11 - Dermatology Flashcards
Why is there erythema in psoriatic plaques?
- Dilatation of blood vessels in the epidermis
- Always offer to look at hair, scalp, nails and examine joints with psoriasis
How does acne vulgaris present?
Blockage and inflammation of the pilosebaceous unit (hair follicule, shaft, sebaceous gland)
- Comedones (non-inflammatory) and, papules, pustules, nodules
- On face, back, chest
- Complications include scarring, hyper pigmentation and anxiety
What are the meanings of the following words?
- Plaque is palpable flat topped area
- Erosion is loss of epidermis
- Ulcer is loss of dermis and epidermis
- Lichenification is thickening of the skin with exagerrated skin markings
How do you do a dermatological exam once you have taken a history?
- Wipe off any creams or makeup
- Look generally and look for systemic illness
- Comment on morphology and site/distribution (asymmetrical often exogenous cause, symmetrical endogenous)
- Include hair, scalp, nails, mucosa inspection
- Palpate
- Examine other systems like joints/lymph nodes
What system is used to describe the morphology of a skin lesion or rash?
- When describing colour use purpuric (non-blanching) or erythematous (blanching)
- When describing configuration use confluent, discrete, target or linear
- When describing surface features think about scale (built up keratin), crust (dried exudate), erosion/ulcers and excoriation
What system is used to describe pigmented lesions?
ABCD
What is Koebner’s phenomenon?
When a person has a skin condition such as psoriasis or vitaligo and when there is trauma to the normal skin, the lesion that develops is similar to their underlying condition
How do you take a dermatological history ?
- Patient demographics e.g sex, race, country of origin
- Presenting Complaint: site of onset and evolution, duration (acute/chronic), distribution: a/symmetrical, flexors/extensors, mucous membranes, sun sites, itchy, exacerbating/relieving
- PMH
- FH of atopy, skin type, cancer, systemic/autoimmune diseases
- Drug history inc OTC and if tried anything for this PC
- Social, occupational, sexual, travel history
- Psychosocial impact of skin condition
How does acne vulgaris present?
- Blockage and inflammation of the pilosebaceous unit (hair follicle, shaft and sebaceous gland)
- Propionibacterium acnes bacteria
- Comedomes (non-inflammatory), papules/pustules/nodules
- On face, chest and back
How is acne vulgaris managed?
Advise not to overclean the skin, do not pick as will scar, use non-comedomic makeup, warn treatment can take up to 8 weeks to start working
12 week course
Mild Acne (mainly comedones):
- Topical retinoid* like adapalene (not in pregnancy or breastfeeding) alone or in combination with benzoyl peroxide
- Topical antibiotic* like clindamycin with benzoyl to prevent bacterial resistance
- Azelaic Acid 20%*
Moderate/severe Acne (mainly papules/pustules):
- -A fixed combination of topical adapalene with topical benzoyl peroxide to be applied once daily in the evening.
-A fixed combination of topical tretinoin with topical clindamycin to be applied once daily in the evening.
-A fixed combination of topical adapalene with topical benzoyl peroxide to be applied once daily in the evening, together with either oral lymecycline 408 mg or oral doxycycline 100 mg once daily.
-Topical azelaic acid (15% or 20%) applied twice daily, with either oral lymecycline 408 mg or oral doxycycline 100 mg once daily.
Review after 8-12 weeks and consider maintenance with retinoid or azelaic acid
When should a referral for acne vulgaris to secondary care be made?
- Immediately if severe variant of acne e.g acne fulminans (ulcers)
- Severe hyperpigmentation/scarring including those at risk
- Persistent acne with multiple treatments in primary care
- Significant psychologicl distress
- Refer to endocrinology if signs of hyperandrogenism e.g hirtuism, PCOS, alopecia, oligomenorrhea
What are some of the different types of eczema?
- Atopic dermatitis
- Contact dermatitis
- Seborrhoeic eczema
- Venous eczema
How does atopic eczema present and what are some complications of it?
- Chronic relapsing itchy inflammatory skin condition with drying, excoriation and thickening usually on flexor surfaces
- FH and environment are big risk factors
- Complications: secondary infection with S.Aureus/HSV and psychosocial issues like difficulty sleeping
- Immediate hospital admission is suspect eczema herpeticum (painful, blisters and punched out erosions)
How is atopic eczema managed?
1st Line/Flares: Emollient like E45/Aveeno with topical steroid if red and inflammed
2nd Line: if persistent, severe itch or urticaria trial 1 month non-sedating antihistamine like cetirizine/loratadine
3rd Line: if severe and extensive consider short term PO corticosteroids like prednisolone 7/7 and if weeping/pustules consider abx like flucloxacillin or erythromycin for bacterial infection
- Can also consider phototherapy and immunosupressants (azathioprine, prednisolone, ciclosporin) for very severe
How is contact dermatitis managed?
