to be very cautious.

Avoid sun from 10-2pm.

o Use sunscreen SPF 30 is better.

SPF 30 filters out 96.3 % of rays, which is only 3% extra

from SPF15. SPF15 filters out 93.3% of the rays. Wear

long sleeves t shirt, broad-brimmed hats, sunglasses to

protect your eyes.

o Slip-slop-slap-wrap

Slip into a t-shirt,

slop on sunscreen,

slap on a hat and

wrap on a pair of sunglasses.

o Give reading material.

o Review after a few days and she can come back to you if it get

worsens.

2:

Your next patient is a 50-year-old male patient presenting with a swelling on his

back.

Task

o Physical examination

(medial margin of the scapula on the right side,

3x5 cm, rounded and well-circumscribed, no

signs in inflammation, lobulated, no presence of

punctum, rubbery in consistency, movable, non-

tender, no change in temperature

o Diagnosis and management

DDx:

Lipoma

Neurofibromatosis

PEx:

I understand that you have come here because of a swelling on your

back. My task is to examine your swelling. For the examination, I

need you to remove your shirt and expose the swelling. During

examination I will touch the swelling and your back. If at any time you

feel any pain, please let me know and I will stop my examination. Is

that alright with you?

Consent and Wash Hands

How is your general health? Vital signs?

Inspection: site, size, shape and border, surface overlying the mass.

Can I see any punctum? Any ulceration?

Palpation: tenderness, temperature, consistency, mobility. Does it

move when the muscle is contracted? Fluctuation test (stabilize

swelling with 2 fingers and press in the center; determines if cystic or

solid swelling)? Because the fluctuation test is negative, I will not do

a transillumination.

Check any lumps and bumps in the body and regional lymph nodes.

Is it painful? Is it increasing in size?

Dx and Mx

From the examination, the lump is moving freely which means it is

not attached to the skin. The other findings suggest a subcutaneous

lump which we call as lipoma. It is the most common benign tumor of

fat cells. Let me assure you that it is not a nasty growth.

If its not causing any problems or you are not concerned about

cosmetic reasons, we can leave it. If not, I will arrange referral to the

surgeon to excise the lump.

Complications? It can get infected and gets painful or increasing in

size. If at any time it happens, please come back because we need

to excise it.

Reading material.

3:

You are working in a general practice in a small country town. A 58 year old farmer,

who lives with his family, 160km outside of town, comes to see you as he is

concerned about his family members, having seen a television program about skin

cancer. He has taken photographs of his familys various skin lesions and asks for

your advice about the need for them to seek medical attention, and whether

attendance is urgent. They are all very busy harvesting crops and will be so for

several weeks.

Task

o Indicate which lesions are likely to be benign, and which are likely to

be malignant or suspicious of malignancy.

o Indicate which members of the family require(s) the most urgent

treatment

o Indicate the mode of spread of any malignant lesions you diagnose.

Hello Patrick. Its very thoughtful of you to make photos and bring them with

you today. Lets start with three photos that we are not concerned about

Photo number 3:

o Seborrhoeic Keratosis

o o The condition what your father have is most likely Seborrhoeic

Keratosis. Also known as Seborrhoeic warts. Seborrhoeic Keratosis

are more common with advancing age and are most often found on

the trunk and the face. They are often said to have a painted on

appearance or look like a dried sultanas has been pressed on the

skin. They usually gradually get larger. And darker and increase in

number. Theres no risk associated with Seborrhoeic Keratosis and

surgery is recommended only for cosmetic purposes.

Photo number 5:

o Spider Naevus

o o Your brother has Spider Naevus. Its a benign skin lesion. They are

described as spiders due to their appearance. Red central spot

resembling the body of a spider with fine radiating vessels looking

like legs of a spider. Almost all Spider Naevus occur on the upper

part of the body. Spider Naevus may be an indication of underlying

liver disease but can also occur in a healthy individuals. Its a benign

skin lesion. Ideally Id like to see your brother to organize LFT +/-

ultrasound.

