13 - Dermatological History, Examination and Drugs Flashcards
How do you take a general dermatological history?
- Always start with where is it, how long and how has it evolved??
- DHx: Immunosupressants? Anticoagulants?
- ICE: is the itch affecting their sleep, does it affect their mood or self esteem
- Can also consider sexual history e.g herpes, syphillis
What are some important questions to ask for a dermatological history of a pigmented lesion or mole?
- Initial appearance and evolution of lesion
- Symptoms e.g itch, pain, bleeding
- History of sunburn or sunbed use
- Skin type
- Family history of skin cancer
What is the best way to exam a skin lesion in dermatology?
- Inspect: SCAM or ABCD (6 S’s, Size, Shape, Shade, Site, Symmetry, Surface)
- Palpate: surface, consistency, mobility, tenderness, temperature
- Dermoscopy
- Systematic check: hair, scalp, nails, mucosa, joints, lymph nodes general exam of all systems
How do you describe a skin lesion after doing a dermatological exam?
Always start with site and distribution…
Non-Pigmented (SCAM)
- Size and Shape
- Colour
- Associated secondary changes
- Morphology and Margins (border)
Pigmented (ABCD)
- Asymmetry
- Border irregular
- Colours two or more
- Diameter >6mm
How can you describe the distribution of lesions?
Symmetrical or Asymmetrical
Where do you need to exam in a dermatological exam apart from the skin?
ALWAYS NEED GOOD LIGHTING
- Hair
- Nails
- Scalp
- Mucosa
- Lymph nodes
- Joints
What is the meaning of the following words:
- Patch
- Macule
- Papule
- Nodule
- Vesicle
- Bulla
- Macule: flat area <5mm e.g freckle
- Patch: flat area>5mm
- Plaque: flat area with raised edges
- Papule: lump <5mm
- Nodule: lump >5mm
- Vesicle: clear fluid filled <5mm
- Bulla: clear flud filled >5mm
What is the meaning of the following:
- Erythematous
- Purpuric
- Erosion
- Ulcer
- Keratotic
- Lichenification
- Excoriation
- Striae
- Erythematous: red and blanching
- Purpuric: red and non-blanching
- Erosion: loss of epidermis so superficial
- Ulcer: loss of dermis and epidermis so deep
- Keratotic: scaly
- Lichenification: thickening of skin with exaggerated skin markings
- Excoriation: scratch marks
- Striae: stretch marks
What is a boil/furuncle and carbuncle?
What is the difference between hirsutism and hypertrichosis?
How would you describe the following nail changes?
What is the most important part of a dermatological history?
ICEEEEE!!!!!!!!!
What is a fissure?
Linear crack!
What are the differences between ointment, creams and lotions?
All can be called an emollient, whatever form the patient likes best they should use
Creams: emulsions of oil and water, well absorbed into the skin. Less greasy and easier to apply than ointment
Ointments: greasy preparations that have no added water and are more occlusive than creams. Mild anti-inflammatory effect. Chronic dry lesions
Lotions: less common, have a cooling effect eg calamine lotion.
A large amount of itchy skin is not due to primary skin lesions but due to systemic disease. What systemic diseases cause pruritis and what investigations should you do if somebody is complaining of pruritis?
- Iron deficiency (check nails and conjuctival pallor)
- Lymphoma (check lymphnodes and hepatosplenomegaly)
- Hypo/hyperthyroidism
- Liver disease (check spider naevi)
- Chronic renal failure
- Metastases
- Drugs (statins, ACEi, opiates)
Ix: FBC, ESR, Ferritin, LFT, U+Es, Glucose, TSH, CXR
How should you treat pruritis?
- Treat any primary disease
- Emollients (eg Diprobase®) to soothe dry skin
- Sedating antihistamines at night
What are some skin manifestations of the following systemic diseases:
- Diabetes
- Coeliacs
- IBD
Diabetes: flexural candidiasi, necrobiosis lipoidica (waxy, shiny yellowish area on shins), acanthosis nigricans, granuloma annulare, folliculitis.
Coeliacs: Dermatitis herpetiformis (very itchy blisters on elbows, scalp, shoulders, ankles)
IBD: erythema nodosum, pyoderma gangrenosum
What are some skin manifestations of the following systemic diseases:
- SLE
- Systemic Sclerosis
-
- SLE: butterfly facial malar rash, alopecia areata, photosensitivity, chillblains, Raynaud’s, oral ulcers, palmar erythema
- SS: see image
- Sarcoidosis: Lupus Pernio (diagnostic!!!), hypopigmented patches, yellow-brown firm papules, scarring alopecia
What cancers are the following skin phenomena associated with?
- Leser–Trélat sign
- Acanthosis nigricans
- Dermatomyositis
- Acquired ichthyosis
- Hypertrichosis lanuginosa
- Tripe palms
Tumours makes transforming growth factor (similar to epidermal growth factor) and goes to distant keratinocytes
In a 2 week wait dermatology appointment what are some important questions to ask?
