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Core clinical problems > 37. Itch > Flashcards

37. Itch Flashcards

1
Q

History taking PC: itch

A

HoPC: timing, severity, location, crawling sensation? Prickling sensation? Burning? Relieving factors?
Red flags: weight loss, night sweats, fatigue, fever, lumps
Nocturnal itch may suggest
MHx: any skin problems, any liver problems, any kidney problems
DHx:
FHx: haematological cancers?, autoimmune problems, atopy?
SHx: alcohol (liver), living conditions, anyone else got an itch?, stress
ICE: impact on persons life and mental wellbeing/confidence

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2
Q

Examination: itch

A

General: skin colour (jaundiced?plethroic?), skin lesions, scratch marks, pattern of rash?, signs of iron deficiency anaemia? weight loss? weight gain?
Lymph nodes: lymphadenopathy?

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3
Q

surgical sieve PC:itch

A

Vascular
Immune/infectious: scabies, eczema, psoriasis
Trauma:
Autoimmune: urticaria, thyroid, diabetes
Metabolic: liver pathology, renal failure, cholestasis, iron deficiency anaemia
Iatrogenic: drugs?
Neoplastic: lymphoma, polycythaemia vera
Congenital: liver problem?
Degenerative:
Environment: allergic to cosmetic
Functional: prolonged itch,
Psychiatric: parasitosis,
Pregnancy:

Topical:
Infection : scabies
Immune : eczema, psoriasis, urticaria
Allergy: contact dermatitis, allergic to cosmetic

Systemic:
- metabolic: diabetes, iron deficiency anaemia, allergy to drug
- autoimmune : thyroid pathology
- organ: liver failure, cholestasis, renal failure
- neoplastic : lymphoma, polycythaemia Vera

Functional : prolonged itch
Psychiatry : parasitosis
Pregnancy: liver things

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4
Q

Plan invetsigation widespread itch with no rash?

A

Skin:
Inflammatory markers such as ESR and/or CRP

Systemic:
Liver: LFTs, viral hepatitis serology
Metabolic: FBC, U&E, iron studies, TFTs, HbA1c
Neoplastic: FBC, blood film, bone chemistry
CXR
Pregnancy: pregnancy test

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5
Q

severe itch with skin marks and scratch marks present for 2 weeks and getting worse, itch worse at night time- impacting sleep,

A

scabies

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6
Q

typical history and examination scabies

A

PC: severe itch with skin marks and scratch marks present for 2 weeks and getting worse
HoPC: itch worse at night time- impacting sleep,
Red flags: no fever, no weight loss, some fatigue but thinks this is due to reduced sleep due to itch, no night sweats, no lumps
MHx: none
DHx: none
Allergies: nkda
FHx: none
SHx: 1st year at uni, new sexual partner also experiencing severe itch
ICE: sleep is severely affected and is affecting uni work, skin marks affecting confidence, concerned it is infectious as her partner is having the same problem - is embarrassed to talk to anyone about it

o/e: Widespread erythematous papules on fingers, front of torso, genitalia, extensor surfaces of arms, scratch marks, thread-like tracks measuring around 5–10 mm in between fingers,

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7
Q

pathophysiology scabies

A

Scabies is a transmissible skin disease caused by the ectoparasitic mite Sarcoptes scabiei var. Hominis.

Itch is due to a delayed type-IV hypersensitivity reaction to the mite and mite products (faeces and eggs) so symptoms appear 4-6 weeks after infection.

