Derm + Breast Flashcards
Eczema
Features
itchy, erythematous rash
repeated scratching may exacerbate affected areas
in infants the face and trunk are often affected
in younger children, eczema often occurs on the extensor surfaces
in older children, a more typical distribution is seen, with flexor surfaces affected and the creases of the face and neck
Management
avoid irritants
simple emollients
large quantities should be prescribed (e.g. 250g / week), roughly in a ratio of with topical steroids of 10:1
if a topical steroid is also being used the emollient should be applied first followed by waiting at least 30 minutes before applying the topical steroid
creams soak into the skin faster than ointments
emollients can become contaminated with bacteria - fingers should not be inserted into pots (many brands have pump dispensers)
topical steroids
wet wrapping
large amounts of emollient (and sometimes topical steroids) applied under wet bandages
in severe cases, oral ciclosporin may be used
Eczema dyshidrotic (pompholyx)
What is it?
Triggers?
Features?
Pompholyx is a type of eczema which affects both the hands (cheiropompholyx) and the feet (pedopompholyx). It is also known as dyshidrotic eczema.
Pompholyx eczema may be precipitated by humidity (e.g. sweating) and high temperatures.
Features
small blisters on the palms and soles
pruritic
often intensely itchy
sometimes burning sensation
once blisters burst skin may become dry and crack
Mx = cool compresses + emollients + topical steroids
Epidermoid and pilar cysts (sebaceous cysts)
What are they?
Where are they?
Mx?
Sebaceous cysts is a general term which encompasses both epidermoid and pilar cysts. It is a bit of a misnomer and probably best avoided where possible.
Epidermoid cysts are due to a proliferation of epidermal cells within the dermis. Pilar cysts (also known as trichilemmal cysts or wen) derive from the outer root sheath of the hair follicle.
Location: anywhere but most common scalp, ears, back, face, and upper arm (not palms of the hands and soles of the feet).
They will typically contain a punctum.
Mx = Excision of the cyst wall needs to be complete to prevent recurrence.
Erythema multiforme
Erythema multiforme is a hypersensitivity reaction that is most commonly triggered by infections. It may be divided into minor and major forms.
Previously it was thought that Stevens-Johnson syndrome (SJS) was a severe form of erythema multiforme. They are now however considered as separate entities.
Features
target lesions
initially seen on the back of the hands / feet before spreading to the torso
upper limbs are more commonly affected than the lower limbs
pruritus is occasionally seen and is usually mild
Causes
viruses: herpes simplex virus (the most common cause), Orf*
idiopathic
bacteria: Mycoplasma, Streptococcus
drugs: penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill, nevirapine
connective tissue disease e.g. Systemic lupus erythematosus
sarcoidosis
malignancy
Erythema multiforme major
The more severe form, erythema multiforme major is associated with mucosal involvement.
*Orf is a skin disease of sheep and goats caused by a parapox virus
Erythema nodosum
What is it?
Name some causes?
inflammation of subcutaneous fat
typically causes tender, erythematous, nodular lesions
usually occurs over shins, may also occur elsewhere (e.g. forearms, thighs)
usually resolves within 6 weeks
lesions heal without scarring
Causes
infection
streptococci
tuberculosis
brucellosis
systemic disease
sarcoidosis
inflammatory bowel disease
Behcet’s
malignancy/lymphoma
drugs
penicillins
sulphonamides
combined oral contraceptive pill
pregnancy
Erythroderma (red man syndrome)
What is it?
Causes?
What is Erythrodermic psoriasis?
Erythroderma is a term used when more than 95% of the skin is involved in a rash of any kind.
Causes of erythroderma
eczema
psoriasis
drugs e.g. gold
lymphomas, leukaemias
idiopathic
Erythrodermic psoriasis
may result from progression of chronic disease to an exfoliative phase with plaques covering most of the body. Associated with mild systemic upset
more serious form is an acute deterioration. This may be triggered by a variety of factors such as withdrawal of systemic steroids. Patients need to be admitted to hospital for management
Lipoma
A lipoma is a common, benign tumour of adipocytes.
