16 - Common Dermatological Conditions Flashcards
What are some of the different types of eczema?
DIFFERENT TYPES CAN CO-EXIST
Endogenous:
- Atopic dermatitis (children)
- Seborrhoeic (more so in adults)
- Varicose
- Discoid
Exogenous:
- Contact dermatitis
What is the pathophysiology of eczema?
- 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
How does atopic eczema typically present and what is the disease pattern?
- 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
What are some differential diagnoses for atopic eczema?
- Psoriasis (not itchy)
- Seborrhoeic dermatitis
- Fungal infections
- Contact dermatitis
- Scabies
What are some risk factors for developing eczema?
- Family history of atopy
- Personal history of atopy (hayfever, asthma), food allergies or allergic conjunctivitis
How is atopic eczema different in Asian, Black Caribbean and Black African children?
- Often affects extensors rather than flexors
- Discoid and Follicular patterns more common
How is atopic eczema diagnosed?
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
What area does atopic eczema usually spare?
- Nappy area
- Most children grow out of this eczema by 13 years old
What is an important question to ask in the history when a patient has eczema?
- 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
How is atopic dermatitis managed in general terms?
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
How would you advise a patient with eczema to use emollients?
- 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
What are the different preparations of emollient and what are some examples of each?
- 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
What advice would you give to an eczema patient when prescribing them topical corticosteroids?
- 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
What are some side effects of topical steroids?
- Burning sensation
- Thinning of skin
- Contact dermatitis
- Acne
- Depigmentation
What is the steroid ladder?
- Mildly potent: Hydrocortisone
- Moderately potent: Clobetasone (Eumovate)
- Potent: Betamethasone (Betnovate)
- Very potent: Clobetasol propionate (Dermovate)
If eczema is not controlled by emollients and potent topical steroids, what is the next option to try within dermatology?
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
If topical calcineurin inhibitors are still not controlling eczema, what is the next stage of treatment?
- Phototherapy
- Oral immunosuppressants e.g Azathioprine, ciclosporin, or methotrexate
What are some complications of atopic eczema and what is the prognosis?
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
What is seborrheic dermatitis and how does it present?
Chronic dermatitis thought to be caused by an inflammatory reaction related to a proliferation of a normal skin inhabitant, a fungus called Malassezia furfur - It is common, affecting around 2% of the general population.
Features
* eczematous lesions on the sebum-rich areas: scalp (may cause dandruff), periorbital, auricular and nasolabial folds
* otitis externa and blepharitis may develop
How is the presentation of seborrhoeic dermatitis different to atopic dermatitis?
Red, scaly rash affects scalp (dandruff), eyebrows, nasolabial folds, cheeks, and flexures
Due to overgrowth of fungus not atopy
Both can co-exist together
How is seborrhoeic dermatitis treated?
- Mild topical steroid/antifungal preparations, eg Daktacort
- Ketoconazole shampoo
How is irritant and contact dermatitis treated?
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)
What is the pathophysiology of acne vulgaris?
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
What are the clinical features of acne?
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
(Comedone = A plug in a sebaceous follicle containing altered sebum, bacteria, and cellular debris. Can present as open (blackheads) or closed (whiteheads))
What is Acne Conglobata and Acne Fulminans?
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
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
When should you refer someone with acne to a dermatologist?
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
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
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
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
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
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.
What are some complications of acne vulgaris?
- Scarring
- Hyper/hypopigmentation
- Psychological distress
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 and 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
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)
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
- Moderate-severe: topical ivermectin + oral doxycycline
What is the epidemiology of psoriasis?
- Two peaks, 20-30 and 50-60
- Affects caucasians mostly
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
What is the pathophysiology of psoriasis?
Autoimmune condition due to hyperproliferation of keratinocytes
What are some associated conditions with psoriasis?
- Psoriatic arthritis
- IBD
- Metabolic syndrome
- CVD
- Psoriatic nail disease
- Other autoimmune conditions
- Uveitis and blepharitis
- DEPRESSION!!!!
What are the different subtypes of psoriasis and how do they present?
Chronic Plaque Psoriasis (most common)
- 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
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
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
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
What is the secondary care management of psoriasis?
Phototherapy
• Narrowband ultraviolet B light is now the treatment of choice. If possible this should be given 3 times a week
• photochemotherapy is also used - psoralen + ultraviolet A light (PUVA)
Adverse effects: skin ageing, squamous cell cancer (not melanoma)
Systemic therapy
• oral methotrexate is used first-line. It is particularly useful if there is associated joint disease
• ciclosporin
• systemic retinoids
• biological agents: infliximab, etanercept and adalimumab
• ustekinumab (IL-12 and IL-23 blocker) is showing promise in early trials
What is Dovobet and Enstilar?
A mixture of Vitamin D and a potent steroid used to treat severe psoriasis
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)
What are some of the different types of psoriatic arthritis?
- Monoarthritis or oligomonoarthritis
- Psoriatic spondylitis
- Asymmetrical polyarthritis
- Arthritis mutilans (destructive)
- Rheumatoid-like polyarthritis.
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
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
Is psoriasis itchy?
Not really, should consider eczema if itchy!!!