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8
Q

Plan ?scabies

A

Management:
Permethrin 5% cream
Inform close contacts
Wash bedding and clothes at 60 degrees

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9
Q

typical history urticaria

A

PC: widespread rash that came up yesterday
HoPC: itchy, burning sensation
Red flags: no throat swelling, no difficulty breathing, has an epi-pen on her,
MHx: asthma, current URTI, has been taking ibuprofen as feels rubbish, has had this type of rash in the past
DHx: blue inhaler, brown inhaler
Allergies: egg
SH: none
ICE:

o/e: widespread areas of raised patchy skin swelling (weals)

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10
Q

triggers urticaria

A

classic allergy: food allergy, bee sting, contact urticaria-rubber latex

infection:acute infection

drugs: antibiotics, NSAIDs, vaccination, radiocontrast,

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11
Q

plan ?urticaria

A

Management:
non-sedating antihistamines are first-line eg: cetirizine, loratadine, and fexofenadine
prednisolone is used for severe or resistant episodes

In children: cetirizine

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12
Q

pathophysiology urticaria

A

type 1 hypersensitivity

Weals are due to release of chemical mediators from tissue mast cells and circulating basophils. These chemical mediators include histamine, platelet-activating factor and cytokines. The mediators activate sensory nerves and cause dilation of blood vessels and leakage of fluid into surrounding tissues. Bradykinin release causes angioedema.

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13
Q

typical history polycythaemia vera

A

PC: Pruritus particularly after warm bath
HoPC:
Red flags: fatigue, weight loss, night sweats, fever
MHx: previous DVT, previous stroke,
DHx:
FHx:
SHx:
ICE:
o/e: ruddy complexion, splenomegaly

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14
Q

pathophysiology polycythaemia vera

A

uncontrolled proliferation of a single type of stem cell: in PV this is erythroid cells

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15
Q

plan ?polycythaemia vera

A

Investigation:
diagnosis: JAK2 + raised haematocrit or if not JAK2 more complicated

bloods:
FBC - inc haematocrit (high)
Ferritin - low in primary, normal in secondary
JAK2 mutation
U&E, LFTs

Management:
- aspirin: reduces the risk of thrombotic events

  • venesection (first-line treatment to keep the haemoglobin in the normal range)
  • chemotherapy (hydroxyurea - slight increased risk of secondary leukaemia, phosphorus-32 therapy)
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16
Q

complications polycythaemia vera

A

can lead to secondarily myelofibrosis or acute myeloid leukemia

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17
Q

typical history atopic dermatitis

A

PC: rash, general dry skin, itchiness in flexures. In infants=face and trunk, in slightly older = extensor surfaces, >4 in flexures
HoPC:
Red flags:
Environment: triggers: irritants eg soaps, detergents, food allergy (particularly in children), house dust mites, pollens, pets, stress, hormonal changes
MHx:
DHx:
Allergies:
FHx: family history of atopy. Genetic mutations affecting production of filaggrin
SHx:
ICE:

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18
Q

plan ?atopic dermatitis

A

Emollient 500g/week for an adult, 250g/week for a child

Steroid ladder (mild if face) HEAD Hydrocortisone, Eumovate, Betnovate, Dermovate

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19
Q

name 2 thin emollients and 2 thick emollients

A

thin:
Diprobase cream
cetraben cream
E45
Aveeno

thick:
diprobase ointment
cetraben ointment

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20
Q

typical history contact dermatitis

A

PC: dermatitis following direct skin contact with irritant - most commonly on the hands
HoPC:
Red flags:
Environment: work involves irritants, new job
MHx: none, no atopy
DHx:
Allergies:
FHx:
SHx:
ICE:

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21
Q

plan ?contact dermatitis

A

Avoid irritant
Emollient
Steroid

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22
Q

inflamed greasy areas with fine scaling, locations: beard area, nasolabial folds, eyelashes/eyebrows, behind ear, scalp

A

seborrhoeic dermatitis

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23
Q

typical history seborrhoeic dermatitis

A

PC: inflamed greasy areas with fine scaling, locations: beard area, nasolabial folds, eyelashes/eyebrows, behind ear, scalp
HoPC:
Red flags:
Environment: change of season, stress,
MHx: may have HIV or recent illness,
DHx: certain medications eg buspirone, chlorpromazine, cimetidine, griseofulvin, haloperidol, lithium, interferon alfa and methyldopa
Allergies:
FHx:
SHx:

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24
Q

pathophysiology seborrhoeic dermatitis

A

affects areas rich in sebaceous glands (​​microscopic glands found in your hair follicles that secrete sebum) so is most common on face, scalp and chest. Inflammatory reaction to yeast called malassezie spp.