Photo number 6:

o Melanocytic Dermal Naevus

o o Your daughter has a benign Melanocytic Dermal Naevus also known

as moles. They are common on head, neck and trunk. They are well

defined, slightly raised above the skin lesion with a variety in size

shape and amount of hair present.

Photo number 1:

o Squamous Cell Carcinoma of the lip

o o The condition which your son has is most likely Squamous Cell

Carcinoma. Typically, it presents as non-healing ulcer in one of a

higher risk sun expose area. Classically, farmers, lower lips, heads

and hands. This tumour can metastasize to lymph nodes. Treatment

is surgical excision. Overall prognosis after treatment is good. (Its

above 95% for 5 year survival) If

4:

Your next patient is a 30-year-old patient old farmer who came for result of biopsy of

a skin lesion which was on the right temporal site.

Features:

2nd most common cancer of the skin

Arises from keratinocytes of the epidermis

Precursor/Premalignant lesions:

o Solar/ actinic keratosis

o Back of hand

o Sun-exposed areas

o (+) scaly lesions w/ hyperemic base that bleeds with

scratching

Treatment:

excision/cryotherapy

If w/o treatment, 15-20% progress to SCC

Bowen disease

Scaly red plaque w/ clearly defined margins

Not related to sun damage

Treatment:

excision/cryotherapy

Treatment: Wide excision

If lesions 1cm >5mm

Metastasize to lymph nodes but prophylactic dissection does not give

any advantage

If in the outer sulcus SCC but if lesion inside BCC; if in helix

17x more likely to metastasize (do early wedge resection)

Ulcers of SCC also known as Marjolin ulcer

Hx:

How are you feeling?

o Any pain on the surgical site? John I dont have good news

for you. The result of the biopsy is not what we expected. It

shows that it is a squamous cell carcinoma which is a kind

of a skin cancer. It is a common condition.

Draw diagram:

o Epidermis and dermis. In your case, the epidermis has

started to divide in an uncontrolled manner. The ulcers are

superficial. As you are a farmer, the most likely cause for

your case is sunlight exposure. The other causes are burns

and scars. Are there any lumps and bumps in the body?

The specimen which we have taken is not with adequate margins so

I would refer you to a surgeon for further excision. If the lesion is

1cm should be >5mm around the margin up to the

deep fat level.

Use sunscreen.

o If you stay longer in the sun apply it every four hourly. Try

to avoid sun exposure from 10am to 3pm. Wear long-

sleeved shirts and wide brimmed hat and sunglasses.

Avoid sunburns or any kinds of burns.

o Check yourself monthly for any lumps and bumps or any

other change in lesions.

Do I need radiotherapy?

o If we have taken out adequate margins, we dont need to

do that unless it is in a place where we cant get an

adequate margin.

Prognosis:

o The prognosis is good since we caught the lesion early.

We would like to do regular followup to check if there are

lumps and bumps in your body or if there are other

suspicious lesions that we need to take a look at.

Review

5:

Robert aged 55 years presents to your GP clinic with history of non-healing lesion

on the index finger of his left hand. He tells you he got a small burn while having

barbeque a few months ago. He had applied many ointments and had seen his

usual GP 2-3x but ulcer is not healing. Robert works in a factory and finds it hard to

carry on usual duties due to this wound. Robert is otherwise fit and healthy and lives

independently. He is a heavy smoker and drinks alcohol on weekends with his mate.

Task

Focused history

Physical examination

Differential diagnosis and management advise

Features

2nd most common cancer of the skin

Arises from keratinocytes of the epidermis

Precursor/Premalignant lesions: Solar/actinic keratosis and bowen

disease, burns, chronic ulcers, leukoplakia or de novo

Features:

Usually >50 years, initially firm thickening of skin with surrounding

erythema; hard nodules soon ulcerate

Occurs on hands and forearms and head & neck

Ulcers have characteristic everted edge

SCCs of ear, lip, oral cavitiy, tongue and genitalia are serious and

need special management

Treatment:

