derm Flashcards
Treatment of mild to moderate acne
12 weeks course in evening
Topical combination therapy of:
1. Adapalene + benzoyl peroxide
2. Benzoyl peroxide + clindamycin
3. Retinoids + clindamycin
Or topical benzoyl peroxide monotherapy
Acne may be classified into mild, moderate or severe. What are the differences
(a) Mild - comedones +/- sparse inflammatory lesions
(b) Moderate - widespread non-inflammatory lesions, papules and pustules
(c) Severe - extensive inflammatory lesiobs, nodules, pitting, scarring
target lesions are called
erythema multiforme
can be caused by viruses (HSV), NSAIDs, bacteria, penicillin, COCP, lupus, sarcoid, cancers
Pregnancy is a contraindication to which acne treatment
Topical and oral retinoid treatment
And oral Abx tetracyclines (use erthromycin)
Seborrhoeic dermatitis - an inflammatory reaction to which pathogen
Malassezia furfur
Two large vessel vasculitis
Temporal arteritis
Takayasu’s arteritis
Two medium vessel vasculitis
Kawasaki disease
Polyarteritis nodosa
Small vessel vasculitis
1. ANCA-associated - 3 types
2. Immune complex small-vessel vasculitis - 4 types
- ANCA-associated vasculitis
- Granulomatosis with polyangiitis (Wegener’s)
- Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)
- Microscopic polyangiitis - Immune complex small-vessel
- HSP
- Goodpasture’s (anti-GBM)
- Cryoglobulinaemic
- Hypocomplementic urticarial (anti-C1q)
Treatment of urticaria
- Non-sedating antihistamines
- Oral prednisolone for severe or resistant episodes
Perioral dermatitis should be treated with
topical or oral antibiotics
Gram-negative folliculitis may occur as a complication of long-term antibiotic use in acne. What can be used to treat this if this occurs?
High dose oral trimethoprim
Seborrhoeic dermatitis (malassezia furfur) treatment for:
(a) scalp
(b) face and body
Scalp
1. OTC zinc pyrithione (Head and Shoulders) and tar (Neutrogena T gel).
2. Second line ketoconazole
3. Selenium sulphide + topical steroids
Face + body
1. Topical antifungals - ketoconazole
2. Topical steroids
Treatment of Pityriasis versicolor (Malassezia furfur)
- Topical antifungal - ketoconazole shampoo
- If failure to respond to topical, then oral itraconazole + send scrapings
What is treatment for tinea capis
- Oral antifungals
- Terbinafine for trichophyton
- Giseofulvin for Microsporum - Topical ketoconazole for the first 2 weeks to reduce transmission
Tinea corporis (ringworm) pathogen causes
Trichophyton rubrum
Trichophyton verrucosum
Tinea corporis (ringworm) treatment
Oral fluconazole
Alopecia areata has localised, well demarcated patches of hair loss. What is the treatment
- Watch and wait - 50% grows back in 1 year, 80% eventually
- Topical or intralesional steroids
- Topical minoxidil
- Phototherapy
- Dithranol
- Contact immunotherapy
+ wigs
Microsporum canis (cats + dogs) can cause tinea capis. Under Wood’s lamp, what does Microsporum canis show
Green flurescence under Wood’s lamp
Pityriasis versicolor is a superficial cutaneous fungal infection caused by which pathogen
Malassezia furfur
same as seborrhoeic dermatitis
tinea capitis affects which part of body
scalp
Tinea capis is caused by what 2 fungus
Trichophyton tonsurans
Microsporum canis (cats + dogs)
tinea corporis affects which part of body
trunk, legs or arms
Two types of contact dermatitis and main differences
(a) Irritant - non-allergic, due to weak acids, alkalis. On the hands. Erythema but no crusting and no vesicles
(b) Allergic - type IV hypersensitivity. Often on the head after hair days. Acute weeping eczema on hairline, not scalp. Crusting + vesicles.
