Common Important Derm Problems Flashcards
What history is indicative of a venous ulcer?
Painful
Worse on standing
History of venous disease - varicose veins, DVT
Where do venous ulcers commonly affect?
Malleolar area - more commonly medial
Describe how a venous ulcer would appear?
Large shallow irregular ulcer
Exudative and granulating base
What is a venous ulcer associated with?
Warm skin Normal peripheral pulses Leg oedema, haemosiderin and melanin deposition (brown pigment) Lipodermatosclerosis Atrophie blanche
How would you investigate a venous ulcer?
ABPI would be between 0.8-1 (normal)
How are venous ulcers managed?
Compression bandaging
Describe the typical history of an arterial ulcer
Painful - esp. at night
Worse on leg elevation
History of arterial disease - atherosclerosis
What sites are commonly affected by arterial ulcers?
Pressure and trauma areas - pretibial, supramalleolar (usually lateral) and at distal points
What sort of lesion would you expect with an arterial ulcer?
Small, sharply defined, deep ulcer
Necrotic base
What features are associated with arterial ulcers?
Cold skin
Weak or absent peripheral pulses
Shiny pale skin
Loss of hair
What possible investigations would you request for an arterial ulcer?
ABPI - will be <0.8
Doppler studies and angiography
How are arterial ulcers managed?
Vascular reconstruction
Compression bandaging contraindicated!!
How do neuropathic ulcers present?
Painless
Abnormal sensation
History of diabetes/neurological disease
Where do neuropathic ulcers commonly affect?
Pressure sites - soles, heels, toes, metatarsal heads
How do neuropathic ulcers present?
Variable size and depth
Granulating base
May be surrounded by or underneath a hyperkeratotic lesion
What features are associated with neuropathic ulcers?
Warm skin
Normal peripheral pulses - can be weak, cold or absent if neuroischaemic
Peripheral neuropathy
What investigations would you recommend for neuropathic ulcers?
ABPI <0.8 suggest neuroischaemic
X-Ray - exclude osteomyelitis
How are neuropathic ulcers managed?
Wound debridement
Regular repositioning - appropriate footwear and good nutrition
What differentials would you consider for itchy eruptions?
Eczema Scabies Urticaria Lichen Planus Tinea - pedis, capitis, corporis Candida Chicken pox
What key things in a history would indicate eczema as the cause of an itchy eruption?
Personal or family history of atopy - eczema, hay fever, asthma
Exacerbating factor - allergen, irritant
Where does eczema commonly affect?
Varies - usually flexural aspects if atopic eczema
How would an eczematous lesion appear?
Dry, erythematous patches
Acute is erythematous, vesicular and exudative
What features may be associated with eczema?
Secondary bacterial or viral infection
How would you investigate eczema?
Patch testing
Serum IgE
Skin swab
How is eczema managed?
Copious use of emollients
Topical corticosteroids - step up intensity
Immunomodulators
Non-Sedating Antihistamines - loratadine/ceterizine
Can use light therapy or oral corticosteroids (prednisolone)
Manage secondary infections with appropriate antibiotics
What is the step wise progression of topical corticosteroids for eczema?
Hydrocortisone
Eumovate - Clobetsone Butyrate 0.05%
Betnovate - Betamethasone Valerate 0.1%
Dermovate - Clobetasol Propionate 0.05%
What history would be indicative of scabies?
History of contact with symptomatic individuals
Pruritus worse at night
History of sleeping rough/on unclean mattress
What are the common sites that scabies affects?
Sides of fingers Finger webs Wrists Elbows Ankles Feet Nipples Genitals
Describe a scabies lesion
Linear burrows - may be tortuous
Rubbery nodules
Erythematous papules
What features may be associated with scabies?
Secondary eczema
Impetigo
How would you investigate scabies?
Skin scrape - extraction of mite
View under microscope
How would you manage scabies?
Permethrin 5% applied to whole body and washed off after 8-12 hours. Repeat in a week
Antihistamines
Treat all household members and sexual contacts
Wash bedding and clothing at 60 degrees
What findings in the history would be indicative of urticaria?
Precipitating factors - food, drugs, contact
Describe a lesion that is typical of urticaria
Pink wheals - transient
May be round, annular or polycyclic
Raised itchy rash
What features may be associated with urticaria?
Angioedema
Anaphylaxis
What investigations would you do for urticaria?
Bloods and urinalysis to exclude systemic cause
How would you manage urticaria?
Antihistamines
Corticosteroids
What findings in the history would indicate lichen planus?
Family history - 10% of cases
May be drug induced
Where does lichen planus usually affect?
Forearms
Wrists
Legs
Always examine oral mucosa
How would you describe a lichen planus rash?
5P’s
Pruritic
Planar
Purple
Polygonal Papule
Symmetrically distributed
What features are associated with lichen planus?
Nail changes
Hair loss
Wickham’s Striae - lacy white streaks on oral mucosa and skin lesions
How would you investigate lichen planus?
Skin biopsy
How would you manage lichen planus?
Corticosteroids - topical, oral if extensive
Antihistamines
Benzydamine mouth wash if oral
Which drugs can cause lichenoid eruptions?
Thiazides
Gold
Quinine
What are the causes of a changing pigmented lesion?
Benign - typically dont need management, can be excised
- Melanocytic Naevi
- Seborrhoeic Keratoses
Malignant
- Malignant Melanoma
What findings in the history would be typical or melanocytic naevi?