Wide excision with 4mm margin to deep fat level

Refer for specialized surgery and for radiotherapy if large, in difficult

site or lymphadenopathy

SCC of ear and lip wedge excision

Metastasize to lymph nodes but prophylactic dissection does not give

any advantage

If in the outer sulcus SCC but if lesion inside BCC; if in helix

17x more likely to metastasize (do early wedge resection)

6:

Variant 1:

Thompson aged 54 years presents to your GP clinic with flu-like symptoms. While

you were examining him, you noticed a pigmented lesion on his back. The lesion is

irregular in shape and measures about 1x1.13 cm in diameter. When you tell

Thompson about this lesion, he becomes quite worried and seeks your advice what

to do next.

Task

o Further history

o Examination findings

o Investigations and treatment advise

Variant 2:

A typical picture of melanoma with the report which shows its a superficial

spreading with .4mm in depth. Level two in Clarks classification.

Task

o Explain this condition

o Outline further management plan.

DDx:

Thrombosed hemangioma

Dermatofibroma (button like nodule)

Pigmented seborrheic keratosis

Pigmented BCC

Junctional and compound nevi

Blue nevi

Dysplastic nevi

Lentigines

Features

1/3 of melanomas arise from pre-existing nevus

Most aggressive tumor

Risk factors

Presence of many moles (especially atypical dysplastic nevi)

History of previous melanoma (5x)

Family History

History of many sunburn

Sun-sensitive skin/fair complexion

Age and sex (increasing age and male)

Tanning (solarium treatments)

RED Flags

New or changing lesion

Rapidly growing nodule of any color

o Non-healing lump or ulcer

o ugly duckling syndrome: prominent pigment lesion that

stands out from any other

o Lesion that concerns the patient

o Dermoscopic changes on follow-up or poor dermoscopic-

clinical correlation

ABCDE:

o Asymmetry

o Border

o Color

o Diameter (mostly more than >5mm )

o Elevation/evolution

o Firm

o Growth pattern in last 4 weeks

Others:

o ulceration or itching;

o development of satellite nodules;

o lymph nodes

Dermatoscope:

o check symmetry,

o meshwork (reticular),

o white and blue structures (skin adhesions)

Biopsy:

o Pigmented lesion: excision biopsy

o Non-pigmented lesion: punch or shave biopsy

Any suspicious lesion 2mm

o BCC 3mm

o SCC 4mm

o Melanoma 5mm (if in situ) and look for re-excisions on

right table

Excision

o Thickness: 4mm (2cm)

o Level/Depth: 1.5mm (2cm)

Prognostic indicators:

o Depth of invasion

o Level (epidermis, reticular/papillary dermis, etc)

o Site: head, neck, trunk

o Gender: Male

o Age >50 years

o Amelanocytic melanoma

o Ulceration

5-year Survival rate based on depth:

o 0 mm - very good

o 4mm 30-60%

Types:

o Hutchinson melanotic freckle (lentigo maligna)

commonly in elderly; slow-growing intraepidermal lesion

mainly on sun-exposed areas

o Superficial spreading melanoma most common type;

striking color variation; always grows laterally/radially

o Nodular melanoma grows vertically; blueberry

appearance

o Acral lentiginous melanoma occurs on palms and soles;

poorer prognosis; variety which can be seen in dark-

skinned people

o Amelanocytic melanoma

Clark Breslow (mm)

Involvement Prognosis Margin Re-excision

I (in situ)

0 Epidermis 5mm

II 4mm Subcutaneous tissue 30-60% 2cm

Hx:

o Since when? ABCDE? Occupation? Sun exposure?

o Do you have any lumps and bumps? Any weight loss? Any

problem with Lungs? SOB? Offer Chest XRay.

o Metastasis: Lungs, Liver, Brain, Bone and Intestine. Did

you notice any mass in the tummy? Any tummy pain? Any

headache? Any bone pain?

o Family history of skin cancers?

o Physical Examination

o General appearance and BMI

o Vital Signs

o Head to toe examination: Backs of ears, neck, back and

back of arms, buttocks and back of legs

o With patient facing you: Anterior hairline, front of ears,

forehead, cheeks and neck, anterior chest, abdomen, pubic

hairs, Anterior surface of legs

o Maggy lamp , Lymph nodes, Chest, Abdomen: liver and

spleen

o Investigations:

FBE, UE, LFTs, Chest X-Ray, CT scan/MRI:

Chest abdomen and brain. Bone scan, LN

biopsy.

