574 August Skin Conditions - V10 2

Unit 574
August 2020
Skin conditions
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Skin conditions
Unit 574 August 2020
About this activity 3
Case 1 Jessica has itchy hands 5
Case 2 Apinya thinks she is going bald 9
Case 3 Holden has a rash on his buttocks 13
Case 4 Paulo has uncomfortable genital itching 17
Case 5 Zivko has a painful rash 21
Multiple choice questions 26
The five domains of general practice
Communication skills and the patient–doctor relationship

Applied professional knowledge and skills
Population health and the context of general practice
Professional and ethical role
Organisational and legal dimensions
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About this activity check Skin conditions
About this activity Australian expert consensus statement. (RACGP’s) Specific Interests group for
Australas J Dermatol 2019;60(2):163– Dermatology. His additional work
Skin conditions, including pathology 70. doi: 10.1111/ajd.12941.
includes acting as a contributor to the
affecting the nails and hair, account for 5. Australian Immunisation Handbook.
world-renowned DermNet NZ and a
15.3 of every 100 patient encounters in Zoster (herpes zoster). Canberra, ACT:
DoH, 2018. Available at https:// reviewer for Australian Journal of
general practice in Australia, and 11.3%
immunisationhandbook.health.gov.au/ General Practice and RACGP
of the total reasons for encounters.1 vaccine-preventable-diseases/zoster- conferences’ abstracts.
herpes-zoster [Accessed 23 June 2020].
Contact dermatitis was the most
6. Melbourne Sexual Health Centre. Lichen
Alvin H Chong (Case 3) MBBS,
common skin-related presentation to
sclerosus. Carlton, Vic: MSHC, 2017. MMed, FACD is a Specialist
general practice in 2015–16, accounting
Available at www.mshc.org.au/ Dermatologist and Adjunct Associate
for 1.1% of total reasons for encounters.1 SexualHealthInformation/Sexual Professor at St Vincent’s Hospital
HealthFactSheets/LichenSclerosus/
Tinea is common2 but, in the case of Melbourne, Skin Health Institute and
tabid/271/Default.aspx#.XvFgkC2r2gQ
tinea incognita, may present with an [Accessed 23 June 2020]. the University of Melbourne. He is also
‘atypical’ appearance.3 It is therefore Principal Dermatologist at Ivanhoe
important that general practitioners Learning outcomes Dermatology Clinic, Victoria. His
(GPs) are alert to cases of tinea that special interests are in dermatology
At the end of this activity, participants education and in the dermatological
have been previously incorrectly
will be able to: care of patients who are
diagnosed and treated with a topical
corticosteroid3 so that this condition • discuss the process of immunosuppressed.
can be treated correctly and potential differentiating between irritant and Senhong Hong (Case 1) MBBS (Hons),
spread limited. allergic contact dermatitis MMed is a Dermatology Registrar at
The lifetime risk of developing alopecia • outline the Australian Immunisation Eastern Health and Northern Health.
areata is approximately 2%, and onset Handbook recommendations for Rebekka Jerjen (Case 2) MChD (Dist),
generally occurs before the age of vaccination for herpes zoster BMSc (Hons) is a Clinical Trials and
40 years.4 The prevalence is the same
• describe the diagnostic criteria used Research Fellow at Sinclair
in men and women.4 Dermatology.
to determine the cause of hair loss
The incidence of herpes zoster Blake Mumford (Case 3) MBBS (Hons)
• identify the differential diagnosis
(shingles) increases with age. is a Research and Education
for a poorly demarcated
Approximately 630 individuals per Dermatology Fellow at the Skin Health
erythematous rash
100,000 in the 50–59-year age range Institute, Victoria.
are affected, compared with 1531 per • outline the optimal management of
penile lichen sclerosus. Rosemary Nixon (Case 1) AM MBBS,
100,000 people aged 70–79 years.5
MPH, FACD, FAFOEM is a
Correct identification of lichen sclerosus Authors Dermatologist and Occupational
is crucial as, although the condition is Medicine Physician at Skin Health
uncommon, progressive scarring can Benjamin Olamide Adeyemi (Case 5) Institute and East Melbourne
occur without treatment; in a small MBBS, DipHIVMan, DipPEC, MPH, Dermatology.
number of cases, untreated disease has MMed Fam Med, FCFP (SA), FRACGP
currently provides full-time general Rodney Sinclair (Case 2) MBBS,
also progressed to malignancy.6
practice services as a Senior Medical MD, FACD is a Professor of
This edition of check considers the Officer with Wide Bay Hospital and Dermatology at the University of
investigation and management of skin Health Service, Queensland Health. He Melbourne and Director of Sinclair
conditions in general practice. Dermatology. He is considered a
has held managerial, specialist and
world leader in hair disease.
academic positions prior to his current
References appointment. He has a keen interest in Charlie Yue Wang (Case 1) MBBS
1. Britt H, Miller GC, Henderson J, et al. health management and policy, (Hons), BMedSci (Hons) is a Clinical
General practice activity in Australia mentoring, primary care research, medical Trials Research Fellow at Skin Health
2015–16. Sydney, NSW: Sydney
education, training and assessment. His Institute, Victoria.
University Press, 2016.
other interests include chronic diseases
2. Healthdirect Australia. Tinea. Sydney,
NSW: Healthdirect Australia, 2019.
management and healthcare delivery for Peer reviewers
Available at www.healthdirect.gov.au/ vulnerable populations.
Roshanak Ranjbaran MBBS, MD is a
tinea [Accessed 23 June 2020].
Tim Aung (Case 4) FRACGP, General Practitioner and Researcher
3. Kovitwanichkanont T, Chong AH.
FRNZCGP, ProfDip (Skin Cancer Surg), who graduated from Tehran University
Superficial fungal infections. Aust J Gen
Pract 2019;48(10):706–11. doi: 10.31128/ ProfDip (Gen Derm) is a Primary Care of Medical Sciences. Dr Ranjbaran has
AJGP-05-19-4930. Practitioner in Brisbane, Qld. He is also worked in general practice for more
4. Cranwell WC, Lai VW, Photiou L, et al. Deputy Chair of The Royal Australian than 17 years and has a special interest
Treatment of alopecia areata: An College of General Practitioners’ in skin care.
3
Skin conditions check About this activity
Brendan Chun-Yu Wu MBChB,

FRACGP, FHKCP, FHKAM(FM),
PGDipClinDerm(Lond), DPD(Cardiff),
MScPD(Cardiff) is a Family Medicine
Specialist in Hong Kong. Dr Wu serves
in Lady Trench General Outpatient
Clinic, which is a government primary
care clinic under the Hospital Authority.
His special interests are clinical
dermatology and dermatology
education. He is an Honorary Assistant
Professor in the Department of Family
Medicine and Primary Health Care at
the University of Hong Kong.
Abbreviations
ACD allergic contact dermatitis
GLS genital lichen sclerosus
GP general practitioner
HSV herpes simplex virus
HZ herpes zoster
HZ/su herpes zoster subunit
HZO herpes zoster ophthalmicus
ICD irritant contact dermatitis
Ig immunoglobulin
PCR polymerase chain reaction
PHN post-herpetic neuralgia
PLS penile lichen sclerosus
RCT randomised controlled trials
SCC squamous cell carcinoma
STI sexually transmissible infection
TCS topical corticosteroid
VZV varicella zoster virus
4
Skin conditions check Case 1
CASE Further information
1
Jessica tells you that she frequently washes her hands at work;
Jessica has itchy hands more than a dozen times per day. She also comes in contact
with hair dyes, bleaches, perming chemicals and shampoos
every day. She usually wears rubber gloves when she handles
Jessica, aged 28 years, presents with a red, dry, scaly
dyes and bleach. She uses cosmetics occasionally, but has
rash on both hands associated with itch and a burning
never developed a rash on her face or other parts of the body.
sensation (Figure 1). The rash has been present for a
She does not have any significant contact with animals or
few months and is worsening despite Jessica’s use of
plants. She reports a history of childhood eczema only and
emollients. She does not have any active medical
occasional bouts of hay fever in spring.
conditions and has been working full time as a
hairdresser for the past six months.
Question 3
What is the most likely diagnosis based on Jessica’s history?
Figure 1. Dorsum of Jessica’s right hand, which shows

redness, scaling, cracking and dryness Question 4
What investigations would you consider for Jessica?
Question 1
What potential exposures or other relevant history would you
seek from Jessica?
Question 5
What are some common occupations at risk of significant
work-related dermatitis?
Question 2
What conditions would you include in your differential
diagnosis for Jessica?
5
Case 1 check Skin conditions
Further information Question 8

You take skin scrapings from Jessica and send the sample for Would you refer Jessica to a skin specialist? If so, when?
microscopy and fungal testing. After weeks of culture, no fungus
has grown. You refer Jessica to a patch testing clinic. The results
of the pertinent patch test are shown in Table 1.
Table 1. Results of Jessica’s patch test
Allergen Presence of reaction after five days
Nickel sulfate No reaction
Thiuram mix No reaction
Methylisothiazolinone Minimal erythema
Formaldehyde No reaction
Balsam of Peru No reaction
Paraphenylenediamine base Minimal erythema
Toluene diamine sulphate No reaction
Ammonium persulfate Minimal erythema

CASE 1 Answers
Glyceryl monothioglycolate No reaction

Answer 1
A basic screen of questions should include the below, but not
be limited to:
Question 6
• occupational details (current and previous, duration of
Based on the results of the patch testing, what is your
employment, routine tasks, exposures [eg hair dye,
diagnosis for Jessica?
hairdressing bleach, shampoos])
• exposure to water and frequency of wet work
• skin care (eg liquid soaps, fragrances, moisturisers, cosmetics)
• glove use (work and home), as well as type of glove

(eg latex/rubber, polyvinyl chloride or nitrile)
• hobbies – use of any glues or chemicals, plants
• pets
• history of atopic eczema, asthma and hay fever, including

family history
• treatment used and effectiveness (eg over-the-counter,

Question 7 prescribed, from friends)
What would you suggest as a management plan for Jessica’s • any improvement when not at work (eg on holiday or
hand dermatitis? annual leave).
Answer 2
Conditions to include in the differential diagnosis are:
• irritant contact dermatitis
• allergic contact dermatitis
• atopic dermatitis
• vesicular hand dermatitis
• fungal infection
• contact urticaria.
6
Answer 3 and occupational exposures. The site of patch application

(usually the back) is marked to guide interpretation later. After
The most likely diagnosis is contact dermatitis (irritant or allergic).
application, the patches are removed and interpreted after
Contact dermatitis is classified as irritant or allergic 48 hours and then again after 4–5 days. Positive reactions are
depending on the underlying precipitant and mechanism of usually erythematous and infiltrated, often with vesicles or
injury. Irritant contact dermatitis (ICD) is a direct cutaneous bullae. Difficulty arises in interpreting weakly positive reactions,
response to the physical or toxic effects of external agents in as these can be confused with irritant reactions. Fading from
the environment or workplace. ICD accounts for the initial to the second reading may be suggestive of an irritant
approximately 80% of cases of contact dermatitis.1 reaction (ie the ‘crescendo–decrescendo’ phenomenon).5
Allergic contact dermatitis (ACD) results from an activation of