Rx: potent steroid
When are escharotomies indicated for burns
circumferential full thickness burns to the torso or limbs
orange-red lesions with pinpoint redder spots on the glans and adjacent areas of the foreskin in uncircumcised men
Zoon’s balanitis
(circumcision is curative, can also use laser therapy + topical steroids)
tinea pedis affects which part of body
feet
broken ‘exclamation mark’ hairs is seen in what condition
alopecia areata
Assessing burn depths - what are the main appearances for:
(a) Superficial epidermal - 1st degree
(b) Partial thickness (superficial) - 2nd degree
(c) Partial thickness (deep) - 2nd degree
(d) Full thickness - 3rd degree
(a) Red, painful, dry, no blisters
(b) Pink, painful, blisters
(c) White, patches of non-blanching erythema, painful, reduced sensation
(d) White waxy/ brown /black, no blisters, no pain
Rosacea treatment
If there is prominently erythema/flushing
Topical brimonidine gel - as required, typically reduces within 30mins
Referral is considered for rosacea if
- Symtoms have not improved in GP
- Laser therapy may be done for those with teleangectasia
- Rhinophyma
Rosacea treatment
Topical brimonidine gel is given for redness. What is given for:
Mild to moderate papules and/or pustules
Topical ivermectin
Or topical metronidazole or azelaic acid
Are SCCs arising in a chronic scar are typically more or less aggressive?
more aggressive
carry an increased risk of metastasis
IV fluids are given to patients with burns of greater than what % total body surface area affected
(a) adults
(b) children
(a) adults >15%
(b) children >10%
Course of treatment of oral terbinafine for fungal nail (Trichophyton rubrum) infection
6 weeks - 3 months daily
n.b. if Candida infection, then oral itraconazole is recommended 1st line
Treatment options for actinic keratosis
- Avoid sun
- 5-fluorouracil cream for 2-3 weeks +/- topical steroids to help inflammatio
- Topical 3% diclofenac
- Topical imiquimod
- Cryotherapy
- Curettage and cautery
4 skin manifestations of SLE
- Photosensitive butterfly rash
- Discoid lupus
- Alopecia
- Livedo reticularis - net-like rash
Management for hyperhidrosis
(4 steps - TIBS)
- topical aluminium chloride
- botulium toxin
- surgery e.g. endoscopic transthoracic sympathectomy
What % diclofenac is used for actonic keratoses
3%
Treatment for dematitis herpetiformis
dapsone
Which stage of burns are referred to secondary care
- All deep dermal (2nd degree - partial thickness deep), and full-thickness (3rd degree) burns
- Partial thickness superficial dermal (2nd degree dermal) burns of more than 3% TBSA in adults or 2% in children
- Inhalation injury
- Electrical/chemical injury
- Non-accidental injury
autoimmune blistering disorder
itchy
NO mucosal involvement
bullous pemphigoid
Rosacea treatment
Topical brimonidine gel is given for redness. What is given for:
Moderate to severe papules and/or pustules
Topical ivermectin AND
Oral doxycycline
Main dermatophyte causative organism for fungal nail infection
Trichophyton rubrum
Acute flares of Hidradenitis suppurativa are treated with steroids and flucloxacillin. What is long-term disease treated with
Topical clindamycin
Or oral lymecycline or clindamycin and rifampicin
Consider surgical excision of some lumps
Skin biopsy immunofluorescence for bullous pemphigoid shows what at the dermoepidermal junction?
IgG and C3
autoimmune blistering disorder
mucosal involvement
pemphigus
erythema multiforme (target lesions) are caused by what most commonly
herpes simplex virus
Hirsutism is often used to describe androgen-dependent hair growth, what describes androgen-independent growth
Hypertrichosis
small blistering rash that arises on the rim of the ears in boys aged 5-14 years old in the spring is called…
juvenile spring eruption
if guttate psoriasis covers greater than what % then when should the patient be referred for phototherapy under dermatology
> 10%
patients with psoriasis should be screened annually for …?