Pathophysiology
they are generally found in subcutaneous tissues
rarely, they may also occur in deeper adipose tissues
malignant transformation to liposarcoma is very rare
Epidemiology
lipomas are common, with an annual incidence of around 1 in 1,000
most commonly seen in middle-aged adults
Features
lump characteristics:
smooth
mobile
painless
The diagnosis is usually clinical based on the typical examination findings.
Management
may be observed
if diagnosis uncertain, or compressing on surrounding structures then may be removed
Liposarcoma
Features suggestive of sarcomatous change:
Size >5cm
Increasing size
Pain
Deep anatomical location
In one series the presence of all 4 features was associated with up to 85% being sarcomatous.
Melanoma and melanocytic lesions
pass med
Molluscum contagiosum
Molluscum contagiosum is a common skin infection caused by molluscum contagiosum virus (MCV), a member of the Poxviridae family. Transmission occurs directly by close personal contact, or indirectly via fomites (contaminated surfaces) such as shared towels and flannels. The majority of cases occur in children (often in children with atopic eczema), with the maximum incidence in preschool children aged 1-4 years.
Typically, molluscum contagiosum presents with characteristic pinkish or pearly white papules with a central umbilication, which are up to 5 mm in diameter. Lesions appear in clusters in areas anywhere on the body (except the palms of the hands and the soles of the feet). In children, lesions are commonly seen on the trunk and in flexures, but anogenital lesions may also occur. In adults, sexual contact may lead to lesions developing on the genitalia, pubis, thighs, and lower abdomen. Rarely, lesions can occur on the oral mucosa and on the eyelids.
Self-care advice:
Reassure people that molluscum contagiosum is a self-limiting condition.
Spontaneous resolution usually occurs within 18 months
Explain that lesions are contagious, and it is sensible to avoid sharing towels, clothing, and baths with uninfected people (e.g. siblings)
Encourage people not to scratch the lesions. If it is problematic, consider treatment to alleviate the itch
Exclusion from school, gym, or swimming is not necessary
Treatment is not usually recommended. If lesions are troublesome or considered unsightly, use simple trauma or cryotherapy, depending on the parents’ wishes and the child’s age:
Squeezing (with fingernails) or piercing (orange stick) lesions may be tried, following a bath. Treatment should be limited to a few lesions at one time
Cryotherapy may be used in older children or adults, if the healthcare professional is experienced in the procedure
Eczema or inflammation can develop around lesions prior to resolution. Treatment may be required if:
Itching is problematic; prescribe an emollient and a mild topical corticosteroid (e.g. hydrocortisone 1%)
The skin looks infected (e.g. oedema, crusting); prescribe a topical antibiotic (e.g. fusidic acid 2%)
Referral may be necessary in some circumstances:
For people who are HIV-positive with extensive lesions urgent referral to a HIV specialist
For people with eyelid-margin or ocular lesions and associated red eye urgent referral to an ophthalmologist
Adults with anogenital lesions should be referred to genito-urinary medicine, for screening for other sexually transmitted infections
Pressure sores
Psoriasis
Recognised 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
Beta-blockers are known to exacerbate plaque psoriasis
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
Mx - passmed
Management is targeted at disease control and includes:
* education;
* stress and alcohol avoidance;
* topical drugs are regarded as the mainstay of therapy (e.g. tar,
dithranol, vitamin D analogues, topical steroid* and antibiotic/fungal
treatment is beneficial in flexural disease).
For psoriasis that is not responsive to conventional therapy (also known
as relcalcitrant psoriasis), topical retinoids, phototherapy, oral drugs (e.g.
methotrexate, cyclosporin, acitretin, hydroxycarbamide) may be considered.
Parenteral cytokine inhibitors or monoclonal antibodies may be considered for recalcitrant psoriasis unresponsive to systemic therapy mentioned
above.
*When prescribing potent topical steroids such as Betnovate (betamethasone), NICE advises that you should aim for a 4-week break between courses to reduce the occurrence of local and systemic side effects.
Skin grafts and flapsProcedure
Axillary clearanceProcedure
Benign ductal disease (duct ectasia & papilloma)
What is it?
What does it get confused with?
Mx?
