Derm Key Flashcards

Question

Eczema Rx: - Emollients (1st line) - Topical Steroids Chronic, Relapsing Inflammatory skin condition. • Itchy red rash. • Affects skin creases (Flexures) ( eg, wrist, elbow folds, behind the knees, face in babies). • Triggered by environmental irritants and allergens. Also,

Answer 1

URTIs can cause a flare up of eczema. • Family Hx of atopic diseases (eg, Asthma, Hay fever).

Answer 2

• Scaling rash. • Affects sebaceous glands. • Found on face, scalp chest. • Inflammatory reaction to yeast. • Presents as inflamed, greasy areas with fine scaling. • Can present as dandruff when on scalp.

Answer 3

- Hx of immunosuppression (e.g. Taking oral or inhaled corticosteroids), - Hx of smoking. - Thick white marks ± Inflamed mouth/ tongue. - Note that Plaques might enlarge and become painful, causing discomfort while eating and swallowing. - It might also present with red inflamed painful sore mouth angles. - Can be rubbed out. Management of oral thrush: - Stop Smoking. - Good inhaler techniques, spacer device, rinse mouth with water after use. - Oral Fluconazole 50 mg OD for 7 days or Fluconazole oral suspension.

Answer 4

- Lace like appearance. (Cannot be removed) - Remember also in Lichen Planus: 4Ps + F: purple, pruritic “itchy”, polygonal, papular rash on flexor surfaces. Q) A 58 YO woman presents complaining of 6 weeks of irregular white streaks on her tongue sides and buccal mucosa. They are adherent and difficult to be removed by spatula. She also has persistent painful tongue ulcers. She does not smoke. The likely Dx → lichen planus

Answer 5

√ Oral Candidiasis → Thick white marks + Can be rubbed out ± Inflamed mouth. Leukoplakia → White marks, cannot be rubbed out, sharply defined O woman presents complaining of 6 weeks of irregular white streaks on her tongue sides and buccal mucosa. They are adherent and difficult to be removed by spatula- lichen planus

Answer 6

√ Eczema occurs in around 15-20% of children and is becoming more common. √ It typically presents before the age of 6 months but clears in around 50% of children by 5 years of age and in 75% of children by 10 years of age. Features • In infants the face and trunk are often affected then extremities. • 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

Answer 7

• 1st line → Emollients (at least BID) + washing, bathing (Moisturising). • 2nd line → Topical Steroids (for eczema itself). Examples:

Answer 8

Mild strength Hydrocortisone acetate (0.5% or 1% or 2.5%). This is to be started if mild eczema or a new case that is not responding to emollients alone. (If still not responding, try a more potent option).

Answer 9

Moderate strength Betamethasone valerate (0.025%) Clobetasone butyrate (0.05%) (for moderate eczema: WIDE area of dryness, crackling, redness) imp √

Answer 10

Betamethasone valerate (0.1%) Mometasone 0.1% (for severe eczema that causes bleeding, intense itching that prevents sleeping, and not responding to emollients and hydrocortisone) imp √ Hydrocortisone Butyrate

Answer 11

Clobetasol propionate

Answer 12

Important: if emollients and topical steroids are to be given together → Apply Emollient first, then wait for 30 minutes, then apply the Topical steroids. “Creams soak into the skin faster than ointments”

Answer 13

→ Athlete’s foot, fungal groin infections, fungal nappy rash

Answer 14

√ Itching without features of anaphylaxis (e.g., after insect bite) → give oral anti-histamine. √ If severe reaction develops (e.g., affecting breathing)? → IM Adrenaline.

Answer 15

• Basal cell carcinoma (BCC) is one of the three main types of skin cancer. • Lesions are also known as Rodent Ulcers. • Characterised by slow-growth and local invasion. • Metastases are extremely rare. • BCC is the most common type of cancer in the Western world.

Answer 16

• Many types of BCC are present. • The most common type is Nodular BCC, which is described here. • Sun-exposed sites, especially the head and neck account for the majority of the lesions. • Initially → pearly, flesh-coloured papule with telangiectasia. • May later ulcerate leaving a central “crater”

Answer 17

• surgical removal • curettage • cryotherapy • topical cream: imiquimod, fluorouracil • radiotherapy

Answer 18

Basa Cell Carcinoma “Rodent Ulcer”

Answer 19

- They resolve spontaneously within 6-24 months → Reassure. √ cheesy, or white material. - If squeezed, they produce - They usually affect children, and immunocompromised patients (eg, AIDS). So, if a patient presents with extensive pink umbilicated papules, consider AIDS. - Remember: CHILDREN, HIV (AIDS), think → Molluscum Contagiosum.

