16 - Common Dermatological Conditions Flashcards

1
Q

What are some of the different types of eczema?

A

DIFFERENT TYPES CAN CO-EXIST

Endogenous:

  • Atopic dermatitis (children)
  • Seborrhoeic (more so in adults)
  • Varicose
  • Discoid

Exogenous:

  • Contact dermatitis
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2
Q

What is the pathophysiology of eczema?

A

- Chronic atopic condition

- Defects in the barrier that the skin provides so there is an entrance for irritants, microbes and allergens that create an immune response (exaggerated IgE response), resulting in inflammation

  • Often genetic due to inheritance of FLG (fillagrin) gene that is a protein needed for the skin barrier
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3
Q

How does atopic eczema typically present and what is the disease pattern?

A
  • Relapsing and remitting in infants
  • Scaly, itchy, dry and erythematous patches commonly affecting the flexures. Can affect cheeks of infants and in black patients can affect extensors
  • Excoriation and lichenification (thickening of skin)

- Areas of hypo/hyperpigmentation after rash

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4
Q

What are some differential diagnoses for atopic eczema?

A
  • Psoriasis (not itchy)
  • Seborrhoeic dermatitis
  • Fungal infections
  • Contact dermatitis
  • Scabies
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5
Q

What are some risk factors for developing eczema?

A
  • Family history of atopy
  • Personal history of atopy (hayfever, asthma), food allergies or allergic conjunctivitis
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6
Q

How is atopic eczema different in Asian, Black Caribbean and Black African children?

A
  • Often affects extensors rather than flexors
  • Discoid and Follicular patterns more common
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7
Q

How is atopic eczema diagnosed?

A

Under 12s. Have itchy skin plus at least 3 of the following:

  • Onset of symptoms was before 2 years old
  • Past flexural symptoms
  • History of dry skin in the last 12 months
  • Personal or first degree family history of atopy
  • Visible flexural dermatitis or on cheeks
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8
Q

What area does atopic eczema usually spare?

A
  • Nappy area
  • Most children grow out of this eczema by 13 years old
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9
Q

What is an important question to ask in the history when a patient has eczema?

A
  • Is it affecting your sleep?
  • How does it affect your life?

Always need to consider if they need a referral to a psychologist for their mental health

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10
Q

How is atopic dermatitis managed in general terms?

A

Advice to give:

  • Identify and avoid triggers e.g soaps, hormones, pets, foods
  • Discourage elimination diet
  • Report any weeping/oozing rashes as could be eczema herpeticum
  • Keep nails short to prevent scratching

Treatment:

  • Emollients and Soap substitutes: as maintenance
  • Topical corticosteroids: for flares
  • Sedating antihistamine: for itch at night
  • Oral antibiotics: if secondary infection
  • Topical tacrolimus: if not controlled by above
  • Systemic immunosuppressants: if severe e.g methotrexate, azathioprine
  • Phototherapy: if severe
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11
Q

How would you advise a patient with eczema to use emollients?

A
  • Need to be applying at least 3 times a day very liberally even when eczema not active as provides a barrier
  • Use emollients as a soap substitute as normal soaps strip skins oils
  • Best emollient is the one the patient likes the most
  • Apply 30 minutes before application of steroid
  • AVOID NAKED FLAMES DUE TO PARAFFIN CONTENTS
  • Wet wrap when severe flare
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12
Q

What are the different preparations of emollient and what are some examples of each?

A

- Lotions (e.g. Dermol 500, E45): High water content. Spread easily and absorb quick. Not effective at moisturising very dry skin.

- Creams (e.g. Diprobase, Epaderm): Mixture of fat and water. Spread easily. Not as greasy so often preferred by patients

- Sprays (e.g. Emollin): Useful for hard to reach areas.

- Ointments (e.g. Diprobase, Epaderm): Contain minimal water making them thick and greasy. Patients may find them cosmetically displeasing. Very effective at holding water and repairing skin

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13
Q

What advice would you give to an eczema patient when prescribing them topical corticosteroids?