Duct ectasia is a dilatation and shortening of the terminal breast ducts within 3cm of the nipple. It is common and the incidence increases with age.
It typically presents with nipple retraction and occasionally creamy nipple discharge.
It may be confused with periductal mastitis, which presents in younger women, the vast majority of whom are smokers. Periductal mastitis typically presents with periareolar or subareolar infections and may be recurrent.
Mx: Patients with troublesome nipple discharge may be treated by microdochectomy (if young) or total duct excision (if older).
Intraductal papilloma =
Commoner in younger patients
May cause blood stained discharge
There is usually no palpable lump
Breast cysts
Who gets it?
Ix?
Palpable cysts constitute 15% of all breast lumps. They occur most frequently in perimenopausal females and are caused by distended and involuted lobules.
They may be readily apparent on clinical examination as soft, fluctuant swellings.
It is important to exclude the presence of an underlying mass lesion.
On imaging they will usually show a ‘halo appearance’ on mammography.
Ultrasound will confirm the fluid filled nature of the cyst.
Symptomatic cysts may be aspirated and following aspiration the breast re-examined to ensure that the lump has gone.
Breast reconstructionProcedure
MastectomyProcedure
Sentinel node biopsyProcedure
Wide local excision
Eczema herpeticum
What is it?
Mx?
Eczema herpeticum describes a severe primary infection of the skin by herpes simplex virus 1 or 2 (and uncommonly coxsackie B)
It is more commonly seen in children with atopic eczema and often presents as a rapidly progressing painful rash.
On examination, monomorphic punched-out erosions (circular, depressed, ulcerated lesions) usually 1–3 mm in diameter are typically seen.
Mx:
As it is potentially life-threatening children should be admitted for IV aciclovir!
seborrhoeic eczema
Seborrhoeic dermatitis in adults is a chronic dermatitis thought to be caused by an inflammatory reaction related to a proliferation of a normal skin inhabitant, a fungus called Malassezia furfur (formerly known as Pityrosporum ovale). It is common, affecting around 2% of the general population.
Features
eczematous lesions on the sebum-rich areas: scalp (may cause dandruff), periorbital, auricular and nasolabial folds
otitis externa and blepharitis may develop
Associated conditions include
HIV
Parkinson’s disease
Scalp disease management
over the counter preparations containing zinc pyrithione (‘Head & Shoulders’) and tar (‘Neutrogena T/Gel’) are first-line
the preferred second-line agent is ketoconazole
selenium sulphide and topical corticosteroid may also be useful
Face and body management
topical antifungals: e.g. ketoconazole
topical steroids: best used for short periods
difficult to treat - recurrences are common
Contact dermatitis
What are the 2 types?
Cause?
There are two main types of contact dermatitis
Irritant contact dermatitis (common) = non-allergic reaction due to weak acids or alkalis (e.g. detergents). Often seen on the hands. Erythema is typical, crusting and vesicles are rare
allergic contact dermatitis: type IV hypersensitivity reaction (uncommon) = Often seen on the head following hair dyes. Presents as an acute weeping eczema which predominately affects the margins of the hairline rather than the hairy scalp itself. Topical treatment with a potent steroid is indicated
Cause:
Cement is a frequent cause of contact dermatitis. The alkaline nature of cement may cause an irritant contact dermatitis whilst the dichromates in cement also can cause an allergic contact dermatitis
Mx for dermatitis herpetiformis
A course of dapsone, a sulphone antibiotic, will reduce the symptoms
of itching
Pityriasis versicolor
Pityriasis versicolor, also called tinea versicolor, is a superficial cutaneous fungal infection caused by Malassezia furfur (formerly termed Pityrosporum ovale)
Features
most commonly affects trunk
patches may be hypopigmented, pink or brown (hence versicolor). May be more noticeable following a suntan
scale is common
mild pruritus
Predisposing factors
occurs in healthy individuals
immunosuppression
malnutrition
Cushing’s
Management
topical antifungal. NICE Clinical Knowledge Summaries advise ketoconazole shampoo as this is more cost effective for large areas
if failure to respond to topical treatment then consider alternative diagnoses (e.g. send scrapings to confirm the diagnosis) + oral itraconazole
Pyoderma gangrenosum
Diagnosis
often made by the characteristic appearance, associations with other diseases, the presence of pathergy, histology results and when other diseases have been ruled out
histology is not specific and can vary depending on the time and site of the specimen but may be helpful in ruling out other causes of an ulcer.