Changing pigmented lesion
Not usually present at birth but develop during infancy, childhood or adolescence
Asymptomatic
How would you describe a melanocytic naevi lesion?
Congenital - May be large, pigmented, protuberant and hairy
Junctional - small, flat and dark
Intradermal - Dome-shaped
Compound - raised and warty, hyperkaratotic, hairy
What findings in the history are typical of seborrhoeic keratoses?
Arise in middle age or elderly
Asymptomatic
Describe a common seborrhoeic keratoses lesion
Usually on face or trunk
Warty, greasy papules or nodules
Stuck on appearance - well defined edges
Keratotic plugs may be seen
What findings in the history are indicative of a malignant melanoma?
Adults/middle age
Evolution of lesion
May be symptomatic - bleeding or itchy
Risk factors
Describe a common malignant melanoma lesion
More common on legs in women, trunk in men
Asymmetrical shape Border irregularity Colour irregularity Diameter >6mm Evolution of lesio
How are malignant melanomas managed?
Must be excised
What differentials would you consider for a purpuric eruption in children?
Meningococcal septicaemia ALL Congenital bleeding disorders ITP HSP Non-accidental injury
What history would be indicative of meningococcal septicaemia?
Acute
Meningitis symptoms - headache, photophobia, N&V, stiff neck etc.
Septicaemia
Systemically unwell
Where does meningococcal septicaemia commonly affect?
Extremities
Describe a meninococcal rash
Petechiae Ecchymoses Haemorrhagic bullae Non-blanching Tissue necrosis
How would you investigate meningococcal septicaemia?
Bloods
Lumbar Puncture
How would you manage meningococcal septicaemia?
Ceftriaxone
What history would be indicative of DIC?
History of trauma, malignancy, sepsis, obstetric complications. transfusions or liver damage
Systemically unwell
Where does DIC commonly affect?
Spontaneous bleeding from ENT, GI tract, resp tract or wound site
Describe a DIC lesion
Petechiae
Ecchymosis
Haemorrhagic Bullae
Tissue necrosis
What history is indicative of a vasculitis?
Painful lesions
Where do vasculitis lesions commonly affect?
Dependent areas - legs, buttocks, flanks
Describe a vasculitis lesion
Palpable purpura
What investigations would you request for DIC?
Bloods - clotting screen
How would you manage DIC?
treat underlying cause
Transfuse for coagulation deficiency
Anti-coagulants for thrombosis
How would you investigate a vasculitis rash?
Bloods
Urinalysis
Skin biopsy
How would you manage a vasculitis rash?
Treat underlying cause
Steroids and immunosuppressants - systemic involvement
What history is indicative of senile purpura?
Elderly population
Sun damaged skin
Systemically well
Describe where and how a senile purpura would appear
Extensors surfaces of hands and forearms - easily traumatised
Non-palpable purpure
Atrophic, thin surrounding skin
How would you investigate senile purpura?
None needed - no management required
What could be the cause of a red swollen leg?
Cellulitis
Erysipelas
Venous thrombosis
Chronic venous insufficiency
What history would indicate cellulitis/erysipelas?
Painful spreading rash
History of abrasion or ulcer
Systemically unwell - fever and malaise
May have lymphangitis
What is the difference between erysipelas and cellulitis in appearance?
Erysipelas - well defined edge (confined to upper dermis)
Cellulitis - diffuse edge (affect deeper layers)
What investigations would you recommend for erysipelas/cellulitis? How is it managed?
Anti-streptococcal O titre
Skin swab
Antibiotics - flucloxacillin (clarithromycin in pen allergic)
What history would indicate venous thrombosis?
Pain with swelling and redness
History of prolonged bed rest - long haul flight, clotting tendency
Systematically well but can present with PE
Describe how a venous thrombosis lesion may appear?
Red swollen leg
Complete occlusion can lead to cyanotic discolouration
How is venous thrombosis investigated and managed?
D dimer
Doppler ultrasound
Anticoagulants - DOACS (rixaroxaban/apixaban)
What history would chronic venous insufficiency present with?
Heaviness or aching of leg - worse on standing and relieved by walking
History of DVT
Describe skin features seen with chronic venous insufficiency
Discoloured - blue-purple
Oedema - improve in morning
Venous congestion and varicose veins
Lipodermatosclerosis - erythematous induration - champagne bottle appearance
Stasis dermatitis - eczema with inflammatory papule, scaly and crusted erosions
Venous ulcer
How would you investigate/manage chronic venous insufficiency?
Doppler ultrasound
Leg elevation and compression stockings
Sclerotherapy or surgery for varicose veins
What causes scabies?
Mite burrow into epidermis and tunnel through stratum corner
What causes intense pruritus in scabies?
Delayed type IV hypersensitivity reaction to mites/eggs - occur 30 days after initial infection
How would you manage seborrhoeic keratosis?
Reassure of benign nature
Options for removal - curettage, cryosurgery and shave biopsy
What is purpura?
Bleeding into the skin from small blood vessels which produce a non-blanching rash
What causes for purpuric eruptions would you consider in adults?
ITP
Bone marrow failure - secondary to leukaemia, myelodysplasia or bone metastases
Senile purpura
Drugs
Nutritional deficiency - vitamin B12, C and folate
