Common Important Problems Flashcards
What are types of Chronic Leg Ulcers?
- Venous Ulcers
- Arterial Ulcers
- Neuropathic Ulcers
- Vasculitic Ulcers (purpuric, punched out lesions)
- Infected Ulcers (purulent discharge, may have systemic signs)
- Malignancy (e.g. squamous cell carcinoma in long-standing non-healing ulcers).
What are the different histories in Venous, Arterial and Neuropathic ulcers?
Venous Ulcers: Often painful and worse on standing. There is a history of venous disease e.g. varicose veins, deep vein thrombosis
Arterial Ulcers: Painful especially at night, worse when legs are elevated. History of arterial disease e.g. atherosclerosis
Neuropathic Ulcers: Often painless and abnormal sensation. There is a history of diabetes or neurological disease
What are the common sites in Venous, Arterial and Neuropathic ulcers?
- Venous Ulcers: Malleolar area (more common over medial than lateral malleolus)
- Arterial Ulcers: Pressure and trauma sites e.g. pretibial, supramalleolar (usually lateral), and at distal points e.g. toes
- Neuropathic Ulcers: Pressure sites e.g. soles, heel, toes, metatarsal heads
What are the appearances of lesions in Venous, Arterial and Neuropathic ulcers?
- Venous Ulcers: Large, shallow irregular ulcer. They have a exudation and a granulating base
- Arterial Ulcer: Small, sharply defined deep ulcer with a necrotic base
- Neuropathic Ulcer: Variable size and depth. Has a granulating base. May be surrounded by or underneath a hyperkeratotic lesion (e.g. callus)
What are associated features of Venous Ulcers?
- Warm skin
- Normal peripheral pulses
- Leg oedema, haemosiderin and melanin deposition (brown pigment)
- Lipodermatosclerosis
- Atrophie blanche (white scarring with dilated capillaries)
What are associated features of Arterial Ulcers?
- Cold skin
- Weak or absent peripheral pulses
- Shiny pale skin
- Loss of hair
What are associated features of Neuropathic Ulcers?
- Warm skin
- Peripheral neuropathy
- Normal peripheral pulses but *cold, weak or absent pulses if it is a neuroischaemic ulcer*
What are possible investigations for Venous Ulcers, Arterial Ulcers, and Neuropathic Ulcers?
- Venous Ulcers: Normal ankle/brachial pressure index (i.e. ABPI 0.8-1)
- Arterial Ulcers: ABPI <0.8 shows presence of arterial insufficiency. Doppler studies and angiography
- Neuropathic Ulcers: ABPI <0.8 implies a neuroischaemic ulcer. X-ray to exclude osteomyelitis
What are management options for Venous Ulcers, Arterial Ulcers, and Neuropathic Ulcers?
- Venous Ulcers: Compression bandaging (after excluding arterial insufficiency)
- Arterial Ulcers: Vascular reconstruction. Compression bandaging is contraindicated
- Neuropathic Ulcers: Wound debridement. Regular repositioning, appropriate footwear and good nutrition
What is the history of Eczema, Scabies, Urticaria, and Lichen Planus?
- Eczema: Personal or family history of atopy. Exacerbating factors (e.g. allergens, irritants)
- Scabies: May have history of contact with symptomatic individuals. Pruritus worse at night
- Urticaria: Precipitating factors (e.g. food, contact, drugs)
- Lichen Planus: Family history in 10% of cases. May be drug-induced
What are common sites of Eczema, Scabies, Urticaria, and Lichen Planus?
- Eczema: Variable (e.g. flexor aspects in children and adults with atopic eczema). Lichen nitidus pattern in darker skin
- Scabies: Sides of fingers, finger webs, wrists, elbows, ankles, feet, nipples and genitals
- Urticaria: No specific tendency
- Lichen Planus: Forearms, wrists, and legs. Always examine the oral mucosa
What is the presentation of lesions in Eczema, Scabies, Urticaria, and Lichen Planus?
Eczema: Dry, erythematous patches. Acute eczema is erythematous, vesicular and exudative
Scabies: Linear burrows (may be tortuous) or rubbery nodules
Urticaria: Pink wheals (transient). May be round, annular, or polycyclic
Lichen Planus: Violaceous (lilac) flat-topped papules or hyperpigmented papules (in darker skin). Symmetrical distribution
What are the associated features aside from the lesions in Eczema, Scabies, Urticaria, and Lichen Planus?
- Eczema: Secondary bacterial or viral infections
- Scabies: Secondary eczema and impetigo
- Urticaria: May be associated with angioedema or anaphylaxis
- Lichen Planus: Nail changes and hair loss. There are lacy white streaks on the oral mucosa and skin lesions(Wickham’s striae)
What are possible investigations for Eczema, Scabies, Urticaria, and Lichen Planus?
- Eczema: Patch testing, Serum IgE levels, Skin swab
- Scabies: Skin scrape, extraction of mite and view under microscope
- Urticaria: Bloods and urinalysis to exclude a systemic cause
- Lichen Planus: Skin biopsy
What is the management for Eczema, Scabies, Urticaria, and Lichen Planus?
Eczema: Emollients, Corticosteroids, Immunomodulators, Antihistamines
Scabies: Scabicide (e.g. permethrin or malathion), Antihistamines
Urticaria: Antihistamines, Corticosteroids
Lichen Planus: Corticosteroids, Antihistamines
What is the history of Melanocytic Naevi, Seborrhoiec Wart and malignant melanoma?
Melanocytic Naevi: Not usually present at birth but develop during infancy, childhood or adolescence. It is asymptomatic
Seborrhoiec Wart: Tend to arise in the middle-aged or elderly. Often multiple and asymptomatic
Malignant melanoma: Tend to occur in adults or the middle-aged. History of evolution of lesion and may be symptomatic (e.g. itchy, bleeding). There is a presence of risk factors usually
What are common sites for Melanocytic naevi, Seborrhoeic wart, Malignant melanoma?