psoriatric arthropathy
using validated screening tool e.g. PEST
What 3 vitamin deficiencies can cause angular cheilosis/stomatitis (crusty corners of mouth)
Zinc
Vitamin B2 (riboflavin)
Iron
Psoriasis chronic plaque trunk and limbs management
- Topical steroid OD + topical vitamin D daily up to 4 weeks
- If no improvement after 8 weeks, offer topical vitamin D twice daily
- If no improvement, then topical steroid twice daily for up to 4 weeks; or coal tar preparation once or twice daily
- Short acting dithranol
facial hirsuitism treatment
topical eflornithine
CONTRAINDICATED in pregnancy and breastfeeding
Erythema ab igne caused by
infrared radiation
i.e. heat from fireplace
two moderate potency steroids
betnovate RD - betamethasone 0.025%
eumovate - clobetasone 0.05%
two potent steroids
cutivate - fluticasone 0.05%
betnovate - betamethasone 0.1%
a very potent steroid
dermovate - clobetasol 0.05%
NICE advises that potent topical steroids for psoriasis should not be used continuously on the same site for longer than how many weeks, and how long of a break should there be after
Do not use on same site for over 8 weeks
Take a break for at least 4 weeks between courses
VERY potent ones - not for more than 4 weeks, with 4 week break
first-line treatment for lichen planus
potent topical steroids
benzydamine mouthwash for oral lichen planus
extensive - oral steroids, immunosuppression
what aged can kids be started on oral tetracyclines for acne
12 or older
shin lesions - yellow and waxy in diabetics are called
necrobiosis lipoidica diabeticorum
for chronic psoriasis, first line is usually vitamin D + topical steroid OD at first. in what regions of the body is just MILD-MOD topical steroid prescribed (without vit D)
Scalp
Face
Flexures
For TWO weeks
NOTE THE STEROID IS MILD-MOD POTENCY NOT STRONG.
rare psycho-dermatological condition characterised by self-inflicted skin lesions and normal skin punch biopsy
dermatitis artefacta
pregnant woman with itchy rash around her umbilicus - no blisters
Polymorphic eruption of pregnancy
pregnant woman with itchy rash around her umbilicus - there are blisters
Herpes gestationis
Areas of skin - typically axillae, neck and skin folds - become thickened and hyperpigmented in T2DM patients. What is this called
Acanthosis nigricans
On the neck, axilla and groin
The most significant complication of PUVA therapy for psoriasis is
squamous cell carcinoma
chronic itch on medial border of scapula - what condition
notalgia paraesthetica
when can kids with impetigo return to school
when lesions are crusted over or 48 hours after treatment starts
when can kids with measles or rubella return to school
until 4 days after onset of rash
venous ulceration is typically seen where
above the medial malleolus
what investigation is done with venous ulceration (above the medial malleolus)
ABPI
Normal values 0.8-1.3
Treatment of venous ulceration + peripheral vascular disease
- compression bandaging (4 layer)
- oral pentoxifylline - a vasodilator to improve healing rate
Crusted scabies is seen in immunosuppressed i.e. HIV patients. What is the treatment
Ivermectin
A 34-year-old man presents to his GP with an itchy rash on his genitals and palms. He has also noticed the rash around the site of a recent scar on his forearm. Examination reveals papules with a white-lace pattern on the surface. What is the diagnosis?
Lichen planus
Planus
Pruritis
Papular
Polygonal rash on flexor
Lichen sclerosis typically shows what sign on what region of elderly women
Itchy white spots on vulva
Keloid scars are most common on
sternum
Otitis externa and blepharitis are common complications of which skin condition
seborrhoeic dermatitis
Pruritus particularly after warm bath
‘Ruddy complexion’
Gout
Peptic ulcer disease
which condition
polycthaemia
what psych medication can trigger exacerbation of psoriasis
lithium
Recurrent nosebleeds (epistaxis)
Iron deficiency anaemia
Erythema and red dots on skin/hands
What is the condition
Hereditary haemorrhagic telangectasia
i.e. osler weber rendu syndrome
- abnormal blood vessel formations in skin, mucous membranes, lungs, liver, brain
4 main diagnostic crtieria of hereditary haemorrhagic telangectasia
- epistaxis - recurrent nosebleeds
- telangectasia - at lips, oral, fingers, nose
- visceral lesions - e.g. GI telangectasia (with or without bleeds), lung, hepatic, cerebral AVMs
- family history
Patients with erythoderma or generalised pustular psoriasis should be referred for dermatology to be seen in what timeframe
same day
A 17-year-old girl attends your surgery to look at her feet. For the last 3 weeks, her feet show cracking and peeling. The soles of her feet are shiny and glazed but the heel is unaffected. The web spaces between the toes are spared. What is the diagnosis
Juvenile plantar dermatosis
- spares the web spaces. athletes foot. tinea pedis would not spare these.