Answer 20

• Appearance: White or pink, firm, dome-shaped/ round papules with a central umbilicated (depressed) punctum. • Location: Can appear anywhere on the skin. • Resolution: Spontaneously resolves. It can take up to 6-24 months; → reassurance is often sufficient. • Content: Squeezing the lesions produces cheesy or white material. • Commonly Affects: Children and immunocompromised individuals (e.g., HIV/AIDS patients). Extensive lesions may indicate underlying immunosuppression. • Transmission: Spread through direct skin contact, contaminated objects (fomites), or autoinoculation. So, as long as the lesions are active, there is a potential for transmission. Once the papules disappear, the virus is no longer present on the skin, and the infection is not transmissible.

Answer 21

: o Reassure in most cases. o Physical treatments like cryotherapy or curettage for persistent lesions. o Prevent spread by avoiding scratching and sharing personal items.

Answer 22

√ Impetigo is a superficial bacterial skin infection usually caused by either Staphylcoccus aureus or Streptococcus pyogenes. √ It can be a primary infection or a complication of an existing skin condition such as eczema, scabies or insect bites. √ Impetigo is common in children, particularly during warm weather. √ The infection can develop anywhere on the body but lesions tend to occur on the face, flexures and limbs not covered by clothing. √ Contagious! √ Spread is by direct contact with discharges from the scabs of an infected person. √ The bacteria invade skin through minor abrasions and then spread to other sites by scratching. √ Infection is spread mainly by the hands, but indirect spread via toys, clothing, equipment and the environment may occur. √ The incubation period is between 4 to 10 days.

Answer 23

◙ 'golden', crusted skin lesions typically found around the mouth (Honey-coloured crust), Brown. ◙ very contagious! Management **Limited, localised Non-bullous disease** (New Update) √ Hydrogen peroxide cream 1% (first line). “anti-septic”. √ Fusidic acid 2% or mupirocin (2nd line). “antibiotic”. **Extensive non-bullous or bullous impetigo** • Oral flucloxacillin. • Oral erythromycin if penicillin allergic. Important Note - Children should be excluded from school until the lesions are crusted and healed. - Or: 48 hours after commencing the antibiotic treatment.

Answer 24

Impetigo: bacterial, contagious, honey-coloured crusts, hydrogen peroxide cream is first-line, fusidic acid is 2nd line

Answer 25

→ (Bullous impetigo). It is caused by Staph. Aureus. These bullae eventually rupture leaving yellow crusts. Note that Non-bullous impetigo is more common.

Answer 26

This is impetigo. He has been using a topical antiseptic “hydrogen peroxide 1%” “first line”. Now, the second line is → “antibiotics”: either fusidic acid or mupirocin.

Answer 27

Note, if the rash is painful and associated with fever, especially in a child with Hx of eczema → consider eczema herpeticum, and give aciclovir (antivi

Answer 28

Points towards Cold Sore of HSV: - Hx of Recurrent episodes - Pain (tingling, itching, burning) before the onset of vesicles (prodromal pain) - Vesicles initially filled with clear fluids - In Adults

Answer 29

Features • Typically affects nose, cheeks and forehead. • Flushing is often the first symptom (especially after alcohol or sunlight exposure). • Telangiectasia is common. • Later develops into persistent erythema with papules and pustules • Rhinophyma: Nose disfigurement √ • Ocular involvement: blepharitis

Answer 30

◙ If erythema (redness) predominant → topical brimonidine. ◙ If papules/ pustules predominant: √ First line → ivermectin. √ √ Second line → topical metronidazole. ◙ More severe disease is treated with additional systemic antibiotics eg, Oxytetracycline, Tetracycline.

Answer 31

√ It is a fungal infection involving the hair follicles and causing hair loss (Alopecia) very rapidly. √ Because of the risk of scarring, treatment is with a systemic (oral) antifungal such as → Oral Terbinafine, itraconazole, or fluconazole. √ In children, Griseofulvin is used.

