Derm Flashcards
1
Q
What are treatment options for symptomatic relief of itch?
A
- Moisturise
- Use emollients as substitute for body soap
- Non-sedating oral antihistamine for 2-3 weeks e.g. cetirizine
- If nocturnal itch give sedating oral antihistamine for 2-3 weeks
2
Q
What are the 2 categories of dermatitis?
A
- Atopic dermatitis
- Contact dermatitis
3
Q
What is atopic dermatitis also known as?
A
Eczema
4
Q
What are chronic features of atopic dermatitis?
A
- Scaling
- Lichenification (thickened areas of skin)
- Prurigo like lesions (nodules formed by scratching)
- Xerosis (dry skin)
5
Q
Give some atopic stigmata
A
- Dennie Morgan folds (folds of lower eyelids)
- Keratosis pilaris
- Peri-orbital darkening (can look like black eye)
6
Q
What is the stepwise management of atopic dermatitis?
A
- Basic skin care
- Topicals
- Phototherapy - narrow band UVB/PUVA
- Systemic therapy
- Biologics
7
Q
What are systemic treatment options for atopic dermatitis?
A
- Course of prednisolone
- Methotrexate
- Ciclosporin
- Azathioprine
8
Q
How much emollient should under 12s use every 1-2 weeks?
A
- 250-500g
- Adults should use more
9
Q
What should you warn all pts using emollients of?
A
Emollients are highly flammable - risk of severe/fatal burns
10
Q
What is the equivalent area of a fingertip amount of topical steroid? How much steroid is this?
A
- Two palms worth
- 1.5g
11
Q
What is the topical steroid potency ladder?
A
- Hydrocortisone
- Eumovate
- Betnovate
- Dermovate
HEAD but HEBD
12
Q
What are potential side effects of topical steroids?
A
- Skin thinning
- Stretch marks
- Hypopigmentation
- Hair growth
- Long term use of potent/v. potent can lead to cushings syndrome/adrenal insufficiency
13
Q
What frequency are topical steroids prescribed during a flare?
A
OD
14
Q
How long should you continue using a topical corticosteroid following a skin flare (e.g. eczema)?
A
Continue treatment for 48 hrs after flare is controlled
15
Q
What are the two main types of contact dermatitis?
A
- Irritant CD
- Allergic CD
16
Q
What is irritant CD? Where is it often seen? How does it present? How is it managed?
A
- Non allergic reaction due to weak acids or alkalis
- Hands
- Presents with erythema. Crusting and vesicles are rare
- Managed the same as atopic dermatitis
17
Q
What is allergic CD? What is it often caused by? How does it present? How is it managed?
A
- Type IV hypersensitivity reaction (delayed)
- Hair dyes
- Presents with acute weeping eczema
- Managed the same as atopic dermatitis
18
Q
Stasis dermatitis:
1. Age group?
2. Who is it more common in?
3. What is it often mistreated as?
A
- Middle/older age
- People with venous insufficiency
- Cellulitis
19
Q
Nummular dermatitis:
1. AKA?
2. Age group?
3. How does it present?
4. Common complication?
A
- Discoid eczema
- Young people
- Coin shaped lesions
- Often get secondary infections
20
Q
What is seborrhoeic dermatitis?
A
A hypersensitivity reaction to Malassezia yeast and seborrhoea
21
Q
Seborrhoeic dermatitis in children:
1. Affected areas?
2. Management?
A
- Scalp, nappy area, face
- Reassure, topical emollient on the scalp -> brush gently with a soft brush and wash off with shampoo. Severe: topical imidazole cream
22
Q
Seborrhoeic dermatitis in adults:
1. Affected areas?
2. Management?
A
- Scalp, periorbital, nasolabial folds
- Scalp: Ketoconazole 2% shampoo.
Face and body: Topical antifungals and topical steroids
23
Q
Eczema herpeticum:
1. Cause?
2. How does it present?
3. Management?
A
- HSV 1/2
- Rapidly progressing painful rash, monomorphic punched out erosions
- Admit, IV acyclovir
24
Q
How could you define psoriasis?
A
An immune mediated inflammatory disorder
25
What are the subtypes of psoriasis? Which is most common?
- Chronic plaque
- Flexural
- Palmar plantar
- Scalp
- Guttate
- Sebopsoriasis
- Nail
26
What are the peaks of age onset of psoriasis?
- 20-30
- 50-60
27
What can trigger psoriasis?
- Infections (particularly guttate)
- Alcohol
- Local skin injury
- Drugs
- Stress
- Obesity
- Smoking
28
What drugs can trigger psoriasis?