Pyoderma gangrenosum may be the first signs of ulcerative colitis, Crohn’s disease and rheumatoid arthritis and can be idiopathic in 50 per cent of sufferers.
Management
the potential for rapid progression is high in most patients and most doctors advocate oral steroids as first-line treatment
other immunosuppressive therapy, for example, ciclosporin and infliximab, have a role in difficult cases
any surgery should be postponed until the disease process is controlled on immunosuppression to risk worsening of the disease (pathergy)
Bowen’s disease
Bowen’s disease is a type of precancerous dermatosis that is a precursor to squamous cell carcinoma. It is more common in elderly patients. There is around a 5-10% chance of developing invasive skin cancer if left untreated.
Features
red, scaly patches
often 10-15 mm in size
slow-growing
often occur on sun-exposed areas such as the head (e.g. temples) and neck, lower limbs
Management options:
may sometimes be diagnosed and managed in primary care if clear diagnosis or repeat episode
topical 5-fluorouracil
typically used twice daily for 4 weeks
often results in significant inflammation/erythema. Topical steroids are often given to control this
cryotherapy
excision
Seborrhoeic keratoses
Seborrhoeic keratoses are benign epidermal skin lesions seen in older people. Often mistaken for malignant melanoma
Features
large variation in colour from flesh to light-brown to black
have a ‘stuck-on’ appearance
keratotic plugs may be seen on the surface
Management
reassurance about the benign nature of the lesion is an option
options for removal include curettage, cryosurgery and shave biopsy
Ring worm of the head, body, foot (tinea capitis, copus, pedis) mx
Mx:
topical preparations – terbinafine, imidazoles;
oral preparations (which are reserved for severe cutaneous infections
involving multiple body sites) – griseofulvin and terbinafine.
Acne vulgaris mx
Acne may be classified into mild, moderate or severe:
mild: open and closed comedones with or without sparse inflammatory lesions
moderate acne: widespread non-inflammatory lesions and numerous papules and pustules
severe acne: extensive inflammatory lesions, which may include nodules, pitting, and scarring
A simple step-up management scheme often used in the treatment of acne is as follows:
1 = single topical therapy* (topical retinoids, benzoyl peroxide)
2 = topical combination therapy (topical antibiotic, benzoyl peroxide, topical retinoid)
3 = oral antibiotics for a max of 3 months!** :
tetracyclines: lymecycline, oxytetracycline, doxycycline
OR COCP as tetracyclines should be avoided in pregnant or breastfeeding women and in children younger than 12 years of age
4 = oral isotretinoin: only under specialist supervision
*pregnancy is a contraindication to topical and oral retinoid treatment. Erythromycin may be used in pregnancy
**Gram-negative folliculitis may occur as a complication of long-term antibiotic use - high-dose oral trimethoprim is effective if this occurs
minocycline is now considered less appropriate due to the possibility of irreversible pigmentation
a topical retinoid (if not contraindicated) or benzoyl peroxide should always be co-prescribed with ORAL antibiotics to reduce the risk of antibiotic resistance developing. Topical and oral antibiotics should not be used in combination
combined oral contraceptives (COCP) are an alternative to oral antibiotics in women
as with antibiotics, they should be used in combination with topical agents
Dianette (co-cyrindiol) is sometimes used as it has anti-androgen properties. However, it has an increased risk of venous thromboembolism compared to other COCPs, therefore it should generally be used second-line, only be given for 3 months and women should be appropriately counselled about the risks
There is no role for dietary modification in patients with acne.
Hidradenitis suppurativa
Hidradenitis suppurativa is a painful skin condition which causes multiple abscesses in areas which contain apocrine sweat glands.
Common areas involved are the armpits and groin region. Obesity is a risk factor. In the later stages, it can lead to fistula and sinus tract formation which discharge pus.