Other (less relevant) tests
antigen-specific acquired immunity leading to T cell–mediated
skin inflammation.2 Antigens are usually non-protein chemicals, Allergen-specific IgE testing
termed haptens, and sensitisation occurs via topical application
Laboratory testing of serum immunoglobulin (Ig) E levels
and usually takes between 10 days and three weeks. However,
against certain allergens depends on the testing panel, and
sensitisation may not occur following the first exposure and
may include foods, insects, plants, latex, mould, dust mites,
sometimes does not occur for years. Clinical symptoms after
etc. IgE testing is generally of limited utility and is not a
sensitisation are often delayed, appearing 48–72 hours after
diagnostic test by itself; however, it may support a clinical
exposure to an allergen. Symptoms may arise earlier with each
diagnosis if there is a suggestive clinical history (eg suspected
subsequent exposure, sometimes within hours.2
contact urticaria to latex).
In some instances, the distribution of skin inflammation can also
assist with the diagnosis. For example, the most common sites Skin prick testing
for nickel dermatitis are the wrists (from watch straps), lower
Skin prick testing involves depositing allergens into the skin of
abdomen (from jean studs) and ear lobes (from earrings).3
the forearm with a sterile lancet. Skin reactions are observed
Clinically, it is often difficult to distinguish between ACD and after 15–30 minutes and compared against positive and
ICD. Furthermore, most people with work-related contact negative controls. Skin prick testing’s main utility lies in the
dermatitis are exposed to a variety of agents that can cause assessment of immediate hypersensitivity reactions, and a
both irritant and/or allergic reactions. Existing ICD or breaches referral to an immunologist or allergist is usually required.
of the skin barrier also increase the likelihood of complicating Immediate reactions may occur to ammonium persulphate
ACD. As a result, hand dermatitis is often multifactorial. (hairdressing bleach), and, not uncommonly, hairdressers may
present with immediate symptoms including rhinitis or asthma.
Fungal skin infections are an important differential, as they
may mimic hand dermatitis. Clinical features that favour
Answer 5
fungal hand infection (tinea manuum) over contact dermatitis
include asymmetrical involvement (one hand is usually People working in the following occupations may be at risk of
affected; if both hands are affected, involvement is significant work-related dermatitis:6
asymmetrical), presence of tinea pedis (‘one hand, two foot’
• healthcare workers
syndrome), involvement of both dorsum and palm, and
elevated borders of the rash.4 Nevertheless, as a result of • metal workers
similar predisposing factors (eg gloves, wet work), tinea • concreters/bricklayers
manuum may coexist with or complicate hand dermatitis.
• food handlers
Answer 4 • machine operators

• hairdressers
Skin scrapings
• mechanics
Scrapings from the rash can be sent for microscopy and • printers
fungal culture. Microscopy may immediately identify hyphae,
but a result for the culture may take weeks. • florists.
Answer 6
Referral for patch testing
Jessica’s symptoms and patch testing results support a diagnosis
Patch testing is indicated if ACD is suspected, and referral to a
of ICD. As a result of her occupation, Jessica is exposed to several
patch testing dermatology clinic is required. The basis of the
irritants at work including wet work, hot water, shampoos and
test involves eliciting an immune response by challenging an
conditioners, and sweating from occlusive gloves.
already-sensitised individual with standardised amounts of
allergens prepared on adhesive patches.5 The tests usually A diagnosis of ICD requires exclusion of other cutaneous
include a baseline series of allergens that frequently cause ACD disorders, especially ACD. Although several chemicals in
(this can vary between countries and patch testing centres), as Jessica’s patch testing series elicited very mild reactions,
well as additional allergens on the basis of the individual’s daily these were not consistent with true hypersensitivity
7
reactions. Experience is required to interpret patch testing Treatment

results. Based on Jessica’s history of frequent hand washing,
Regular application of emollients, especially after finishing
negative skin scraping results and negative patch testing
work, is the key to preventing dermatitis, alleviating symptoms
results, ICD is the most likely diagnosis. There is no test
of dermatitis and promoting skin barrier recovery.9
available for ICD, and it is often a default diagnosis.
Treatment of contact dermatitis often necessitates prescription
Notably, there is a much higher prevalence of ACD among
of topical corticosteroids or calcineurin inhibitors. Treatment
hairdressers when compared with other professions.7 This is
regimens are generally similar to that of atopic dermatitis.9
probably a result of the large number of allergens found in
hairdressing chemicals, especially those found in hair dyes If contact dermatitis is severe or acute, a short course of oral
(toluene diamine sulphate, paraphenylenediamine), bleach corticosteroids (25–50 mg daily for up to one week, then
(ammonium persulfate), perming solutions (glyceryl tapered over two weeks) may be useful.10
monothioglycolate) and rubber chemicals in gloves.7,8
Causes of ICD in hairdressers include frequent hand Answer 8
washing with hot water, friction from handling damp hair,
Referral to a patch testing dermatologist or clinic should be
use of occlusive gloves, shampoos and conditioners, and
considered if ACD is likely (especially occupational). ACD is
contact with irritating hair chemicals.
often suspected when an eczematous disorder persists or fails
Skin conditions are among the most common occupational to respond to standard therapies and there is a possible
diseases and an important reason for workers’ compensation trigger for the rash. Topical or oral corticosteroids should be
claims.8 Contact dermatitis accounts for 90% of all weaned prior to appointments to avoid interference with
occupational dermatoses.1 Non-occupational contact dermatitis patch testing results. Furthermore, patients should be
is important to consider during the work-up, especially if a encouraged to bring in all cosmetics, fragrances, jewellery and
work-related precipitant is not apparent. Furthermore, if a non– chemicals with which they are in regular contact.
work related exposure is responsible, this may have a
Referral to a dermatologist should also be considered for
significant implication for a worker’s compensation claim.
severe or recalcitrant contact dermatitis despite precipitant
avoidance/protection and basic management with emollients
Answer 7
and topical steroids or tacrolimus. Patients may require
The management of contact dermatitis is based on the second-line treatment options such as systemic
principles of avoidance, protection, substitution and immunosuppression or ultraviolet therapy.9
treatment of dermatitis.9,10
References
Avoidance 1. Sasseville D. Occupational contact dermatitis. Allergy Asthma Clin
Immunol 2008;4(2):59–65. doi: 10.1186/1710-1492-4-2-59.
The cornerstone of managing contact dermatitis is based on
identification of the irritant or allergens followed by 2. Vocanson M, Hennino A, Rozieres A, et al. Effector and regulatory
mechanisms in allergic contact dermatitis. Allergy
avoidance. Complete avoidance of water during work may be
2009;64(12):1699–714. doi: 10.1111/j.1398-9995.2009.02082.x.
impractical as a hairdresser. A change in occupation may
3. Dermnet NZ. Nickel allergy. Hamilton, New Zealand: Dermnet NZ,
result in a more favourable long-term prognosis and should 1997. Available at www.dermnetnz.org/topics/nickel-allergy
be considered if Jessica’s condition is refractory to treatment. [Accessed 02 June 2020].
4. Dermnet NZ. Tinea manuum. Hamilton, New Zealand: Dermnet NZ,
Protection 2003. Available at https://dermnetnz.org/topics/tinea-manuum/
[Accessed 27 April 2020].
If precipitant avoidance is not possible, reduction of contact
5. Griffiths C, Barker J, Bleiker T, Chalmers R, Creamer D, editors.
is advised (eg through use of personal protective equipment). Rook’s Textbook of Dermatology. 9th edn. Chapter 130,
In Jessica’s case, wearing gloves for all water work and Occupational Dermatology. New Jersey, USA: Wiley-Blackwell, 2016.
chemical handling would be advised. Glove type should be 6. Nixon R, Frowen K, Mignon M. Occupational dermatoses. Aust Fam
selected on the basis of chemical exposure according to the Physician 2005;34(5):327–33.
workplace’s materials safety data sheet. For basic household 7. Carøe T, Ebbehøj N, Agner T. Occupational dermatitis in
tasks, rubber or polyvinyl chloride gloves (ideally with a hairdressers – Influence of individual and environmental factors.
Contact Dermatitis 2017;76(3):146–50. doi: 10.1111/cod.12686.
cotton liner or over cotton gloves) should still be worn.
8. Cahill J, Williams D, Matheson C, et al. Occupational contact
Barrier creams may also be an effective option in preventing dermatitis: A review of 18 years of data from an occupational
occupational dermatitis by reinforcing the skin barrier and dermatology clinic in Australia. Canberra, ACT: Safe Work Australia;
2012.
reducing transepidermal water loss.9
9. Johnston G, Exton L, Mohd Mustapa MF. British Association of
Dermatologist’s guidelines for the management of contact
Substitution dermatitis 2017. Br J Dermatol 2017;176(2):317–29. doi: 10.1111/
bjd.15239.
Replacing other potential allergens or irritants is advised, even
if these are not the cause of the contact dermatitis (eg using 10. Expert Group for Dermatology. Dermatitis: Contact dermatitis. In:
eTG complete [Internet]. West Melbourne, Vic: Therapeutic
fragrance-free skin care products).
Guidelines Limited, 2015.
8
CASE On examination, you see three well-defined round/oval
2
patches of hair loss on the scalp. Using a dermatoscope, you
see small exclamation mark hairs towards the periphery of the
Apinya thinks she is going bald area of hair loss. A hair pull test is negative. Apinya’s eyebrows
and eyelashes appear normal, and she reports no change in
Apinya, aged 27 years, has come to see you concerned other body hair. Three of her fingernails reveal small pits. The
about patches of hair loss on her scalp. She first noticed remaining physical examination is unremarkable.
the patches three weeks ago and thinks she had a
similar episode with just one small patch eight months
Question 3
earlier, which resolved on its own. She is self-conscious
about the hair loss and worried that she might lose all What diagnosis do you suspect, given the results of the
her hair and have to wear a wig like her aunt. history and examination?
Question 1
What would you ask Apinya to narrow your differential
diagnosis for this presentation?
Question 4
What, if any, investigations would you request for Apinya?
What would you expect to find?
Question 2
What physical assessment would you undertake?
Further information
From the history and examination findings, you

diagnose alopecia areata. Apinya asks you what, and
how common, alopecia areata is.
Question 5
How would you answer Apinya?
Further information
Apinya tells you she is otherwise well and has regular periods.
Her only regular medication is a salbutamol inhaler, which she
uses as needed for well-controlled asthma. She recalls having
mild eczema as a child. Apinya admits to being more stressed
lately because she has started a new job. She tells you her
father has been bald for many years, while her maternal aunt
lost all her body hair many years ago.
9
Question 6 CASE 2 Answers

