Dermatology - Primary syphilis
Syphilis is a sexually transmitted infection caused by the spirochete bacterium Treponema pallidum. It is transferred through contact with the skin and mucous membranes, and can affect several organs in the body.

Regional lymphadenopathy typically manifests within a week. The nodes are distinct, solid, elastic, painless, usually seen on one side; they may last for several months.

An ulcer or chancre, ranging in size from 1 mm to 2 cm, appears on the mucocutaneous site where the infection was introduced. It starts as a button-like bump and then progresses to a painless erosion until eventually developing into an ulcer with a raised border and a small amount of clear fluid discharge. The surface might exhibit a crust formation. Extragenital chancres can develop at any location where the infection was introduced; sores on the fingers can cause discomfort. Even in the absence of medical intervention, a chancre will fully heal after a period of 4 to 6 weeks. At this point, the infection may either enter a dormant stage or progress into secondary or tertiary syphilis.

The diagnosis is established through clinical examination and can be further validated using dark-field microscopy or serological testing.
The potential causes for the condition are genital herpes, traumatic ulcer, fixed drug eruption, chancroid, and lymphogranuloma venereum.

Administer a single dose of intramuscular benzathine penicillin G at a dosage of 2.4 million units, or alternatively, take oral doxycycline at a dosage of 100 mg twice daily for a duration of 14 days. This treatment is highly effective and serves to prevent the occurrence of secondary or tertiary syphilis.

​Dermatology - Impetigo
The primary causative agents of impetigo are Staphylococcus aureus and beta-hemolytic streptococcus group A. Bullous impetigo occurs due to the localized synthesis of epidermolytic toxin by Staphylococcus aureus bacteria. These microorganisms are not commonly found in the normal human skin microbiota, but instead temporarily inhabit the skin and can lead to surface-level diseases. Primary infections are most prevalent in youngsters, however both primary and secondary infections can occur in individuals of all age groups.

Superficial infections frequently lack noticeable symptoms.

Impetigo manifests as erosions characterized by golden-yellow crusts of 1 to 3 cm in diameter. These lesions exhibit central healing after several weeks of presence. The lesions are spread out, separate, and might merge together; satellite lesions form by self-infection. Secondary infection is frequently observed. Bullous impetigo is characterized by the presence of blisters filled with clear yellow or slightly cloudy fluid, surrounded by a red ring, on skin that appears normal. Rupture leads to the decompression of bullous lesions. Removing the roof of a bulla results in the formation of shallow and wet erosion. Ecthyma is characterized by the presence of ulceration accompanied by a thick crust that adheres firmly to the skin. This condition may cause tenderness and hardening of the affected area.


The diagnosis is made based on clinical observations and validated through laboratory culture testing. The differential diagnosis comprises excoriation, allergic contact dermatitis, herpes simplex, epidermal dermatophytosis, scabies, burns, porphyria cutanea tarda, venous stasis, and ischemic ulcers.

Manage lesions by applying mupirocin and retapamulin ointment, and prevent them from happening again by using benzoyl peroxide wash and/or applying mupirocin and retapamulin ointment to the nostrils.
Examine family members for symptoms of impetigo and urge all those in close proximity to cleanse their hands with ethanol or isopropyl gel. Treatment using antibiotics that act throughout the body.

​Dermatology - Anogenital Region Malignant Melanoma
Although malignant melanoma of the anogenital region is uncommon, the prognosis is unfavorable due to early metastasis through lymphatic veins. Moreover, due to the lack of regular examination of the anogenital region for precancerous and cancerous abnormalities, the diagnosis is frequently delayed until the disease has progressed significantly.
The presence of macules or papules displaying a mixture of brown-black color, uneven boundaries, and frequently accompanied by raised papular elevation or ulceration. In males, lesions are predominantly found on the glans (67%), prepuce (13%), urethral meatus (10%), penile shaft (7%), and coronal sulcus (3%). In females, lesions are primarily seen on the labia minora and clitoris.