- 8-12 week avoidance of the trigger or if can’t avoid wear gloves or wash hands afterwards
- Emollient
- Topical steroids
How does venous (stasis/varicose) eczema present? What are the risk factors and complications?
Skin changes that occur on the lower legs in people with chronic venous insufficiency/venous hypertension
Characterized by red, itchy, scaly, or flaky skin, which may have blisters and crusts on the surface and lipodermatosclerosis may occur
Risks: obese, immobility, varicose veins, DVT, cellulitis
Complications: pain, infection, secondary eczema, contact dermatitis, permanent skin discolouration, skin ulceration
How is venous eczema and lipodermatosclerosis managed?
- Regular application of emollient
- Treat flares with topical steroid (needs to be very high potency for lipodermatosclerosis)
- Consider referral to vascular service
- Give compression stockings
- Advise to avoid injury, elevate leg when resting, lose weight
What is lichen planus?
- T cell mediated autoimmune disorder where cells attack a protein in the mucosal and skin keratinocytes
- Can occur on penis, vulva, mouth, skin, nails
- Can treat with topical steroids, retinoids, topical calcineurin/tacrolimus or if extensive oral steroids for 1-3 months
What might pathology of the dermis and epidermis be?
Epidermis: changes in pigmentation, changes in skin surface (e.g scales, crusting), changes in epidermal turnover time (e.g psoriasis)
Dermis: changes in the contour of the skin (papules, nodules, ulcers), disorders of skin appendages (acne), changes related to lymph and blood vessels (urticaria, purpura, erythema due to vasodilation)
What is the difference between discoid, annular, discrete, target, linear and confluent?
What is erythema multiforme and how is it managed?
Acute self-limiting inflammatory condition usually trigger by drugs and infections like HSV. Mucosal involvement is absent or to one mucosal surface
Starts as small red spots, usually on hands and feet that spreads to trunk and turn into target lesions. May be itchy
Need to rule out Steven Johnson’s syndrome
Mx: if drug responsible withdraw drug, HSV antiviral, analgesics, steroid cream, reassure not contagious
What is erythema nodosum and how is it managed?
What is milliara rubra and how is it managed?
- Prickly heat/sweat rash
- Itchy papulovesicles in sweaty/heated areas often found in neonates or tropical environments
- Treat by staying in AC environment, sleeping and dressing in cool clothes, cold compresses etc
How is impetigo treated?
- Stay away from school until all lesions have crusted or 48 hours after antibiotic treatment starts
- Wash with soap and water, avoid sharing towels etc as infectious and reassure not likely to scar
- Topical hydrogen peroxide for 5 days if localised non-bullous or if not suitable topical antibiotic like fusidic acid or mupriocin
- Oral flucloxacillin or clarithromycin for 5 days if severe or bullous
What is intertrigo, what are the complications and what is the management?
Rash in the flexures e.g behind ears, under protruding abdomen due to moisture not being able to evaporate from these areas so friction and chafing and then skin commensal can get into the broken skin
Can be caused by lots of things e.g atopic dermaitits, thrush etc
Keep areas dry after bathing or sweating and treat based on cause e.g antifungals etc
How does a basal cell carcinoma present?
- Pearly nodule with rolled telangiectactic edge usually on face or sunexposed site
- May have a central ulcer
- Can also present as red scaly plaque with raised smooth edge
How is a basal cell carcinoma managed?
- Routine referral for suspicious lesion, only urgent 2 week if concerns delay may cause harm
- Excision, cryotherapy or if superficial topical flurouracil or imiquimod
- 50% will reoccur after 3 years of treatment, try to avoid UV exposure!!!!!
What are the differences in the appearance of squamous and basal cell carcinomas?
Basal cell usually has rolling edges but squamous arises from acitinic keratoses and has irregular borders
What lifestyle adivce can you give to someone with psoriasis?
- Weight loss, smoking cessation, alcohol reduction
- Manage stress and anxiety as these are triggers
- Tell them to seek advice if they get joint pain or swelling as may be sign of arthritis
- Assess CVD risk every 5 years and help keep VTE risk down
- Signpost to PAPAA
When should you refer someone with psoriasis to secondary care?
- uncertainty about the diagnosis.
- extensive or moderately severe
- resistant to topical drug treatments in primary care
- nail disease which is severe and having a major functional or cosmetic impact.
- significant impact on the person’s physical, psychological, or social wellbeing
- if erythrodermic/pustular
Secondary care can prescribe topical calcineurin inhibitors (e.g Tacrolimus) , phototherapy and systemic/biological therapy
What pharmacological treatments can you offer a patient with psoriasis in primary care?
