Commonly encountered skin problems Flashcards
How are leg ulcers classified?
They are classified according to the aetiology In general there are 3 types 1) arterial 2) venous c) neuropathic
Other causes of ulcers= vasculitic ulcers, infected ulcers, malignancy
What are venous ulcers?
Ulcers which are though to occur due to the improper functioning of venous valves
What is the history of venous ulcers likely to be?
Often painful, worse on standing
History of venous disease- varicose veins, deep vein thrombosis
What are the common sites for venous ulcers?
Malleolar area (more common over the medial than lateral malleolus)
How does a venous ulcer present?
A large, shallow irregular ulcer
The ulcer will have an exudative and granulating base
Associated features
- Warm skin
- Normal peripheral pulses
- Leg oedema, hemosiderin, melanin deposition (brown pigment), lipodermatosclerosis, atrophie blanche (white scarring with dilated capillaries)
What investigations would you do for a venous ulcer?
Ankle brachial pressure index
Would be normal: (0.8-1)
What would a typical history of arterial ulcer be?
Painful, especially at night, pain is worse when the legs are elevated
Patient may have history of arterial disease eg: atherosclerosis
Where are the typical sites of an arterial ulcer?
Pressure and trauma sites- pretibial and supramalleolar and at distal points eg: toes
What does an arterial ulcer present like?
Small, sharply defined deep ulcer
Will have a necrotic base
Associated features
- Cold skin
- Weak or absent peripheral pulses
- Shiny pale skin
- Loss of hair
What are the investigations for an arterial ulcer?
ABPI will be <0.8- there will be presence of arterial insufficiency
Doppler studies and angiography
What is the management of arterial ulcer?
In the UK, NICE guidance states that any patient with critical limb ischaemia (i.e. those with ulcers) should be urgently referred for a vascular review. The management of such patients requires a combination of:
Conservative – All patients should be advised lifestyle changes, including smoking cessation, weight loss, and increased exercise (specific supervised exercise programmes are available).
Medical – Suitable pharmacological cardiovascular risk factor modification should also be prescribed, including statin therapy, an antiplatelet agent (aspirin or clopidogrel), and optimisation of blood pressure and glucose.
Surgical – Angioplasty (with or without stenting) or bypass grafting (usually for more extensive disease).
Any non-healing ulcers despite a good blood supply may also be offered skin reconstruction with grafts.
Compression bandaging is contra-indicated
What is the hx of neuropathic ulcer?
- often painless
- abnormal sensation ‘glove + stocking’
- hx of diabetes or neurological disease
what are the common sites of neuropathic ulcer?
affects pressure sites- soles, heel, toes, metatarsal heads
What would a neuropathic ulcer look like?
variable size + depth
granulating base
may be surrounded by or underneath a hyperkeratotic lesion eg: callus
What are the associated features of neuropathic ulcer?
Warm skin
Normal peripheral pulses (cold, weak or absent pulses if it is a neuroischaemic ulcer)
Peripheral neuropathy
What are the possible ix of a neuropathic ulcer?
ABPI <0.8 implies a neuroischaemic ulcer
X ray to exclude osteomyelitis
What is the management of neuropathic ulcer?
Wound debridement
Regular repositioning,
What is scabies?
Scabies is a very itchy rash caused by a parasitic mite that burrows in the skin surface. The human scabies mite’s scientific name is Sarcoptes scabiei var. hominis.
What would be in the hx of someone with scabies?
They may have a hx of contact with symptomatic individuals and pruritis which is worse at night
Who gets scabies?
Scabies affects families and communities worldwide. It is most common in children, young adults, and older persons. Factors leading to the spread of scabies include:
Poverty and overcrowding
Institutional care, such as rest homes, hospitals, prisons
Refugee camps
Individuals with immune deficiency or that are immune suppressed
Low rates of identification and proper treatment of the disease.
How is scabies diagnosed
The clinical suspicion of scabies in a patient with an itchy rash, especially when reporting itchy household members, can be confirmed by:
Dermatoscopy: the mite at the end of a burrow has characteristic jet-plane or hang-glider appearance
Microscopic examination of the contents of a burrow
Skin biopsy: this may reveal characteristic scabies histopathology, but this is often negative or nonspecific, eg if taken from the inflammatory rash rather than the surface of a burrow.
How is scabies managed?
Use of insecticides called sabicides
Ie: permethrin (lyclear) or malathion (prioderm)
Anthistamines for the itch