What treatment options can you offer Apinya?
Answer 1
Key aspects to consider on history-taking include the
duration, onset and pattern (diffuse or patchy) of hair loss
as well as experiences of hair thinning (ask about changes
in ponytail thickness) and hair shedding (ask about hair on
the brush or that comes out when washing). This last
symptom can be quantified using the Sinclair hair shedding
scale, which allows comparison between visits and
assessment of treatment response over time.1 Additionally,
it is important to ask Apinya about details of previous
Further information
episodes of hair loss and regrowth, loss of other body hair
After a discussion of the treatment options, you administer and any associated pain, itchiness or burning of the scalp.2
intralesional triamcinolone 5% with lignocaine 1% to Apinya’s Some patients may identify a trigger for the hair loss, such
scalp patches. She tolerates the procedure well. as recent stress, changes in medications, illness or travel.3,4
Finally, history-taking should include questions about
Apinya comes back to see you and asks if she is likely to have
haircare practices such as tight ponytails, use of hair
further episodes of hair loss in the future.
pieces, hair products and curlers.2 A general past medical
history and family history is also essential, with special
attention to autoimmune diseases as well as symptoms of
Question 7
thyroid dysfunction or anaemia. Women should be
How would you respond? screened for symptoms of androgen excess (eg irregular
menses, acne and hirsutism).
Table 1 outlines how to group conditions considered in the

differential diagnosis and potential clues on history.
Answer 2
Good lighting and positioning are important for
examination of the hair and scalp. It is necessary to
determine the pattern of hair loss (diffuse thinning or
localised loss) and the extent of scalp involvement. A
dermatoscope should be used to examine the area(s) of hair
loss and the underlying scalp skin; in particular, it is
Further information important to look for perifollicular scale or erythema and
loss of hair follicles (suggestive of scarring alopecia),
You explain to Apinya her unpredictable long-term prognosis
exclamation mark hairs (indicating active alopecia areata),
and arrange to see her again every 4–6 weeks to repeat the
areas of hair regrowth (seen in telogen effluvium), broken
intralesional steroid injections. If she does not show
hairs (seen in tinea capitis and trichotillomania), comma
improvement after six months, you plan to commence
hairs (seen in tinea capitis) and hairs of different lengths
systemic treatment and refer her to a dermatologist.
(seen in trichotillomania).2,5
A positive hair pull test, in which at least 5–6 hairs are

Question 8 removed when 50–60 hairs are pinched and pulled firmly but
gently away from the scalp, is consistent with telogen
What else is important for Apinya’s management and for any
effluvium, active alopecia areata and thinning areas of
patient presenting with hair loss?
androgenic alopecia.2,6 However, this test is difficult to
standardise, and its sensitivity is poor; as a result, negative
tests cannot be used to reliably exclude diagnoses.6
For many people with skin and hair disorders, including more
than one-third of patients with alopecia areata, involvement
of the nails can occur. Therefore, examination of fingernails
and toenails may reveal additional clues to the diagnosis.7
A routine physical examination with attention to growth and

distribution of other body hair is also necessary.
10
Alopecia areata is known to be associated with other organ-

Table 1. Classic signs and symptoms from a patient’s
specific autoimmune disorders such as Grave’s disease, vitiligo
history that are consistent with different aetiologies of
and type 1 diabetes.11,12 Despite these associations, there is
hair loss
insufficient evidence to recommend routine screening for
Aetiology Signs and symptoms on history autoimmune disease at the time of alopecia areata diagnosis.
Non-scarring hair loss Routine full blood examination and screening for infectious
diseases would be necessary prior to the initiation of systemic
Male or female • Diffuse hair thinning immunosuppressive therapy.
pattern hair loss • Gradual onset
(androgenic • May have family history of same Answer 5
alopecia)
Alopecia areata is an immune-mediated disorder that
Alopecia areata • Typically aged <40 years classically presents with one or more discreet patches of non-
• Abrupt onset scarring scalp hair loss.13 These patches are asymptomatic
• May have personal or family history of but may progress to involve the whole scalp (alopecia totalis)
autoimmune disease or atopy
or all body hair (alopecia universalis). The lifetime incidence of
Telogen • Abrupt onset alopecia areata is approximately 2%.14 It typically affects
effluvium • Diffuse hair thinning people aged <40 years, although there are exceptions, and
• May be secondary to iron deficiency, thyroid there is no predilection for any specific ethnicity or sex.12,14
dysfunction or postpartum
Answer 6
Tinea capitis • Usually occurs in children
• Gradual or abrupt onset There is no cure for alopecia areata and no known method for
• Localised hair loss preventing future relapses; however, treatment options are
• History of contact with animals or travel available that aim to arrest disease progression and reverse hair
loss. In 2019, an Australian expert consensus statement included
Trichotillomania • Typically occurs in children and adolescents an easy-to-use alopecia areata treatment algorithm. Treatment
• Gradual or abrupt onset options include conservative management, topical therapy (with
• Patient may report that hair pulling relieves an corticosteroids, minoxidil or immunotherapy), intralesional
inner tension corticosteroids and systemic therapies, including corticosteroids
• May have associated psychiatric disorders and steroid-sparing agents.15 However, none of the systemic
therapies included in the expert consensus statement are
Traction alopecia • History of wearing hair in tight braids or ponytails
approved for alopecia areata by the Therapeutic Goods
Scarring hair • Typically gradual onset Administration. The consensus statement recommends initiation
loss (various • Associated with pruritic, burning and/or of such medication only by experienced dermatologists.15
causes) painful scalp
For hair loss that is limited and has a recent onset, the
• No hair regrowth
Therapeutic Guidelines recommend 3–4 months of topical
corticosteroids as first-line therapy.16 However, for more
severe cases of alopecia areata, an initial trial of topical
Answer 3 corticosteroids has been shown to lack efficacy and delay
patient referral.17 In cases such as Apinya’s, in which multiple
Patchy hair loss in a young female with atopy is suggestive alopecia areata patches are present, the consensus algorithm
of alopecia areata. This can be confirmed by the recommends the use of intralesional corticosteroids
characteristic finding of exclamation mark hairs on administered every 4–6 weeks as first-line therapy, with the
dermoscopy.8 Apinya’s history and physical examination are potential for topical or systemic immunotherapy if there is no
consistent with alopecia areata. significant response within six months.16 Intralesional
injections can be administered in the general practice setting
Answer 4 if the practitioner feels comfortable doing so; otherwise,
patients can be referred to a dermatologist for treatment.
Alopecia areata is a clinical diagnosis. Further
investigations are not indicated at this stage. If there is While waiting for hair to regrow or as part of a conservative
uncertainty, or a scarring alopecia is suspected, then a scalp management strategy, there are various cosmetic solutions that
biopsy may be indicated. In these cases, it is important to biopsy can be offered to Apinya including colour-matched wool fibres
an area of active disease (with persistent hair fibres) that is to conceal the scalp, hair pieces, wigs or hair extensions.16
ideally also cosmetically inconspicuous.9 Histologically, alopecia
areata is characterised by a lymphocytic (T cell) infiltrate in and Answer 7
around the anagen hair bulb or the lower part of the hair follicle.10
The natural course and treatment response of alopecia areata
If tinea capitis is considered as a differential diagnosis, scalp are unpredictable. Approximately 40% of patients experience
scrapings for microscopy and culture are required. full regrowth of a solitary patch of alopecia areata within six
11
months, while 27% develop additional patches.18 Many people 8. Sinclair R, Banfield C, Dawber R. Handbook of diseases of the hair
who develop additional patches still achieve persistent and scalp. Oxford, UK: Blackwell Science, 1999.
remission at 12 months.18 Of the patients whose alopecia areata 9. Madani S, Shapiro J. The scalp biopsy: Making it more
efficient. Dermatol Surg 1999;25(7):537–38.
follows a chronic relapsing–remitting course that persists
doi: 10.1046/j.1524-4725.1999.99045.x.
beyond 12 months, 30% ultimately progress to alopecia totalis
10. Sperling LC, Lupton GP. Histopathology of non-scarring alopecia.
and 15% to alopecia universalis.18 Poor prognostic factors J Cutan Pathol 1995;22(2):97–114. doi: 10.1111/j.1600-0560.1995.
include extensive hair loss (>50%), ophiasis pattern, associated tb01391.x.
nail changes, early age of onset (before six years of age), a 11. Tan E, Tay YK, Goh CL, et al. The pattern and profile of alopecia
positive family history and concomitant atopy or autoimmune areata in Singapore – A study of 219 Asians. Int J Dermatol
disease.12,19 2002;41(11):748–53. doi: 10.1046/j.1365-4362.2002.01357.x.
12. Gilhar A, Etzioni A, Paus R. Alopecia areata. N Engl J Med
In Apinya’s case, her initial history indicates that she has had a 2012;366(16):1515–25. doi: 10.1056/NEJMra1103442.
prior episode of alopecia areata in the past 12 months. Her 13. Alkhalifah A, Alsantali A, Wang E, et al. Alopecia areata update:
associated nail changes, positive family history (aunt wears a Part I. Clinical picture, histopathology, and pathogenesis. J Am
wig) and history of atopic disease (asthma, eczema) are all poor Acad Dermatol 2010;62(2):177–88. doi: 10.1016/j.jaad.2009.10.032.
prognostic factors. She may go on to have a chronic disease 14. Mirzoyev SA, Schrum AG, Davis MDP, et al. Lifetime incidence
course and develop additional areas of hair loss that are risk of alopecia areata estimated at 2.1% by Rochester
epidemiology project, 1990–2009. J Invest Dermatol
persistent, and she may never achieve complete remission.15
2014;134(4):1141–42. doi: 10.1038/jid.2013.464.
15. Cranwell WC, Lai VW, Photiou L, et al. Treatment of alopecia
Answer 8 areata: An Australian expert consensus statement. Australas J
Dermatol 2019;60(2):163–70. doi: 10.1111/ajd.12941.
Alopecia areata has a significant, often underappreciated,
psychological impact on patients and their families. Patients 16. Expert Group for Dermatology. Hair loss disorders: Alopecia
areata. In: eTG complete [Internet]. West Melbourne, Vic:
experience an increased lifetime prevalence of psychiatric
Therapeutic Guidelines Limited, 2015.
disorders, especially mood and anxiety disorders.20,21 Similar
17. Meah N, Wall D, York K, et al. The Alopecia Areata Consensus of
to patients with other chronic relapsing skin disorders such as Experts (ACE) study: Results of an international expert opinion on
psoriasis, patients with alopecia areata consistently report treatments for alopecia areata. J Am Acad Dermatol 2020;S0190-
poor health-related quality of life.22 Therefore, it is 9622(20)30375-3. doi: 10.1016/j.jaad.2020.03.004.
recommended to screen Apinya for symptoms of anxiety and 18. Ikeda T. A new classification of alopecia areata. Dermatologica
depression and provide early referral to support services as 1965;131(6):421–45. doi: 10.1159/000254503.
required. You can also direct patients to local support groups 19. Barahmani N, Schabath MB, Duvic M. History of atopy or
or the Australian Alopecia Areata Foundation. autoimmunity increases risk of alopecia areata. J Am Acad
Dermatol 2009;61(4):581–91. doi: 10.1016/j.jaad.2009.04.031.
20. Colón EA, Popkin MK, Callies AL, et al. Lifetime prevalence of
Resources for health professionals
psychiatric disorders in patients with alopecia areata. Compr
• DermNet New Zealand – Alopecia areata, https:// Psychiatry 1991;32(3):245–51. doi: 10.1016/0010-440x(91)90045-e.
dermnetnz.org/topics/alopecia-areata 21. Pratt CH, King LE Jr, Messenger AG, et al. Alopecia areata. Nat
Rev Dis Primers 2017 Mar 16;3:17011. doi: 10.1038/nrdp.2017.11.
Resources for patients 22. Liu LY, King BA, Craiglow BG. Health-related quality of life
(HRQoL) among patients with alopecia areata: A systematic
• Australian Alopecia Areata Foundation, https://aaaf.org.au review. J Am Acad Dermatol 2016;75(4):806–12. doi: 10.1016/j.
jaad.2016.04.035.
References
1. Sinclair R. Hair shedding in women: How much is too much?
Br J Dermatol 2015;173(3):846–48. doi: 10.1111/bjd.13873.
2. Mubki T, Rudnicka L, Olszewska M, et al. Evaluation and diagnosis
of the hair loss patient: Part I. History and clinical examination.
J Am Acad Dermatol 2014;71(3):415.e1-415.e15. doi: 10.1016/j.
jaad.2014.04.070.
3. McDonagh AJG, Tazi-Ahnini R. Epidemiology and genetics of
alopecia areata. Clin Exp Dermatol 2002;27(5):405–09.
doi: 10.1046/j.1365-2230.2002.01077.x.
4. Chen CH, Wang KH, Hung SH, et al. Association between herpes
zoster and alopecia areata: A population-based study. J Dermatol
2015;42(8):824–25. doi: 10.1111/1346-8138.12912.
5. Al-Refu K. Clinical significance of trichoscopy in common causes
of hair loss in children: Analysis of 134 cases. Int J Trichology
2018;10(4):154–61. doi: 10.4103/ijt.ijt_101_17.
6. Dhurat R, Saraogi P. Hair evaluation methods: Merits and demerits.
Int J Trichology 2009;1(2):108–19. doi: 10.4103/0974-7753.58553.
7. Gandhi V, Baruah M, Bhattacharaya S. Nail changes in alopecia
areata: Incidence and pattern. Indian J Dermatol Venereol Leprol
2003;69:114–15.
12
CASE
3 Holden has a rash on his