The diagnosis is established through clinical examination and further validated by doing a biopsy of the affected area. Complete excisional biopsy with limited margins is the most favorable approach, while incisional or punch biopsy is acceptable in cases where complete excisional biopsy is not feasible. Avoid utilizing shave biopsy since it does not accurately indicate the extent of invasion. The possible causes for the condition are genital lentiginosis, old fixed drug eruption, squamous cell carcinoma (SCC), hemangioma, and intraepithelial neoplasia (Bowenoid papulosis).

The treatment involves the complete removal of tissue down to the fascia. When dealing with lesions that are less than 1 mm thick, it is important to have margins of 1 cm from the edges of the lesion. Biopsy of lymph nodes should only be done if the nodes can be felt. For lesions that are larger than 1 mm in thickness, it is important to have a margin of 2 cm and do a biopsy of the sentinel lymph nodes. Proceed with excision followed by immediate closure or repair using skin grafts. Perform lymphadenectomy exclusively for nodal basins exhibiting occult tumor cells or in cases where nodes are clinically palpable and display suspicious characteristics indicative of tumor presence. Adjuvant therapy should be considered in cases where there is a danger of recurrence, such as when there are positive regional lymph nodes or the cancer is in an advanced stage.

​Dermatology - Genital Human Papilloma Virus (HPV) Infection
The majority of sexually active individuals have subclinical HPV infections, and approximately 1% of sexually active adults between the ages of 15 and 19 acquire lesions. The infection has the ability to remain inactive for extended periods of time and can become contagious periodically. An emerging vaccination targeting certain strains of HPV has the potential to reduce the occurrence of HPV-induced cancer.

The dysplasia of the anogenital and oral skin and mucosa varies in severity from minor to severe.
Warts have the potential to progress into squamous cell cancer. Recurrences typically arise from reactivation rather than reinfection. During pregnancy, warts may have an augmentation in both size and quantity, exhibit heightened vaginal involvement, and demonstrate an elevated incidence of secondary bacterial infection.
Children born through the vaginal canal to moms with genital HPV infection are susceptible to developing recurrent respiratory papillomatosis.
Abnormalities
The lesions, known as condylomata acuminata, vary in appearance from little papules to larger nodules or even merging masses. They can be found on the skin or mucous membranes of the anogenital area, as well as the oral mucosa, including the external genitalia, perineum, cervix, and oropharynx. The lesions can appear in various colors such as skin-colored, pink, red, tan, or brown. They can be either solitary, dispersed, or isolated, or they might form large, merging clusters.


The diagnosis is primarily based on clinical evaluation, and in some cases, it may be further validated with a biopsy. The differential diagnosis includes various conditions, such as normal anatomical variations (sebaceous glands, pearly penile papules, vestibular papillae), squamous cell carcinoma, benign tumors (moles, seborrheic keratoses, skin tags, pilar cyst, angiokeratoma), inflammatory skin diseases (lichen nitidus, lichen planus), molluscum contagiosum, condylomata lata, folliculitis, and scabietic nodules.


There is currently no therapy that has been proven to completely eliminate HPV or effectively prevent cervical or anogenital cancer.
Optimal treatment outcomes are more likely when warts are of diminutive size and have been present for less than one year. Treatment options are determined based on the specific requirements of the patient, with the aim of avoiding costly, harmful therapies, as well as procedures that may lead to scarring. The use of Imiquimod 5% cream or podophylox 0.5% solution by the patient is both efficacious and feasible. Cryosurgery, intralesional podophyllin (10-25%), trichloroacetic acid (80-90%), surgical removal, and electrodesiccation are all viable possibilities for treatment.

​Dermatology - Nodular Melanoma 
Nodular melanoma (NM) is the second most prevalent type of melanoma in individuals with light skin. It primarily affects middle-aged individuals and tends to develop on parts of the body that receive less sun exposure. Initially, this tumor undergoes vertical development, specifically affecting the dermis. For unexplained reasons, NM is significantly more prevalent among individuals of Japanese heritage, occurring eight times more frequently than superficial spreading melanoma.

