225 - Malignant Melanoma Flashcards
Name 3 common skin commensals
Staph epidermidis
Staph hominis
Micrococci
Which 2 bacteria commonly cause cutaneous infections?
Staph Aureus
Strep Pyogenes
What sort of cutaneous infection does Staph aureus cause?
Superficial ones Impetigo Folliculitis ecthyma Abscess/carbuncles/furuncles/boils
What sort of cutaneous infection does Strep Pyogenes cause?
Deeper infections
Cellulitis
Abscess
Nectrotising fasciitis
What is the treatment for staph/strep cutaneous infectioms?
Staph - Flucloxacillin
Strep - Penicillin
Or Erythromycin
What sort of cutaneous infection can be caused by a mycobacterium?
Fisktank granulmoa - eg. mycobacterium marinus
Red scaly plaques
What sort of cutaneous infections are caused by spirochaetes
Syphilis (Primary- painles lesion on heals, then secondary rash on hands, then tertiary neuro problems)
Lyme disease - Borrelia burgotferi, transmitted by tick
Rash that spreads. Use doxy
What is Erythrasma cause by?
Diptheroid skin commensal - Corynebacterium minutissimum
Red/brown dry patches in flexures
Fungal infections can cause cutaneous infections - What types are there?
Yeasts - Candida albicans - thrush/intertrigo…
Pityriasis versicolour - malassezie furfur
Dermatophytes - tinea corpis/pedis/ungum..
How do you treat fungal cutaneous infections?
Imidazoles - clotrimazole
Terbinafine
Lots of choice
Systemic - Itraconazole
What sort of cutaneous manifestations does Herpes simplex cause?
Highly contagious, direct contact spread
Penetrates epidermis
HSV I and II - Primary on skin, oral or genital
Reoccurs as coldsore of genitals
VZV - Zoster: Primary chicken pox (crops of vesicles), can reoccur as shingles
Complications:
Can cause Eczema herpitcum, Herpes enchephalitis, Keratoconjunctivitis
What cutaneous manifestation does HPV have?
Viral warts - dif types in dif locations
Treat: paring down/excision
They spontaneously resolve in 6-12 months
Can use salicylic acid / cryotherapy
What cutaneous manifestation does the Pox virus have?
Molluscum contagiosum
(in sheep = Orf)
Contagious, umbilicated papules associated w. atopic dermatitis, contain jelly like material
What is Erythema nodosum? What is it a cutaneous manifestation of?
Erethmatous tender nodules, usually on shins, more common in women
Causes:
TB, OCP, Pennicillin, Pregnancy, IBD…
What is Pyoderma Gangrenosum? What is it a cutaneous manifestation of?
Ulcer with irregular boarders, violaceous edge _ necrotic areas. Very painful
Causes:
RA, IBD, Haematological disease, Wegnar’s, PAPA syndrome
Can manage with immunosuppression therapy
What is a malar eruption/butterfly rash? What is it a cutaneous manifestation of?
Red patches across cheeks + photosensitivity
Systemic Lupus Erythematous
Also: mouth ulcers, urticaria, hair thinning
+ve ANA, ENA, anti dsFNS, anti-sm
Manage - sun protection, camouflage, topical steroids, antimalarials
What is Scleroderma? What is it a cutaneous manifestation of?
Localised skin hardening/thickening
Cause?
Morphea = only on skin -> can follow lyme disease, pregnancy, radiotherapy.
Systemic Sclerosis = systemic autoimmune disease against connective tissue
Increase in dermal collagen + ECM = thickening
What is Dermatomyositis?
Inflammation of coluntary muscles + a rash
2x as common in women
Get red/bluish-purple patches on sun exposed sites Heliotrope rash on eyelids Gottron's papules on bony prominances Calcinosis Raynauds
Investigations - CK, ANA, Skin biopsy, Muscle biopsy, EMG…
Manage - Systemic steroids, immunosupression, Ca channel blockers, sun protection
What is Pseudoxanthoma Elasticum (PXE)
Recessive disorder - affecting elastic tissue of skin, blood vessels + eyes - abnormal collagen
Ca accumulates in elastic fibres of skin/blood vessels/eyes/heart
- > small yellow papules / patches
- > Soft, lax, wrinkled skin - at neck first
No skin management, but can address vessel complications (eg. mitral valve prolapse..)