buttocks
Holden, a male accountant aged 58 years, presents
with a rash affecting his buttocks. It has been present
for several weeks, causing a persistent itch that he
finds embarrassing. His medical history is significant
for type 2 diabetes and obesity.
Question 1
What further history would be helpful in determining the
aetiology of Holden’s rash? What specifically would you look
for on examination?
Further information
Holden has not noticed the rash anywhere else on his body and Figure 1. Erythematous rash on the buttocks, which is poorly
he has never had this problem before. He lives with his wife, demarcated with no evidence of scale
who does not have a rash or any symptoms; they have no pets.
Reproduced with permission of The Royal Australian College of General
Holden has never been diagnosed with skin disease previously. Practitioners from Kovitwanichkanont T, Chong AH, Superficial fungal infections,
Aust J Gen Pract 2019;48(10):706–11, doi: 10.31128/AJGP-05-19-4930.
He reports using hydrocortisone 1% cream for two weeks that
he purchased over the counter at the recommendation of his
pharmacist. The itch lessens when he uses the topical
corticosteroid, but the rash has continued to increase in size, Question 3
and the itch returns on cessation of therapy.
What further investigations would you consider?
Examination reveals an annular erythematous patch that is
poorly demarcated from the normal skin with no scale
(Figure 1). There are no pustules, vesicles or bullous lesions. You
find no evidence of psoriasis or other skin disease elsewhere.
Question 2
What is your working diagnosis and the differential diagnosis
for this rash?
Further information
Skin scrapings are obtained, and a potassium hydroxide

preparation reveals segmented hyphae consistent with
dermatophyte infection. Fungal cultures are positive for
Trichophyton rubrum.
13
Case3 check Skin conditions
Question 4
What treatment would you recommend?
Question 5 Figure 2. Multiple dystrophic nails exhibiting yellow discolouration

What advice would you give Holden and his wife to minimise suggestive of onychomycosis
the risk of transmission? Reproduced with permission of The Royal Australian College of General
Practitioners from Kovitwanichkanont T, Chong AH, Superficial fungal infections,
Aust J Gen Pract 2019;48(10):706–11, doi: 10.31128/AJGP-05-19-4930.
Question 7
How would you confirm whether Holden has onychomycosis?
Further information
Holden’s rash completely resolves after two weeks of

treatment, but he re-presents a month later with the same
problem, this time affecting his groin.
Question 6 Further information
Why has Holden’s rash recurred? Aside from the skin surface, Nail clippings are acquired for fungal microscopy and culture,
what would you also examine? which confirms onychomycosis with T. rubrum. The nails have
hence been a reservoir for Holden’s recurrent tinea corporis.
Question 8
What is the appropriate treatment for Holden’s onychomycosis?
Further information
Examination of Holden’s feet reveals multiple nails with

chalky yellowish-brown discolouration, subungual
hyperkeratosis and onycholysis (Figure 2).
14
Erythrasma
CASE 3 Answers
Erythrasma is an infection caused by Corynebacterium
minutissiumum, a Gram-positive bacillus. It typically affects
interdigital and intertriginous areas and presents as well-
Answer 1
defined erythematous patches or thin plaques. Erythrasma
A detailed history should be obtained as this will often yield may have fine scale and wrinkling described as ‘cigarette
important information about the likely aetiology. The paper’ appearance. It typically lacks an active scaling border.
duration and distribution of the rash, as well as any previous
The short duration of Holden’s symptoms and lack of
episodes or treatment, should be determined.
response to topical corticosteroids favour an infectious
Enquiring about the patient’s close contacts who exhibit aetiology, and the clinical appearance is more in keeping
similar symptoms may assist in determining either an with tinea incognita.
infectious or familial aetiology. Similarly, exposure to
animals including domestic pets may indicate zoonotic Answer 3
transmission of tinea infection. It would also be useful to
Appropriate investigations would include obtaining skin
know whether Holden has a personal or family history of
scrapings and swabs for fungal and bacterial microscopy
skin disease, particularly psoriasis, which commonly
and culture. Tinea and candidal intertrigo are readily
affects the natal cleft.
diagnosed on microscopy and fungal culture. Skin scrapings
Examination of his skin from head to toe should be can be obtained from the leading edge of the lesion with the
undertaken, paying attention to areas commonly affected by blunt side of a No. 15 blade.4 Topical treatments can
psoriasis including the extensor surfaces of the limbs, nails, diminish the amount of scale, making it difficult to obtain
scalp and hairline. skin scrapings; cessation of topical treatments allows the
scale to return after a few days. A skin biopsy for histology
Answer 2 and periodic acid–Schiff staining for fungal elements is an
alternative investigation, but it is more invasive.
Several conditions should be considered as part of the
differential diagnosis.
Answer 4
Tinea incognita Dermatophytes is the collective name for fungal pathogens
capable of invading keratinised tissue (skin, hair and nails)
Tinea incognita refers to tinea that has been treated
and resulting in an infection called tinea.3 Tinea is further
with a topical immunosuppressive agent, most
defined by appending the body site affected in Latin (Table 1).
commonly a corticosteroid, resulting in an atypical
appearance of the rash.1 There can be reduced scale,
erythema and loss of the well-demarcated leading edge. Table 1. Classification of tinea affecting different areas of
Note: Ive and Marks published a case series in 1968 the body3
coining the term ‘Tinea incognito’, which is widely
accepted and understood but is grammatically incorrect. Classification of tinea Location
Tinea incognita is the correct term.

Tinea pedis Feet
Psoriasis Tinea manuum Hands
While psoriasis commonly affects the extensor surfaces, Tinea barbae Beard
there is a variant that affects the skin folds called flexural (or
inverse) psoriasis. Flexural psoriasis lacks the characteristic Tinea cruris Groin
thick white scale of the other types of psoriasis, often
Tinea capitis Scalp
exhibiting a smooth, shiny surface but retaining the
prominent erythema and well-demarcated raised border.2 Tinea corporis Body, excluding the sites above
Eczema/dermatitis Tinea unguium (onychomycosis) Nails
Eczema can give rise to an itchy patch of skin that partially