- Melanocytic naevi: Variable
- Seborrhoeic wart: Face and trunk
- Malignant melanoma: More common on the legs in women and trunk in men. Darker skin tones present on acral sites
What is the presentation of Melanocytic Naevi?
- Congenital naevi may be large, pigmented, protuberant and hairy
- Junctional naevi are small, flat and dark
- Intradermal naevi are usually dome-shape papules or nodules
- Compound naevi are usually raised, warty, hyperkeratotic, and/or hairy
What is the presentation of a Seborrhoeic Wart?
- Warty greasy papules or nodules
- ‘Stuck on’ appearance, with well-defined edges
What is the presentation of Malignant Melanoma?
- Asymmetrical shape
- Border irregularity
- Colour irregularity
- Diameter > 6mm
- Evolution of lesion
What is the management of melanocytic naevi, seborrhoeic wart and malignant melanoma?
- Melanocytic Naevi: Only if symptomatic. Shave or complete excision
- Seborrhoeic Wart: Only if symptomatic. Curette and cautery or Cryotherapy
- Malignant Melanoma: Local Excision. Treatment based on Breslow Thickness
What are common causes of Purpuric Eruptions?
- Meningococcal septicaemia
- Disseminated intravascular coagulation
- Vasculitis
- Actinic purpura
What is the history of Purpuric Eruptions?
- Meningococcal Septicaemia: Acute onset. Symptoms of meningitis and septicaemia
- Disseminated Intravascular Coagulation: History of trauma, malignancy, sepsis, obstetric complications, transfusions, or liver failure
- Vasculitis: Painful lesions
- Actinic Purpura: Arise in the elderly population with sun-damaged skin
What are common sites for Meningococcal septicaemia, Disseminated intravascular coagulation, Vasculitis, Actinic purpura?
- Meningococcal septicaemia: Extremeties
- Disseminated intravascular coagulation: Spontaneous bleeding from ear, nose and throat, gastrointestinal tract, respiratory tract or wound site
- Vasculitis: Dependent areas (e.g. legs, buttocks, flanks)
- Actinic purpura: Extensor surfaces of hands and forearms. Such skin is easily traumatised
What is the presentation of Meningococcal septicaemia, Vasculitis, Disseminated intravascular coagulation and Actinic purpura?
- Meningococcal septicaemia: Petechiae, ecchymoses, haemorrhagic bullae and/or tissue necrosis
- Disseminated intravascular coagulation: Petechiae, ecchymoses, haemorragic bullae and/or tissue necrosis
- Vasculitis: Palpable purpura (often painful)
- Actinic purpura: Non-palpable purpura that surrounds skin which is atrophic and thin
What are the investigations for Meningococcal septicaemia, Vasculitis, Disseminated intravascular coagulation and Actinic purpura?
- Meningococcal septicaemia: Bloods, Lumbar puncture
- DIC: Bloods (a clotting screen is important)
- Vasculitis: Bloods and urinalysis, Skin biopsy
- Actinic Purpura: No investigation is needed
What is the management for Meningococcal septicaemia, Vasculitis, Disseminated intravascular coagulation and Actinic purpura?
Meningococcal septicaemia: Antibiotics
DIC: Treat the underlying cause, Transfuse for coagulation deficiencies, Anticoagulants for thrombosis
Vasculitis: Treat the underlying cause. Steroids and immunosuppressants if there is systemic involvement
Actinic Purpura: No treatment is needed
What common reasons for a red swollen leg?
- Cellulitis/Erysipelas
- Venous thrombosis
- Chronic Insufficiency
What are the different histories in Cellulitis/Erysipelas, Venous thrombosis and Chronic Insufficiency?
- Cellulitis/Erysipelas: Painful spreading rash. Has a history of abrasion or ulcer
- Venous thrombosis: Pain with swelling and redness. Has a history of prolonged bed rest, long haul flights or clotting tendency
- Chronic Insufficiency: Heaviness or aching of leg, which is worse on standing and relieved by walking. Has a history of venous thrombosis
What are the examination signs of Cellulitis/Erysipelas, Venous thrombosis and Chronic Insufficiency?
- Cellulitis/Erysipelas: Erysipelas has a well-defined edge and Cellulitis has a diffuse edge
- Venous thrombosis: Complete venous occlusion may lead to cyanotic discolouration
- Chronic Insufficiency: Discoloured (blue-purple), and Oedematous (improved in the morning). Venous congestion and varicose veins
What are associated features of Cellulitis/Erysipelas?
- Systemically unwell with fever and malaise
- May have lymphangitis
What are associated features of Venous thrombosis?
- Usually systemically well
- May present with pulmonary embolism
What are associated features of Chronic Venous Insufficiency?
- Lipodermatosclerosis: erythematous induration, creating ‘champagne bottle’ appearance)
- Stasis dermatitis: eczema with inflammatory papules, scaly and crusted erosions)
- Haemosiderin deposition
- Venous ulcer
What are the possible investigations for Cellulitis/Erysipelas, Venous thrombosis and Chronic Insufficiency?
- Cellulitis/Erysipelas: Anti-streptococcal O titre (ASOT), Skin Swab
- Venous thrombosis: D-dimer, Doppler ultrasound and/or venography
- Chronic Insufficiency: Doppler ultrasound and/or venography
What is the management of Cellulitis/Erysipelas, Venous thrombosis and Chronic Insufficiency?
- Cellulitis/Erysipelas: Antibiotics
- Venous thrombosis: Anticoagulants
- Chronic Insufficiency: Leg elevation and compression stockings. Sclerotherapy or surgery for varicose veins