Vitiligo is associated with which 5 conditions
- Addison’s disease
- Type ONE diabetes
- Autoimmune thyroid disorders
- Pernicious anaemia
- Alopecia areata
Pemphigus vulgaris is an autoimmune blistering disease with mucosal involvement. There is Nikolsky’s sign - bullae spread and pop with pressure.
What is seen on biopsy?
Acantholysis
4 nail changes seen in psoriasis arthropathy
- Pitting
- Oncholysis
- Subungual hyperkeratosis
- Loss of nail
What is the preferred method for diagnosing contact dermatitis e.g allergy to nickel
Skin patch test
What type of allergy is allergic contact dermatitis i.e. to nickel
Type IV hypersensitivity
Oral isotretinoin should not be used in combination with tetracyclines due to the risk of
Benign intracranial hypertension
Shingles vaccine is given as a one-off dose for old people at age…
70
offered again at 78
molluscum contagiosum is caused by which pathogen
poxvirus
Isoretinoin 6 adverse effects
- Teratogenicity
- Low mood
- Dry eyes and lips
- Raised TGs
- Thin hair
- Nosebleeds
What is recommended first-line for non‑bullous impetigo (i.e. no fluid filled vesicles, no blisters)
Hydrogen peroxide 1%
Two or three times daily for 5 days
How does erythromycin affects the P450 system
P450 INHIBITOR
What type of skin cancer does psoriasis increase the risk of
non-melanoma skin cancer
What oral antibiotic can be used for acne vulgaris in pregnancy
Oral erythromycin
photosensitive rash with blistering and skin fragility on the face and dorsal aspect of hands
with hypertrichosis, hyperpigmentation
what is the diagnosis
porphyria cutanea tarda
niacin deficiency (pellagra) presents with what triad
dermatitis
diarrhoea
dementia
What is seen in urine in porphyria cutanea tarda?
Elevated uroporphyrinogen
Pink fluroscence of urine under Wood’s lamp
Serum iron ferritin levels help to guide therapy also
What is the management of porphyria cutanea tarda
Chloroquine
Venesection if ferrin >600
Erythrasma is a generally asymptomatic, flat, slightly scaly, pink or brown rash usually found in the groin or axillae. What bacteria is overgrown here
Corynebacterium minutissimum
Erythasma - flat, slightly scaly, pink or brown rash usually found in the groin or axillae.
What is shown with Wood’s light
Coral-red fluorescence
What is the treatment for erythrasma
- Topical miconazole or antibacterial
- Oral erythromycin for more extensive infection
The most appropriate management for this patient with a keloid scar is
to refer for intralesional triamcinolone (steroid)
What type of vaccine is the shingles vaccine
Live-attenuated
Given subcutaneously
Grave’s disease
Orange peel shin lesions
Shiny appearance
What is this skin lesion called
Pretibial myxoedema
One finger tip unit (FTU) for steroids for hands
1 FTU = twice area of the flat of an adult hand
Scabies treatment (not crusted)
- Permethrin 5%
Keep on for 8-12 hours - Malathion 0.5%
Keep on for 24 hours
Then wash off
If washed off, then reapply. Reapply treatment 7 days later.
Head lice treatment
Malathion
What two medications are the systemic agents that are used first-line for severe psoriasis
Methotrexate
Ciclosporin
What type of melanoma can arise in areas not associated with sun exposure e.g. soles of feet and palms
Acral lentiginous melanoma
What is the most common type of melanoma (70%)
Superficial spreading
What are the 3 major criteria “change in” diagnostic features of melanoma
Change in size
irregular shape
irregular colour
How should patients with a rhinophyma secondary to rosacea be treated
Refer to dermatology
Juvenile spring eruption treatment
- emollients
- potent topical steroids
- avoid sun
- antihistamines to help itch
which emollient is most likely to cause skin irritation
aqueous cream
Port wine stains can be associated with certain syndromes such as
Sturge-Weber syndrome
Klippel-Trenaunay syndrome
Port wine stains do not disappear over time. What happens to them
Become darker and raised
When should acne be referred to dermatology?