responds to topical corticosteroids. However, eczema tends Holden should commence topical terbinafine, which is the
to be less annular in appearance and typically does not have first-line treatment for tinea corporis, tinea cruris and tinea
central clearing. pedis for both adults and children.5,6 He should continue
treating the area once or twice daily for up to two weeks.
Candidal intertrigo
Answer 5
Candida albicans infection of the skin folds could produce
this appearance and, unlike tinea cruris, will be uniformly red General advice should be provided to avoid the infection
without central clearing. It occurs more commonly in propagating to other areas, prevent transmission and
patients with diabetes and those who are obese.3 mitigate risk of recurrence:
15
• Avoid walking barefoot in communal bathing areas. 2. Omland SH, Gniadecki R. Psoriasis inversa: A separate identity or
a variant of psoriasis vulgaris? Clin Dermatol 2015;33(4):456–61.
• Wash socks daily and avoid moist footwear. doi: 10.1016/j.clindermatol.2015.04.007.
3. Havlickova B, Czaika VA, Friedrich M. Epidemiological trends in
• Do not share footwear, clothing or sports equipment.
skin mycoses worldwide. Mycoses 2008;51 Suppl 4:2–15.
• Avoid touching the affected area. doi: 10.1111/j.1439-0507.2008.01606.x.
4. Raghukumar S, Ravikumar BC. Potassium hydroxide mount
• Wash hands after touching the affected area. with cellophane adhesive tape: A method for direct diagnosis of
dermatophyte skin infections. Clin Exp Dermatol
• Regularly wash clothing that comes into contact with the 2018;43(8):895–98. doi: 10.1111/ced.13573.
affected area. 5. Kovitwanichkanont T, Chong A. Superficial fungal infections. Aust
J Gen Pract 2019;48(10):706–11. doi: 10.31128/AJGP-05-19-4930.
Answer 6 6. Expert Group for Dermatology. Tinea. In: eTG complete [Internet].
West Melbourne, Vic: Therapeutic Guidelines Limited, 2015.
Tinea may spread to other areas of the body via
7. Daniel CR, Jellinek NJ. The pedal fungus reservoir. Arch Dermatol
autoinoculation, thus examination of other sites that may
2006;142(10):1344–46. doi: 10.1001/archderm.142.10.1344.
serve as a reservoir for infection is necessary. The recurrence
8. Szepietowski JC, Reich A, Garlowska E, Kulig M, Baran E. Factors
of tinea must always prompt examination of the feet and influencing coexistence of toenail onychomycosis with tinea pedis
toenails as this area is a common source of fungal and other dermatomycoses: A survey of 2761 patients. Arch
pathogens.7,8 Treatment of these areas is usually needed to Dermatol 2006;142(10):1279–84. doi: 10.1001/
cure the condition. archderm.142.10.1279.
9. Saunte DML, Hare RK, Jørgensen KM, et al. Emerging terbinafine
Resistance to terbinafine outside of India is not common and resistance in Trichophyton: Clinical characteristics, squalene
is unlikely to be the reason treatment has failed in this case.9 epoxidase gene mutations, and a reliable EUCAST method for
detection. Antimicrob Agents Chemother 2019;63(10):e01126–19.
doi: 10.1128/AAC.01126-19.
Answer 7
10. Fletcher CL, Hay RJ, Smeeton NC. Onychomycosis: The
The diagnosis of onychomycosis should be confirmed by development of a clinical diagnostic aid for toenail disease. Part I.
sending a nail clipping for fungal microscopy and culture. It Establishing discriminating historical and clinical features. Br J
Dermatol 2004;150:701–05. doi: 10.1111/j.0007-0963.2004.05871.x.
is important to note that the false-negative culture rate is
approximately 30%, and repeated testing is sometimes 11. Eisman S, Sinclair R. Fungal nail infection: Diagnosis and
management. BMJ 2014;348:1–11. doi: 10.1136/bmj.g1800.
required.10 It is also important to remember that not all
12. Kreijkamp-Kaspers S, Hawke K, Guo L, et al. Oral antifungal
dystrophic, discoloured nails are due to onychomycosis;
medication for toenail onychomycosis. Cochrane Database Syst
psoriasis, for example, is a common mimic.11 Rev 2017;7(7):CD010031. doi: 10.1002/14651858.CD010031.pub2.
13. O’Sullivan DP. Terbinafine: Tolerability in general medical practice.
Answer 8 Br J Dermatology 1999;Suppl 141:21–25.
The recommended first-line treatment for onychomycosis of 14. Elewski B, Tavakkol A. Safety and tolerability of oral antifungal
agents in the treatment of fungal nail disease: A proven reality.
toenails is oral terbinafine 250 mg daily for 12 weeks.12
Ther Clin Risk Manag 2005;1(4):299–306.
Terbinafine is well tolerated, with mild, transient
15. Stolmeier DA, Stratman HB, McIntee TJ, Stratman EJ. Utility of
gastrointestinal adverse effects most commonly observed.13 It laboratory test result monitoring in patients taking oral terbinafine
is contraindicated in patients with acute or chronic liver or griseofulvin for dermatophyte infections. JAMA Dermatology
disease because of rare cases of hepatic failure occurring in 2018;54(12):1409–16. doi: 10.1001/jamadermatol.2018.3578.
this subgroup.14 Blood tests prior to initiation or during 16. Scher RK, Baran R. Onychomycosis in clinical practice: Factors
treatment for monitoring are not required for patients without contributing to recurrence. Br J Dermatology 2003;149 Suppl
65:5–9. doi: 10.1046/j.1365-2133.149.s65.5.x
significant comorbidity.15 Studies have shown that, overall,
99.9% of monitoring tests resulted in no clinical action.15 17. De Berker D. Fungal nail disease. N Engl J Med
2009;360(20):2108–16. doi: 10.1056/NEJMcp0804878.
More than 80% of patients treated with systemic antifungal
therapy achieve mycological cure; however, complete cure
(normal nail appearance and negative mycology) is only
achieved in 25–50% of patients.16,17 Patients concerned about
ongoing abnormal nail appearance may be referred to a
dermatologist for consideration of alternative causes of
dystrophic nails that could have predisposed the nail to fungal
infection. Topical treatments for onychomycosis achieve low
rates of cure and are generally not recommended.5,6
Recurrence of onychomycosis is not uncommon, and it often

occurs many years after the cessation of systemic therapy.17
References
1. Ive FA, Marks R. Tinea incognito. Br Med J 1968;3(5611):149–52.
doi: 10.1136/bmj.3.5611.149.
16
CASE Question 3
4 Paulo has uncomfortable

genital itching
From those conditions listed in the differential diagnosis,
which is the most likely?
Paulo, aged 55 years, is a married man who

presents with worsening of an itchy and painful
penile foreskin that is difficult to retract, a condition
he has had for two years. A year ago, he was treated
with hydrocortisone 1%/clotrimazole 1% cream at
another practice for assumed candidiasis with no
satisfactory effect.
Question 1
Question 4
How would you approach this presentation?
How would you proceed to diagnose this condition?
Question 5
Further information
What is lichen sclerosus and what are the clinical features of
On examination, you note whitish discolouration of the penile lichen sclerosus (PLS) or genital lichen sclerosus (GLS)?
previously pink-red mucosa of the prepuce. The prepuce is also
characterised by white papules and plaques with
hyperkeratosis, fissures and atrophy, resulting in partial
phimosis. Paulo tells you that initially he experienced only
pruritus, but symptoms have worsened recently, leading to pain
and difficulty in retraction. Paulo discloses that he has painful
sexual function, and anxiously says he has had no sexual
partners other than his wife during his 25-year marriage.
Question 2
What conditions would you include in your differential Question 6
diagnosis, on the basis of this presentation?
What is the aetiology and epidemiology of GLS?
17
Further information
You explain to Paulo the typical appearance of GLS (Figure 1)

and explain its aetiology and epidemiology. Paulo is worried
about the long-term effects of his condition.
Question 7
What are the potential complications of GLS?
Further information Penile lichen sclerosus

White papules and plaques, and fissures with phimosis. The loose
You reassure Paulo that PLS is not a sexually transmissible
white material is wet scales of lichen sclerosus in the mucosa; it is not
infection (STI) and refer him to a urologist for structural
induced by Candida sp. infection.
treatment for phimosis. Paulo wants to know if there are any
other treatments available.
Question 8
What are the management options for GLS?
CASE 4 Answers
Answer 1
Vulva lichen sclerosus
More information should be sought regarding the progression A. Buried clitoris; B. Involvement of clitoris hood; C. Distorted labia
of the symptoms and whether an STI should be considered as minora; D. Extending to perineum
part of the differential diagnosis. With Paulo’s permission, it is
Figure 1. Genital lichen sclerosus in a man (upper) and woman
important to conduct a physical examination of his foreskin.
(lower)
Answer 2
Conditions to consider in the differential diagnosis include:1,2
• psoriasis (characterised by prominent erythema with scales)
• lichen sclerosus (itchy white sclerotic lesions; almost always
• vitiligo (no symptom of itch; generally homogenous white patch)
found in the anogenital area; fissures; phimosis)
• post-inflammatory hypopigmentation (no itch; important to
• lichen simplex chronicus (itchy patches that are temporarily
enquire about past history of any genital lesion)
relieved with scratching; usually crusted)
18
• lichen planus (more pain than itch) Lichen sclerosus often can be associated with autoimmune-
related diseases such as thyroid disease, vitiligo, alopecia
• Candida sp. infection (Candida balanitis; rare in men;
areata and pernicious anaemia.2,6
excluded with swab)
• Zoon balanitis (shiny red mucosa) Answer 6
• morphoea (no itch, with hard and thick skin; rare in The exact aetiology of lichen sclerosus remains unknown. Several
genital areas) theories have been proposed such as autoimmune (approximately
20% association), genetics (12% positive family history), hormonal
• penile neoplasm (slow-growing tumour; important to
factors, chronic trauma and irritation.1,6,7 Lichen sclerosus
enquire about any bleeding from the lesion).
commonly affects individuals aged in the fifth decade and
onwards but can be seen in patients of any age including
Answer 3
prepuberty. The precise incidence and prevalence of GLS is
Given the pale-white prepuce with white sclerotic papules difficult to ascertain. This is due to lack of awareness of the
and plaques (hyperkeratosis), fissures and anatomical condition, embarrassment resulting in reluctant disclosure of
distortion, the most likely diagnosis is PLS. symptoms, and presentation at and referral to different
practitioners such as general practice, sexual health, gynaecology,
Answer 4 urology and dermatology.1,3,6 However, GLS is 10 times more
common in women than men. Although early literature reported
Diagnosis of PLS can be made clinically without a
that lichen sclerosus affects a greater proportion of people of
mandatory biopsy. If uncertainty exists, a punch biopsy from
Caucasian ethnicity, it can occur in people of all ethnicities.1
the whitest area is warranted to confirm the diagnosis and
exclude alternative diagnoses including development of As a result of the association with autoimmune diseases, a
squamous cell carcinoma (SCC). The histopathology usually blood test for autoantibodies may be ordered if the patient has
shows an atrophic or hyperkeratotic epidermis with lichenoid any suggestive symptoms.
infiltrate in the dermal–epidermal junction, and
homogenisation of collagen in the upper dermis.2–4 Answer 7
The complications of GLS are:

