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.
