Derma Case Write Up.docx

CASE WRITE UP DERMATOLOGY POSTING NAME : SANGARI A/P SARKUNA SINGAM STUDENT ID : 1001439079 Year 4, Group 1 Date : 21/1/2015

HISTORY TAKING Patient's Information Name : Mr X. Age : 31 years old Gender: Male Race: Malay Religion : Islam Marital Status : Married Address: Kuala Terengganu. Occupation : Works at TNB. Date of clerking: 21/2/2016 Chief Complaint Patient came in for follow up and continuation of treatment for the papular and pustular skin lesions of his face, trunk and back. History of presenting illness Patient's skin condition started when he was in late teens, he noticed that his face became oily very fast and he would frequently get comedones both white and black (>10) with papules and pustules ( >5) on his face, around the neck and his back but at that time it was minimal and he did not seek for treatment until last year when his skin condition worsened especially his back and trunk with the number of comedones ( >50 )and papulopustular( >50) whereas his face had a number of comedones ( >20) and papulopustular( > 20). His face skin became red and looked inflamed. Patient then started to get worried about his appearance which then prompt him to seek for treatment at HSNZ dermatology clinic last year. He was assessed and given a topical agent( retinoid) and oral antibiotic ( doxycycline) which he has been on for 2 months now. His skin condition has markedly improved with his face only having a few remaining skin lesions which is barely visible and this is same with the skin on his trunk. There are however scarring marks seen over the face and trunk. The lesions on his back is

still numerous in number but has improved compared to before. The other parts of the body were no affected. Systemic Review : ( Unremarkable) Cardiovascular system : No exertional dyspnea, paroxysmal nocturnal dyspnoea, orthopnea and ankle edema, chest pain, palpitation Respiratory system : No shortness of breath , cough, sputum production, hemoptysis or coryzal symptoms. Gastrointestinal system : No abdominal pain, vomiting or change in bowel movement. Urinary system : No dysuria, urinary frequency or hesitancy. Nervous system: No headache, fainting attacks, seizure, weakness or numbness of extremities Musculoskeletal system : No joint, bone or muscular pain. Past history of skin and related disorders Patient has similar problem when he was in his teens but it was milder and affected his face and back mostly otherwise he did not have any skin conditions or atopic diseases like eczema, asthma or hay fever previously. Past medical History Patient has no known chronic medical illness like diabetes,hypertension, tuberculosis and HIV. Drug History Patient has been on topical agent ( retinoids) and oral doxycyclin for two months. He has no known drug allergy. Family History None of his family members have skin problem like him and there is no family history of skin diseases like psoriasis or history of atopic diseases like asthma or eczema.

Social and Occupational History The patient works at tenaga nasional berhad ( TNB) as a technician and there is no history of exposure to oils, tars, hydrocarbons or any chemicals. He is smoker but does not take alcohol or any recreational drugs. He has a normal balanced diet although he does frequently take food high in sugar content and fat. Effect of the disease on the patient. Patient's self esteem and confidence has reduced due to his condition although it is not severe to the extent of affecting his daily life activities, work and marriage life. PHYSICAL EXAMINATION

General examination The patient is a medium built man and he appeared healthy. Vital Signs Blood Pressure: Was not able to take. Pulse rate : 82 beats per minute, normal volume and regular rhythm Respiratory rate : 18 breaths per minute Temperature : 37◦C Pain score : 0 General Observation: Hands : No pallor or cyanosis and capillary refill time was 2 seconds. On the arms there were no rashes. Face : No conjuctival pallor and there was no central cyanosis and the oral hygiene was good. Neck : There were no cervical lymph node enlargement. Trachea was centrally located. Lower limbs : There were no pitting edema

