Derm Flashcards
What is acne vulgaris?
Common condition characterised by inflammation of hair follicles and sebaceous glands.
What are three main factors that contribute to the development of acne?
Increase sebum production
Common change seen in normal puberty due to changes in hormone expression
Presence of Cutibacterium acnes
Blocked pores
What bacterial species contributes to the development of acne?
Presence of Cutibacterium acnes
Clinical features of acne vulgaris
Presence of open and closed comedones
May be associated with surrounding inflammation
Acne can lead to scarring and post-inflammatory hyperpigmentation
Management of mild to moderate acne
Offer 12-week course of one of the following:
Topical adapalene with topical benzoyl peroxide
Topical tretinoin with topical clindamycin
Topical benzoyl peroxide with topical clindamycin
Consider topical benzoyl peroxide as monotherapy if any of the combinations are contraindicated
Management of moderate to severe acne
Offer 12-week course of one of the following:
Topical adapalene with topical benzoyl peroxide
Topical tretinoin with topical clindamycin
Topical adapalene with topical benzoyl peroxide with oral lymecycline 408 mg OD or oral doxycycline 100 mg OD
Topical azelaic acid with either oral lymecycline 408 mg OD or oral doxycycline 100 mg OD
Consider benzoyl peroxide as monotherapy if any of the combinations are contraindicated
What can be considered as an alternative to antibiotics in females with moderate to severe acne?
Consider combined oral contraceptives as alternative to systemic antibiotics in females
NOTE: oral progesterone-only contraceptives and progestin implants may worsen acne
Co-cyprindiol has some antiandrogenic properties and may be a suitable option
When should patients who start systemic antibiotic therapy for acne be reviewed?
NOTE: all patients should be reviewed in at least 12 weeks to assess response to treatment
When should specialist dermatology referral be considered in acne vulgaris?
Diagnostic uncertainty
Acne conglobata
Nodulo-cystic acne
Acne that fails to respond to two completed courses of treatment
Acne with scarring
Significant psychological distress due to acne
What is alopecia areata? How does it present?
Autoimmune disease resulting in patches of non-scarring hair loss
Well-defined area of non-scarring hair loss
Usually round
No skin changes
Nail changes (e.g. pitting)
Management of alopecia areta
Most cases will resolve spontaneously without active treatment
Conservative Measures
Hairstyling
Wigs
If the patient fails to show signs of regrowth or has more than 50% hair loss, the following options may be considered:
Potent topical steroids (e.g. betamethasone valerate 0.1%)
Intralesional steroids
Systemic corticosteroids
Minoxidil
Calcineurin inhibitors
What medication can be considered in alopecia areata? When should it be considered?
If the patient fails to show signs of regrowth or has more than 50% hair loss, the following options may be considered:
Potent topical steroids (e.g. betamethasone valerate 0.1%)
Intralesional steroids
Systemic corticosteroids
Minoxidil
Calcineurin inhibitors
What is eczema? How does it present?
Dry and itchy skin primarily affecting the flexures
In infants, it more commonly affects the face
Prolonged itching can lead to lichenification
Where does eczema predominantly affect? How does this differ in infants?
Dry and itchy skin primarily affecting the flexures
In infants, it more commonly affects the face
What other conditions is eczema often associated with?
Allergic rhinitis
Asthma
Food allergy
How is mild eczema managed?
Emollients
Mild Potency Topical Corticosteroids
moderate eczema management
Emollients
Moderate Potency Topical Corticosteroids
Topical Calcineurin Inhibitors
Bandages
Severe eczema management
Emollients
Potent Topical Corticosteroids
Topical Calcineurin Inhibitors
Bandages
Phototherapy
Systemic Therapy
Examples of steroids used in eczema and their potency
Mild: Hydrocortisone 1%
Moderate: Betamethasone Valerate 0.025% or Clobetasone Butyrate 0.05%
Potent: Betamethasone Valerate 0.1%, Mometasone
If Very Severe: Oral Steroids
Example of mild steroid used in eczema
Mild: Hydrocortisone 1%
Example of moderate steroids used in eczema
Moderate: Betamethasone Valerate 0.025% or Clobetasone Butyrate 0.05%
Example of potent steroids used in eczema
Betamethasone Valerate 0.1%, Mometasone
What type of steroid may be used if very severe eczema?
