Clinical Questions Flashcards
A women presents with well defined red plaques, with a silvery scale on her elbows and knees.
Plaque psoriasis
What nail signs are you looking for in a patient who presents with symptoms suspicious of psoriasis?
Pitting and onchylyis (separation from the nail bed)
What systemic symptom is is important to ask about in psoriasis patents?
Joint pain
A man presents with clear demarcated pink lesions on his groin and perinanal region. The rash is aggravated by sweat and friction.
Flexural psoriasis
A teenage girl come in complaint of many small lesions on her back and chest. On questioning she reveals she had a soar throat 2 weeks ago.
Guttate psoriasis
A man complains of a psoriatic like lesion on top of a surgical scar. What is this phenomenon called?
Koebner phenomenon
What would be appropriate first line therapies for a patient presenting with psoriasis?
Emolliants Vitamin D analogue (calcitriol) Topical corticosteroids Coal tar preparations Dithranol
Describe how calcitriol works
A vitamin D analogue which inhibits cell proliferation and promotes keratincyte differentiation.
In a patient which psoriasis what do you expect a skin biopsy to show?
Epidermal acanthosis and parakeratosis (increased skin turnover)
Absence of the granular layer
What is hyperkeratosis?
Increased thickness of the keratin layer
What is parakeratosis?
Persistence of nuclei in the keratin layer
What is acanthosis?
Increases thickness of the epidermis
What is papillomatosis
Irregular epithelial thickening
What is spongiosis?
Oedema between keratinocytes
What is meant by an inflammatory cell infiltrate?
Acute or chronic lymphocytes and/or neutrophils.
A 40 year old man with psoriasis has just stopped a 2 week course of prednisolone for his asthma. What life threatening complication is he at risk of?
Erythroderma. (An inflammatory dermatitis over 90% of the skin) which can be fatal
A child presents with a weeping, crusty, golden lesion beside her mouth. Her mum reveals that 4 other children in her nursery have recently had the same appearance.
Impetigo
What is the most common causative organism for impetigo?
Staph aureus
How would you treat a child with staph aureus impetigo?
Oral flucloxacillin 500mg 4x daily for 7 - 10 days
How would you treat a child with a beta haemolytic streptococci impetigo?
Oral phenoxypenicillin 500mg 4 times daily
What advice would you give to the parent of a child with impetigo?
Good personal hygiene (e.g. avoid towel sharing)
Avoid school for 1 week
What bacteria is responsible for staphylococcal scalded skin syndrome?
Staph aureas
What bacteria usually causes cellulitis?
Beta haemolytic streptococci
How would you treat a cellulitis?
Phenoxymethylpenicilllin and flucloxacillin 500mg 4 x daily.
A child present with a circular lesion on his chest which is red around the outside but appears to be healed in the middle.
Tinea corporis
How would you treat a child with two small ringworm lesions?
Clotrimazole cream
A lady comes in complaining of a redness under her breasts. You swap for a culture, what do you expect to find.
Candida (yeast infection)
How do you treat a candida skin infection?
Clotrimazole cream
Oral fluconazole
A man comes in with an intensely itchy rash all over his body, particularly in his finger ends and wrist. All his family have the same symptoms.
Scabies
How would you treat scabies?
Malathion lotion applied overnight to whole body and washed off the next day. Benzyl benzoate (avoid in children)
How do you treat head lice?
Malathion
What type of reaction is a contact allergic dermatitis?
Delayed type (type 4)
What is the principle histological finding in dermatitis?
Spongiotic dermatitis
In a child with atopic excema, which serum antibody do you expect to be raised?
IgE
1 year old child comes into your clinic with an eryhthamtous rash on her face and the back of her arm which appears to be very itchy. Her mum suffers from asthma.
Atopic eczema
Mutations in the coding of which protein appear often in eczema?
Fillagrin protein
Which parts of the skin does atopic eczema affect?
The epidermis and the dermis
What can happen to your skin in the long term as a result of scratching?
Lichenification of he skin
What would you prescribe for a 2 year old child with moderate eczema?
Emolliants
1% Hydrocortisone cream
Soap substitutes
A mother complains that her 5 year old daughter, who has severe eczema, is not sleeping at night due to constant itching. What treatments would you try?
Medicated bandages/wet wraps
Sedative anti histamines
A 15 year old girl had had severe eczema since she was 2. She is on emollients and topical steroids without relief and is tired of using creams. What other therapy could you try?
A course of PUVA and UVB
What oral medications would you consider using in a severe unresponsive eczema patient?
A short course of prednisolone or ciclosporin.
How would you treat infected eczema?
Oral flucloxacilin for 7 - 10 days.
A man comes in with a red itchy rash stretching from his umbilicus to his underpants. He has no history of excema or asthma
Allergic contact dermatitis to nickel
A women comes in with well demarcated, scaly patches that are itchy. Sometimes they are terrible and sometimes they do not bother her.
