Epidermolysis bullosa requires lifelong monitoring

24 Oct 2019Paid-up subscribers

Epidermolysis bullosa (EB) arises from mutations within genes encoding for different proteins which contribute to the structural integrity of the epidermis and basement membrane zone. There are four major EB types: EB simplex (EBS), dystrophic EB (DEB), junctional EB (JEB) and Kindler syndrome. The main cutaneous features of inherited EB are mechanical fragility of the skin and formation of blisters and erosions with minimal trauma. The initial diagnosis of EB is based on the patient’s personal and family history and examination. Skin biopsies are taken from newly induced blisters to identify the level of skin cleavage which helps to determine the subtype.

Holistic assessment key in hidradenitis suppurativa

25 Sep 2019Paid-up subscribers

Hidradenitis suppurativa is a chronic inflammatory skin disease which can develop from puberty onwards, with painful, deep-seated inflamed lesions at characteristic sites. It is much more common in smokers. There is also a clear link with obesity. Patients complain of recurring painful boils in one or more of the typical areas. In women the most common areas affected are under the arms, under the breasts, in the groin, medial thighs, or suprapubic area and in men the armpits, buttocks and perianal area. Hidradenitis suppurativa is diagnosed on history and clinical appearance.

Managing common skin conditions in infants

24 Jun 2019Paid-up subscribers

Atopic eczema, or atopic dermatitis, affects up to 20% of children and often presents in infancy. Cow’s milk allergy can also manifest as eczema and gastrointestinal (GI) symptoms. Food allergy should be suspected if there is a clear history of a reaction to a food in infants with moderate to severe eczema not responding to standard treatment, in infants with very early onset eczema (under 3 months) and those with GI symptoms. Seborrhoeic dermatitis is often an early manifestation of atopic eczema. Naevus simplex is a common congenital capillary malformation occurring in up to 40% of newborns. Port wine stains are less common, affecting about 0.3% of infants. 

Pruritus may be a symptom of underlying systemic disease

22 Mar 2018Paid-up subscribers

Itch is a common symptom of many dermatological conditions (e.g. eczema, urticaria and lichen planus) but can also be a manifestation of underlying systemic, neurological and psychological disorders, or an adverse reaction to medication. The assessment of patients with generalised itch but no rash requires a detailed history and examination to narrow the spectrum of potential causes. Examination should include inspection of the entire skin. Physical examination should include palpation for lymphadenopathy and organomegaly.

Recognising the pattern of hair loss key to managing alopecia

23 Nov 2017Registered users

Alopecia affects up to 50% of men and women at some time in their lives. In primary care the first step is to establish whether hair loss is focal or diffuse and if focal whether it is scarring or non scarring. It is usually possible to establish the pattern of hair loss from a combination of the history and clinical examination. Dermatoscopic examination and pull testing can be useful in confirming the diagnosis. If hair loss is accompanied by scaling or significant inflammation it is important to exclude infective causes.

Diagnosing childhood eczema can be challenging

25 Sep 2017Registered users

Atopic eczema is the most common endogenous type of eczema in infants and children and affects around 15-20% of school-age children in the UK. Its prevalence is highest in children under the age of two and subsequently diminishes with age. It has a chronic, relapsing course. An emergency referral to a dermatologist or paediatrician should be made via telephone when there is a suspicion of eczema herpeticum or eczema coxsackium. Other indications for referral include diagnostic uncertainty, recurrent secondary infection, when control remains poor despite topical treatments, and for patients with emotional distress or significant sleep disturbance.

Be vigilant for skin manifestations of inherited cancer syndromes

23 Jan 2017

More than 200 hereditary cancer susceptibility syndromes have been described, and it is thought that they account for 5-10% of all cancers. Many have dermatological manifestations (usually lesions, occasionally rashes) which frequently precede other systemic pathology. Dermatological signs are usually non-specific and often trivial in appearance, making their significance easy to overlook and a clinical diagnosis challenging.

Managing actinic keratosis in primary care

24 Oct 2016Registered users

Actinic, or solar, keratosis is caused by chronic ultraviolet-induced damage to the epidermis. In the UK, 15-23% of individuals have actinic keratosis lesions. Dermatoscopy can be helpful in excluding signs of basal cell carcinoma when actinic keratosis is non-keratotic. It is always important to consider the possibility of squamous cell carcinoma. The principal indication for referral to secondary care is the possibility of cutaneous malignancy. However, widespread and severe actinic damage in immunosuppressed patients also warrants referral.

Managing patients with hidradenitis suppurativa

23 May 2016Paid-up subscribers

Hidradenitis suppurativa affects the apocrine-bearing areas of the skin. The onset is variable but usually occurs in the second and third decades of life, coinciding with development of the apocrine glands. The condition is characterised by painful, inflammatory papules and nodules which frequently progress to form abscesses, sinus tracts and hypertrophic scars.The most important non-genetic factors implicated in hidradenitis suppurativa are obesity and smoking.

Tailor systemic therapy to the patient with severe psoriasis

22 Feb 2016Registered users

There is no standard definition regarding the severity of psoriasis, and a number of factors should be considered, including the extent and stability of skin disease, involvement of joints, response to treatment, and impact on quality of life. Erythrodermic psoriasis and pustular psoriasis are severe conditions and the patient may be systemically unwell and febrile.