A
  • Apply thin layer 30 minutes after emollient application
  • Explain they are safe if used as prescribed
  • Only use in active eczema/flares and only up to a week at a time
  • 1 Fingertip is enough to cover two adult hands worth of skin

STEP UP AND DOWN DEPENDING ON RESPONSE TO EACH STEROID

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14
Q

What are some side effects of topical steroids?

A
  • Burning sensation
  • Thinning of skin
  • Contact dermatitis
  • Acne
  • Depigmentation
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15
Q

What is the steroid ladder?

A

- Mildly potent: Hydrocortisone

- Moderately potent: Clobetasone (Eumovate)

- Potent: Betamethasone (Betnovate)

- Very potent: Clobetasol propionate (Dermovate)

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16
Q

If eczema is not controlled by emollients and potent topical steroids, what is the next option to try within dermatology?

A

Topical calcineurin inhibitors (stops activation of T-Lymphocytes) as steroid sparing agents

Tacrolimus: Used aged >2 if moderate-severe and topical corticosteroids have not controlled symptoms and there is a risk of adverse effects from further steroids

Pimecrolimus: Used aged >2 for same reasons as above but on face and/or neck

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17
Q

If topical calcineurin inhibitors are still not controlling eczema, what is the next stage of treatment?

A
  • Phototherapy
  • Oral immunosuppressants e.g Azathioprine, ciclosporin, or methotrexate
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18
Q

What are some complications of atopic eczema and what is the prognosis?

A

Complications:

  • Secondary bacterial infections (crusting, oozing, weeping)
  • Eczema herpeticum
  • Secondary viral infections e.g molluscum
  • Poor mental health

Prognosis:

  • Tends to improve as child grows up and most grow out of it by 16
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19
Q

How is the presentation of seborrhoeic dermatitis different to atopic dermatitis?

A

Red, scaly rash affects scalp (dandruff), eyebrows, nasolabial folds, cheeks, and flexures

Due to overgrowth of fungus not atopy

Both can co-exist together

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20
Q

How is seborrhoeic dermatitis treated?

A
  • Mild topical steroid/antifungal preparations, eg Daktacort
  • Ketoconazole shampoo
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21
Q

How is irritant and contact dermatitis treated?

A

Irritant:

  • Avoid all irritants
  • Hand care (soap substitutes; regular emollients; careful drying)
  • Topical steroids for acute flare-up

Contact: (e.g nickel, rubber)

  • Consider patch testing and avoidance of allergens
  • Topical steroid appropriate for severity (decrease strength and stop as it settles)
22
Q

What is the pathophysiology of acne vulgaris?

A

Inflammation of the pilosebaceous unit

- Basal keratinocyte proliferation in pilosebaceous unit (androgen driven)

- Increased sebum production

- Propionibacterium acnes colonisation

- Inflammation

  • Comedones (white- & black-head) blocking secretions so papules, nodules, cysts, and scars form
23
Q

What are the clinical features of acne?

A

Non-inflammatory lesions (mild): open and closed comedones

Inflammatory lesions (moderate/severe): papules, pustules, nodules, cysts

May have scarring (e.g ice pick, rolling) and post-inflammatory depigmentation and hyperpigmentation

24
Q

What is Acne Conglobata and Acne Fulminans?

A

Conglobata: Inflammatory nodulocystic disease with interconnecting sinuses and abscesses. Can cause severe scarring. Associated with androgen-producing tumours and steroid use. Mainly affects men

Fulminans: Form of acne conglobata with systemic features such a fever, arthralgia and lymphadenopathy. Needs same day urgent referral to dermatology