Answer 32

√ So, a patient with bloating, loose stools, abdominal pain, iron deficiency anemia, folate deficiency → Celiac disease. √ With Severely ITCHY Rash distributed over scalp, sacrum, elbows, knees → Dermatitis Herpetiformis. √ In Celiac Disease: Tissue Transglutaminase IgA, endomysial Abs are +positive

Answer 33

- Hoarseness of voice, - Wheezes, - SOB, - Stridor, - Shock, - Facial, Tongue, or Cheek swelling. • In Allergic reaction with urticaria → Oral Anti-histamine eg, Cetirizine, Loratadine • If Anaphylaxis (e.g., Difficulty breathing) → IM Adrenaline

Answer 34

• Pruritic (Itchy urticaria-like rash) condition • Usually occurs during the last trimester • “Usually in the first-time pregnancy ie, primiparous” . • The lesions often first appear as abdominal striae. • No Blisters. • Spares the umbilicus. • The management depends on the severity → emollients , mild potency topical steroids and oral steroids may be used.

Answer 35

• pruritic blistering lesions • often develops in the peri-umbilical region and later spread to the trunk, back, buttocks and arms • usually presents in the 2nd or 3rd trimester and is rarely seen in the first pregnancy • oral corticosteroids are usually required

Answer 36

Note that Polymorphic Eruption of Pregnancy (PEP) = Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) It is Pruritic (Itchy urticaria-like rash) However, there are no associated blisters, bullae or vesicles. Also, it tends to spare the umbilicus. N.B. Obstetric Cholestasis DOES NOT present with a rash.

Answer 37

• Contact dermatitis → redness and itching of a single affected area. • Chickenpox → systemic symptoms (fever and malaise) + Vesicles on face, neck, trunk. • Measles → ‘’K’’: Koplik spots, Cough, Coryza, Conjunctivitis.

Answer 38

Features • Target lesions: a vesicle surrounded by an often hemorrhagic maculopapule. (Dusky red blistering centre, with surrounding pale area) • Initially seen on the back of the hands / feet before spreading to the torso (the trunk). • upper limbs are more commonly affected than the lower limbs • pruritus is occasionally seen and is usually mild. Causes (the red coloured are more important for PLAB 1) • Viruses: Herpes simplex virus (HSV) (the most common cause), • Idiopathic • Bacteria: Mycoplasma (e.g. Mycoplasma Pneumonia), Streptococci (Streptococcal sore throat). • Drugs: Penicillin (e.g., Amoxicillin), sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill. • Connective tissue disease e.g., Systemic lupus erythematosus. • Sarcoidosis • Malignancy

Answer 39

Causes (the red coloured are more important for PLAB 1) • Viruses: Herpes simplex virus (HSV) (the most common cause), • Idiopathic • Bacteria: Mycoplasma (e.g. Mycoplasma Pneumonia), Streptococci (Streptococcal sore throat). • Drugs: Penicillin (e.g., Amoxicillin), sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill. • Connective tissue disease e.g., Systemic lupus erythematosus. • Sarcoidosis • Malignancy

Answer 40

Example: eruption of erythema multiforme on the back of hands first then on trunk and different parts of the body after streptococci infection, mycoplasma pneumonia, or taking antibiotics for URTI (penicillin; amoxicillin). For all forms of erythema multiforme (EM), the most important treatment is usually symptomatic, including 1.oral antihistamines, analgesics, local skin care, and soothing 2.mouthwashes (e.g., oral rinsing with warm saline or 3.a solution of diphenhydramine, xylocaine, and kaopectate). 4. Topical steroids may be considered.

