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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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418
SCALES AND PLAQUES
The GP overview
Skin scales represent an abnormally fast piling up of keratinised epithelium. Scales and plaques
are common at all ages and have a variety of causes. e presentation will centre on cosmetic
appearance, itching, fears about serious disease or a combination of these.
Differential diagnosis
COMMON
psoriasis
eczema (in all its various forms)
fungal infections (e.g. scalp, body, feet)
seborrhoeic dermatitis
seborrhoeic keratosis
OCCASIONAL
lichen simplex
lichen planus (usually scaly only on legs)
solar keratosis
pityriasis versicolor and rosea
juvenile plantar dermatosis
guttate psoriasis (scaly papules)
RARE
malignancy: Bowen’s disease and mycosis fungoides (cutaneous T-cell lymphoma)
drug induced (e.g. β-blockers and carbamazepine)
ichthyosis (various forms)
keratoderma blenorrhagica (part of Reiter’s syndrome)
pityriasis lichenoides chronica
secondary syphilis
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SCALES AND PLAUES 419
Ready reckoner
Psoriasis Eczema Fungal Seborrhoeic dermatitis Seborrhoeic keratosis
Plaque Ye s Possible No No Possible
Well-demarcated border Ye s No Ye s No Ye s
Markedly itchy No Ye s Possible Possible No
Symmetrical Ye s Ye s No Possible No
Severe dandruff Possible Possible Possible Ye s No
Possible investigations
LI KE LY: None.
POSSIBLE: Wood’s light, skin scrapings/hair samples, patch testing.
SMALL PRINT: Skin biopsy, syphilis serology, FBC, ESR/CRP, fasting glucose or HbA1c.
Green uorescence under UV (Wood’s) light is diagnostic of microsporum f ungal infection.
Skin scrapings and hair samples for mycology: Will help dierentiate funga l infections from
similar rashes.
Skin biopsy: May be the only way to achieve a rm diagnosis in obscure rashes, and is essential
if malignancy suspected.
Patch testing: To establish the likely allergen in allergic contact eczema.
Syphilis serology: If justied by clinical features or obscure pattern.
FBC and ESR/CRP: May suggest signicant underlying disease (e.g. T-cell lymphoma);
ESR/CRP also elevated in Reiter’s disease.
Fasting glucose or HbA1c: Check for diabetes in recurrent fungal infections.
TOP TIPS
To help distinguish between fungal and eczematous rashes, look at the symmetry and edges
of the lesions. Fungal rashes are usually asymmetrical with a scaly, raised edge.
In the presence of a fungal rash, look for infection elsewhere (e.g. groins and feet) and treat
both areas, otherwise the problem is likely to recur.
In uncertain cases, explain to the patient that the real diagnosis may only become apparent
as the rash develops (the typical example being the herald patch of pityriasis rosea looking
like initially tinea corporis) – invite the patient to return for reassessment if your initial
treatment proves unsuccessful.
A symmetrical, glazed, scaly and ssured rash on the soles of a trainer-loving child or
adolescent is juvenile plantar dermatosis.
Eight percent of people with psoriasis will have arthropathy, which is usually also associated
with nail changes. Check the nails and ask about joint symptoms in patients with psoriasis.
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420 SYMPTOM SORTER
Erythroderma – universal redness and scaling caused, rarely, by psoriasis, eczema, mycosis
fungoides and drug eruptions – renders the patient systemically unwell. Urgent inpatient
treatment is required.
A solitary, well-dened, slowly growing scaly plaque on the face, hands or legs of the middle-
aged or elderly patient is probably Bowen’s disease – but it can easily be mistaken for an
isolated patch of eczema or psoriasis.
If a pityriasis rosea-like rash extends to the palms and soles, with fever, malaise, sore throat
and lymphadenopathy, consider secondary syphilis.
NOTES:
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421
SKINFOLD RASH
The GP Overview
Given that this type of rash aects inaccessible and uninviting nooks and crannies of the body, it
may be dealt with in a cursory way. In most cases, that won’t be a problem, as the diagnosis may
be clear. e dierential is wider than many imagine, though, and the symptoms troublesome
or painful enough to cause the patient real distress.
Differential diagnosis
COMMON
fungal infection (candida or tinea)
seborrheic dermatitis
erythrasma
eczema (e.g. antecubital and popliteal fossae)
nappy rash (usually a mixture of irritant dermatitis and candida superinfection, can also be
seen in the incontinent elderly)
OCCASIONAL
irritant eczema from sweat
exural psoriasis
staphylococcal infection (folliculitis or impetigo)
allergic eczema (e.g. deodorant)
hidradenitis suppurativa
skin tags
RARE
molluscum contagiosum (common, but rarely presents as skinfold rash)
acanthosis nigricans
Hailey-Hailey disease
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422 SYMPTOM SORTER
Ready reckoner
Fungal infection Seborrheic dermatitis Erythrasma Eczema Nappy rash
Satellite lesions Possible No No No Possible
Itchy Possible Possible No Ye s Possible
In babies Possible Possible No Possible Yes
Very symmetrical No Possible Possible Ye s Possible
Fluoresces under Wood’s light No No Ye s No No
Possible investigations
LI KE LY: None.