Oral Steroids
When should topical calcineurin inhibitors be considered in eczema?
May be considered as second line in moderate-to-severe eczema in children over 2 years old who have not responded well to steroids
When should antihistamines be considered in eczema?
Offer a 1-month trial of non-sedating antihistamines (e.g. cetirizine) if severe itching or urticaria
Consider 7-14 day trial of sedating antihistamine (e.g. chlorphenamine) if flare is affecting sleep
How long should medication be continued for after a flare in eczema?
48 hours after symptoms resolve
Complications of eczema, how is it treated?
Bacterial Superinfection
Swab the affected area
Flucloxacillin
Penicillin Allergy: Clarithromycin, Erythromycin
LIFE THREATENING COMPLICATION OF ECZEMA, HOW IS IT TREATED?
Eczema Herpeticum
If widespread, start aciclovir and refer for same-day dermatological advice
What is Impetigo? How does it present?
A localised and contagious skin infection caused by Staphylococcus or Streptococcus
Lesions usually found on the face
Erythematous macules that have a characteristic golden crust
How do lesions in impetigo present?
Lesions usually found on the face
Erythematous macules that have a characteristic golden crust
erythematous macules around the face with a characteristic golden crust
impetigo
Management of localised non bullous impetigo
Hygiene measures (e.g. wash with soap and water, avoid sharing towels)
1st Line: Hydrogen Peroxide 1% Cream (apply 2-3 times for 5 days)
2ndLine
Fusidic Acid 2% (TDS for 5 days)
Mupirocin 2% (TDS for 5 days)
Management of widespread non-bullous impetigo
1stLine
Topical: Fusidic Acid 2% or Mupirocin 2%
Oral: Oral Fluxloxacillin
Alternative: Oral Clarithromycin or Oral Erythromycin
Management of bullous imeptigo
oral ABs
What is infantile seborrhoeic dermatitis? What is the cause? AKA?
Common skin disorder that usually affects the scalp, face and trunk. It is thought to be associated with Malassezia. Commonly known as Cradle Cap
Clinical features of cradle cap
Greasy, yellow scales on the scalp
Flaky but not itchy
Management of cradle cap if scalp is affecteed
Recommend topical emollient to loosen scales before gently brushing off
If the above is ineffective, consider topical imidazole cream:
Clotrimazole 1% Cream (2-3 times daily for up to 4 weeks)
Miconazole 2% Cream (2 times daily for up to 4 weeks)
Management of cradle cap if areas other than scalp are affected
Advise bathing infant daily using emollient as soap substitute
Encourage frequent nappy changes and use of barrier emollients
Consider topical imidazole (clotrimazole or miconazole) for up to 4 weeks
Low potency topical corticosteroids may be considered in some circumstances
What is molluscum contagiosum? How does it present?
Viral skin infection manifesting with clusters of umbilicated papules
Clusters of round, umbilicated papules
Usually found in moist places (e.g. groin, armpit)
Management of molluscum contagiosum
Self-limiting condition
Treatment not usually needed in immunocompetent patients
The rash will likely fully resolve within 18 months
If treatment is required, consider:
Imiquimod 5% Cream
Podophyllotoxin 0.5%
Cryotherapy
Offer hygiene advice to prevent spread
Avoid sharing towels, clothing and bedding
Avoid scratching or squeezing lesions
Exclusion from school is NOT necessary
PACES: What advice should be given regarding molluscum?
Self limiting condition, no treatment needed, will fully resolve within 18 months
Offer hygiene advice to prevent spread
Avoid sharing towels, clothing and bedding
Avoid scratching or squeezing lesions
Exclusion from school is NOT necessary
Is exclusion from school needed for molluscum?
No
What is nappy rash? What causes it?
Rash that appears in the area that is usually covered by a nappy in babies.