Nodular melanoma (NM) can originate from a preexisting nevus, but it is more frequently developed from normal skin without any prior conditions. It typically progresses over a few months and is often identified by the patient as a new growth resembling a mole.
Abnormalities
The lesion is a consistently raised, thick plaque or a protruding, polypoid, or dome-shaped growth, typically exhibiting smooth and regular boundaries. The color pattern typically lacks variation, with the lesion appearing consistently blue or blue-black. In rare cases, it may be mildly pigmented or completely nonpigmented (amelanotic melanoma). Nodular melanoma (NM) is a kind of primary melanoma that develops quickly (between a few months to 2 years) from normal skin or a melanocytic nevus. It grows vertically without an adjacent epidermal component, which is always seen in lentigo maligna melanoma and superficial spreading melanoma. Initial lesions have a size ranging from 1 to 3 cm, however they can significantly increase in size if not discovered.

The diagnosis is made through a clinical assessment, which is then confirmed with dermoscopy and/or biopsy. Performing a complete excisional biopsy with minimal margins is the most effective approach. If the biopsy results are positive, it is necessary to perform a reexcision. Incisional or punch biopsy is a suitable alternative when it is not possible to do a complete excisional biopsy or when the lesion is large and would require considerable surgery to remove it entirely. The differential diagnosis for blue/black lesions includes hemangioma (with a long history), pyogenic granuloma, and pigmented basal cell cancer. Any newly formed nodule like a blueberry should be surgically removed or, if it is of significant size, subjected to a biopsy.


The treatment involves surgically removing tissue down to the fascia. To guarantee proper treatment for lesions that are less than 1 mm thick, it is important to have a margin of 1 cm from the edges of the lesion. Biopsy of lymph nodes should only be performed if the nodes can be felt or detected through touch. For lesions that are larger than 1 mm in thickness, it is important to have a 2-cm margin and do a biopsy of the sentinel lymph nodes. Proceed with excision followed by immediate closure or repair using skin grafts. Perform lymphadenectomy exclusively for nodal basins that contain hidden tumor cells or if the nodes are clinically detectable and show signs of potential tumor presence. Adjuvant therapy should be considered in cases where there is a danger of recurrence, such as when there are positive regional lymph nodes or the cancer is in an advanced stage.

​Dermatology - Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)
SJS and toxic TEN are both severe and potentially fatal mucocutaneous reactions marked by widespread necrosis and separation of the epidermis. SJS and TEN are different forms of the same disease, which might be caused by unknown factors or drugs. The main difference between them is the extent to which the body surface is affected.


The interval between initial drug exposure and the appearance of symptoms typically ranges from 1 to 3 weeks, but this is more frequently observed with subsequent exposure. Prior to the eruption, there is commonly a prodrome characterized by fever, malaise, and arthralgia that typically lasts for 1-3 days. Malnutrition, sensitivity to light, uncomfortable urination, and anxiety may manifest.
Abnormalities
The individual experiences a mild to moderate sensation of tenderness in the skin, along with a burning or itchy feeling in the conjunctiva. This is followed by skin pain, a burning sensation, tenderness, and paresthesia. Oral ulcers cause significant discomfort and sensitivity. The initial rash is characterized by a morbilliform appearance and may exhibit target-like patterns, with or without the presence of purplish discoloration. The lesions quickly merge together; alternatively, there may be no distinct lesions, but instead a widespread redness and absence of a rash. As the rash advances, the outer layer of the skin undergoes necrosis, resulting in wrinkled patches that grow in size and merge together. Subsequently, there is a detachment of the outer layer of the skin, known as the epidermis, in a sheet-like manner. This is accompanied by the formation of soft and raised blisters that can spread when pressure is applied sideways (known as the Nikolsky sign) on reddened parts of the skin. Following trauma, the skin experiences a complete separation of the outermost layer, resulting in the exposure of the underlying dermis. This exposed dermis appears red and is accompanied by leaking, similar to a second-degree burn caused by heat. The lips, buccal mucosa, conjunctiva, and vaginal and anal skin are consistently affected. The eyes exhibit conjunctival diseases characterized by hyperemia, pseudomembrane development, keratitis, corneal erosions, and subsequent adhesions between the eyelids and bulbar conjunctiva.

The differential diagnosis comprises drug eruptions, erythema multiforme, scarlet fever, phototoxic eruptions, toxic shock syndrome, graft-versus-host disease, thermal burns, staphylococcal scalded-skin syndrome (rare in adults but present in young children), fixed drug eruption, and exfoliative dermatitis.