Answer 41

1. Erythema Multiforme Target lesion, Causes (look in the stem for): HSV, Mycoplasma pneumonia , the use of Penicillin (Amoxicillin) If extensive mucus membrane involvement → Steven-Johnson Syndrome (rarely asked). 2. Dermatitis herpetiformis Severe itchy rash Associated with Celiac disease (loose fatty stools difficult to flush, IDA, vit B12 and folic acid def.) 3. Erythema Migrans Target lesion, Cause: Lyme Disease (Hx of camping, walking in jungles)

Answer 42

1. Erythema Marginatum Rheumatic fever (Considered in Major Jone’s criteria for Rhe. fever) (Pink rings, barely raised, non-itchy) 2. Erythema Nodosum Painful tender nodules over shins Hx of: IBD (UC, CD), Penicillin, Sarcoidosis, TB (India) 3. Erythema infectiosum Parvovirus B19 (Fifth disease) Children: Slapped cheek appearance The rash appears initially on the cheeks, then on the limbs and sometimes the trunk. Rx → Rest and Analgesia. 4. Erythema Ab Igne Due to chronic exposure to infrared radiation in the form of heat e.g., an elderly sits close to heater or fire

Answer 43

Hx of Sarcoidosis, TB (India), Inflammatory bowel (UC, CD), Penicillin

Answer 44

Remember that: • Lichen Planus: On the flexor surfaces. Not Contagious. • Psoriasis: On the Extensor Surfaces. Not Contagious. Itchy. ± FHx. • Eczema: On the creases (Flexures). Not Contagious. In infants, it usually starts on the face - cheeks, then trunk and extremities). ITCHY.

Answer 45

1- Molluscum Contagiosum: Viral, in AIDS and Children, Resolve Spontaneously, Contagious. 2• Scabies: On the flexor surfaces. Contagious. 3- Impetigo: Bacterial, Golden Crusts, Children, Needs treatment (Hydrogen peroxide cream 1% is first line, Topical Fusidic Acid: 2nd Line), VERY CONTAGIOUS.

Answer 46

◙ Bluish discoloration over the base of the back and the buttocks. ◙ They are benign, pigmented, flat, congenital birthmarks. ◙ They usually fade after a few years. ◙ Rx → Reassurance “inform mother that it will fade with time”

Answer 47

- Multiple, different sized, yellow, soft, raised plaques on eyelids. - They occur with or without hyperlipidemia. Management • Patients should have their fasting lipid levels checked. • Those with hyperlipidaemia should have a formal cardiovascular risk assessment using appropriate charts, with measures for prevention of cardiovascular disease as indicated. • The lesions can be left alone unless the patient wishes them removed for cosmetic reasons (not usually available on the NHS). → Thus, a referral to a private clinic is done. • Various options are available 1. including surgical excision ( with or without skin grafting for large lesions), 2 chemical treatment, laser treatment and cryocautery. 3. Full-thickness skin grafting obtained via blepharoplasty is available. Xanthelasmas may recur after any of these interventions. Lipid-lowering medication and diet modification have a limited (if any) effect on these lesions.

Answer 48

◙ Pathophysiology is multifactorial √ Follicular epidermal hyperproliferation resulting in the formation of a keratin plug. This in turn causes obstruction of the pilosebaceous follicle. Activity of sebaceous glands may be controlled by androgen, although levels are often normal in patients with acne. √ colonisation by the anaerobic bacterium Propionibacterium acnes. Important: Adding topical benzoyl peroxide (BPO) to the antibiotics can reduce resistant Propionibacterium acnes in patients with acne receiving antibiotic therapy. √ inflammation

Answer 49

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. (In this case, Oral isotretinoin is used.).

Answer 50

◘ single topical therapy (topical retinoids “isotretinoin” , benzoyl peroxide) ◘ Topical combination therapy (topical antibiotic, benzoyl peroxide, topical retinoid) ◘ Oral antibiotics → tetracyclines: lymecycline, oxytetracycline, doxycycline. Tetracyclines should be avoided in pregnant or breastfeeding women and in children younger than 12 years of age. (Erythromycin may be used in pregnancy). Retinoids are contraindicated in pregnancy. ◘ (COCPs) are an alternative to oral antibiotics in women. “They should be used in combination with topical agents”. ◘ Oral isotretinoin: only under specialist supervision. (Preferred in severe acne, eg, if there is scarring, pitting, and or nodules).

Answer 51

√ A single oral antibiotic for acne vulgaris should be used for a maximum of three months. √ 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. √ Gram-negative folliculitis may occur as a complication of long-term antibiotic use → high-dose oral trimethoprim is effective if this occurs. √ Pregnancy is a contraindication to topical and oral retinoid treatment. √ There is no role for dietary modification in patients with acne.

Answer 52

(Q1) Acne → give 13-cis-retinoic acid, i.e., isotretinoin