Diagnosis directs treatment in fungal infections of the skin

21 Oct 2015Registered users

Dermatophyte fungi are confined to the keratin layer of the epidermis and include three genera: Microsporum, Epidermophyton and Trichophyton. These infections can be transmitted by human contact (anthropophilic), from the soil (geophilic) and by animal (zoophilic) spread. Dermatophyte infections usually present as an erythematous, scaly eruption, which may or may not be itchy. Asymmetry is an important clinical clue to fungal infection, as is annular morphology.

Improving detection of non-melanoma skin cancer

05 Aug 2015Registered users

Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) are clinically and pathologically distinct and both are locally invasive. However, while BCCs rarely metastasise, SCCs have the potential to do so especially when they arise on the ears or lips. Patients with one non-melanoma skin cancer (NMSC) have a higher risk of developing another NMSC and of malignant melanoma.

Managing urticaria in primary care

23 Feb 2015Paid-up subscribers

Urticaria is characterised by transient wheals that consist of a swollen palpable centre often surrounded by an erythematous flare, associated with itching or, less commonly, a burning sensation. Individual wheals usually disappear within 1 to 24 hours leaving normal skin. The prognosis for eventual recovery from spontaneous and inducible urticaria is excellent. However, the time course is unpredictable and may extend to years, often following a relapsing and remitting course.

Improving the management of rosacea in primary care

23 Oct 2014

Rosacea is more common in women than men and occurs more frequently in fair-skinned individuals, usually in the middle years of life. It tends to localise to the cheeks, forehead, chin and nose, sometimes showing marked asymmetry. Only very occasionally does it involve areas other than the face. Important distinguishing features from acne are a lack of comedones, absence of involvement of extra-facial areas, and the presence of flushing. Rosacea is a disfiguring condition that can have a major psychosocial impact, and its detrimental effect on emotional health and quality of life is often overlooked.

Identifying the causes of contact dermatitis

23 Jun 2014Paid-up subscribers

Contact dermatitis results from skin contact with an exogenous substance. It can be caused by direct contact, airborne particles, vapours or light. Individuals of any age can be affected. The two most common variants are irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD). ICD is more common and has a worse prognosis. ICD is a form of eczema and is induced by direct inflammatory pathways without prior sensitisation. If eczema is recurrent/persistent, or occurs in an individual with no previous history of eczema, contact dermatitis should be considered. If ACD is suspected the patient should be referred to secondary care for patch testing.

Improving the management of seborrhoeic dermatitis

24 Feb 2014Paid-up subscribers

Seborrhoeic dermatitis usually starts at puberty with a peak incidence at 40 years of age and is more common in males. Patients develop symmetrical, well demarcated, dull or yellowish red patches and plaques with overlying adherent, yellowish greasy scales. Seborrhoeic dermatitis has a distinctive distribution in areas rich in sebaceous glands. Patients presenting with sudden onset severe seborrhoeic dermatitis should be screened for risk factors for HIV.

Alopecia areata: more than skin deep

23 Sep 2013Paid-up subscribers

Alopecia areata is a chronic inflammatory non-scarring condition affecting the hair follicle that leads to hair loss ranging from small well defined patches to complete loss of all body hair. The severity of hair loss at presentation appears to be the strongest predictor of long-term outcome. Individuals with alopecia areata should be referred for dermatological advice if there is diagnostic uncertainty, they have extensive hair loss, they are suffering severe psychological distress or they would like a wig.

GPs have key role in early detection of melanoma

24 Jun 2013Registered users

Lesions which have a high index of suspicion for melanoma should not be removed in primary care. Patients should be referred urgently to secondary care with a history recording the duration of the lesion, change in size, colour, shape and symptoms. 

Intense nocturnal itching should raise suspicion of scabies

23 May 2013Paid-up subscribers

Scabies is spread by a mite transferring to the skin surface of an unaffected person, usually by skin to skin contact with an infested person, but occasionally via contaminated bed linen, clothes or towels. Patients with classical scabies usually present with an itchy non-specific rash. Often, the history alone can be virtually diagnostic. An intense itch, affecting all body regions except the head, typically worse at night, appearing to be out of proportion to the physical evidence, with a close contact also itching, should prompt serious consideration of scabies. The crusted variant of scabies may not be itchy. It is characterised by areas of dry, scaly, hyperkeratotic and crusted skin, particularly on the extremities.

Improving outcomes in patients with psoriasis

24 Jan 2013Paid-up subscribers

The majority of patients with psoriasis can be managed in primary care, although specialist care may be necessary at some point in up to 60% of cases. Patients with erythrodermic or generalised pustular psoriasis should be referred for a same day dermatological opinion, and if psoriatic arthritis is suspected, early referral for a rheumatological opinion is recommended. Recent guidance from NICE and SIGN will contribute significantly to the care of psoriasis sufferers in both primary and secondary care. [With external links to the evidence base]

Be vigilant for scurvy in high-risk groups

24 Oct 2012Paid-up subscribers

Scurvy is a disabling, potentially fatal, but entirely treatable, condition that can easily pass unrecognised. It has by no means been confined to the history books, even in affluent cultures, and vitamin C deficiency appears to be relatively common in the UK, particularly in those living on a low income. The occurrence of a macular purpuric eruption on the legs should always prompt consideration of the diagnosis of scurvy, especially in those at risk.