Prompt identification and cessation of potentially implicated medication(s) are of utmost significance. Patients receive optimal care in an intermediate or intensive care unit. Administer IV fluids and electrolytes in a manner consistent with patients suffering from a severe third-degree heat burn. However, a smaller amount of fluid is typically needed for a thermal burn of same size. Administering systemic glucocorticoids during the onset of the disease can be beneficial in minimizing the occurrence of illness or death, particularly when given in large quantities. In the advanced stages of the condition, they are not recommended. Administering a large amount of immunoglobulin through an intravenous route during the initial phases.
It is not advisable to have surgical debridement.
Early treatment of ocular lesions with erythromycin ointment is recommended.

​Dermatology - Meningococcemia
Neisseria meningitides establishes itself in the human nasopharynx and is transmitted from one person to another through respiratory droplets.
The symptoms of meningococcal meningitis are characteristic of bacterial meningitis, including fever, headache, neck stiffness, and the presence of polymorphonuclear leukocytes (PMNs) in the cerebrospinal fluid.
Abnormalities
Shortly after the condition begins, there are small, pink spots and raised areas on the skin that can turn white when pressed. Petechiae and ecchymoses are observed on the ankles, wrists, axillae, mucosal surfaces, and conjunctivae due to vascular fragility and bleeding. Petechiae may form in clusters at areas of pressure, whereas ecchymoses and purpura might develop into hemorrhagic bullae, experience necrosis, and eventually ulcerate. Purpura fulminans, in extreme instances, manifests as irregularly shaped, merging necrotic hemorrhagic lesions that appear grayish to black. Fulminant disease may exhibit disseminated intravascular coagulation. Patients may develop sepsis, a potentially life-threatening condition characterized by a systemic infection. Additionally, they may experience peripheral gangrene, a condition where tissue in the extremities dies due to reduced blood flow. Waterhouse-Friderichsen syndrome is an acute and severe form of meningococcal septicemia. It is marked by symptoms such as high fever, shock, extensive purpura (purple discoloration of the skin), disseminated intravascular coagulation (abnormal blood clotting throughout the body), thrombocytopenia (low platelet count), and adrenal insufficiency (inadequate functioning of the adrenal glands).

A conclusive diagnosis necessitates the isolation of meningococci from either the bloodstream or the specific location of illness. The differential diagnosis encompasses adverse cutaneous drug eruptions, vasculitis, Rocky Mountain spotted fever, and infective endocarditis.


Administer third-generation cephalosporins (ceftriaxone or cefotaxime) as the initial treatment.
If the strain is susceptible, possible alternatives include penicillin G, ampicillin, fluoroquinolone, or aztreonam. The typical period of therapy is 7 days. For people with a strong allergy to penicillin, it is recommended to administer chloramphenicol (1 g IV every 6 hours) instead of taking the risk of experiencing cross-reactions with a third-generation cephalosporin. Administer supportive care measures to safeguard the functionality of affected organs.

​Dermatology - Nail Findings of Lichen Planus 
Approximately 10% of persons with disseminated lichen planus experience nail involvement, which can result in the destruction of the nails. In other cases, nail lesions may be the sole indication of the condition. The condition known as "twenty-nail syndrome" refers to the involvement of one, few, or all 20 nails, resulting in the loss of all nails without any other signs of lichen planus elsewhere on the body.

Onychorrhexis, characterized by longitudinal ridging and fissuring of the nail plate resulting in brittleness and breakage, is observed. However, it should be noted that this is not a distinctive feature and can also occur as a result of aging. Similar alterations occur in lichenoid graft-versus-host disease. Swelling and blue/red staining of the proximal nail fold are observed on the skin's dorsum.