What is neurofibromatosis?
Genetic disorder: skin bone soft tissue + nervous system.
Type 1: Cafe au lait spots, neurofibromas, axillary freckling, iris tumour (Lisch nodule)
Type 2: Brain + spinal cord tumour
Auditory nerve tumour
Name 4 cutaneous markers for malignancy
Peutz-Jegher’s syndrome - dark spots on lips, mouth, anus, and polps in GI tract.
Paraneoplastic Pempigus - autoimmune disorder due to tumour, painful blisters + denuded areas in mouth, skin, oesophagus
Acanthosis Nigricans - Darkened thickened skin in neck, armpit, groin
Sweet syndrome - Tender lesions - papules + vesicles. Acute neurophilic dermatoses
What are 2 pre-malignancy changes seen in skin cancer?
Actinic/Solar Keratoses - discreet rough scaly patches in sun exposed areas
Bowen’s disease - single patch of red, scaly skin, often on lower leg, expands over time
Both can be removed - cryotherapy, chemo cream, photodynamic therapy..
What are the 2 types of non-melanocytic skin cancer?
Squamous cell carcinoma
- Less common, where pre-malig changes were, fast growing, can be on lip from smoking/sun, risk of metastasis increases with size/immunocompromised state.
Basal Cell Carcinoma - most common tumour in white pop. Locally invasive, rarly metastasize. 80% head/neck.
What are the risk factors for BCC?
Cummulative sun exposure Fair skin Age Radiotherapy damage Aresnic Tars
What do BCCs look like?
Nodular-cystic Purly, telangetic vessels Central dip/ulcer Soft Bleed easily
Can be pigmented with a rolled, smooth, shiny boarder
How do you treat a BCC?
Surgical excision gold standard
Radiotherpahy
Cryotherapy or PDT or curitage if superficial.
What is Moh’s micrographic surgery?
Histology os checked to ensure you’ve cut out edge during surgery.
Describe malignant melanoma
Serious, malignant potential.
More in females. Incidence doubled last decade.
- New black/brown mole, or old one that has changed in size/shape/colour.
What are 4 types of malignant melanoma?
Superficial spreading - horizontal growth
Nodular - vertical growth - lumpy
Acral - lentigenous - under nail
Lentigo maligna - face/scalp, sun linked, elderly
What treatment is available for malignant melanomas?
Surgery - with 1-3cm margin Sentinal lymph node biopsy Adjuvant interferon Chemo New therapies: for mets - BRAF inhibitors - vemurafenib - immune therapy - ipilimumab
What is uricaria/angioedema?
Looks like nettle sting - raised areas, red around, lasts a day. Angioedema - severe joined up, diffuse swelling.
50% ideopathic, 50% trigger - allergens, viral,NSAIDS…
Treat: antihistamines, steroids, fluids if needed.
What is toxic epidermal necrolysis?
Type IV cell mediated immune response
Reaction to drug
Ketitonocyle apoptosis
STOP DRUG eg. allopurinol, carbamazopine
What is necrotising fasciitis?
Severe infection spreading along fascial planes
V painful, tense swelling, feverish, hard woody purplish skin
Lots of different bacteria can cause tissue necrosis
Urgent surgical debridement needed
What is staphylococcal scalded skin syndrome?
V red, flaking skin
Staph exfoliative toxin
Flucloxacillin essential + emolliants
What is anaphylaxis?
Systemic release of histamine -> oropharyngeal oedema + extreme urticaria. Rapidly fatal
Treatment: Adrenaline 1:1000 IM ? intubation + ventilation Fluid bolus Steroids + antihistamines
What are 3 autoimmune blistering disorders?
Bullois pemphigoing (intact bulla) Pemphogus Vulgaris (fragile bulla) Dermatitis herpetiformis (on extensor surfaces)
What is an infective blistering disorder?
Bullous impetigo
Exfoliative toxin
What is the treatment for blistering disorders?
Pop blisters
Prevent infection - iodine dressings
Barrier restoration - emollient
What is eczema?