Causes
Irritant dermatitis (MOST COMMON)
Seborrhoeic dermatitis
Candida
Atopic eczema
Most common cause of nappy rash
Irritant dermatitis (MOST COMMON)
Clinical features of nappy rash
Erythematous skin around nappy area
Conservative management of nappy rash
High-absorbency nappies
Leave nappies off for as long as possible to allow the skin to dry
Clean the skin and change the nappy every 3-4 hours and as soon as possible after wetting/soiling
Use fragrance-free and alcohol-free baby wipes
Management of nappy rash is mild erythema and asymptomatic
dvise use of barrier preparation to protect skin (should be applied thinly at each nappy change)
e.g. Zinc and Castor oil ointment, white soft paraffin BP ointment
Management of nappy rash if inflamed and causing discomfort?
Hydrocortisone 1% cream (only if > 1 month old) until symptoms settle (max 7 days)
Management of nappy rash if persistent and candida infection suspected
Avoid barrier preparation
Topical imidazole
e.g. clotrimazole, econazole, miconazole
Management of nappy rash if persistent and bacterial infection suspected
Oral Flucloxacillin for 7 days
Penicillin Allergy: Clarithromycin for 7 days
What is pediculosis? How does it present?
Infestation of the scalp by Pediculus humanus capitis (small insect)
Itchy scalp
Lice may be visible
Crusting
Areas of hair loss due to scratching
Management of head lice
Wet combing
Four sessions over 2 weeks
Physical insecticide
E.g. dimeticone 4% gel, isopropyl myristate
Chemical or Traditional insecticide
E.g. malathion 0.5% aqueous liquid
What is pityriasis rosea? What is it associated with?
Benign, self-limiting infection of unknown cause.
It is thought to be associated with HSV6 and HSV7
Clinical features of pityriasis rosea
Characterised by the appearance of a single large patch (known as a Herald patch), followed by the appearance of multiple smaller macules
Patients may also complain of coryzal symptoms in the days leading up to the development of the rash
Herald patch
Pityriasis rosea
Management of pityriasis rosea
Self-limiting disease
The rash usually resolves over 4-6 weeks
What is ringworm? What is it caused by?
Fungal skin infection giving rise to characteristic ring-shaped lesions.
Primarily caused by Trichophyton and Microsporum.
Clinical features of ringworm
Usually presents with single circular red patch with raised scaly edge
There may be multiple lesions that develop over time
Management of ringworm
Mild infections are treated with topical antifungals
E.g. terbinafine cream, clotrimazole
If marked inflammation, consider hydrocortisone 1% cream
More severe infections will require systemic antifungals
1st line: oral terbinafine
2nd line: oral itraconazole, oral griseofulvin
Management of mild ringworm
Mild infections are treated with topical antifungals
E.g. terbinafine cream, clotrimazole
Management of ringworm if marked inflammation
If marked inflammation, consider hydrocortisone 1% cream
Management of ringworm if severe infection
More severe infections will require systemic antifungals
1st line: oral terbinafine
2nd line: oral itraconazole, oral griseofulvin
Management of tinea capitis (ringworm infection of scalp)
Systemic antifungal therapy (e.g. griseofulvin or terbinafine)
2nd line: itraconazole or fluconazole
Topical antifungal shampoo is recommended in some patients (e.g. selenium sulfide or ketoconazole topical)
What is scabies? How does it present?
Common highly contagious skin infection caused by Sarcoptes scabiei
Typically affects the hands and feet (and can affect other body folds)
Often symmetrical
Linear burrows may be seen on the skin
Excoriation marks
Symptoms worse at night
Management of scabies in children over 2 months
For children over 2 months:
1st Line: Permethrin 5%
2nd Line: Malathion Aqueous 0.5
PACES: How should contacts of scabies be treated?
All members of household and close personal contacts within 1 month should be treated
Bedding, clothing and towels should be decontaminated by washing at a high temperature and drying in a hot dryer
Advise that itching may continue for 2-4 weeks after last treatment application
How should crusted scabies be treated?
Seek specialist advice
What are viral warts? What do they present with?
Benign growths of thickened skin caused by human papillomavirus (HPV)
Rough papules with hyperkeratotic surface
Often found on the fingers
Management of viral warts
Often does NOT require treatment
Treatment should be considered if:
Wart is painful (e.g. on soles of feet)
Wart is cosmetically unsightly
Treatment is persistent
If treatment is indicated, consider one of:
Topical salicylic acid applied daily for up to 12 weeks
Cryotherapy with liquid nitrogen