25
Classifying the severity of acne is importnat to help guide the management. How is the severity of acne classified?
**_Mild to Moderate Acne:_** - Any number of non-inflammatory lesions (comedones) - Up to 34 inflammatory lesions - Up to 2 nodules **_Moderate to Severe Acne:_** - 35 or more inflammatory lesions (with or without non-inflammatory lesions) - 3 or more nodules
26
When should you refer someone with acne to a dermatologist?
27
What is the general management of acne vulgaris? (bottom three medicines only for moderate to severe)
- Skin care advice (see future flashcard) - Advise will take 6-8 weeks for any treatment to start working **_Medicine: (use for 12 weeks before review)_** - Topical adapalene (retinoid) with topical benzoyl peroxide - Topical tretinoin with topical clindamycin - Topical benzoyl peroxide with topical clindamycin - Topical azelaic acid plus either oral lymecycline or oral doxycycline - Oral lymecycline or doxycycline (if \>12) - Oral isotretinoin
28
How do each of the medications for acne vulgaris treatment work?
**Oral isotretinoin:** Retinoid, (Vit A analogue). Reduces production of sebum, reducing inflammation and reducing bacterial growth
29
What are some of the side effects of the following acne treatments? - Topical benzoyl peroxide/clindamycin/adapalene - Oral tetracyclines - Oral isotretinoin
**Topical:** burning sensation, bleaching of hair and clothes, photosensitivity, skin irritation **Oral Abx:** photosensitivity, cannot be used if pregnant or breast feeding **Oral Isotretinoin:** HIGHLY TERATOGENIC, dry skin and lips, photosensitivity, depression, anxiety, aggression and suicidal ideation, TEN/SJS
30
Which patients should you consider oral isotretinoin in? (Vit A derivative/Retinoid)
Aged over 12 and topical treatments and systemic antibiotics have failed with: - Nodulocystic acne - Acne conglobata - Acne fulminans - Acne at risk of permanent scarring
31
What do you need to counsel patients on before starting isotretinoin?
**- Risk of suicidal ideation**, need to mental health screen them first **- Highly teratogenic** so need to be on contraception and stop taking at least a month before trying to get pregnant **- May cause initial flare** when starting, can start short course of oral steroids if this happens - Other side effects
32
What patients is oral isotretinoin contraindicated in?
- Hypervitaminosis A - Hyperlipidaemia - Liver dysfunction - Pregnancy It must be used with caution in those with renal impairment, diabetes and dry-eye syndrome.
33
What are some complications of acne vulgaris?
- Scarring - Hyper/hypopigmentation - Psychological distress
34
What general skin-care measures can you give to a patient who is suffering with acne?
- Use a **non-alkaline** (skin pH neutral or slightly acidic) **cleansing product** twice daily - **Avoid oil-based and comedogenic preparations** of sunscreen and moisturisers **- Avoid oil-based a**nd comedogenic makeup products, and remove make-up at the end of the day. **- Persistent picking or scratching** of acne lesions can increase the risk of **scarring**
35
What are some signs of rosacea?
**Pre-rosacea**: flushing triggered by stress/blushing, alcohol & spices. **Signs:** - Central facial rash (usually symmetrical) with erythema, teleangi- ectasia, papules & pustules (without comedones) that is PERIORAL SPARING - Blepharitis/conjunctivitis (ocular rosacea) - Rhinophyma (swelling + soft tissue overgrowth of the nose)
36
How is Rosacea treated?
- Avoid sun overexposure - Sun glasses - Topical ivermecting or metronidazole for papules - Brimonidine for redness - Eyelid hygeine, ocular lubricants ± ciclosporin for ocular rosacea - Oral doxycycline for phymatous disease
37
What is the epidemiology of psoriasis?
- Two peaks, 20-30 and 50-60 - Affects caucasians mostly
38
What are some trigger factors for Psoriasis?
- FHx - Streptococcal Throat infections (Guttate psoriasis) - Trauma (Koebner Phenomenon) - Hormone changes (puberty, menopause) - Drugs e.g beta-blockers, lithium, chloroquine and ACEi - HIV - Smoking and Alcohol - Stress
39
What is the pathophysiology of psoriasis?
Autoimmune condition due to hyperproliferation of keratinocytes
40