Local Skin Examination Face : There are minimal comedones and papules seen ( hardly visible from 2.5m away from skin) with a few scarring marks and the skin appeared greasy. Otherwise the skin does not looked inflamed and there are no pustules, cyst or nodules seen. Neck : There were a few comedones ( > 5) and pustules ( 2-3) seen with scarring. Trunk : There were papules ( > 20) and a few pustules ( > 5) seen with scarring marks which covered less than half of the affected area. No cyst or nodules seen. Back : There were numerous comedones ( > 50) and papules (>50) seen with a few pustules ( > 10) and scarring marks covering more than half of the affected area. No cyst or nodules seen. No significant findings on other parts of the body. Abdominal Examination Inspection : Abdomen is not distended, no scars, moves with respiration and umbilicus is centrally located and inverted. Palpation: Soft and non-tender. No hepatosplenomegaly and kidneys are not ballotable. Percussion: Was resonant and shifting dullness was negative. Auscultation : Normal bowel sounds were heard. Respiratory System Examination Inspection: Chest moves symmetrically with respiration and there is no signs of laboured breathing. Palpation : Trachea is centrally located. Chest expansion is equal and vocal fremitus is normal. Percussion : Equally resonant on both sides. Auscultation : Normal air entry on both sides and there is no added sounds like crepitations or wheeze. Vocal resonance is normal.

Cardiovascular System Inspection : No chest deformity or scars. Palpation : Apex is felt at 5th intercostal space, mid-clavicular line. No heaves or thrills. Auscultation : Normal first and second heart sound heard. Central Nervous System No abnormal posture or fasiculations. Tone, power and reflexes are normal on both extremities. Higher cortical function and sensory function is intact.

Summary Mr.X, a 31 year old man who came in to the dermatology clinic for follow up for the papulopustular skin lesions on his face, trunk and back which started when he was in his teens and worsened over the years. Local examination of the skin revealed that there were minimal remaining comedones and papules on his face and trunk but extensive on his back. Provisional Diagnosis Moderate acne vulgaris ( Based on CASS scale) Differential diagnosis - Rosacea - Systemic lupus erythematosus - Photodermatoses - Seborrhoeic dermatitis Management - Advice the patient on how to care of his skin. Use non-drying soap to wash face and do not pick on the acnes. - Topical agents and oral antibiotic preferably topical retinoids and oral doxycycline.( In this case, ask patient to continue the treatment)

Discussion Acne is a chronic inflammation of the pilosebaceous units. It can be divided into inflammatory( papules, pustules and nodules) and non-inflammatory( open and closed comedones). Pathogenesis is multifactorial and the most important factors involved are : a. Increased sebum production b.Propionibacterium acnes proliferation c.Altered follicular keratinisation d.Inflammation Clinical features Usually effects the face and often the trunk. Hallmark is the comedones : Open comedones ( Blackheads): dilated keratin-filled follicles and closed comedones ( Whiteheads) : accumulation of sebum and keratin deeper in the pilosebaceous ducts. Inflammatory papules, nodules and cyst occur and may arise from comedones. Distinct clinical variants Acne conglobata : Severe cystic acne with more involvement of the trunk than the face. Coalescing nodules, cysts, abscesses, and ulceration; occurs also on buttocks. Acne fulminans : Rare but severe presentation of acne, associated with fever, arthralgias and systemic inflammation with raised neutrophil count and plasma viscocity. Acne excoriee : Self inflicted excoriations due to compulsive picking of pre-existing or imagined acne lesions. Secondary acne : Comedonal acne can be caused by cosmetics or occupational exposure to oils, tars or chlorinated aromatic hydrocarbons.

Comprehensive Acne Severity Scale( CASS)

Acne treatment Can be pharmacological and non-pharmacological. Pharmacological treatment is divided into 2 phases : Induction ( Aim for remission) and maintenance therapy. Induction therapy Consist of topical and systemic treatment. Example of tropical treatment : Benzoyl peroxide ( BPO), retinoids ( isotretinoin, tretinoin), antibiotics ( clindamycin, erythromycin),dapsone, azelaic acid, salicylic acid, sulfur and its combination. Example of systemic treatment: Antibiotics ( tetracycline, doxycycline, erythromycin, minocycline, azithromycin), hormonal therapy ( COCs) and isotretinoin. Maintenance therapy Mainly topical therapy. ( Eg adapalene, tazarotene, azelaic acid) Non-pharmacological treatment includes physical therapy such as laser, phototherapy, chemical peels and comedone extraction.