- BB
- Lithium
- Antimalarials
- Abx
- ACE-In
- NSAIDs
29
Describe the appearance of plaque psoriasis
Well demarcated erythematous plaques with overlying silvery scale
30
What is Auspitz sign?
Small bleeding points on removal of successive layers of scale on psoriatic plaques
(seen in plaque psoriasis)
31
What is another name for flexural psoriasis? Appearance?
- Inverse psoriasis
- Shiny, smooth lesions. Often lack plaque
32
What features are seen in nail psoriasis? What is it associated with?
- Nail pitting/onycholysis (nails comes away from bed)
- Associated with psoriatic arthritis
33
Guttate psoriasis:
1. Age group?
2. Typical history?
3. Appearance?
4. Management?
1. Children and young adults
2. Strep infection 2-4 wks before
3. 'Tear drop' papule on trunk and limbs
4. Self limiting (3/4 months)
34
What is the stepwise management of psoriasis?
- Topicals
- Phototherapy - narrowband UVB/PUVA
- Conventional systemics
- Biologics
35
Are emollients used for psoriasis?
Emollients have less benefit in psoriasis
36
What is the topical management of plaque psoriasis?
1. Potent topical corticosteroid + Vit D analogue (e.g. calcipotriol) OD
2. No improvement after 8 wks - Vit D analogue BD
3. No improvement after 8-12 wks - potent topical corticosteroid BD for up to 4 wks OR coal tar preparation OD/BD
37
Impetigo:
1. First line management of localised non-bullous impetigo
2. First line management of widespread non-bullous impetigo
3. First line management of bullous impetigo
1. Hydrogen peroxide 1% cream for 5 days
2. Topical fusidic acid 2% or mupirocin 2% for 5 days
3. Oral flucloxacillin 500mg QDS for 5 days
38
What is melanoma?
Malignant neoplasm of melanocytes
39
What are risk factors for melanoma?
- Older age
- UV exposure
- Fair skin
- Moles
- FHx
- PHx melanoma
40
What is the weighted 7-point checklist for assessment of pigmented skin lesions? What indicates referral?
Major features (2 points each):
- Change in size
- Irregular shape
- Irregular colour
Minor features (1 point each):
- Largest diameter 7 mm or more
- Inflammation
- Oozing
- Change in sensation (including itch)
3 points or more = referral
41
What are the 4 melanoma subtypes? Which is most common? Which is the most common in darker skin?
- Superficial spreading melanoma (most common overall)
- Nodular melanoma
- Lentigo malignant melanoma
- Acral lentiginous melanoma (most common in darker skin)
42
How can melanoma be staged?
1 - confined to skin
2 - thicker tumours confined to skin
3 - lymph node involvement
4 - distant mets (30% 5 yr survival)
43
What is the management of suspected and confirmed melanoma?
GP:
- 2ww referral
Secondary care:
- Diagnostic excision with 2mm peripheral margin
- Sentinel lymph node biopsy depending on thickness
- Staging scans for more advanced
- Testing for bRAF mutation (found in 40-50% of melanomas and opens tx options with BRAF inhibitors)
44
Is melanoma/non-melanoma skin cancers more common?
Non-melanoma skin cancer
45
What are the two main non-melanoma skin cancers?
- SCC
- BCC
46
What are 2 pre-cancerous skin changes?
- Actinic keratosis
- Bowen's disease
47
What is the management of Actinic keratosis and Bowen's disease?
- Field change - topical treatments
- Discrete lesions - topicals, cryotherapy, C+C
48
What are red flag features for malignant lesions (e.g. SCC)? Are these seen in pre-cancerous lesions?
- Rapid growth
- Raised base
- Ulceration +/- bleeding
- Pain
Not seen in pre-cancerous skin lesions (Actinic keratosis/Bowen's disease)
49
What are risk factors for SCC?
- Chronic sun exposure
- Immune suppression
- Chronic wounds (e.g. long standing leg ulcers)
- Smoking
- HPV
- Actinic keratosis and Bowen's disease (low risk)
50
What is the management of SCC?
- Lesion <20mm - surgical excision with 4mm margins
- Lesion >20mm - Mohs micrographic surgery
- Radiotherapy - non melanomas are radiosensitive
51
What are the typical features of BCC?
- Slow growing
- Skin coloured/pink/shiny
- Rolled edges
- Telangiectasia
- Ulceration +/- bleeding
52
What are the subtypes of BCC? Which is most common?