What are some associated conditions with psoriasis?
- Psoriatic arthritis - IBD - Metabolic syndrome - CVD - Psoriatic nail disease - Other autoimmune conditions - Uveitis and blepharitis - DEPRESSION!!!!
41
What are the different subtypes of psoriasis and how do they present?
**_Chronic Plaque Psoriasis (most common)_** ## Footnote - Well demarcated thickened erythematous plaques with silver scales usually in extensor surfaces or scalp - Post inflammatory hyperpigmentation **_Flexural/Inverse_** **_Guttate Psoriasis (second most common - Raindrop Psoriasis)_** - Papular rash that occurs about 2 weeks after a strep throat infection - Usually self limiting after 3 weeks but a third will go on to develop chronic plaque psoriasis **_Erythrodermic Psoriasis_** - Widespread erythema and psoriasis affecting a large portion of the bodies surface area (at least 75-90%) - Recent infection, drugs or stress can induce it - Often needs hospital admission as emergency - Needs biologics **_Pustular Psoriasis_** - Pustules form under areas of erythematous skin - Develop plaques with peripheral pustules - Dermatological emergency and patients are often systemically unwell with fever, malaise and arthralgia
42
What are some features of psoriatic nails (strongly associated with psoriatic arthritis)?
- Subungual hyperkeratosis - Nail pitting - Oil drop discolouration (yellow/pink patches) - Leukonychia (white discolouration) - Onycholysis (detachment of the nail from the nail bed) - Splinter haemorrhages
43
What are some 'signs' of psoriasis?
**- Auspitz sign**: small points of bleeding when plaques are scraped off **- Koebner phenomenon:** development of psoriatic lesions to areas of skin affected by trauma **- Residual pigmentation** of the skin after the lesions resolve
44
What is the general management of psoriasis?
EDUCATE IT IS CONTROL NOT CURE **- Emollients** **- Topical steroids** **- Vitamin D analogues** **- Tar preparations** (helps to reduce scaling and slow plaque formation) **- Short contact dithranol:** (10-30 minutes then rinse) (Applied to chronic extensor plaques only, avoiding normal skin. It stains objects and skin) **- Phototherapy:** usually UVB **- Systemic:** methotrexate, ciclosporin, acitretin, biologics
45
What is Dovobet and Enstilar?
A mixture of Vitamin D and a potent steroid used to treat severe psoriasis
46
What are the different types of phototherapy that are used to treat psoriasis?
**_- UVB:_** narrow-band ultraviolet B therapy. Used in plaque psoriasis that has not responded to topical therapy. **_- PUVA (Psoralen + UVA)_:** is a form of photochemotherapy, combination of a photosensitising drug and UV therapy. Complications include ***skin irritation, damage*** and ***SCC skin cancer*** (a risk that is compounded if given ciclosporin)
47
What are some of the different types of psoriatic arthritis?
- Monoarthritis or oligomonoarthritis - Psoriatic spondylitis - Asymmetrical polyarthritis - Arthritis mutilans (destructive) - Rheumatoid-like polyarthritis.
48
What are some of the systemic therapies for psoriasis and how do you decide which therapy is best for the patient?
**- Methotrexate (1st line):** Antifolate immunosuppressant, teratogenic so need contraception whilst using and for 6 months after (both men and women). Preferred in elderly or arthropathy as long term use can cause hepatic fibrosis **- Ciclosporin**: Can raise blood pressure and drop renal function but can be used in pregnancy. Rapid control can be gained **-Acitretin:** Is a retinoid. Need to avoid pregnancy whilst using and for 3 years after stopping. Dry skin and mucosae, rasied lipids, glucose rasied, raised LFTs (reversible) **- Infliximab/Biologics:** given as IV injection for severe, treatment resistant disease **_- Mycophenalate Mofetil_**
49
What are some complications of psoriasis?
**- Psychological issues** like depression and anxiety **- Systemic upset** with erythrodermic psoriasis and generalised pustular psoriasis can cause organ damage **- Side effects from treatment** e.g skin irritation, malignancies
50
Is psoriasis itchy?
Not really, should consider eczema if itchy!!!
51
52
How can you tell the difference between rosacea and acne?
ROSACEA HAS NO COMEDONES