What is lichen planus?
Fairly common non infectious rash in adults
Lichen - small bumps on the skin, planus - flat
As flat topped papules
a chronically inflammatory condition affecting the skin and mucosal surfaces.
Pathology: t-cell mediated autoimmune disorder inflammatory cells attack an unknown protein within the skin and mucosal keratinocytes.
How can you tell the difference between rosacea and acne?
ROSACEA HAS NO COMEDONES
Lichen planus presentation
Most common on flexural aspects of wrists, ankles, lumbar region
Linear grouped lesions in scratch marks - Koebner’s
Papules flatten over few months, replaced by hyperpigmentation
Clinical features: may cause small number or an extensive amount of lesions on the skin and mucosal surfaces.
papules
polygonal plaques – shiny flat topped and firm on palpation
plaques crossed with white lines – whickham striae
location can be anywhere but most often on the wrists , lower back and
ankles.
50% have oral involvement
Lichen planus presentation
Most common on flexural aspects of wrists, ankles, lumbar region
Linear grouped lesions in scratch marks - Koebner’s
Papules flatten over few months, replaced by hyperpigmentation
Clinical features: may cause small number or an extensive amount of lesions on the skin and mucosal surfaces.
papules
polygonal plaques – shiny flat topped and firm on palpation
plaques crossed with white lines – whickham striae
location can be anywhere but most often on the wrists , lower back and
ankles.
50% have oral involvement
Lichen planus management
Dx: Clinical features → Skin biopsy to confirm
Management:
potent topical steroids – mainstay of treatment
topical calcineurin inhibitors e.g tacrolimus ointment
topical retinoids
for widespread infections – 1-3 month course of oral pred while commencing one of:
hydroxychloroquine
methotrexate
azathioprine
mycophenolate mofet
What is seborrheic keratosis? (presentation and management)
Benign overgrowth of epidermal keratinocytes
a harmless warty spot that appears during adult life as a common sign of skin ageing. Some will have hundreds of them.
Clinical features: arise on skin only , never on mucous membranes. highly variable appearance:
* flat or raised papules or plaque - might itch
* 1cm > several
* colour: skin coloured , yellow , gray , dark brown
* waxy/wary surface.
* maybe grouped in some areas
Management
reassurance about the benign nature of the lesion is an option
options for removal include curettage, cryosurgery and shave biopsy
What is bullous pemphimgoid?
Autoimmune Blistering skin disorder
Autoantibodies against antigens between epidermis and dermis, causes sub-epidermal split in the skin
pathology:
autoantibodies against the epidermis and dermis
proteolytic destruction of adhesives e.g hemidesmosomes.
leads to sub-epidermal split in the skin
Bullous pemphigoid is more common in elderly patients. Features include:
* itchy, tense blisters typically around flexures
* the blisters usually heal without scarring
* there is stereotypically no mucosal involvement (i.e. the mouth is spared)
* in reality around 10-50% of patients have a degree of mucosal involvement. It would, however, be unusual for an exam question to mention mucosal involvement as it is seen as a classic differentiating feature between pemphigoid and pemphigus.
What investigation and management for bullous pemphimoid?
Skin biopsy
immunofluorescence shows IgG and C3 at the dermoepidermal junction
Management
referral to a dermatologist for biopsy and confirmation of diagnosis
oral corticosteroids are the mainstay of treatment
topical corticosteroids, immunosuppressants and antibiotics are also used
What is Pemphigus Vulgaris?
Features
* mucosal ulceration is common and often the presenting symptom.
* Oral involvement is seen in 50-70% of patients
* skin blistering - flaccid, easily ruptured vesicles and bullae. Lesions are typically painful but not itchy.
* These may develop months after the initial mucosal symptoms. Nikolsky’s describes the spread of bullae following application of horizontal, tangential pressure to the skin
* acantholysis on biopsy
Pemphigus vulgaris is an autoimmune disease caused by antibodies directed against desmoglein 3, a cadherin-type epithelial cell adhesion molecule. It is more common in the Ashkenazi Jewish population.
What is the management for pemphigus vulgaris?
General management:
good skin care ERS - good oral care - wound dressing
Medical management: aims to reduce the formation of blisters.
Systemic oral steroids , high dose
Immunosuppressive agents – azathioprine/methotrexat
What is Pityriasis Rosea? (presentation, management)
Pityriasis rosea describes an acute, self-limiting rash which tends to affect young adults. The aetiology is not fully understood but is thought that herpes hominis virus 7 (HHV-7) may play a role.
Features
* in the majority of patients there is no prodrome, but a minority may give a history of a recent viral infection
* herald patch (usually on trunk)
* followed by erythematous, oval, scaly patches which follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer. This may produce a ‘fir-tree’ appearance
Management: Self limiting
What is seborrheic dermatitis and how does it present?
Chronic dermatitis thought to be caused by an inflammatory reaction related to a proliferation of a normal skin inhabitant, a fungus called Malassezia furfur - It is common, affecting around 2% of the general population.
Features
* eczematous lesions on the sebum-rich areas: scalp (may cause dandruff), periorbital, auricular and nasolabial folds
* otitis externa and blepharitis may develop