- Acne conglobate - rare severe in men, extensive inflammatoy papules + nodules, cysts on trunk
- Nodulo-cystic acne
CONSIDER IF:
- mild to moderate and not responded to 2 courses of treatment
- moderate to severe that has not responded to oral Abx
- severe acne - scarring,
hyperpigmentation, widespread pustules, causing psych distress
What psoriasis treatment gives typical brown staining as a side effect
dithranol
What medication can be used in refractory pain in acute shingles if simple analgesia and neuropathic analgesia do not help
Prednisolone
Which antifungal is contraindicated in hepatic liver failure
Fluconazole
How long should co-cyprindiol (Dianette) be used for acne? ue to the increased risk of venous thromboembolism with
Due to the increased risk of venous thromboembolism, it should be discontinued 3-4 cycles after acne has cleared and change to COCP
Which oral antibiotic for acne can cause irreversible skin hyperpigmentation
Minocycline
Treatment of moderate to severe acne
12 week course of topical combination of:
- adapalene + benzoyl peroxide
- tretinoin + clindamycin
- adapalene + benzoyl peroxide + ORAL Abx (lyme/doxycycline)
- topical azelaic acid + ORAL Abx (lyme/doxycycline)
To reduce the risk of antibiotic resistance developing, what 3 treatment options should not be used to treat acne?
- Monotherapy with topical antibiotic
- Monotherapy with oral antibiotic
- Combination of topical antibiotic and oral antibiotic
strawberry naevus treatment
watch and wait - most resolve by 10 years of age
if treatment is needed for visual field obstruction, then propranolol, oral steroids or topical b-blockers (timolol)
capillary haemangioma not present at birth but may develop rapidly in the first month of life. what is another name?
strawberry naevi
erythematous, raised and multilobed tumours
mycoplasma pneumonia causes what type of skin lesions
erythema multiforme
target lesions
what scoring system is used to assess severity of hirsuitism
Ferriman-Gallwey scoring system
what is management of hirsuitism
- weight loss
- cosmetic techniques e.g. waxing/bleaching - not on NHS
- COCP (Yasmin or Dianette - n.b. dianette has increased VTE)
- Facial hirsuitism - topical eflornithine
if impetigo first line treatment of hydrogen peroxide cream does not work, what is next step
topical fusidic acid
Koebner phenomenon is when trauma precipitates new lesions. what conditions does this happen with?
psoriasis
vitiligo
keratoderma blenorrhagica is typically seen in what condition
Reiter’s syndrome
two flat vascular birthmarks present from birth
salmon patch (stork mark) - common, in nape of neck or forehead or eyelids, self-resolve
port wine stain
what antifungal is not prescribed orally due to risk of severe hepatic toxicity
oral ketoconazole
Treatment of moderate to severe acne
12 weeks course of one of:
- Topical adapalene + topical benzoyl peroxide
- topical tretinoin + topical clindamycin
- topical adapalene + topical benzoyl peroxide with oral Abx
- topical azelaic acid with oral Abx
OR can use COCP instead of oral Abx in combination with topical Rx in women
Once acne has cleared what is maintenance therapy recommendation
Maintenance Rx is not always necessary
If frequent relapse, then can consider fixed combination of topical adapalene and topical benzoyl peroxide (or monotherapy with these or azelaic acid)
Review after 12 weeks
If a person is taking oral tretinoin for acne, when should they be reviewed after initiation of treatment
1 month after starting - face to face appt
2ww referral should be sent if suspicious of melanoma if any of ABCDE criteria, or if the mole scores more than 3 with the 7 point criteria.
What are the 7 point criteria?
Major criteria (2 points each)
- change in size
- irregular shape
- irregular colour
Minor criteria (1 point each)
- diameter >7mm
- oozing
- inflammation
- change in sensation