Topical Tx:
- Emollients
- Vit D analogues (Calcipotriol) with topical steroid
- Coal Tar
- Salicyclic acid
- Dithranol for large plaque psoriasis
- Urgent referral to rheumatology if unexplained joint swelling
Why do we draw around cellulitis with pen?
- To see the spread of infection and check not necrotising fascitis
- Can also get peau d’orange and abscesses with cellulitis
When do you need to refer someone with eczema to secondary care?
Refer urgently if atopic eczema not responding to a week of topical treatment
Refer to dermatology if:
Not controlled by normal management so lots of flares
Recurrent secondary infections e.g abscesses
If affecting psychosocially e.g sleep
Treatment technique e.g bandaging
What are some examples of emollients and topical steroids used in the management of eczema?
Emollients: (Ointment > Cream > Lotion)
- Dermol
- Emulsiderm
- Oilatum
- E45
- Diprobase
Steroids (see image)
What advice do you need to give patients when they are applying topical steroids?
- Apply emollient 30 mins before
- Finger tip amount so thin layer
- Thinning skin/striae is rare with short course
- May have stinging/burning. Also side effects may include acne, folliculitis, excessive hair growth in area, contact dermatitis
- If applying to large area or long term there may be systemic absorption e.g decreased growth in children and Cushing’s
How does a patient with urticaria present?
Superficial swelling of the epidermis that becomes angio-oedema once swelling has spread to the dermis
Red, raised itchy rash with wheals
Chronic if >6 weeks (chronic spontaneous, autoimmune, chronic inducible)
How is urticaria managed?
- Rule out anaphylaxis and angiooedema
- Remove triggers e.g NSAIDs
- UAS Score
- If mild reassure self limiting
- If symptoms offer non sedating antihistamine (loratadine, cetirizine, fexofenadine) for up to 6 weeks then consider if needed daily for 3-6 months if chronic
- If severe consider oral corticosteroids alongside antihistamine for 7 days
- Topical antipruitic e.g calamine lotion
- Sedating antihistamine (chlorphenamine) if itch disturbing sleep
When should you refer someone to secondary care with urticaria?
- Vasculitic urticaria which is painful and persistent
- Food or latex allergy
- People whose symptoms are not controlled on antihistamines
- People with chronic irreducible urticaria that is difficult to control e.g cold urticaria
What is the typical presentation of pityriasis rosea?
Usually herald patch followed by eruption of red patches with scaly edges and central clearance. Often follows a cold or herpes infection
Rash in christmas tree pattern on back and V shape on chest
How is pityriasis rosea managed?
- Explain will get worse before better and new lesions may continue for up to 6 weeks
- Rash will settle after 2-3 months with no treatment and may leave hypo/hyperpigmentation
- If itch give emollient, mildly potent corticosteroid (e.g hydrocortisone) or sedating antihistamine (chlorphenamine) if affecting sleep
- Do not prescribe oral steroids
What do you prescribe for cellulitis? And if allergic?
If allergic to flucloxacillin then give clarithromycin or doxycycline
https://cks.nice.org.uk/topics/cellulitis-acute/
How does pityriasis versicolour present and how is it investigated?
- Fungal infection of the stratum corneum.
- Multiple round or oval macules and confluent patches that are fawn or white usually on back, upper arms, chest
- Common in hot, humid environments and in teenagers as they have increased sebaceous glands
- Diagnosis is clinical or by skin scrapings
How does acne rosacea appear and how is it managed non-pharmacologically?
Episodes of facial flushing, erythema, telangectasia, papules and pustules +/- eye symptoms. Relapsing and remitting
Mx:
- Refer for support to British Skin Foundation
- Avoid triggers e.g keep diary to find triggers
- High factor suncream and sunglasses
- Use non-oily emollients and soap free cleansers
- Use green and yellow camouflage makeup
- Offer referral to skin camouflage service
What are some risk factors for acne rosacea and some complications from this disease?
- Increasing age
- Photosensitive skin types
- UV exposure.
- Smoking and alcohol
- Spicy foods and hot drinks
- Heat or cold temperature
- Emotional stress and exercise
- Colonization with Demodex folliculorum mites
Complications: rhinophyma, blepharitis, dry eye, conjunctivitis
When should you refer someone with acne rosacea to secondary care?
Dermatology: persistent erythema or papules/pustules not responding to treatment, severe telangiectasia that has not responded to self management, diagnosis not clear
Plastic Surgeon: prominent non inflamed phymatous disease
Opthamologist: eye complication like uveitis/keratitis or if eye issues not responding to treatment e.g artifical tears
How can acne rosacea be managed pharmacologically?