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25
Q

plan ?seborrhoeic dermatitis

A

Investigation:
1. Consider HIV testing
Management

Adults
+ Non-greasy emollient soaps
+ Olive oil leave on and rub scales off
1. Ketoconazole 2% shampoo or cream depending on area

Children
+ Non-greasy emollient soaps
+ Olive oil leave on and rub scales off
1. A topical imidazole cream (clotrimazole 1% or miconazole 2%)

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26
Q

larger plaques, elbows, knees and lower back, and scalp. silvery scale. Kobhner phenomenon- new plaques at sites of skin trauma

A

Chronic plaque psoriasis

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27
Q

widespread small papules/plaques, trunk and limbs

A

Guttate psoriasis

28
Q

redness in body folds/genitals

A

?flexural psoriasis

29
Q

what are the psoriasis nail signs

A

pitting, onycholysis, arthritis

30
Q

Typical history psoriasis

A

Chronic plaque psoriasis: larger plaques, elbows, knees and lower back, and scalp. silvery scale. Kobhner phenomenon- new plaques at sites of skin trauma

Guttate psoriasis: widespread small papules/plaques, trunk and limbs

Flexural psoriasis: affects body fold and genitals

HoPC:
Red flags:
Environment: stress, skin trauma,
MHx: recent strep throat in guttate psoriasis
DHx: lithium
FHx:
SHx:
ICE:

o/e: nail signs: pitting, onycholysis, arthritis

31
Q

genetic associations psoriasis

A

HLA-B13, -B17, and -Cw6.

32
Q

General management psoriasis

A

+ Improved by sunlight
+ Regular emollients

  1. Potent corticosteroid once daily and vitamin d analogue once daily (separate times) for up to 4 weeks
  2. Vitamin d analogue twice daily for 8 weeks
  3. Potent corticosteroid twice daily for 4 weeks or coal tar prep applied once or twice daily

Secondary care management:
Phototherapy UVB 3x per week
Methotrexate

33
Q

Management scalp psoriasis

A
  1. Potent corticosteroid once daily for 4 weeks
  2. Different formulation
34
Q

Management face/flexural/genital psoriasis

A
  1. Mild/moderate potency corticosteroid once or twice daily for maximum 2 weeks
35
Q

Time limits on topical steroid use?

A
  • Potent steroids no longer than 8 weeks at a time
  • Very potent corticosteroids for no longer than 4 weeks at a time

NICE recommend that we aim for a 4-week break before starting another course of topical corticosteroids

36
Q

when may topical steroids cause systemic effects?

A

systemic side-effects may be seen when potent corticosteroids are used on large areas e.g. > 10% of the body surface area

37
Q

limits on corticosteroids face/flexures/genitals

A

no more than 2 weeks in a month

38
Q

side effects of topical corticosteroids

A

skin atrophy
striae
rebound symptoms - burning, redness, and itchy skin. Steroid cream withdrawal symptoms may be worse than the skin condition you were taking the steroids to treat.

39
Q

Examples of vitamin D analogues

A

calcipotriol (Dovonex), calcitriol and tacalcitol

40
Q

how do topical vitamin D analogues work

A

they work by ↓ cell division and differentiation → ↓ epidermal proliferation

they tend to reduce the scale and thickness of plaques but not the erythema

41
Q

Restrictions on topical vit D analogues

A

they should be avoided in pregnancy
the maximum weekly amount for adults is 100g

42
Q

rapidly developing widespread erythema, followed by the eruption of white, sterile non-follicular pustules which coalesce to form large lakes of pus.

