derm 1

Question 1

what are the features of features acne rosacea

Answer 1

typically affects nose, cheeks and forehead
flushing is often first symptom
telangiectasia are common
later develops into persistent erythema with papules and pustules
rhinophyma
ocular involvement: blepharitis

Question 2

What is the treatment of acne rosacea?

Answer 2

Management
topical metronidazole may be used for mild symptoms (i.e. Limited number of papules and pustules, no plaques)
more severe disease is treated with systemic antibiotics e.g. Oxytetracycline
recommend daily application of a high-factor sunscreen
camouflage creams may help conceal redness
laser therapy may be appropriate for patients with prominent telangiectasia

Question 3

What are the features of acne vulgaris?

Answer 3

Comedones are due to a dilated sebaceous follicle
if the top is closed a whitehead is seen
if the top opens a blackhead forms

Inflammatory lesions form when the follicle bursts releasing irritants
papules
pustules

An excessive inflammatory response may result in:
nodules
cysts

This sequence of events can ultimately cause scarring
ice-pick scars
hypertrophic scars

In contrast, drug-induced acne is often monomorphic (e.g. pustules are characteristically seen in steroid use)

Acne fulminans is very severe acne associated with systemic upset (e.g. fever). Hospital admission is often required and the condition usually responds to oral steroids

Question 4

What is the treatment of acne vulgaris?

Answer 4

A simple step-up management scheme often used in the treatment of acne is as follows:
single topical therapy (topical retinoids, benzoyl peroxide)

topical combination therapy (topical antibiotic, benzoyl peroxide, topical retinoid)

oral antibiotics: e.g. Oxytetracycline, doxycycline. Improvement may not be seen for 3-4 months.
oral isotretinoin: only under specialist supervision

Question 5

what are the key features of BCC?

Answer 5

sun-exposed sites, especially the head and neck account for the majority of lesions
initially a pearly, flesh-coloured papule with telangiectasia
may later ulcerate leaving a central ‘crater’

many types of BCC are described. The most common type is nodular BCC, which is described here

Question 6

what is the treatment for BCC?

Answer 6

surgical removal
curettage
cryotherapy
topical cream: imiquimod, fluorouracil
radiotherapy

Question 7

what are the features of Actinic, or solar, keratoses (AK) ?

Answer 7

small, crusty or scaly, lesions
may be pink, red, brown or the same colour as the skin
typically on sun-exposed areas e.g. temples of head
multiple lesions may be present

Question 8

what are the key features of Seborrhoeic keratoses?

Answer 8

Features
small, crusty or scaly, lesions
may be pink, red, brown or the same colour as the skin
typically on sun-exposed areas e.g. temples of head
multiple lesions may be present

Question 9

What is dermatofibroma

Answer 9

People may have 1 or up to 15 lesions.
Size varies from 0.5–1.5 cm diameter; most lesions are 7–10 mm diameter.
They are firm nodules tethered to the skin surface and mobile over subcutaneous tissue.
The skin dimples on pinching the lesion.
Colour may be pink to light brown in white skin, and dark brown to black in dark skin; some appear paler in the centre.
They do not usually cause symptoms, but they are sometimes painful or itchy

Question 10

What are the preisposing factor Vaginal candidiasis?

Answer 10

Predisposing factors
diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV, iatrogenic

Question 11

what are the key features of vagional candidiasis?

Answer 11

Features
‘cottage cheese’, non-offensive discharge
vulvitis: dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen

Question 12

What is the management of vagional candidiasis?

Answer 12

Management
options include local or oral treatment
local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)
oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

Question 13

A 19-year-old patient of South Asian ethnicity presents to their GP having developed several small patches of pale skin on their face over the past 4 weeks. They have a past medical history of eczema, atopy and depression. They last visited their GP 6 weeks ago when they were prescribed sertraline and clobetasone topical cream.

What is the most likely cause of their symptoms?

Answer 13

clobetasone - Topical corticosteroids may cause patchy depigmentation in patients with darker skin

Question 14

what are the triggers for psoriasis?

Answer 14

Triggers
 Stress
 Infections: esp. streps
 Skin trauma: Kobner phenomenon
 Drugs: β-B, Li, anti-malarials, EtOH
 Smoking

Question 15

what are the sub-types of psoriasis? and what are their features?

Answer 15

ecognised subtypes of psoriasis

plaque psoriasis: the most common sub-type resulting in the typical well demarcated red, scaly patches affecting the extensor surfaces, sacrum and scalp

flexural psoriasis: in contrast to plaque psoriasis the skin is smooth

guttate psoriasis: transient psoriatic rash frequently triggered by a streptococcal infection. Multiple red, teardrop lesions appear on the body

pustular psoriasis: commonly occurs on the palms and soles

Other features
nail signs: pitting, onycholysis
arthritis

Complications
psoriatic arthropathy (around 10%)
increased incidence of metabolic syndrome
increased incidence of cardiovascular disease
increased incidence of venous thromboembolism
psychological distress

Question 16

what is the management of chronic plaque psoriasis?

Answer 16

Management of chronic plaque psoriasis
regular emollients may help to reduce scale loss and reduce pruritus
first-line: NICE recommend a potent corticosteroid applied once daily plus vitamin D analogue applied once daily (applied separately, one in the morning and the other in the evening) for up to 4 weeks as initial treatment
second-line: if no improvement after 8 weeks then offer a vitamin D analogue twice daily
third-line: if no improvement after 8-12 weeks then offer either: a potent corticosteroid applied twice daily for up to 4 weeks or a coal tar preparation applied once or twice daily
short-acting dithranol can also be used

Secondary care management

Phototherapy
narrow band ultraviolet B light is now the treatment of choice. If possible this should be given 3 times a week
photochemotherapy is also used - psoralen + ultraviolet A light (PUVA)
adverse effects: skin ageing, squamous cell cancer (not melanoma)

Systemic therapy
oral methotrexate is used first-line. It is particularly useful if there is associated joint disease
ciclosporin
systemic retinoids
biological agents: infliximab, etanercept and adalimumab
ustekinumab (IL-12 and IL-23 blocker) is showing promise in early trials

Mechanism of action of commonly used drugs:
coal tar: probably inhibit DNA synthesis
calcipotriol: vitamin D analogue which reduces epidermal proliferation and restores a normal horny layer
dithranol: inhibits DNA synthesis, wash off after 30 mins, SE: burning, staining

Question 17

What are the features of Leukoplakia?

Answer 17

Leukoplakia is a premalignant condition which presents as white, hard spots on the mucous membranes of the mouth. It is more common in smokers.

Leukoplakia is said to be a diagnosis of exclusion. Candidiasis and lichen planus should be considered, especially if the lesions can be ‘rubbed off’

Biopsies are usually performed to exclude alternative diagnoses such as squamous cell carcinoma and regular follow-up is required to exclude malignant transformation to squamous cell carcinoma, which occurs in around 1% of patients.

Question 18

What erythema ab igne?

Answer 18

Erythema ab igne is a skin disorder caused by over exposure to infrared radiation. Characteristic features include reticulated, erythematous patches with hyperpigmentation and telangiectasia. A typical history would be an elderly women who always sits next to an open fire.