Prompt treatment of acne improves quality of life

20 Jun 2012Paid-up subscribers

Acne vulgaris is an inflammatory disorder of the pilosebaceous (hair follicle) units. It is very common, affecting 90% of teenagers, albeit often mildly. However, its onset may be delayed until the late twenties or early thirties, and very occasionally even later. In the majority of cases, acne settles by the mid-twenties, but for some patients it may still be problematic in their forties and beyond. Patients should be referred to a dermatologist if they have: a very severe variant; severe social or psychological problems; risk of scarring; failed to respond to treatment or are suspected of having an underlying endocrinological cause. [With external links to the evidence base]

Improving the management of atopic eczema in primary care

25 Apr 2012Paid-up subscribers

Although generally considered a childhood ailment, 38% of patients with atopic eczema in the UK are adults. The condition often has a significant detrimental effect on the quality of life of affected individuals and their families. Despite national evidence-based guidelines in the UK, standards of care in the community setting can vary. Patients or carers should receive a full explanation of how to use topical treatments and a demonstration of how to apply dressings, if applicable. [With external links to the evidence base]

Improving recognition of psoriatic arthritis

17 Dec 2009Registered users

 Psoriatic arthritis (PsA) is a common form of inflammatory arthritis but is underdiagnosed. Psoriasis affects more than 1.5% of the UK population so a GP with an average list size is likely to care for around 40 patients with psoriasis. Around 15% of these patients will be diagnosed with PsA, but up to 40% of them may have evidence of arthritis if reviewed thoroughly. [With external links to the evidence base]



Papulosquamous conditions

23 Sep 2016Registered users

• Pityriasis rosea • Discoid lupus erythematosus • Lichen planus • Seborrhoeic dermatitis • Tinea corporis • Plaque psoriasis

Sun damage

23 Jun 2016

 • Squamous cell carcinoma • Actinic keratosis horn • Bowen’s disease • Solar elastosis • Rosacea • Discoid lupus

Conditions affecting the hair and scalp

25 Apr 2016Registered users

• Dermatitis artefacta • Alopecia mucinosa • Lichen planopilaris • Discoid lupus erythematosus • Sebaceous naevus • Basal cell carcinoma

Fungal infections

21 Mar 2016Registered users

• Lingua villosa nigra • Onychomycosis • Tinea corporis • Tinea pedis • Id reaction • Tinea incognito

Inherited disorders

22 Feb 2016Registered users

• Darier’s disease • Diffuse palmoplantar keratoderma • Familial hypercholesterolaemia • Neurofibromatosis type 1 • Haemophilia A • Epidermolysis bullosa simplex

Skin conditions in children

25 Jan 2016

 • Classic spitz naevus •  Irritant saliva dermatitis •  Umbilical granuloma •  Cradle cap •  Molluscum contagiosum •  Juvenile plantar dermatosis

End of year photo quiz - 2015

22 Dec 2015Registered users

Test your diagnostic skills

Urgent referral for skin lesions

25 Nov 2015Registered users

• Anaplastic large-cell lymphoma • Bullous pemphigoid • Malignant melanoma • Squamous cell carcinoma • Gangrene • Necrotising fasciitis

Photoguide: Pigmentation disorders

21 Oct 2015Registered users

Vitiligo • Melanonychia • Pigmented basal cell carcinoma • Haemosiderin deposition • Blue naevus • Lead pellet

Allergic reactions

24 Sep 2015

• Fixed drug eruption • Fabric plaster reaction • Latex allergy • Morbilliform drug reaction • Allergic conjunctivitis • Anaphylaxis

Sun damage

05 Aug 2015Registered users

• Actinic keratosis • Photodermatitis • Polymorphic light eruption • Sunburn • Solar lentigenes • Malignant melanoma


22 Jun 2015Registered users

• Facial psoriasis • Guttate psoriasis • Nail psoriasis• Scalp psoriasis • Palmoplantar pustulosis

Conditions in infants

21 May 2015Registered users

• Candida intertrigo • Sticky eyes • Roundworm • Infantile eczema • Lick lip dermatitis • Milk blisters


23 Apr 2015Registered users

•Late onset acne •Acne agminata •Exogenous acne •Acne rosacea •Acne conglobata •Folliculitis


23 Mar 2015

•Cholestatic pruritus •Phytodermatitis •Insect bites •Chickenpox •Urticaria •Hypertrophic lichen planus


23 Feb 2015Registered users

• Nickel allergy • Tinea incognito • Infected eczema • Varicose eczema • Atrophie blanche • Asteatotic eczema

Scalp conditions

22 Jan 2015Registered users

•Squamous cell carcinoma •Intradermal naevus •Actinic keratosis •Seborrhoeic keratosis •Scalp psoriasis •Sebaceous naevus