- Persistent erythema: topical brimonidine 0.5% gel OD for temporary relief as needed. advise telenangectasia may look worse when using
- Mild papules/pustules: topical ivermectin OD for 8-12 weeks or topical metronidazole or azelaic acid if pregnant/breast feeding
- Moderate-to-severe papules/pustules: topical ivermectin + oral doxycycline for 8-12 weeks OD modified release
- Phymatous Disease: oral doxycycline for 6 weeks
- Occular Rosacea: lid hygeine and use of artifical tears/occular lubricants
What are some skin lesions that are precursors for a squamous cell carcinoma and how are they managed?
Acitinic Keratoses (10% lifetime risk of SCC):
- Found on sun exposed areas of skin. Often multiple lesions that are scaly/crusty and mimic scabs.
- Topical fluorouracil, or topical diclofenac sodium gel
- Biopsy and cryotherapy/excision to remove
- Emollient
- Advise good sun protection, avoid sun beds and tanning, skin checks every month
Bowen’s Disease
- More red and scaly than acitinic keratoses
- Same management
Cutaneous Horn:
- Hyperkeratotic acitinic keratosis that may have underlying malignancy
- Excision with appropriate margins and biopsy
How does squamous cell carcinoma present that would prompt a two week referral?
- Raised nodular lesion that is crusting or becoming necrotic and ulcerating in the middle
- Tumour may bleed
- Acitinic keratose may getting more lumpy, nodular or bleeding and this may show it is turning into a SSC
How is a squamous cell carcinoma managed?
- Excisional surgery (90% cure). Send for histology when excised
- If large and poorly defined then radiotherapy and excision may be considered. Rare to metastasise
- If superficial then 5-fluorouracil (5-FU) or imiquimod cream
- Advise good sun care and skin checks
When should you do a 2 week referral for a pigmented lesions a.k.a suspected melanoma?
- Lesions suggestive of malignant melanoma ABCDE
- Lesions which score 3 points or more (based on major features scoring 2 points each and minor features scoring 1 point each) on the 7-point checklist-
- New nodules, which are pigmented, or vascular in appearance.
- Nail changes, such as a new pigmented line in the nail or something growing under the nail.
What are some risk factors for malignant melanoma?
- History of skin cancer
- FH
- Pale skin (type I and II)
- Red, blond or light-coloured hair
- Blue or green eyes
- History of sunburn, particularly blistering sunburn in childhood.
- Sunbeds
- Lots of moles
- Increasing age
- Organ transplant recipients
What advice should you give to a patient at risk of developing skin cancer e.g red hair, over 100 moles?
- Avoid sun from 11am-3pm
- Minimum SPF 15 half an hour before the sun and reapplied every 2 hours
- Wear hats and clothes that cover the skin
- Regular skin checks
- Take photos of skin lesions to check for changes
What is ring worm called in different regions of the body?
- Foot: tinea pedis or athlete’s foot
- Groin: tinea cruris or jock’s itch
- Head: capitis
- Body: corporis
How does ringworm (tinea corporis/tinea cruris) present and why should you not use just topical steroids to manage this condition?
- Itchy skin lesions that have an active red, scaly advancing edge and a clear central area. Often annular and slightly raised or flat
- Using steroids risks tinea incognito (ill defined less scaly ringworm that is still contagious)
How does athlete’s foot present and how is it managed?
- Itchy painful flaky skin of the feet often interdigital
- Wear well fitting shoes to keep moisture out and replace old footwear that could have spores
- Wear different shoes every 2- 3 days with cotton socks
- Dry feet thoroughly after watching
- Same pharmacological treatment as tinea corporis
How is tinea capitis managed?
- Take skin scrapings
- Soften any surface crusts and tease away
- Hygiene like washing pillows, disposing of brushes
- If any househould pets that could be the source get them checked by vets
- Oral terbinafine or griseofulvin for 4-8 weeks
- Co-prescribe topical antifungal at first like selenium sulfide or ketoconazole shampoo to be used at least twice weekly for 2–4 weeks, or an imidazole cream
How does fungal nail infection present (onchomycosis)?
- Discouloured nail unit, thickened nail, distorted nail plate, white/yellow streaks on the nail
- If paronychia suggests candida infection
How is fungal nail treated?
- Ask about symptoms e.g pain on walking and take nail clippings
- Wear well fitting non-occulusive footwear, wear shoes in communal pools and gyms and keep nails short to prevent
- Only needs treatment if walking is uncomfortable, cosmetic distress or if nail is source of skin infection
- If topical treatment is appropriate, Topical amorolfine is used.
- If dermatophyte nail infection is confirmed, Prescribe oral terbinafine first-line
What is the difference between erysipelas and celluitis?
- Erysipelas more common on face, cellulitis more common on leg
How do we stage acne vulgaris?