Mx:

o Avoid going out from 10-2pm, 11-3pm. Wear the wide

brimmed hat

o Wear clothes cover your body and head, neck and ear.

o Stay in the shade.

o Self-examination: If theres any change in the: Shape

(asymmetry), size, colour(black blue white) , borders,

bleeding, itch, diameter, elevation, ulcer. Look for any

lumps and bumps.

o Metastasis: lung, brain, liver, small intestine

Checking for Metastasis:

Sentinel lymph node biopsy

CT chest, abdomen and pelvis

o Follow ups:

If lesion 2mm: regular reviews by GP and derma x 10

years

Do CXR annually

o Support Groups

o Refer to psychologist

o Reading material. Review.

Suspicious nevus

Excisional biopsy (2-

3mm margin)

Benign nevus

Dermatofibroma

Malignant Melanoma

Melanoma in-situ/ Lentigo Maligna

(re-exciseto 5mm margin)

1.5 mm depth

(re-excise up to 2 cm margin)

7:

You are working in a general practice. You are seeing a 30yo man who works as a

bank teller. He has consulted you about a rash on the extensor surfaces of both

elbows and both knees, over the sternal and lower back areas, and in the scalp. It

first appeared after a motor accident six months ago in which he suffered a fractured

femur. The patient remembers that his father, now deceased, used to be bothered

by a chronic rash.

It has been getting steadily worse over the last few months with some improvement

following the last few months with some improvement following the use of cream

obtained from the local pharmacist (Egopsoryl TA). This has helped the rash on his

body but not on elbows, knees and in the hair.

Examination has revealed the typical lesions of plaque type psoriasis. The plaques

vary in size from a few mm to several cm. They are raised, pink and covered with a

silvery waxy scale. The nails are not affected. The level of severity for this patients

psoriasis should be regarded as moderately severe.

You are about to discuss the disease and its management with the patient. The

photograph shows details of the skin lesions on the knees. Explain the nature of the

condition.

Task

o Explain the nature of his condition to the patient

o Advise the patient about management

Draw a picture: Upper part of the skin called epidermis and the lower dermis two

lines are enough

The cells proliferate over here in the epidermis. The vessels dilate

and some inflammation comes at the level of the dermis causing the

skin to become thick (white plaque and scale). The redness is

because of the dilatation of the vessels.

Typical age is 10-60yo. Affects 2-4% of population in Australia.

No lab investigation to diagnose this condition but we can do skin

biopsy if required. There are some general measures and some

drugs can be used.

Any stress, reduce the stress. Stop the drugs and alcohol. Risk

factors? Stop all of them. Sunlight has the protective effect.

The drugs that you can advice the patient:

o Topical steroid. (Main stay of the treatment)

o Dithranol.

o Tar: messy and smelly, staining.

o Calcipotril (Vit D derivative): use with combination.

o Emollients (to protect the irritation of the skin): can use

frequently.

o Keratolytics (soften the scales) salicylic acid.

It depends on your condition and its extent of the lesions. When it is

on the face the drug on face/genital area: low dose of topical steroid:

low potency 2% hydrocortisone).

On the body:

o High potency steroid betamethaxone.

o Dithranol: Causes irritation and burning, staining. Use for

extensive condition

o If there are small plaques that can be mild to moderate:

use intra lesional steroid.

o If the condition is extensive/not responding to the drugs:

Methotrexate/Cyclosporine

It depends how your condition is progressing. If mild or not extensive,

we can start from mild steroid with emollient. If the condition is

getting worse we can change the drugs to high potency.