- Nodular (most common)
- Morphoeic/infiltrative - locally aggressive, can eat other structures
- Pigmented - can be hard to tell from melanoma
- Superficial
53
What is the management of BCC?
- Superficial BCCs - cautery/cryotherapy/topicals (due to less invasive nature)
- Surgical removal
- Radiotherapy
54
List some common benign skin lesions
- Viral warts
- Molloscum contagiosum
- Epidermoid cyst
- Pilar cyst
- Seborrhoeic keratosis
- Dermatofibroma
- Lipoma
55
What causes viral warts?
HPV
56
How are viral warts spread?
Direct skin contact
57
What are some risk factors for viral warts?
- Childhood eczema
- Immune suppression
58
What are treatment options for viral warts?
- Soaking
- Chemicals (salicylic acid)
- Cryotherapy
- C+C
- Laser
59
What causes molloscum contangiosum?
Pox virus (MCV)
60
How do you differentiate epidermoid and pilar cysts?
- Epidermoid have a central punctum
- Pilar tend to be located on the scalp
61
What are features of seborrhoeic keratosis? How common is it?
- Brown/pink/skin colour lesions
- 'Struck on' appearance
- Warty/waxy surface
90% of >60 year old have
62
What is the treatment of seborrhoeic keratosis?
- None
- If symptomatic - cryotherapy / C+C
63
What are features of dermatofibroma? Where are the normally located
- Solitary firm nodule (can feel like a frozen pea under the skin)
- Overlying skin dimples on pinching
- 5-10 mm
- Normally located on arms and legs
64
What is lipoma?
Benign tumour of adipocytes
65
Where are lipoma normally found?
- Neck
- Shoulders
- Trunk
- Arms
66
What are features of lipoma?
Smooth, mobile, painless lump
67
What is a ddx of lipoma? How would it differ?
Liposarcoma
- Size >5cm
- Increasing size
- Pain
- Deep anatomical location
68
List some common vascular skin lesions?
- Spider telangiectasia
- Cherry angioma
- Pyogenic granuloma
69
What is pyogenic granuloma? How do they present? Where are they normally located?
- Acquired proliferation of blood vessels
- Bleed a lot
- Fingers and face
70
What happens in acne vulgaris?
Obstruction of pilosebaceous follicles with keratin plugs which results in comedones, inflammation and pustules
71
What bacteria is associated with acne vulgaris?
Anaerobic bacteria Propionibacterium acnes
72
What medications are used to treat acne vulgaris?
- Topical benzoyl peroxide
- Topical retinoids
- Oral retinoids
- Topical antibiotics
- Oral antibiotics
- Oral contraceptive pill
73
What is the function of benzoyl peroxide in the treatment of acne vulgaris?
- Reduces inflammation
- Helps unblock the skin
- Toxic to P. acnes bacteria
74
What is the function of topical retinoids in the treatment of acne vulgaris?
- Retinoids are chemical related to vitamin A
- Slow the production of sebum
75
What is an example of a topical antibiotic prescribed for acne vulgaris? What is it often prescribed with?
- Clindamycin
- Prescribed with benzoyl peroxide to reduce bacterial resistance
76
What is an example of an oral antibiotic prescribed for acne vulgaris?
Lymecycline
77
What is the function of the oral contraceptive pill in the treatment of acne vulgaris? Which is most effective?
- Can help female pts stabilise their hormones and slow the production of sebum
- Co-cyprindiol (Dianette) - most effective due to its anti-androgen effects
78
What is an example of an oral retinoid used for acne vulgaris? How does it work? What are some side effects? What is important in women of child bearing age?
- Oral isotretinoin (Roaccuntane)
- It works by reducing the production of sebum, reducing inflammation and bacterial growth
- Side effects:
- Dry skin and lips
- Photosensitivity
- Depression/agression/suicidal ideation
- Rarely - SJS toxic epidermal necrolysis
- High teratogenic - effective contraception required, must stop isotretinoin for at least a month before getting pregnant
79
What is another name for fungal nail infections?
Onychomycosis
80
What's the most common causative organism of fungal nail infections?
Trichophyton rubrum (dermatophyte)
81
What are RF for fungal nail infections?
- Increasing age
- DM
- Psoriasis
- Repeated nail trauma
82
How can you investigate fungal nail infections? When should you do this?
- Send nail clippings +/- scrapings of the affected nail for microscopy and culture
- Should be done for all patients if anti fungal treatment is being considered
83
What is the management of fungal nail infections?