Answer 5
• anatomical distortion (as described in clinical
Lichen sclerosus is a chronic inflammatory dermatosis
manifestations) – resulting in sexual dysfunction and urinary
commonly affecting the anogenital region. It is characterised
problems
by white sclerotic papules, plaques and patches that
subsequently coalesce, becoming a shiny porcelain-white or • psychological effects – psychological distress and low self-
ivory-white colour. When it affects the penis, lichen sclerosus esteem affecting sexual function and quality of life
is called PLS; when it affects the vulva, it is called vulvar
• cancer – the increased risk of SCC is approximately 5%.1,2
lichen sclerosus. The condition was previously known as
balanitis xerotica obliterans (in men) and lichen sclerosus et
Answer 8
atrophicus, leukoplakic vulvitis and lichen albus (in
women).1,5 The clinical manifestations include: Goals of treatment for GLS are to alleviate symptoms such as
pruritus, fissuring and pain; to improve sexual function and
• Intractable pruritus, and pain and bleeding from fissuring
quality of life; and to reduce scarring (structural distortion)
and erosion.
and the risk of cancer.8
• Sexual dysfunction.
An ultra-potent or potent topical corticosteroid (TCS) is the first-
• Phimosis and stricture of urethral meatus from atrophy line treatment for lichen sclerosus. It provides symptom relief as
and scarring. Anatomical distortions in females include well as clinical improvement, reducing complications of scarring
burying of the clitoris, fusion or loss of labia minora, and malignant change.3,4,9 A TCS can be applied twice daily until
stenosis of the introitus, and distortion of urethral orifice symptoms (itch, sore) are relieved (approximately one week), then
(Figure 1). applied daily until the texture of the skin has returned to normal
(usually one month) and then on alternating days after this period.
• Morphological features include white sclerotic papules,
The total treatment time is approximately three months.
plaques and patches on the prepuce and/or glans penis, or
Frequency of TCS use and duration should be individualised
vulva. Areas of purpura, fissures and erosion can occasionally
depending on the extent of hyperkeratosis. Following initial
be seen. Extragenital lichen sclerosus is seen in 15–20% of
treatment, maintenance treatment using twice-weekly
patients with lichen sclerosus2 and usually presents as
application of a lower-potency (mid-strength) TCS such as
hypopigmented and atrophic patches, commonly affecting
betamethasone valerate (0.02%), triamcinolone acetonide
the shoulder, arm, neck, thigh, buttock and breast.
(0.02%) or methylprednisolone aceponate (0.1%) is recommended
• Dermoscopic features include patchy white structureless (Table 1).3,4,6 A TCS with an ointment base is preferred to a cream
areas, ice slivers, comedo-like openings (hair-bearing in the genital area as it is better absorbed and has a barrier
area), purpuric globules, scales and dotted or sparse thin function.6,9 It is advisable to schedule a review in 4–6 weeks from
linear vessels.3 the start of TCS use and again in three months’ time. A 6–12
19
month follow-up is recommended during maintenance.3,6 TCS results in some improvement in symptoms and texture of the
therapy is safe, effective and inexpensive when compared with lesion. He has responded well to your counselling regarding
other treatment modalities such as topical calcineurin inhibitors, the condition.
systemic oral therapy and phototherapy. Treatment failure may
indicate an incorrect diagnosis, noncompliance issue, Summary
development of SCC or superimposed factors such as allergy to
Early detection and treatment with timely referral for genital
specific medication, infection (Candida sp., herpes, bacteria) and
skin disorders such as GLS will reduce patient morbidity,
irritation from sweat and urinary and faecal materials.
physically and emotionally. The prognosis of GLS is usually
General management options include: favourable if it is diagnosed and treated in the early non-
scarring stages, and the patient is compliant with treatment.
• Counselling for the nature of disease, course, treatment
and regular follow-ups. Some individuals may need
Resources for health professionals
reassurance that the condition is not related to STIs.
• DermNet New Zealand, www.dermnetnz.org
• Avoidance of scratching and irritation of the genital area
through use of soap-free emollients and a protective barrier
Resources for patients
(eg paraffin or emollient) to minimise contact with urine and
faeces. Tight underwear and any activities that can • Australian and New Zealand Vulvovaginal Society, www.
aggravate the sensitive mucosa (such as riding a bicycle or anzvs.org/patient-information
horse) should be avoided.
• The Association for Lichen Sclerosus & Vulval Health, www.
• Referral to a dermatologist for review of difficult and lichensclerosus.org
recalcitrant cases and alternative treatments such as
topical calcineurin inhibitors, intralesional injection of References
steroids, systemic oral therapy (pulsed prednisone, 1. Marfatia Y, Surani A, Baxi R. Genital lichen sclerosus et atrophicus
methotrexate, acitretin, cyclosporine), phototherapy and in females: An update. Indian J Sex Transm Dis AIDS
fractionated CO2 laser treatment.4,5,8 2019;40(1):6–12. doi: 10.4103/ijstd.IJSTD_23_19.
2. Nair PA. Vulvar lichen sclerosus et atrophicus. J Midlife Health
• Surgery for correction of anatomical distortion or
2017;8(2):55–62. doi: 10.4103/jmh.JMH_13_17.
carcinoma. Referral to a relevant specialist (eg urologist,
3. Lee A, Fischer G. Diagnosis and treatment of vulvar lichen
gynaecologist or urogynaecologist) is recommended. sclerosus: An update for dermatologists. Am J Clin Dermatol
2018;19(5):695–706. doi: 10.1007/s40257-018-0364-7.
Conclusion
4. Cyrus N, Jacobe HT. Morphea and lichen sclerosus: Lichen
sclerosus. In: Kang S, et al, editors. Fitzpatrick’s Dermatology. 9th
While waiting to see the urologist, Paulo is treated with a edn. New York, USA: McGraw-Hill Education; 2019.
potent TCS (mometasone furoate 0.1% ointment), which
5. Oakley A. Lichen sclerosus. Hamilton, NZ: DermnetNZ, 2016.
Available at https://dermnetnz.org/topics/lichen-sclerosus
[Accessed 30 April 2020].
Table 1. Classification of topical corticosteroid potency
6. Fisher G. Vulval lichen sclerosus diagnosis and treatment.
in Australasia9–11 Medicine Today 2019;20(1):21–29.
7. Fistarol SK, Itin PH. Diagnosis and treatment of lichen sclerosus:
Potency Corticosteroid
An update. Am J Clin Dermatol 2013 Feb;14(1):27–47. doi: 10.1007/
s40257-012-0006-4.
Mild Hydrocortisone 0.5–1%
Hydrocortisone acetate 0.5–1% 8. Lewis F. Inflammatory dermatoses of the vulva: Lichen sclerosus.
[Class I]
In: Griffiths CEM, et al, editors. Rook’s textbook of dermatology.
9th edn. UK: John Wiley & Sons, Ltd; 2016.
Moderate (mid-strength) Clobetasone butyrate 0.05%
9. Oakley A. Topical steroid. Hamilton, NZ: DermnetNZ, 2016.
[Class II] Hydrocortisone butyrate 0.1%
Available at https://dermnetnz.org/topics/topical-steroid
Betamethasone valerate 0.02–0.05% [Accessed 30 April 2020].
Triamcinolone acetonide 0.02–0.05%
10. Best Practice Advocacy Centre New Zealand. Topical
Methylprednisolone aceponate 0.1%* corticosteroids for childhood eczema: Clearing up the confusion.
Dunedin, NZ: BPACNZ, 2016. Available at https://bpac.org.
Potent Mometasone furoate 0.1% nz/2016/topical-corticosteroids.aspx [Accessed 17 June 2020].
[Class III] Betamethasone dipropionate 0.05% 11. The Australasian College of Dermatologists. The Australasian
Betamethasone valerate 0.5%–0.1% College of Dermatologists consensus statement – Topical
corticosteroids in paediatric eczema. Rhodes, NSW: ACD, 2017.
Ultra/super/very potent† Clobetasol propionate 0.05% Available at www.dermcoll.edu.au/wp-content/uploads/ACD-
[Class IV] Betamethasone dipropionate 0.05% in Consensus-Statement-Topical-Corticosteroids-and-Eczema-
optimised vehicle Feb-2017.pdf [Accessed 17 June 2020].
*Some countries classify methylprednisolone aceponate as potent.10

†Topicalcortiocosteroids in the very-potent group are reserved for
dermatologists’ prescription in Australasia.
Note: Some of topical corticosteroids unavailable in Australia are not listed here.
20
CASE Clinically, Zivko appears systemically well with normal vital
5
signs. Examination of his skin shows a right-sided unilateral
dermatomal vesicular rash on his low back area. There is no
Zivko has a painful rash visible excoriation and no sign of superimposed bacterial
infection (Figure 1).
Zivko, aged 69 years, presents to your general
practice and tells you he has a painful rash.
Question 1
What further history would you take from Zivko?
Figure 1. Zivko’s rash

© Professor Raimo Suhonen. Reproduced from DermNet New Zealand (www.
dermnetnz.org/topics/herpes-zoster) under the CC BY-NC-ND 3.0 NZ license.
Question 2
What would you look for on examination?
Question 3
What is your working diagnosis?
Further information
Zivko states that the rash, which started the previous day, is on
Question 4
the right side of his back. He has never had a similar rash
before and has no idea what might have triggered it. He has not What diagnostic tests, if any, would you consider? What other
been in contact with anyone with a similar rash. He also cannot conditions would you consider in your differential diagnosis?
clearly recall whether he had chickenpox as a child. The rash is
only slightly itchy but intensely painful. He describes a constant
throbbing pain that started as a tingling sensation two days
before he noticed the rash. He grades his pain as 6/10 on a
verbal numerical rating scale of zero (no pain) to 10 (worst pain
imaginable). He took paracetamol tablets but they did not
provide adequate pain relief, and he is hoping you will prescribe
more effective pain relief medication. Other than the
bothersome pain, Zivko is otherwise well. He takes amlodipine
5 mg daily for hypertension and has not recently started any
new medication.
21
Further information
Question 8
Zivko wonders why he got shingles. He is anxious about the
What are the potential complications of shingles?
diagnosis and his risk of infecting others.
Question 5
How would you address these concerns?
Further information
Zivko is worried about the recurrence of shingles and asks

what he can do to prevent this.
Question 9
What would you advise Zivko?
Question 6
How would you manage Zivko’s presentation?
Further information
As with most cases of shingles, you are able to successfully

Further information
manage Zivko within the general practice setting. However, as
Zivko wants to know how to care for the rash. part of your routine reflective practice, you consider situations
in which patients with shingles should be referred/discussed
with a non–general practitioner (GP) specialist.
Question 7
What would you recommend?
Question 10
What are some of the scenarios in which you might refer a
patient with shingles to a non-GP specialist?
22
excoriations (seen with pruritic rash) and signs of

CASE 5 Answers superimposed bacterial infection.3
The remainder of the clinical examination will be guided by

Answer 1
the information gathered during history-taking. This may
A targeted history should explore the following aspects of the involve checking for signs of suspected systemic diseases
presentation. such as lymphadenopathy or hepatosplenomegaly.
History of the rash Answer 3