Discoid eczema
Describe the immunopatholgy of allergic contact dermatitis.
Langerhans cells in the epidermis process the antigen on first exposure, after which presented to T helper cells in the dermis. These then migrate to the lymph nodes and on next exposure the sensitised T cells proliferate and cause a dermatitis
How would you test for a suspected contact allergic dermatitis
Patch testing
What advice would you give to someone suffering from a contact allergic dermatitis. What treatment could you prescribe?
Avoid allergen
Corticosteroids (local or systemic)
Oral antihistamines
A baby presents to your cline with a rash on the nappy area but not in the skin flexures.
Irritant contact dermatitis to urine
A women who works as a hairdresser come is with a painful redness and dryness on her hands.
Irritant contact dermatitis
How would you treat an irritant contact dermatitis?
Avoidance
Topical steroid
A man comes in complaint on a brownish, itchy each over his varicose veins. What treatments would you recommend?
Emolliants and topical steroid
Compression bandage to treat the underlying problem
A mother presents with her 1 year old who has yellow crusting across his head. It doesn’t seem to be itching.
Cradle cap/Seborrhoeic dermatitis
A man presents with tiny blisters all across the palms of his hands. What is this and what treatment would you prescribe?
Pompholyx eczema
Advice that it is self limiting, avoid irritants, use of emollients and steroid creams. Pottassium permanganate soak.
A lady with a history of anxiety complains of a rash underneath her ear and down her neck.
Lichen simplex
What is the most common pattern drug eruption?
Fixed drug eruption; where a rash evolves and resolves at the same sit and the same pattern can be reproduced.
A lady, being treated for pneumonia presents with a widespread symmetrical itchy rash. There is no mucosal involvement, and she is currently being treated with penicillin.
Exanthematous drug eruption
What type of reaction is an exanthematous drug eruption?
Type 4 hypersensitivity
What is the histological appearance of lichen planus?
A dense T cell infiltrate in the derma epidermal junction which become ragged and saw toothed.
A lady present with an intensely itchy purple rash with a whit lace appearance on her shins.
Lichen planus
How would you treat a patient with lichen planus?
Potent topical steroids
What type of hypersensitivity drug reaction would urticaria suggest?
Type 1
What type of hypersensitivity to a drug would pemphigous suggest.
Type 2 (Cytotoxic reaction)
What type of hypersensitivity to a drug would purport suggest?
Type 3
What is the most common type of drug reaction?
Exanthematous drug reaction
What type of hypersensitivity is an exanthemtous drug reaction?
Type 4
A lady who has just been started on allopurinol complains of a widespread itchy rash.
Exanthematous drug reaction
What drugs can cause acne as a side effect?
Steroids, androgens, lithium, isonizid
A lady who has just started on an lisinopril develops large blisters on her hands and feet.
Drug induced bullous pemphigoid
What drugs are known to cause bullous pemphigoid?
ACE inhibitors
Penicillin
Furesomide
What drug is known to cause linear IgA disease?
Vancomycin
A women presents with well demarcated, red, painful, oval patches on her skin and genitalia after starting on a course of doxycycline.
Fixed drug eruption
A patient reveals that last time they took NSAIDs they came up with well demarcated, red, painful, oval patches. What is likely to happen if they start on this medication again?
The same reaction at the same site.
What drugs are commonly associated with fixed drug eruptions?
Tetracylcine, doxycycline, paracetamol, NSAIDS, carbamazepine.
A teenage girl presents to you with pinkish scaly lesions on her arms. She has some hypo pigmented small spots also
Pityriasis versicolor
A patient has arthritis, urethritis and iritis. What is this disease called?
Reiter’s disease
An HIV patent who is in hospital is being treated with tramadol suddenly develops widespread sub epidermal blistering and he complains of a burning pain. His vital signs are falling, what are you worried about?
Toxic epidermal necrosis
What drug is most likely to cause prickling, redness and pigmentation of the skin?
Amioderone
What is type 1 necrotising fasciitis?
Anerobic bacteria + multiple other bacteria, allowing a synergistic gangrene
What is type 2 necrotising fasciitis?
Flesh eating baxter (group A strep/strep progenies) either alone or with staph aureus.
How would you treat a case of necrotising fasciitis?
Immediate surgical debridement
Penicillin and Clindamycin
Why are both penicillin and clindamycin used in nectrotizing fasciitis, how do they complement each other?
Penicillin kills actively multiplying bacteria whilst they are in the exponential growth phase. Clindamycin stops bacterial protein production and switches of toxin production; so acts whilst the bacteria is in a stationary phase.
A patient has just undergone surgery to remove his appendix. You see him five hours after his surgery and he is complaining of severe pain at the wound site. You examine him but there is nothing remarkable. What do you suspect is wrong and what do you do?
Necrotizing fasciitis. Urgent surgical debridement and them start on penicillin and clindamycin.
What organism can cause gas gangrene?
Clostridium perfrigens
What kind of bacteria is clostridium perfrigens?