Red flags: weight loss, malaise, night sweats
PMH: Previous skin cancer?
DHx: Immunosuppression? Anticoagulants? Allergies?
FHx: Cancer?
SHx: Skin type? Previous/Current Occupation? Ever lived abroad? Outdoor hobbies? Previous severe sunburn?
What are the differentials for this?
How do we treat venous eczema?
If ulcer need ABPI and Venous Doppler US before compression bandaging
How is seborrhoeic dermatitis treated?
Thought to be caused by Malasezziea yeast
Scalp: Ketoconazole shampoo, left on for 5 minutes before washing off
Body: Cotrimazole or miconazole, used for up to 4 weeks. Localised inflamed areas give hydrocortisone
How can we tell the difference between arterial, venous and neuropathic ulcers?
What are some differentials for generalised pruritis?
Why do we need to be careful when using steroids near the eyes?
Risk of inducing glaucoma
What skin condition is Parkinson’s associated with?
Seborrhoeic dermatitis
What drugs can exacerbate psoriasis?
What is the step-wise management for chronic plaque psoriasis?
How can you tell the difference between Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) and staphylococcal scaled skin syndrome?
Tzanck Smear
How are keloid scars managed?
- Avoidance of further trauma to the skin such as scratching
● Topical steroids and silicone gel
● Intralesional steroid injection if topical treatments are not effective
● Surgery such as excision carried out only as last resort as may cause a larger keloid scar
What is the most common malignancy associated with acanthinosis nigrans?
Gastric adenocarcinoma
When should you suspect Lichen Planus and Lichen Sclerosus?
What is Dianette and when is it used?
A COCP for acne, not prescribed as contraceptive as high risk of VTE
What is this, how do you manage it and what is an important differential to consider?
- Pyogenic Granuloma: occurs as a result of trauma
- Curettage
- Amelanotic Melanoma
What are some causes of pruritus in the elderly?
Split into medical and skin causes
What are some examples of skin changes in HIV?
- Acute sero-conversion rash
- Infections e.g cold sores, candida, molluscum, warts
- Inflammatory disorders e.g seborhhoeic dermatitis
- Kaposi’s sarcoma
What is pityriasis rosea caused by?
HHV6 or HHV7 which can leave lesions up to 3 months
Self resolving, can give sedating anti-histamine at night for itch, emollients and steroids
What are some examples of blistering disorders?
Immunobullous: bullous pemphigoid, pemphigus vulgaris
Infections: Herpes, Impetigo,
Other: acute contact dermatitis, pompholyx (vesicular eczema of the hands and feet,), burns
How does bullous pemphigoid present and what is the pathophysiology of this?
Presentation:
- Tense, fluid-filled blisters that are itchy
- Preceded by non-specific itchy rash
- Erythematous base
- Usually affects the trunk and limbs (mucosal involvement uncommon)
Pathophysiology:
Autoantibodies against antigens between the epidermis and dermis causing sub-epidermal split in the skin
How is bullous pemphigoid managed?
- General: wound dressing, monitor for signs of infection
- Topical (localised disease): HIGH POTENCY topical steroids
- Oral (widespread disease): oral steroids, combination of oral tetracycline and nicotinamide, immunosuppressive agents (e.g. azathioprine, mycophenolate mofetil, methotrexate, and other)
How does Pemphigus Vulgaris present and what is the pathophysiology of this?
Presentation
- Usually affects younger people than bullous pemphigoid
● Flaccid, easily ruptured blisters forming erosions and crusts
● Lesions are painful
● Usually affects the mucosal areas (can precede skin involvement)
Pathophysiology
Autoantibodies against antigens within the epidermis causing an intra-epidermal split in the skin
How is pemphigus vulgaris treated?
Always skin biopsy to diagnose
- General: Wound dressing, Good oral care (if oral mucosa is involved)
- Oral: high-dose oral steroids, immunosuppressive agents (e.g Rituximab and IV immunoglobulins)
What differentials should you be thinking of with an itchy rash?
What differentials should you be thinking of with a red swollen leg?
What are some of the different formulations of emollients and what are they prescribed for?
Formulations
- Aqueous cream,
- Ointment
- Liquid paraffin
- White soft paraffin in equal parts (50:50)
Indications
- Rehydrate skin and re-establish the surface lipid layer
- Useful for dry, scaling conditions and as soap substitutes
What are some of the adverse effects of emollients?
- Irritant or allergic reactions due to perfumes or preservatives
- Flammable if contain paraffin
- Pump dispensers minimise the risk of bacterial contamination; if using a pot, use a clean spoon / spatula every time to reduce risk
What is the potency ladder with topical steroids?
What is acanthosis nigricans associated with?
- PCOS (hyperinsulin state)
- DM (hyperinsulin state)
- GI adenocarcinoma
How can you tell the difference between a dermatofibroma and a mole?
Pinch it
Dermatofibroma will dimple as tethered to underlying subcutaneous tissue
Mole will protrude out
How do you remember the side effects of ciclosporin?