POSSIBLE: Skin scrapings, swab.
SMALL PRINT: Investigations to assess for any underlying cause of acanthosis nigricans.
Skin scrapings: Occasionally needed to conrm a fungal infection if this is in doubt.
Swabs: Occasionally needed to conrm a suspected staphylococcal infection.
Investigations to assess for any underlying cause of acanthosis nigricans: is condition
is associated with a number of systemic conditions, which might require investigation,
depending on the clinical circumstance. is might involve HbA1c or blood sugar for
diabetes, LH, FSH, testosterone, SHBG and pelvic ultrasound for PCOS, and hospital-
based investigations if an underlying malignancy (especially gastrointestinal) is suspected.
TOP TIPS
As a cause of skinfold rashes, seborrheic dermatitis tends to be symmetrical, and fungal
infections less so. at said, they can be dicult to distinguish, and can co-exist, hence the
GP ‘catch-all’ prescription of an anti-fungal/steroid cream combination.
Intertrigo is a loose term with various interpretations – it is most commonly used to describe
the seborrheic dermatitis/fungal-type rash described above, but it’s important to remember
that ‘intertrigo’ can have other causes.
When treating fungal groin infections – ‘tinea cruris’ – check for athlete’s foot, too, and
treat if present.
In persistent or troublesome cases, obesity and/or hyperhidrosis may be signicant
contributory factors – ensure these are addressed, too.
In resistant cases (even in babies), consider exural psoriasis. ere may be no other evidence
of psoriasis evident, and the characteristic scale may be absent – the very well dened lesion
edges are a clue.
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SKINFOLD RASH 423
Remember that acanthosis nigricans can be associated with underlying malignancy,
particularly gastrointestinal. Enquire about relevant symptoms and have a low threshold
for referral.
Patients with ‘recurrent boils’ in groins and/or axillae may well have hidradenitis suppurativa.
ey are oen treated with episodic short courses of antibiotics rather than the more eective
long term antibiotics, and the impact of the problem on the individual can be underestimated.
Always bear in mind the possibility of neglect if you see a baby with horrendous, persistent
or recurrent nappy rash, especially if sent by the health visitor rather than spontaneously
presented by a parent.
NOTES:
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425
URINARY
Blood in urine 426
Dysuria 429
Excessive urination 432
Frequency 435
Incontinence 438
Nocturia 441
Retention 444
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426
BLOOD IN URINE
The GP overview
Bright red blood in the urine causes instant alarm in a patient, and usually generates an
emergency appointment or an out-of-hours call. Blood may also be picked up by dipstick testing
or MSU during the assessment of some other problem or in a routine medical. is is oen less
frightening even when disclosed to the patient, but should prompt full investigation.
Differential diagnosis
COMMON
UTI
bladder tumour
renal/ureteric stones
urethritis
prostatic hypertrophy/carcinoma of prostate
OCCASIONAL
jogging and hard exercise
renal carcinoma
chronic interstitial cystitis
anticoagulant therapy
nephritis/glomerulonephritis
RARE
renal tuberculosis
polycystic kidney disease
blood dyscrasias: thrombocytopenia, haemophilia, sickle-cell disease
infective endocarditis
schistosomiasis (common abroad)
trauma
ketamine-associated ulcerative cystitis
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BLOOD IN URINE 427
Ready reckoner
UTI Bladder tumour Stones Urethritis Prostate
Frank blood Possible Possible Possible No Possible
Dysuria Ye s No Ye s Yes No
Urethral discharge No No No Yes No
Poor urinary stream No Possible Possible No Ye s
Loin pain Possible No Possible No No
Possible investigations
LI KE LY: Urinalysis, MSU, FBC, U&E, ACR/PCR.
POSSIBLE: PSA, ultrasound, plain abdominal X-ray, cystoscopy.
SMALL PRINT: Urethral swab, CT scan, urine cytology, renal biopsy, angiography.
Urinalysis: Pus cells and nitrite in U TI. Pus cells alone in urethritis, TB and bladder tumour.
Presence of protein suggests renal disease.
Urine microscopy and culture to establish pathogen in infection. May show casts in renal
disease.
FBC and U&E help establish ba sic renal function and any associated anaemia or leucocytosis;
consider PSA – usually elevated in prostatic carcinoma.
ACR/PCR: To quantify any proteinuria.
Urethral swabs if urethritis (best done at GUM clinic).
If painless haematuria, ultrasound may show renal tumour or polycystic kidneys; CT may
be more useful.
Specialist investigations include renal imaging, cystoscopy, urinary cytology, renal biopsy
and angiography.
TOP TIPS
Microscopic haematuria in an asymptomatic menstruating woman can be ignored
temporarily; repeat the urinalysis at mid-cycle.
Remember that there are other less common causes of spurious haematuria – sometimes the
blood may be coming from the rectum or vagina. Assess each case carefully and be prepared
to rethink if symptoms persist but urological investigations prove negative.
Some food pigments, beetroot and certain drugs (e.g. nitrofurantoin) can colour the urine
red – conrm haematuria with urinalysis to save the patient unnecessary tests.
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