Important questions to ask Zivko about his rash include:1 Zivko’s presentation is consistent with a diagnosis of herpes
zoster (HZ), also known as shingles. The painful unilateral
• Where is it?
dermatomal vesicular rash typically seen in shingles is due to
• When did it start? reactivation of latent varicella zoster virus (VZV) in a dorsal
root or cranial nerve ganglion.4 Sometimes, natural variation
• Has he had previous episodes of a similar rash?
in innervation may cause few lesions beyond the midline or
• Does he have any idea of what could have caused/triggered the affected primary dermatome.5
the rash?
For 70–80% of patients, the onset of HZ is heralded by
• Has he had any contact with someone with a similar eruption? prodromal acute neuralgia often described as a constant or
intermittent burning, tingling, shooting, throbbing or stabbing
• Are there other associated symptoms (eg pruritus, fever)?
pain.5 Typically, after 2–3 days of prodromal pain, the patient
• Has he used any treatment for the rash? develops a crop of erythematous macules and papules that
evolve rapidly to vesicles.5,6 Pustulation, ulceration, crusting
Pain history and healing occur over the following 2–4 weeks.5,6 Shingles
can affect any part of the body but often affects the thoracic,
An acute pain history exploring the location, duration, nature,
lumbar and cervical dermatomes. Rarely, HZ manifests solely
severity, periodicity and any associated functional impairment
as dermatomal pain and it is called zoster sine herpete.5
(in relation to mood, work, sleep and activities of daily living) is
important. Furthermore, Zivko should be asked about Approximately 20% of patients with HZ have systemic
circumstances surrounding the pain onset and the effect of symptoms such as headache, fever and fatigue.5 Patients who
any treatment that he may have taken.2 are immunocompromised are at risk of severe shingles with
potentially life-threatening complications. They may present
Medication and medical history with disseminated shingles, atypical skin lesions,
multidermatomal disease, systemic illness and visceral HZ
It is important to ask Zivko whether he has started any new
with multi-organ involvement.4,5
medication or non-prescribed products that could have
triggered the rash, and whether he has a medical condition
Answer 4
that may have dermatological associations.1
Typical shingles, such as Zivko’s presentation, can be
Systemic and constitutional symptoms diagnosed clinically.4 Diagnostic laboratory tests are reserved
for atypical presentations such as zoster sine herpete, patients
Fever in the setting of a rash is often due to an infective
presenting with disseminated skin infections or visceral HZ.5
process,1 which may be benign (eg viral exanthem) or
Differentiating between VZV and herpes simplex virus (HSV)
potentially life-threatening.1,3 Without systemic sepsis, most
infection as a cause of painful oral or genital lesions may be
localised rashes will only cause minimal systemic symptoms.3
difficult.5 Zosteriform HSV infection may be misdiagnosed as
Therefore, constitutional symptoms such as fever, unexplained
‘recurrent HZ’.4 Other diagnoses to consider include impetigo
significant weight loss, fatigue and athralgia in the setting of a
and contact dermatitis.5,7
rash should prompt evaluation for serious systemic illnesses
such as malignancy, inflammatory conditions and infection. Also, depending on the location, pre-eruptive acute neuralgia
of HZ or zoster sine herpete may mimic pain related to
Answer 2 coronary artery disease, renal colic, appendicitis and
cholecystitis.8
A focused examination should include an assessment of the
patient’s general wellbeing and vital signs in addition to the Laboratory tests to confirm a diagnosis of HZ include VZV
nature and distribution of the rash. Patients with acute signs polymerase chain reaction (PCR), direct immunofluorescence
of severe systemic illness will require urgent transfer to the antigen testing and viral cultures using viral swabs of the base
emergency department.3 of deroofed vesicles.5,7,8 A comparison of these methods
concluded that VZV PCR testing is the method of choice for
The morphological appearance3 (macules, papules, vesicles,
rapid laboratory diagnosis of HZ as it has the highest
pustules, etc) of the rash and distribution (symmetrical/
sensitivity (95%) and specificity (100%).9 VZV PCR testing is
asymmetrical, localised/generalised or dermatomal) will
widely available in Australia. Serological testing has limited
inform the differential diagnosis. It is important to check for
diagnostic value.8
23
Answer 5
Table 1. Antiviral therapy recommendations for shingles12
Appropriate education about the diagnosis of shingles and
Antiviral Dosage Notes
expected course will address Zivko’s concerns, dispel any
therapy
myths and provide appropriate reassurance. Zivko should
understand that anybody who has had chickenpox (more than Valaciclovir 1 g (child >2 years: While not licensed in
90% of adults in Australia) is at risk of developing HZ.6 20 mg/kg up to 1 g) Australia for use in children
Patients may not clearly recall the episode of chickenpox.8 orally, eight-hourly aged <12 years, it is licensed
Those without vaccination against chickenpox or shingles for seven days internationally for use in
have a one-in-three lifetime risk of developing HZ.10 children aged >2 years.
Emerging evidence from safety
Increasing age is a risk factor for shingles and for severe
data and clinical experience
disease.4 In Australia, most cases of shingles occur in adults
suggest valaciclovir is safe to
who are immunocompetent; however, occasionally a person’s use in pregnancy.
immunocompromised state because of illness (eg from
human immunodeficiency virus infection or malignancy) or Famciclovir 500 mg orally, Treatment duration for patients
immunosuppressive therapy is the trigger.11 eight-hourly for who are immunocompromised
seven days is 10 days.
It is also recommended to advise Zivko that shingles is Famciclovir is not
contagious – through direct or indirect contact with fluid recommended for use in
from vesicles – to people who have never had chickenpox. children.
As such, Zivko should exercise contact precautions4 by
Aciclovir 800 mg (child: Aciclovir has the most evidence
covering his rash8 and avoiding contact with susceptible
20 mg/kg up to on safety data to support use in
individuals (eg children, pregnant women and 800 mg) orally, five pregnancy.
immunosuppressed individuals) until all the lesions have times daily for seven
crusted. Additional airborne precautions are required for days
patients with HZ who are immunocompromised or those
with disseminated lesions.4 10 mg/kg (child In disseminated disease, after
≤12 years: 500 mg/ significant clinical improvement,
m2) intravenously, change to an oral antiviral therapy
Answer 6 eight-hourly to complete a total of 10–14 days.
Antiviral therapy
for mild-to-moderate HZ pain. Combination treatments with
Multiple randomised controlled trials (RCTs) have shown
oral opiates (oxycodone), corticosteroids (prednis[ol]one) and
that commencement of either oral aciclovir, famciclovir or
analgesic adjuvants (eg amitriptyline, pregabalin) are
valaciclovir within 72 hours of rash onset reduces the
recommended options for patients with moderate-to-severe
severity and duration of both acute pain and rash in HZ.5
pain and no applicable contraindications.5,12
These antiviral medications are safe and generally well
tolerated but require dosage adjustment for patients with
Answer 7
renal failure.5 Famciclovir and valaciclovir are the
recommended first-line treatments12 because of more Zivko should cover his rash with a non-adherent dressing
convenient dosing, greater bioavailability5 and better following removal of crusts and exudate with a regular saline
analgesic effect than acyclovir (Table 1).5,12 bath8,11 and application of protective ointment such as
petroleum jelly.6 Until the results of sensitivity testing are
Antiviral therapy is indicated for immunocompetent adults
available, empirical oral antibiotics should be initiated for any
and adolescents who present within 72 hours of the
superimposed bacterial infection with Streptococcus
appearance of the HZ rash.12 Generally, shingles in children is
pyogenes and Staphylococcus aureus.12 Topical antiviral
less painful and requires no antiviral treatment.12 However, all
therapy lacks efficacy,12 while topical antimicrobials or
patients who are immunocompromised, those with severe or
adhesive dressings may delay healing and worsen irritation.7
fulminant shingles, or those with HZ ophthalmicus (HZO)
should receive antiviral therapy irrespective of the duration of
Answer 8
the rash.12 Referral for intravenous aciclovir should be
arranged for patients with severe, fulminant or non- In most cases, shingles is a self-limiting illness.8 Patients who
responding HZO and patients who are immunocompromised are elderly and/or immunocompromised are particularly at
with disseminated disease or HZO.12 risk of complications.
PHN refers to persistent (neuropathic) pain that occurs after

Pain management
resolution of shingles rash. It is the most common
Severe acute pain may be a risk factor for post-herpetic complication of shingles, and risk increases with age.13 The
neuralgia (PHN),5 hence the importance of accurate reported estimated risk varies from 5% to more than 30%.13
assessment and prompt treatment of acute neuralgia. PHN is usually severe and difficult to treat, and it may cause
Paracetamol12 and non-steroidal anti-inflammatory drugs5 (if significant functional impairment.12 Simple analgesics are the
not contraindicated) are the recommended first-line treatment recommended first-line treatment for PHN.12 Treatments
24
options (either individually or in combination) for those who • Ramsay Hunt syndrome – management in consultation with
fail to respond to first-line management include adjuvant an ear, nose and throat surgeon5 or neurologist should be
analgesics (tricyclic antidepressants, pregabalin or considered.
gabapentin), transcutaneous electrical nerve stimulation,
topical anaesthetic or capsaicin.12 Psychological interventions Resources for patients
also have a role in the management of PHN.7,12
• Better Health Channel – Shingles, www.betterhealth.vic.
Post-herpetic itch is a poorly understood complication of HZ gov.au/health/conditionsandtreatments/shingles
characterised by persistent pruritus over dermatomes
previously affected by HZ.5,14 It may exist with or without References
PHN5 and has no established treatment.14 Patients with HZO 1. Nguyen T, Freedman J, Burke M, Playe S. Dermatologic
are at risk of periocular (cicatricial ectropion, paralytic ptosis emergencies: Diagnosing and managing life-threatening rashes.
and trichiasis) and ocular (keratitis, uveitis and glaucoma) Emergency Medicine Practice 2002;4(9):1–27.
complications.5,15 2. Schug SA, Palmer GM, Scott DA, Halliwell R, Trinca J, editors.
Acute Pain Management: Scientific Evidence. 4th edn. Australian
Neurological complications of HZ are uncommon.13
They include and New Zealand College of Anaesthetists and Faculty of Pain
Ramsay Hunt syndrome, myelitis and meningoencephalitis, with Medicine, 2015.
risk factors being an immunocompromised state, cranial nerve 3. DermNet NZ. Fever and a rash. Hamilton, NZ: DermNet NZ, 2016.
HZ and cutaneous dissemination.5 Available at https://dermnetnz.org/topics/fever-and-a-rash
[Accessed 5 May 2020].
Answer 9 4. Cohen JI. Herpes zoster. N Engl J Med 2013;369(3):255–63.