Always Refer to the dermatologist. Dermatologist might do

phototherapy.

You can start with Dithranol/emollient/tar give the patient overnight

and wear old clothes for 3 weeks as it can stain. In the morning take

a shower and use topical steroid.

5% of cases can cause arthropathy (nail) topical steroid.

Types:

o Plaque type,

o Exfoliative,

o Pustular,

o Guttate,

o Nail

One of the complication is infection:

o Group A streptococcal

It is most unlikely that psoriasis will appear on the face.

What causes this?

o Unknown, but the risk factors are stress, drugs, extensive

sunburn.

Can it be cured?

o Not curable but controllable (wax and wanes)

Can it spread to other part of the body?

o Less likely to the face. Extensor part of the body, most

likely in the areas that are covered by the clothes.

Is it infectious?

o No

Can it affect my health?

o Yes: arthritis

Can I pass it on to my children?

o Yes it has genetic predisposition and tends to run in the

family.

Medications:

o Beta blockers, OCP, alcohol, chloroquine, lithium, NSAIDs.

The hormonal changes and also predisposes to psoriasis.

Can it be because of the accident?

o Yes stress is one of the risk factors.

8:

Variant 1:

A 65-year-old man is in the ED where you are working as HMO, complaining of pain

in his right lower leg for the last 2 days. It is also swollen and feels warm to touch. A

picture of the area is also given.

Variant 2:

George aged 65 years presents to your surgery with his wife Anastasia. He had pain

and swelling of the right leg for a few days due to a fall. Today, his wife noticed that

the swelling and redness has increased and that George had a fever. His wife tells

you he looks quite unwell and had refused his breakfast. George had type 2 DM for

the last 10 years and is on Metformin 1gm BID. He had no other significant medical

or surgical problems. He lives with his wife and is an occasional smoker but drinks

everyday.

Task

o History

(small area of redness in lower limb that has

increased in two days and very painful and

swollen and warm to touch; I was gardening and

I think I injured it but there is no obvious injury)

o Physical examination

(unwell, increased temperature, inguinal LN

palpable and tender, involved area is warm,

swollen, red, and tender to touch; pulses and

sensation normal)

o Diagnosis and management

Features

o Inflammation of subcutaneous tissue

o Cause: streptococcus pyogenes or staphylococcus aureus

o Clinical presentation

o Redness

o Swelling

o Increased temperature

o Pain/tenderness

Risk factors:

o trauma/crack, insect bite, ulcers, may have no signs of

injury

DDx:

o Necrotizing fasciitis

o DVT

o Pyoderma Gangrenosum

o Erythema multiforme

History:

o Can you tell me more about it??

o Is it painful? How severe is the pain? Painkillers?

o Did you injure the legs before this happened?

o Did you notice any discharge? Are you able to walk?

o Did this happen for the first time?

o Do you feel feverish? Any N/V?

o Any lumps or bumps in the body?

o How is your general health?

o Any history of clots in the legs?

o Any recent history of long travel or prolonged

immobilization?

o Do you have diabetes? Since when? Do you take any

medications?

o Peripheral vascular disease? Are you on any medication?

o Allergy? SADMA?

Physical examination

o General appearance

o Vital signs

o Lower leg: redness, tenderness, swelling, is the border

elevated or sharply demarcated, regional

lymphadenopathy? Is tenderness disproportional to

examination findings? Lower leg sensation? Vibration?

Pulses and Buerger sign (for PVD)?