A

pustular psoraisis

emergency same day derm appt

43
Q

diffuse, widespread severe psoriasis that affects more than 90% of the body surface area

A

erythrodermic psoriasis

emergency same day derm appt

44
Q

what is lichen planus

A

autoimmune skin codnition

itchy, papular rash most common on the palms, soles, genitalia, oral mucosa and flexor surfaces of arms
rash often polygonal in shape, with a ‘white-lines’ pattern on the surface (Wickham’s striae)

45
Q

pattern of lichen planus

A

palms, soles, genitalia and flexor surfaces of arms, oral involvement

46
Q

what can cause lichenoid drug eruption

A

gold
quinine
thiazides

47
Q

management of lichen planus

A

potent topical steroids are the mainstay of treatment
benzydamine mouthwash or spray is recommended for oral lichen planus
extensive lichen planus may require oral steroids or immunosuppression

48
Q

causes pruritus ani

A

Idiopathic

Secondary to
Skin conditions
Infection eg threadworms
Rectal and anal pathology
Systemic causes of itch

49
Q

approach to pruritus ani

A

assessment
hx as any other itch
examine area and skin for skin conditions

invgn
swab
lower GI invgn if suspected
skin biosy if suspected

if symptoms dont settle, blood tests for itch eg FBC, ferritin etc.

50
Q

PC threadworms

A

usually children

perianal itching, particularly at night
girls may have vulval symptoms

51
Q

management threadworms

A

mebendazole is used first-line for children > 6 months old. A single dose is given unless infestation persists. for all members of the household

hygiene measures

52
Q

causes of pruritis vulvae

A

irritant contact dermatitis (e.g. latex condoms, lubricants): most common cause
atopic dermatitis
seborrhoeic dermatitis
lichen planus
lichen sclerosus
psoriasis: seen in around a third of patients with psoriasis

53
Q

most common cause pruritis vulvae

A

irritant contact dermatitis (e.g. latex condoms, lubricants)

54
Q

general advice pruritus vulvae

A

In relation to washing:
avoid baths, shower instead only 1ce a day
clean w emollient such as epaderm

55
Q

what is lichen sclerosus

A

Lichen sclerosus is a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. It commonly affects the labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men, typically on the foreskin and glans of the penis.

56
Q

symptoms lichen sclerosus

A

Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex (superficial dyspareunia)
Erosions
Fissures
The Koebner phenomenon

57
Q

o/e lichen sclerosus

A

“Porcelain-white” in colour
Shiny
Tight
Thin
Slightly raised
There may be papules or plaques

58
Q

managenment lichen sclerosus

A

Potent topical steroids

usually clobetasol propionate 0.05% (dermovate)

59
Q

complication lichen sclerosus

A

5% risk of developing squamous cell carcinoma of the vulva.

60
Q

what are varicose veins

A

Varicose veins are dilated, tortuous, superficial veins that occur secondary to incompetent venous valves, allowing blood to flow back, away from the heart.

61
Q

reflux in what veins are most common varicose veins

A

reflux in the great saphenous vein and small saphenous vein

62
Q

risk factors varicose veins

A

increasing age
female gender
pregnancy - the uterus causes compression of the pelvic veins
obesity

63
Q

presentation varicose veins

A

PC: cosmetic issue

PC symptomatic: aching, throbbing, itching

PC: a complication of varicose veins

64
Q

complications of varicose veins

A

varicose eczema (also known as venous stasis)
haemosiderin deposition → hyperpigmentation
lipodermatosclerosis → hard/tight skin
atrophie blanche → hypopigmentation
bleeding
superficial thrombophlebitis
venous ulceration
deep vein thrombosis

65
Q

invetsigation varicose veins

A

venous duplex ultrasound: this will demonstrate retrograde venous flow

66
Q

management of varicose veins

A

mainly conservative:
leg elevation
weight loss
regular exercise
graduated compression stockings

if meet criteria for secondary care:
endothermal ablation
foam sclerotherapy
surgery

67
Q

reasons for rf to secondary care - varicose veins

A

symptomatic:
significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling

complication:
skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)

superficial thrombophlebitis

an active or healed venous leg ulcer

previous bleeding from varicose veins

Core clinical problems (94 decks)

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