5. Dworkin RH, Zivkoson RW, Breuer J, et al. Recommendations for
With an estimated recurrence risk of 5% in patients who are the management of herpes zoster. Clin Infect Dis
immunocompetent,5 Zivko should be reassured that 2007;44(Supplement 1):S1–S26.
recurrence of shingles is uncommon. However, he should 6. DermNet NZ. Herpes zoster. Hamilton, NZ: DermNet NZ, 2015.
still be offered a single-dose live attenuated varicella-zoster Available at www.dermnetnz.org/topics/herpes-zoster [Accessed
vaccine (Zostavax) if there are no contraindications. In 5 May 2020].
Australia, Zostavax is publicly funded for people aged 7. Le P, Rothberg M. Herpes zoster infection. BMJ 2019;364.
70 years. There is a catch-up program available for those 8. Wehrhahn M, Dwyer D. Herpes zoster: Epidemiology, clinical
aged 71–79 years until October 2021.16 As the humoral features, treatment and prevention. Aust Prescr 2012;35(5):143–47.
immunity boost from an episode of shingles lasts at least 9. Sauerbrei A, Eichhorn U, Schacke M, Wutzler P. Laboratory
diagnosis of herpes zoster. J Clin Virol 1999;14(1):31–36.
one year, Zivko should be advised to wait at least one year
10. Australian Technical Advisory Group on Immunisation (ATAGI).
before receiving Zostavax.10 The efficacy of Zostavax in
Australian Immunisation Handbook. Canberra: ATAGI, 2018.
reducing the incidence of HZ and PHN has been shown in Available at https://immunisationhandbook.health.gov.au
RCTs and post-marketing studies.17 [Accessed 8 April 2020].
Recently, a non-live recombinant adjuvanted HZ subunit 11. Murtagh J, Rosenblatt J. Acute skin eruptions. In: Murtagh’s
general practice. North Ryde, NSW: McGraw-Hill Education, 2015.
vaccine (HZ/su; Shingrix) was registered in Australia.16 It is p. 1342–44.
given in two doses and can potentially be used in patients
12. Expert Group for Antibiotic. Shingles. In: eTG complete [Internet].
who are immunocompromised.7,17 HZ/su offers more West Melbourne, Vic: Therapeutic Guidelines Limited, 2019.
protection against HZ and PHN than Zostavax,16,17 but supply 13. Kawai K, Gebremeskel BG, Acosta CJ. Systematic review of
is a challenge.16 incidence and complications of herpes zoster: Towards a global
perspective. BMJ Open 2014;4(6):e004833.
Answer 10 14. Ishikawa R, Iseki M, Koga R, Inada E. Investigation of the
correlation between postherpetic itch and neuropathic pain over
GPs should consider referring or consulting an appropriate time. Pain Res Manag 2018;2018:9305126.
non-GP specialist for advice in the following situations: doi: 10.1155/2018/9305126.
15. Ting DSJ, Ghosh N, Ghosh S. Herpes zoster ophthalmicus. BMJ
• patients who are immunocompromised7 2019;364:k5234. doi: 10.1136/bmj.k5234.
• severe shingles, for example, multidermatomal disease, 16. Jayasinghe S, Sheridan S, Macartney K. Herpes zoster vaccination
suspected central nervous system involvement in Australia: What’s available and who benefits? Aust Prescr
2020;43(1):2.
(encephalitis, meningitis, altered sensorium), disseminated
17. Neuzil KM, Griffin MR. Preventing shingles and its complications
disease or severe systemic infection5
in older persons. N Engl J Med 2016;375(11):1079–80.
• HZO – those with suspected/confirmed ocular involvement
require acute ophthalmological assessment4,5,8,12,15
• failure to respond to therapy – it is necessary to exclude rare

aciclovir-resistant VZV, which has been reported in patients
who are immunocompromised15
• refractory PHN, which should be managed in consultation

with a specialised pain clinic4,12
25
Multiple choice questions check Skin conditions
ACTIVITY ID 207936 C. Resistance to systemic antifungal agents in Australia

is common.
Skin conditions D. Topical griseofulvin is first-line therapy for tinea corporis.
This unit of check is approved for six CPD Activity Question 2

points in the RACGP CPD Program. The expected
time to complete this activity is three hours and Which one of the following statements is true regarding
consists of: onychomycosis?
• reading and completing the questions for each A. Recurrence is uncommon after successful mycological cure.
case study
B. Topical treatments are usually sufficient to effect cure.
– you can do this on hard copy or by logging on
C. Autoinoculation to other body sites can occur.
to the RACGP website (www.racgp.org.au),
clicking on the My Account button and D. Fortnightly liver function tests are recommended during
selecting the gplearning 2020 link from the systemic antifungal therapy.
drop-down
Case 2 – Wallace
• answering the following multiple choice questions
(MCQs) by logging on to the RACGP website Wallace, aged 69 years, is a man who presents to you with a
(www.racgp.org.au), clicking on the My Account four-day history of a painful rash on his right forehead. The
button and selecting the gplearning 2020 link eruption was preceded by a two-day history of burning pain in
from the drop-down the area of the eruption. He is otherwise well and has no
ocular symptoms. Clinical examination shows a unilateral,
– you must score ≥80% before you can mark the
dermatomal vesicular rash on an erythematous base. He has a
activity as ‘Complete’
normal eye examination.
• completing the online evaluation form.
Question 3
You can only qualify for CPD points by completing
the MCQs online; we cannot process hard Which one of the following best indicates how you would
copy answers. manage Wallace’s presentation?
If you have any technical issues accessing this A. Commence oral famciclovir
activity online, please contact the gplearning
B. Immediate referral to hospital for intravenous acyclovir
helpdesk on 1800 284 789.
C. Prescribe topical aciclovir 5% cream
If you are not an RACGP member and would like to
access the check program, please contact the D. Supportive treatment only
gplearning helpdesk on 1800 284 789 to purchase
access to the program. Further information
Wallace is worried about the possibility of shingles recurring

and asks what he can do to prevent this.
Case 1 – Tanvir
Question 4
Tanvir, aged 26 years, is a professional football player who
comes to see you regarding a recurrence of tinea that is Which one of the following best represents the advice you
causing itchiness between the toes of both feet. He has would give Wallace?
previously managed this condition with over-the-counter
A. Appropriately reassure Wallace that recurrence of shingles
preparations but is now concerned his toenails are affected.
is uncommon
Your physical examination confirms yellow nail
discolouration on three of Tanvir’s toes, suggesting B. Advise Wallace to wait at least one year before receiving
onychomycosis. You recall your knowledge of the diagnosis varicella-zoster vaccine (Zostavax)
and management of tinea and onychomycosis.
C. Appropriately reassure Wallace that a single episode of
shingles confers lifelong immunity
Question 1
D. Offer Wallace a single-dose of live attenuated varicella-
Which one of the following statements is true regarding tinea?
zoster vaccine (Zostavax) as soon as the lesions have crusted
A. It is caused by the organism Corynebacterium
minutissiumum. Case 3 – Abbas
B. The appearance of the rash may be altered by topical Abbas, aged 28 years, presents with a new rash around his
corticosteroids. right wrist. The rash started one week ago, and it is itchy and
26
Skin conditions check Multiple choice questions
red with blisters. Abbas works as a printer and uses inks, Case 5 – Manisha
solvents and wash-up solutions regularly; however, he reports
Manisha, aged 54 years, comes to see you reporting itchiness
minimal contact with these chemicals as he wears gloves.
of the vulva; she is concerned she has thrush. She also reports
Other than wearing a new watch, he has not made any
that she is finding sex painful. You undertake a thorough history
changes to his skin care products or fragrances. You examine
and a physical examination, which shows white patches of skin
the rest of his skin; his hands and feet are unaffected, but you
in the vulval area. A skin biopsy confirms Manisha has lichen
notice a small coin-sized area of faint erythema below the
sclerosus and you consider how to manage her condition.
umbilicus.
Question 9
Question 5
Which one of the following topical corticosteroids is the most
Which one of the following is the most likely diagnosis?
appropriate for initial treatment of lichen sclerosus?
A. Irritant contact dermatitis from handwashing and
A. Clobetasone butyrate 0.05%
chemical exposure
B. Betamethasone dipropionate 0.05%
B. Allergic contact dermatitis secondary to nickel
C. Triamcinolone acetonide 0.02%
C. Pompholyx
D. Hydrocortisone 1%
D. Dermatophyte infection
Question 10
Question 6
Which one of the following is a structural complication of
Which one of the following is the most appropriate test to
vulvar lichen sclerosus?
confirm the diagnosis of Abbas’s rash?
A. Burying of the clitoris
A. Skin prick testing
B. Fusion or loss of labia minora
B. Allergen-specific immunoglobulin E testing
C. Stenosis of the introitus and urethral orifice
C. Skin scrapings for fungal microscopy and culture
D. All of the above
D. Patch testing
Case 4 – Rhea
Rhea, aged 32 years, is a nurse who comes to see you as she is
concerned about a small patch of hair loss on the back of her
scalp, which was noticed by her hairdresser at a recent
appointment. The hairdresser had not noticed any hair loss at
Rhea’s appointment six weeks earlier, and Rhea does not report
any previous hair loss. In your differential diagnosis, you consider
alopecia areata as a possible cause for Rhea’s symptoms.
Question 7
Which one of the following best indicates signs or symptoms
that may suggest alopecia areata?
A. Diffuse hair thinning, irregular menses, acne and hirsutism
B. Young age, family history of autoimmune disease, abrupt onset
C. Pain, itchiness or burning of the scalp
D. Abrupt postpartum hair thinning
Question 8
Which one of the following is a dermoscopy feature
characteristic of alopecia areata?
A. Perifollicular scaling and erythema
B. Broken hairs and hairs of different lengths
C. Comma hairs
D. Exclamation mark hairs
27
Independent learning program for GPs
Independent learning program for GPs

574 August Skin Conditions - V10 2

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Unit 574

Telephone 03 8699 0414

ABN 34 000 223 807

© The Royal Australian College of General Practitioners 2020

About this activity 3

Case 1 Jessica has itchy hands 5

Case 2 Apinya thinks she is going bald 9

Case 3 Holden has a rash on his buttocks 13

Case 4 Paulo has uncomfortable genital itching 17

Case 5 Zivko has a painful rash 21

Multiple choice questions 26

The five domains of general practice

Communication skills and the patient–doctor relationship

Two new modules coming soon:

Registrations now open | www.racgp.org.au/dermatology

Brendan Chun-Yu Wu MBChB,

CASE Further information

Figure 1. Dorsum of Jessica’s right hand, which shows

Further information Question 8

Table 1. Results of Jessica’s patch test

Allergen Presence of reaction after five days

Nickel sulfate No reaction

Thiuram mix No reaction

Methylisothiazolinone Minimal erythema

Balsam of Peru No reaction

Paraphenylenediamine base Minimal erythema

Toluene diamine sulphate No reaction

Ammonium persulfate Minimal erythema

Glyceryl monothioglycolate No reaction

• exposure to water and frequency of wet work

• skin care (eg liquid soaps, fragrances, moisturisers, cosmetics)

• glove use (work and home), as well as type of glove

• hobbies – use of any glues or chemicals, plants

• history of atopic eczema, asthma and hay fever, including

• treatment used and effectiveness (eg over-the-counter,

• irritant contact dermatitis

• allergic contact dermatitis

• vesicular hand dermatitis

Answer 3 and occupational exposures. The site of patch application

Allergic contact dermatitis (ACD) results from an activation of

Answer 4 • machine operators

reactions. Experience is required to interpret patch testing Treatment

CASE On examination, you see three well-defined round/oval

From the history and examination findings, you

Question 6 CASE 2 Answers

Table 1 outlines how to group conditions considered in the

A positive hair pull test, in which at least 5–6 hairs are

A routine physical examination with attention to growth and

Alopecia areata is known to be associated with other organ-

3 Holden has a rash on his

Skin scrapings are obtained, and a potassium hydroxide

Question 5 Figure 2. Multiple dystrophic nails exhibiting yellow discolouration

Holden’s rash completely resolves after two weeks of

Question 6 Further information

Examination of Holden’s feet reveals multiple nails with

Tinea incognita is the correct term.

Psoriasis Tinea manuum Hands

Eczema/dermatitis Tinea unguium (onychomycosis) Nails

Communication skills and the patient–doctor relationship

ACTIVITY ID 207936 C. Resistance to systemic antifungal agents in Australia

B. Young age, family history of autoimmune disease, abrupt onset