Mx:

o You most likely have cellulitis. It is the infection of the skin

in the subcutaneous tissue caused by bugs that can enter

through a break in the skin (S. pyogenes or S. aureus).

o I will admit you to the hospital and arrange surgical

consultation for further management.

o I would like to do some investigation: FBE, inflammatory

markers, blood culture, skin lesion culture and Doppler

ultrasound to rule out DVT.

o While waiting for the culture, we will start you on IV

antibiotics particularly Flucloxacillin or

phenoxymethylpenicillin (IV cefazolin or cefalexin if

allergic).

o I will give you painkillers particularly panadeine and I would

advise you to take a rest and elevate the limbs. I will mark

the area of redness and inspect it on a daily basis to check

resolution.

o If with wound: Wound dressing

o If diabetic: Foot care

Necrotizing fasciitis:

o Pain out of proportion to symptoms

o Patient systemically unwell fever, N/V, tachycardia,

hypotension, shock

o Can lead to gangrene of adjacent organs and septicemia

o (+) crepitus (crackling sound due to gas, grinding bones

etc.)

o Clostridium

o MRI/CT scan

Treatment:

o surgical debridement

o Penicillin + Gentamycin + Metronidazole

o Managed in high-dependency unit

o Hyperbaric oxygen

9:

You are an HMO working in a primary care clinic attached to a teaching hospital.

Your next patient is a 38-year-old man whos consulting you because of hair loss.

One of the eyebrows is also affected. The patient is very concerned about his future,

diagnosis and treatment.

Task

History

o (started 2-3 weeks, path of baldness, stress (+) due to

baldness, affecting performance, having healthy balanced

diet, general health normal; no FHx of baldness)

Diagnosis and Management

DDx:

Alopecia areata

Androgenetic alopecia: (genetic predisposition 20%, gradual,

temporal recession [males] and not central widening; crown loss

[females])

Drug-induced: (anabolic steroids, testosterone, OCPs, danazol,

lithium)

Telogen effluvium acute excessive hair loss 2-3 months after a

stressor whether physical or emotional; self-limiting; 3-6 months;

thinning is all over the scalp

Zinc and iron deficiency

Thyroid eye problems (outer 1/3)

Trichotillomania

Hx:

I understand it is a very distressing situation for you but let me assure

you that we can do a lot of things about it.

Since when did you start having hair loss? Was it sudden or gradual?

Have you lost hair from anywhere else? How about your diet?

Are you taking a healthy balanced diet? Any acne or change in voice-

? Do you have any weather preferences or mass in your neck? Any

family history of similar conditions?

Are you on any medications like anabolic steroids? SADMA? How is

it affecting your life? Hows your mood? Any change is weight, loss

of appetite? Hows your sleep?

Dx nd Mx:

You have a condition called alopecia areata. We would like to do

some tests which include FBE, iron studies, zinc levels, TFTs,

hormone levels if indicated. The cause is unknown, but it can also be

autoimmune, familial or due to severe stress.

At this stage, I would like to give you some topical therapies potent

topical steroids (OD/BID), intralesional corticosteroids for small

lesions (triamcinolone), topical dithranol, minoxidil (very high

relapse).

I will refer you to the dermatologist. She might consider doing

phototherapy (UV light).

What is the chance of recovery?

o In 6 months, there is 33% chance of regrowth and 50%

chance in 1 year with therapy.

Will I get bald?

o We cannot say for certain. Dont worry even if the outcome

is not good, we can do a lot of things such as wigs, stem

cell therapy, etc.

How long will it take to improve?

o The course is variable from person to person.

Does it have anything to do with my glands?

o NO. It has nothing to do with your glands.

Referral. Review once results are back. Reading material

10:

Nadia, 28 years old presents to your GP clinic complaining of a rash on her nose.

Task

o History

(rash for 3 months; given hydrocortisone 2x a

day; no discharge and not itchy; no medications

and generally healthy; has 3 kids)

o Examination

o Differential diagnosis and diagnosis

o Management

Hx

o When? Where? Does it spread? Anything increase or

decrease spread? Past history? contact with person having

similar symptoms? Itchy? Any previous consultation or

medications? Any pets (cats or dogs) at home?

DDx:

o Eczema

o Tinea of the face

o Cutaneous lupus

Investigations

o Skin scraping (fungal hyphae)

o Fungal culture

o Skin biopsy might be indicated

Management

o Antifungal

o Oral Griseofulvin (not used anymore medical archeology

only), ketoconazole (yes)

o Topical antifungals

o Examine elsewhere to check for primary infection (feet)

o Refer to dermatology.