Commonly encountered skin problems

Question 1

How are leg ulcers classified?

Answer 1

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

Question 2

What are venous ulcers?

Answer 2

Ulcers which are though to occur due to the improper functioning of venous valves

Question 3

What is the history of venous ulcers likely to be?

Answer 3

Often painful, worse on standing

History of venous disease- varicose veins, deep vein thrombosis

Question 4

What are the common sites for venous ulcers?

Answer 4

Malleolar area (more common over the medial than lateral malleolus)

Question 5

How does a venous ulcer present?

Answer 5

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)

Question 6

What investigations would you do for a venous ulcer?

Answer 6

Ankle brachial pressure index

Would be normal: (0.8-1)

Question 7

What would a typical history of arterial ulcer be?

Answer 7

Painful, especially at night, pain is worse when the legs are elevated
Patient may have history of arterial disease eg: atherosclerosis

Question 8

Where are the typical sites of an arterial ulcer?

Answer 8

Pressure and trauma sites- pretibial and supramalleolar and at distal points eg: toes

Question 9

What does an arterial ulcer present like?

Answer 9

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

Question 10

What are the investigations for an arterial ulcer?

Answer 10

ABPI will be <0.8- there will be presence of arterial insufficiency
Doppler studies and angiography

Question 11

What is the management of arterial ulcer?

Answer 11

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

Question 12

What is the hx of neuropathic ulcer?

Answer 12

• often painless
• abnormal sensation ‘glove + stocking’
• hx of diabetes or neurological disease

Question 13

what are the common sites of neuropathic ulcer?

Answer 13

affects pressure sites- soles, heel, toes, metatarsal heads

Question 14

What would a neuropathic ulcer look like?

Answer 14

variable size + depth
granulating base
may be surrounded by or underneath a hyperkeratotic lesion eg: callus

Question 15

What are the associated features of neuropathic ulcer?

Answer 15

Warm skin
Normal peripheral pulses (cold, weak or absent pulses if it is a neuroischaemic ulcer)
Peripheral neuropathy

Question 16

What are the possible ix of a neuropathic ulcer?

Answer 16

ABPI <0.8 implies a neuroischaemic ulcer

X ray to exclude osteomyelitis

Question 17

What is the management of neuropathic ulcer?

Answer 17

Wound debridement

Regular repositioning,

Question 18

What is scabies?

Answer 18

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.

Question 19

What would be in the hx of someone with scabies?

Answer 19

They may have a hx of contact with symptomatic individuals and pruritis which is worse at night

Question 20

Who gets scabies?

Answer 20

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.

Question 21

How is scabies diagnosed

Answer 21

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.

Question 22

How is scabies managed?

Answer 22

Use of insecticides called sabicides
Ie: permethrin (lyclear) or malathion (prioderm)

Anthistamines for the itch