Strict gram positive anaerobe that produces spores.
How would you treat a patient with gas gangrene?
Surgical debridement.
Penicllin and metronidazole
What is the most appropriate investigation for a suspected fungal infection?
Scraping for mycology
What virus causes chickenpox?
Varicella zoster
Describes the sequence of skin lesions in chicken pox
Macules
Papules
Vesicles
Scabs
What lung disease can occur as a result of chicken pox?
Pneumonitis
What kind of vaccine is the chicken pox vaccine?
Live attenuated
What virus is shingles caused by?
Herpes zoster
Why do you get shingles?
Reactivation of the varicella zoster virus (usually in old age)
An elderly lady presents with neuralgic pain and erythematous vesicles over her eye and upper face. What is this and what nerve is affected?
The opthalmic division of the trigeminal nerve
How would you treat a patient with shingles?
Valaciclovir/Aciclovir and analgesia
What syndrome describes vesicles and pain in the auditory canal and throat, facial palsy and irritation of the 8th cranial nerve causing deafness, vertigo and tinnitus?
Ramsay Hunt syndrome
What herpes virus is the most common cause of oral lesions?
HSV 1
How would you treat a child with herpes simplex?
Aciclovir
A lady presents to you with erythematous target lesions on her back.
Erythema multiform
A 10 year old child presents with a fleshy, firm, pearlescent nodule on her leg.
Mollescum contagiosum
What type of HPV virus is commonest is childhood viral warts?
HPV 1 - 4
A blistering rash at the back on the mouth caused by an entero virus?
Herpangina
What virus most commonly causes hand, foot and mouth disease?
Coxsackie virus
A child comes in with a slapped cheek appearing rash?
Erythema infectiosum
What virus causes erythema infectiousum?
Parovirus B19
A sheep farmer present with a firm flesh nodule on his hand.
Orf
A sexually active man presents with painless ulcers on his mouth. What treatment would you initiate?
Syphillis
Long acting penicillin such as benzylpeniciliin
What condition are demodex mites often associated with?
Rosacea
What is the primary feature of immunobullous disease?
Blisters
Name three immunobullous diseases
Pemohigus, bullous pemphigoid, dermatitis herpetiforms
You recieve a report which reads “IgG auto-antibodies against desmoglein 3” What do you think the condition is?
Pemphigus vulgaris
What is acantholysis?
Acantholysis is the loss of intercellular connections, such as desmosomes, resulting in loss of cohesion between keratinocytes
A lady presents to your clinic with fluid filled blisters on her trunk and groin. You can see that some of them have burst and caused small skin erosions.
Pemphigus vulgaris
What is happening at a cellular level in pemphigus vulgaris?
Immune complexes form on the cell surface of desmosomes. This causes complement activating and protease release, disrupting the desmosomes and causing acantholysis.
What is the difference (regarding deepness) between pemphigus vulgaris and bullous pemphigoid
Pemphigus vulgaris is superficial and bullous pemphigoid is the DEJ so effects deep layer.
goiD = Deep (through DEJ) guS = split more superficial, intra epidermal
Where is the blistering in bullous pemphigoid?
Bullous pemphigoid
Is there evidence of acantholysis in bullous pemphigoid?
No
What is the pathology of bullous pemphigoid
Ciculating iGG antibodies react with antigens on the hemidesmosomes anchoring basal cells to the basement membrane. This results in local complement activation and tissue damage.
Why should you send early bullous pemphigoid lesions for histology?
Late lesions how re epitheliasation of their floor, mimicking pemphigus vulgaris
A man with coeliac disease presents with intensly itchy lesions on his forearms.
Dermatitis herpetiformis
What topical treatments would you consider prescribing for acne?
Benzoyl peroxide
Topical vitamin A treatments
Topical antibiotics
What two antibiotics would you use to treat acne rosacea?
Topical metronidazole
Oral tetracycline
Would you expect scarring in bullous pemphigoid?
No
What is Nikolsy sign?
Slight rubbing of the skin results in exfoliation of the outermost layer,forming a blister within minutes.
In which condition is nikolsy sign positive?
Pemphigus vulgaris
In which bullous conditon is nikolsy sign negative?
Bullous pemphigoid
In which bullous disorder is mucosal involvement more likely?
Pemphigus vulgaris
What investigations would you carry out if you suspected pemigus vulgaris/bullous pemphigoid?
Skin biopsy with direct immunofluoresence
Indirect immunofluoresence
Ho w would you treat a patient with pemphgus vulgaris
High dose oral predisolone (60 - 100mg/day)
Azathioprone, ciclosporin
Rituximab
Emolliants and topical steroids
How would you treat a patient would bullous pemphigoid?
High dose oral prednisolone ( 30 - 60mg/day)
Axiothioprine, methotrexate
Tetracycline antibiotics
Emollients, topical steroids
How would you treat a patient with dermatitis herpatiformis?
Gluten free diet
Oral dapsone
