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Under the microscope:

Top news:

Skin Symptoms of Current Monkeypox Outbreak

The British Journal of Dermatology published a review of 185 cases of monkeypox, which outlines the main symptoms of the current outbreak. It has been found that the skin symptoms in the latest episode differ from past cases. 

The research indicates that the latest outbreak presents much rarer pseudo-pustules rather than the more standard pus-filled pustules that are common skin symptoms of monkeypox.

Typical monkeypox symptoms present initially as fever and swelling of the lymph nodes. A four-stage skin rash follows this. However, cases of the new outbreak tend to feature few skin lesions of pseudo-pustules that don't contain any pus, often limited to a single area. 

How do pseudo-pustules present?

While similar in appearance to typical pus-filled pustules found with monkeypox, these pseudo-pustules are solid papules with an off-white appearance. With standard monkeypox pustules, you can scrape away the surface layer of the lesions to access the puss. However, with pseudo-pustules, it is not possible to do this. 

The pseudo-pustules can become necrotic over time and lead to ulcers developing. Other skin symptoms include:

  • A skin rash featuring vesicles surrounded by a halo of inflammation leading to papules that arrive after the initial skin lesions
  • Monkeypox whitlow
  • Ulcers where the pseudo-pustules meet the mucous membranes and inner linings of body cavities such as the nose, mouth, or genitals

Likely transmission route

Research supports the evidence that a primary transmission route for this current monkeypox outbreak is via sexual contact rather than airborne particles. This is because the localised skin lesions were centred in most patients in areas of close contact during sexual intercourse rather than as a typical widespread rash. 

This monkeypox outbreak follows a similar pattern to related viruses, orthopoxviruses and parapoxviruses, which cause localised skin lesions at the site where the disease enters the body.  


On the case:

How hot weather affects chronic skin conditions

People who suffer from long-term chronic skin conditions such as eczema and psoriasis have found that summer's high temperatures have brought their own problems. 

In these temperatures, we tend to perspire more; this irritates the skin and causes the areas where skin folds to retain added moisture, causing further exacerbation of the skin condition and leading to a higher incidence of broken skin and skin infections.

Case study:

Mrs Wilson, a 70-year-old patient who suffered from Atopic Eczema for most of her life, came to see me in a dermatology clinic in July. She was due to be seen in two weeks for her regular 12-weekly systemic review but had asked to be seen earlier as her skin had flared, and she had not managed to control the flare. 

Medical history:

She had been treated in the past with emollients, topical steroids, oral steroids, ichthammol bandages and phototherapy in different dermatology departments across the country where she had lived. 

All of these provided varying periods of relief, but nothing reassured her that she would ever be able to have a considerable time without pain and constant itching. This had a detrimental effect on her mental health, and she was eventually prescribed antidepressants. The rest of her medical history was unremarkable.

Treatment and responses:

After being referred to the Dermatology Service, it was agreed with Mrs Wilson to commence systemic therapy for a short period in the hope of breaking what had now become Stasis Eczema. 

She was initially prescribed Ciclosporin 100mgs daily for four weeks. This significantly positively affected her skin, but she suffered side effects of fatigue, headaches, and nausea. 

What are some other dermatological conditions that Ciclosporin may be used for? Only one answer is correct.

A: Chronic spontaneous urticaria, pyoderma gangrenosum and psoriasis 

B: Androgenetic alopecia, lichen planus and atypical annulare

C: Granuloma annulare, lichen planus and shingles

D: Alopecia areata, androgenetic alopecia and psoriasis 

Hint: Cyclosporine A (CYA) belongs to the calcineurin inhibitor family, which can selectively suppress T cells= immunosuppression.

Answer is A: For further information, check this website. 

The medication was changed to Acitretin, which was more acceptable, and there were no side effects that affected Mrs Wilson. She also managed to maintain her cleared skin. When taking Acitretin, patients are warned that they are at more risk of burning in the sun and should avoid sun beds.

Unfortunately, Mrs Wilson had found that she had developed patches of excoriated skin that had become infected due to the hot weather and the problem of added perspiration gathering under her breasts, axillae, and groin. 

She was prescribed oral flucloxacillin due to the widespread areas of infection and a menthol emollient which cooled the skin and reduced the itching. We also discussed methods of keeping cool and trying to absorb excess perspiration.

Which of the following would have been included in the advice given? Only one answer is correct.

A: Keep windows and curtains opened, take warm showers once a day and wear loose-fitting clothing

B: Wash skin with soap and water and then rub until thoroughly dry; use a fan if available.

C: Use a (hot) water bottle filled with cold water and ice cubes any time but particularly at night.

D: Keep emollients and steroids at room temperature or hotter; apply as needed to reduce the itch.

Answer is C

Additional tips included: 

  • Add old socks or tights containing some porridge oats under the running bath tap, use the gel from the oats to wash with and soak in the oat water
  • Air conditioning, if available
  • Keep emollients in the fridge; nice and cool to apply and reduces itch
  • Keep in the shade outside if possible and wear loose-fitting clothes made of natural fibres such as linen or cotton
  • Keep windows open if possible and curtains closed
  • Pat skin dry; never rub to cause more irritation
  • Some new sportswear clothing is designed to wick away perspiration from the skin so that it can be useful
  • Tepid showers or baths two or three times per day, using soap substitutes 
  • Use a fan if available
  • Use old cotton handkerchiefs or muslin folded under the breasts or abdominal apron

Mrs Wilson returned a week later. Her skin infection had resolved. She had found the above suggestions helpful and felt more in control.

Ask PDUK: 

Rhoda Cowell, Dermatology Clinical Nurse Specialist, answers your questions.

Questions and answers

Question 1: I often see patients with chronic skin conditions that are depressed. Can you recommend any tools that I can use to assess a patient's state of mind?

Answer: This problem has been more widely recognised in the last few years, and there are now several tools such as the SWIFT Tool, the Distress Thermometer, and the General Anxiety Questionnaire GAD-7 that you can use.  

Question 2: When would you refer a patient with a chronic dermatological condition for further assessment?

Answer: The most appropriate time for a referral is either:

A) any time that the patient’s condition is not being managed 


B) there are frequent flares with little time between each episode.

About our expert

Rhoda Cowell has worked in the community as a health care provider for over 30 years. She is a clinical nurse specialist and currently works with the HCRG Care Group as a Dermatology Lead nurse. 

Don't forget to check out our selection of dermatology courses, including our:

Recognising and managing acute skin conditions in primary care: 

Childhood skin conditions:

Recognising and managing skin conditions in people of colour:

And more!