- Nothing if asymptomatic
If dermatophyte/candida is confirmed:
- Limited involvement (<50% of nail/<2 nails affected) -> topical amorolfine 5% nail lacquer. 6m for fingernails. 9-12m for toenails
- If more extensive involvement due to dermatophyte infection -> oral terbinafine. 6w-3m for fingernails. 3-6m for toenails
84
When assessing a suspected drug eruption, what do you need to know?
1. Clinical characteristics (type of lesion/distribution/associated signs)
2. Red flags
3. Chronological factors (all drugs and dates administered/date of eruption/make drug timeline/response to removal of suspected agent)
85
What are red flags for drug reactions?
- Mucosal involvement
- Blistering/skin peeling off
- Pain
- Lymphadenopathy
- Systemic upset (fever, abnormal LFTs/U+Es)
86
How do you manage maculopapular/urticarial drug eruptions?
- Stop suspected drug
- Prescribe regular emollients - symptomatic relief
- Topical corticosteroids - short term for symptomatic relief (only if needed)
- Prescribe regular non-sedating antihistamines if urticaria
- Monitor and discuss with derm if not improving after 48 hrs of treatment
87
What are the severe drug eruptions?
- SJS/TEN
- DRESS
- AGEP
88
What is the association between SJS and Toxic Epidermal Necrolysis (TEN)?
- They are a spectrum of the same pathology
- SJS is less severe
- In SJS epidermal detachment affects <10% of the BSA
- In TEN detachment affects >30% of the BSA
89
What is a key risk factors for SJS/TEN?
- HIV
- Both are 100 times more common in association with HIV
90
What are the main causes of SJS/TEN?
- They are almost always caused by drugs
- Allopurinol
- Anti-epileptics
- Anti-retrovirals
- NSAIDs
- Sulfa- drugs
91
How does SJS/TEN present?
- New drug 7-21 days previously
- Prodrome of respiratory tract symptoms, fever, pain
- Dusky red lesions, atypical targets, erythematous plaques
92
What signs is seen in SJS/TEN?
- Nikolsky sign
- Blisters and erosions appear when the skin is rubbed gently
93
How do you differentiate typical/atypical target lesions on the skin?
- Target lesions = 3 concentric target rings
- Atypical targets = less that 2 rings
94
What is the management of SJS/TEN?
- Admit to derm/burns unit
- Bulk of Rx is supportive
- Nutritional care
- Fluids
- Analgesia
- Ophthalmology input
- Periodic cultures due to sepsis risk
- If extensive denuded areas - biological dressings/skin equivalents
*Don't prescribe these pts any meds unless discussed with someone senior*
95
What is DRESS syndrome?
Drug reaction with eosinophila and systemic symptoms (DRESS)
96
DRESS:
1. When does it present?
2. Give 2 key causes
3. How does it present?
4. What will bloods show?
1. 15-40 days after exposure
2. Anticonvulsants, sulphonamides
3. High fever, morbilliform eruption +/- oedema/purpura/scaling
4. Eosinophilia
97
What is AGEP?
Acute generalised exanthematous pustulosis (AGEP)
98
AGEP:
1. When does it present?
2. What is the main cause?
3. How does it present?
4. What do bloods show?
1. <4 days after exposure
2. Beta lacam antibiotics
3. High fever, small pustules within larger areas of oedematous erythema
4. Marked leukocytosis and raised neutrophils
99
What is erythroderma?
Generalised erythema affecting > 90% of the skins surface
100
What are the top 3 causes of erythroderma?
1. Dermatitis (especially atopic)
2. Psoriasis
3. Drug eruption
101
What is the management of erythroderma?
- Discontinue unnecessary meds
- Monitor and treat BP/HR/fluid/electrolytes/temp (can all be affected by barrier failure)
- Maintain skin barrier with wet wraps/dressings and emollients
- Treat underlying dermatosis e.g. dermatitis
- Topical corticosteroids
102
Which pts require an urgent referral to dermatology?
- Systemically unwell
- Mucosal involvement
- Blistering
- Suspected SJS/TEN/DRESS/AGEP
103
Which pts need to be discussed with dermatology?
- Lymphadenopathy
- Pyrexia
- Eosinophilia
- Abnormal LFTs
104
What is staphylococcal scalded skin syndrome?
- Rare superficial blistering condition which is characterised by the detachment of the outermost skin layer (epidermis)
- Triggered by exotoxin release from staph aureus bacteria
105
How can you differentiate it from TEN?
- Children <5 (normally)
- Mucosa unaffected
- Blistering is superficial epidermis (full thickness in TEN)