Itchy, red, inflammation of skin
Types?
- Endogenous: atopic, seborrhoeic, discoid, venous
- Exogenous - allergic, irritant, photo-reactive
Treatment: Emollient + Steroid
- avoid irritation, use soap substitute..
What will investigations show in eczema?
If allergic - IgE RAST testing for type I
- Patch testing for Type IV allergy
What is a weak topical steroid?
Hydrocortisone
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What is a moderate topical steroid?
Eumovate
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What is a potent topical steroid?
Betnovate
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What is a very potent topical steroid?
Dermovate
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What is the normal pH of skin?
5.5
What is acne vulgaris?
Disorder of pilosebaceous units - increased sebum excretion, hyperkeratosis + blockages of follicle opening, colonisation of ducts with propionibacterium acnes, release of inflam mediators
What are the 3 severities of acne vulgaris?
Mild: comedonal - black + white heads
Mod: papules + pustules
Severe - Nodulocystic
What is the treatment for acne vulgaris?
Topical:
Benzolyl Peroxide
Retinoids
Antibiotics
Systemic:
Antibiotics (tertracycline/erythromycin)
OCP
Isoterinoin (Roaccutaine)
What is Rosacea?
Chronic inflam. facial dermatosis
- Erythema + pustules, comes and goes.
In older group than acne.
Treat: top metronidazole cream, systemic tetracycline
What are papulosquamous eruptions? What can cause them?
Red, scaly, marginated, dry eruptions.
Inflam : lichen planus, pityriasis alba, pityriasis lichenoides
Infective: Pityriasis versicolour, pityriasis rosea, tinea corporis
What is Hidradenitis suppurative?
Acne inversa
Female, overweight, smoker
Treat with antibiotics
What is Psoriasis?
A papulo-squamous skin disorder
Well demarkated, scaly, red plaques
What are the features of chronic plaque psoriasis?
On extensor surfaces, red scaly plaques that are itchy and sore, have a silver sheen.
What are the features of flexural psoriasis?
Later in life onset
Well demarcated, red-glazed plaques
Not scaly
Occurs within flexures
What is Gluttate Psoriasis?
Raindrop like, small circular or oval plaques on trunk.
Often after strep URTI
How do you treat psoriasis?
Topical - Emollients, mild/mod steroids, vit D analogues (cacipotiol) Coal tar Dithranol (accumulated in mitochondria - less proliferation) Tazarotene (reduce keratinocyte prolif)
What associated factors are seen in someone with Psoriasis?
50% get nail changes - pitting, onycholysis, thickening, subungual hyperkeratosis
5-10% get Psoriatic arthritis
When does atopic eczema usually present?
Under 2 years, around 4-6 months - around weaning.
What is the key dysfunction in eczema?
A barrier dysfunction
In addition to emollients and topical steroids, what can you give in moderate eczema?
Topical calcineurin inhibitors + bandaging
In addition to emollients and topical steroids, what can you give in severe eczema?
Phototherapy
Systemic therapy - cyclosporin, Asothyoprine
What can be used in a child older than 2 years in addition to topical steroids or if steroids are unsuitable?
Topical immunomodulators - eg. Elidel cream or Protopic.
Affect the immune response + have local antiinflam response.
Don’t cause thickening or atrophy
What is the prognosis of atopic eczema?
60-70% of children clear by teens
Dry sensitive skin persists
Describe the course of measles
Prodrome period of 10-12 days
Fever, conjunctivitis, coryza(cold) and cough
2-3 days get Koplik’s spots in mouth
4-5 days get rash - ill defined, macula rash, head first
Describe rubella
Less severe than measles, slight fever, sore throat
Rash from head down
Tender lymph nodes
- congenital rubella - can cause blindness if in pregnancy
What causes hand-foot and mouth disease?
Coxsachie enterovirus
Small flat blisters on hands and feet + mouth ulcers
What is the offical name for headlice?
Pediculosis Capitis
What is Scabies?
A mite - sarcoptes Scabei
Spread by direct physical contact, burrows in skin
Must treat whole family and close contacts with Permethrin 5% cream, applied from neck down twice a week apart.