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A minor concentration may be observed in the matrix, manifesting as a protrusion beneath the proximal nail fold and a following vertical red line: The nail plate becomes thinner and develops a split at the distal end, a condition known as onychorrhexis. Matrix involvement refers to the scattered and specific degeneration of the nail plate, characterized by onychorrhexis (nail splitting) and/or transverse splitting. A red lunula can be either localized or widespread, and temporary longitudinal melanonychia may occur. There is a possibility of a total nail fracture. Pterygium development refers to the partial loss of the central nail plate, resulting in the destruction of the underlying matrix. This condition is characterized by a V-shaped extension of skin from the proximal nail fold that is firmly attached to the nail bed. The rapid and ongoing destruction of the nails, resulting in widespread nail shrinkage with or without the formation of a fold of skin over the nail (pterygium), ultimately leads to the total absence of nails (anonychia). Ulcerative lichen planus is characterized by the presence of bullae, erosions, bleeding, and scarring. In this variant, skin lesions typically occur on the palms and soles.
The disease has different forms, such as 20-nail dystrophy of childhood, which goes away on its own; lichen planus-like eruptions that occur after a bone marrow transplant in graft-versus-host disease; drug-induced reactions that resemble lichen planus, and permanent anonychia as the sole manifestation of lichen planus.

Observation of the physical manifestation and presence of LP lesions in other areas of the body. The differential diagnosis include all nail illnesses characterized by destruction, such as psoriasis, Darier disease, and onychomycosis.


Manage nail lesions by using intralesional triamcinolone and systemic glucocorticoids.

​Dermatology - Varicose Veins
Varicose veins occur when there is a chronic problem with the flow of blood back to the heart, leading to increasing pressure in the capillaries. The highest occurrence of the beginning of symptoms often happens between the ages of 30 and 40, with women being afflicted three times more frequently than males. Varicose veins are a hereditary trait that is worsened by factors such as pregnancy, higher blood volume, increased cardiac output, elevated venocaval pressure, and the hormone progesterone.
Legs may have a sensation of heaviness or pain, which worsens when standing and improves when walking.

Superficial leg veins exhibit enlargement, tortuosity, and valve incompetence. The most effective evaluation of these veins is performed with the patient in a standing position. The occurrence of "blow-out" can be observed at locations where there are incompetent communicating veins. Varicose veins can be related to starburst phlebectasia, which typically occurs above an inadequate connecting vein. Superficial venectasias, also known as spider phlebectasia, may be present without a starburst pattern, but they are usually not indicative of chronic venous insufficiency.

The diagnosis is established using the tourniquet test, wherein a tourniquet is given to the elevated leg to drain the veins. When the patient gets up and the tourniquet is removed, a varicose vein instantly fills up due to the absence or malfunctioning of valves.
Doppler and color-coded duplex ultrasound can identify veins that are not functioning properly and discover blockages caused by blood clots.


The effectiveness of injection sclerotherapy, which involves the injection of a sclerosing agent into varicosities and subsequent application of prolonged compression, has been established. Additionally, vascular surgery may be conducted.

Dermatology - Bullous Impetigo
The primary causative agents of impetigo are Staphylococcus aureus and beta-hemolytic Streptococcus group A. Bullous impetigo occurs due to the localized synthesis of epidermolytic toxin by S. aureus bacteria. These microorganisms are not commonly found on human skin, but instead temporarily inhabit the skin and produce surface-level diseases. Primary infections primarily affect youngsters, however both primary and secondary infections can occur in individuals of all age groups.
Superficial infections frequently lack noticeable symptoms.

Impetigo manifests as erosions characterized by golden-yellow crusts measuring 1 to over 3 cm in diameter. These lesions exhibit central healing after several weeks of presence. The lesions are distributed randomly, apart from each other, and might merge together; satellite lesions appear due to self-infection. Secondary infection is frequently observed. Bullous impetigo manifests as blisters filled with transparent yellow or slightly cloudy fluid, surrounded by a red ring, on skin that appears normal. Rupture causes the decompression of bullous lesions. Removing the ceiling of a bulla results in the formation of a shallow and wet erosion.
Ecthyma is a condition characterized by the presence of ulcers covered by a thick crust that can be painful and hardened.


The diagnosis is based on clinical observations and is verified through culture testing. The differential diagnosis comprises excoriation, allergic contact dermatitis, herpes simplex, epidermal dermatophytosis, scabies, burns, porphyria cutanea tarda, venous stasis, and ischemic ulcers.

Manage lesions by applying mupirocin and retapamulin ointment. To avoid future occurrences, use benzoyl peroxide wash and/or apply mupirocin and retapamulin ointment to the nostrils.
Examine family members for symptoms of impetigo and advise any individuals in close proximity to cleanse their hands with ethanol or isopropyl gel.