Lichen planus and sclerosus
Lichen
Planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham’s striae over surface. Oral involvement common
Sclerosus: itchy white spots typically seen on the vulva of elderly women
Blepharitis - features and mx?
Blepharitis is inflammation of the eyelid margins. It may due to either meibomian gland dysfunction (common, posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (less common, anterior blepharitis). Blepharitis is also more common in patients with rosacea
The meibomian glands secrete oil on to the eye surface to prevent rapid evaporation of the tear film!
Any problem affecting the meibomian glands (as in blepharitis) can hence cause drying of the eyes which in turns leads to irritation
Features
Symptoms are usually bilateral
grittiness and discomfort, particularly around the eyelid margins
eyes may be sticky in the morning
eyelid margins may be red. Swollen eyelids may be seen in staphylococcal blepharitis
styes and chalazions are more common in patients with blepharitis
secondary conjunctivitis may occur
Management
softening of the lid margin using hot compresses twice a day
‘lid hygiene’ - mechanical removal of the debris from lid margins
cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo is often used
an alternative is sodium bicarbonate, a teaspoonful in a cup of cooled water that has recently been boiled
artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film
fungal nail infection (Dermatophyte)
Oral terbinafine
Rosacea
Sometimes referred to as acne rosacea is a chronic skin disease of unknown aetiology.
Features
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
sunlight may exacerbate symptoms
Management
simple measures
recommend daily application of a high-factor sunscreen
camouflage creams may help conceal redness
predominant erythema/flushing CKS
topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia
brimonidine is a topical alpha-adrenergic agonist
this can be used on an ‘as required basis’ to temporarily reduce redness
it typically reduces redness within 30 minutes, reaching peak action at 3-6 hours, after which the redness returns to the baseline
mild-to-moderate papules and/or pustules CKS
topical ivermectin is first-line
alternatives include: topical metronidazole or topical azelaic acid
moderate-to-severe papules and/or pustules CKS
combination of topical ivermectin + oral doxycycline
Referral should be considered if CKS symptoms have not improved with optimal management in primary care
laser therapy may be appropriate for patients with prominent telangiectasia
patients with a rhinophyma
Pityriasis rosea
Pityriasis rosea describes an acute, self-limiting rash which tends to affect young adults.
The aetiology is not fully understood but is thought that herpes hominis virus 7 (HHV-7) may play a role.
Features
in the majority of patients there is no prodrome, but a minority may give a history of a recent viral infection
herald patch (usually on trunk)
followed by erythematous, oval, scaly patches which follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer. This may produce a ‘fir-tree’ appearance
Mx;
self-limiting - usually disappears after 6-12 weeks
Burns
Superficial epidermal
First degree
Red and painful, dry, no blisters
Partial thickness (superficial dermal)
Second degree
Pale pink, painful, blistered. Slow capillary refill
Partial thickness (deep dermal) Second degree
Typically white but may have patches of non-blanching erythema. Reduced sensation, painful to deep pressure
Full thickness
Third degree
White (‘waxy’)/brown (‘leathery’)/black in colour, no blisters, no pain
Erythrasma
Erythrasma is a generally asymptomatic, flat, slightly scaly, pink or brown rash usually found in the groin or axillae. It is caused by an overgrowth of the diphtheroid Corynebacterium minutissimum
Examination with Wood’s light reveals a coral-red fluorescence
Topical miconazole or antibacterial are usually effective. Oral erythromycin may be used for more extensive infection
Cutaneous features of GI diseases?
Coeliacs = Dermatitis herpetiformis is a blistering, intensely itchy rash that develops
on the extensor surfaces. mx = dapsone. Other cutaneous features of gastrointestinal disease include:
Malabsorption = Ichthyosis (dry, scaly skin), eczema, oedema
Liver disease = Jaundice, spider naevi, palmar erythema, leukonychia
Renal failure = Itching, half white and half red nails
Crohn’s disease = Perianal abscess, fistulae, skin tags, aphthous ulcers
Ulcerative colitis = Erythema nodosum, pyoderma gangrenosum
Sarcoidosis = Erythema nodosum, lupus pernio (purple indurated lesions)
