Derm, Ophthal, Ear picture quiz Flashcards
*A 55-year-old woman has a 6-week history of an ulcer on her left lower leg. It has been gradually been increasing in size. She reports no pain. There is no past personal or family history of ulceration. There is no history of diabetes. She is an ex-smoker of 10 pack years. She does report having had a swollen left leg 5 years previously after a total hip replacement for osteoarthritis. *
what is the likely aetiology and why?
Venous ulcer
* Gaiter area
* Located below the knee
* It is surrounded by mottled brown staining and/or dry, itchy and reddened skin – these are features of associated gravitational or venous eczema
investigations for venous ulcers
Arterial doppler to be performed beforehand to ensure adequate ABPI (ankle brachial pressure index) prior to applying compression.
management of venous ulcers
Compression stockings to improve venous return
A 73-year-old retired builder has a history of multiple rough patches on his face and scalp. He says the lesions tend to be quite sore. The overlying scale ‘comes and goes’‛, although recently one of the lesions has become thicker
What is the likely aetiology?
Actinic keratosis- Solar keratosis - Pre-malignant SCC
- Feels like sandpaper
management of actinic keratosis that is less high risk of becoming SCC e.g. that you can feel but not really see
5-fluorouracil (5-FU) cream: You apply this once or twice a day for 2 to 4 weeks.
- Avoided in pregnancy
Diclofenac gel: This medication tends to cause less of a skin reaction than 5-FU, but it can still be very effective. You will need to apply it twice a day for 2 to 3 months.
- While using this medication, you must protect your treated skin from the sun.
Imiquimod cream: This can be a good option for the face because you can apply it once (or twice) a week, so you don’t get lots of redness and crusting. You may need to apply it for 12 to 16 weeks.
management of aktinic keratosis at higher risk of becoming SCC
Cryosurgery
Curretage
Wide local excision
A 49-year-old naval officer presents with a red lesion on the back. He describes no symptoms. He says his wife first noticed the lesion approximately 2 years ago. Since that time he says that it has doubled in size. There is no family history of note. There has been no response to Fucidin cream and Hydrocortisone cream prescribed in primary care
What is the likely aetiology?
You describe the lesion as a long-standing erythematous patch. There is an irregular, but well defined, border. When the skin is stretched there is a pearly edge.
Superficial Basal cell carcinoma
- Slow growing
- Hasn’t responded to treatment
- Shiny border if you stretch skin
management of BCC
- Cryotherapy - freezing the BCC with liquid nitrogen
- Curettage and cautery - scraped away (curettage) and then the skin surface is sealed by heat (cautery)
- Creams - these can be applied to the skin. The two most commonly used are 5-fluorouracil (5-FU) and imiquimod
- Surgical excision
margins recommended in wide local excision: BCC and SCC
4mm
margins recommended for wide local excision : melanoma
The margin width for wide local excision of melanoma is
based on the Breslow thickness of the primary tumor.
- Margin width should be 1 cm
for melanomas 1 mm thick - 1 or 2 cm for melanomas 1 to 2 mm thick,
- 2 cm for
melanomas 2 mm thick.
A 37-year-old man has a 2-year history of a symmetrical non-itchy rash.
What is the likely aetiology?
Psoriasis -> plaque
* Thick scale
* Silvery
* Symmetrical
* Non-itchy
commonest sites of involvement for psoriasis
- Nail psoriasis:
o Pitting
o Ridging
o Onycholysis - Associated with inflammatory arthritis (psoriatic arthritis)
- Cardiovascular disease
- IBD
- Uveitis
- Coeliac disease
guttate psoriasis
- Associated with Strep throat
- Tear drop shaped
Pittyriasis rosea
- Associated with recent URTI
- Herald spot appears first
- Christmas tree distribution
managent of psoriasis
General Measures: Emollients, soap substitutes (aqueous cream)
- 1st Line: Topical therapies, corticosteroid (milder first), vitamin D analogues, topical retinoids
- 2nd Line: Phototherapy i.e. UVB
- 3rd Line: Systemic therapy (methotrexate, ciclosporin, acitretin), biologics (infliximab)
A 17-year-old girl has had spots on the face since the age of 14. She has tried numerous over-the-counter preparations without success. She describes the spots becoming worse around the time of her periods.
What is the likely aetiology?
Acne
management of acne
- First line: benzyl peroxide or fusidic acid
- Second line: Topical antibiotics or topical retinoids
- Third line: doxycyline or erythromycin/ COCP
- Fourth line: oral retinoids
Isotetrinonin
- Indications: Severe acne that is not responsive to initial treatment, associated with psychological problems or with scarring
- Considerations: Must be done under expert supervision
- Risks (not an exhaustive list):
◦ Teratogenic
◦ Raises cholesterol
◦ Can cause mood changes, risk of depression and suicidal ideation
A 10-year-old boy has itchy areas in the arm and leg flexures. There is a family history of atopy. His mother has been applying aqueous cream. She is concerned about using topical steroids and is keen for her son to have allergy testing.
What is the likely aetiology?
Flexural eczema
most common first site of presentation of eczema
cheeks
prognosis of eczema
Mostly eczema improves during school years and it may completely clear up by the teens, although the barrier function of the skin is never entirely normal.
A 45-year-old female presents with a 1 year history of an intermittent intensely itchy/sore rash. She has tried chlorphenamine (Piriton), without sustained benefit. She requests allergy tests, dietary advice and a cure for the itching. The lesions ‘come and go’‛ over short periods, are not consistently associated with eating, and resolve without bruising.
What is the likely aetiology?
Urticaria
management of urticaria
- Managed with non-sedating anti-histamines (daily dose licensed for hay fever may need to be increased up to four times in some cases)
- Skin prick tests and radioallergosorbent tests (RAST) should be performed if a drug or food allergy is suspected
A 68-year-old man presents with an abnormal toenail.
what is the likely aetiology?
Onychomyosis
- Common causative organisms are dermatophytes such as Trichophyton rubrum (T. rubrum) and T. interdigitale (tinea unguium)
fungal toenail causative organisms
Dermatophytes
- account for around 90% of cases
- Trichophyton rubrum
Yeasts
- account for around 5-10% of cases
- e.g. Candida
investigations for fungal toenail
nail clippings +/- scrapings of the affected nail
microscopy and culture
management of fungal toenail
do not need to be treated if it is asymptomatic and the patient is not bothered by the appearance
if more extensive involvement due to a dermatophyte infection:
- oral terbinafine is currently recommended first-line
- 3-6 months
if more extensive involvement due to a Candida infection:
- oral itraconazole is recommended first-line; ‘pulsed’ weekly therapy is recommended
A 43-year-old man presents with a pigmented lesion on his back. He is not aware of any change to the lesion, but his partner has persuaded him to seek a medical opinion.
What is the aetiology?
melanoma
- Asymmetry
- Border - the edges of the area may be irregular or blurred, and sometimes show notches
- Colour - Different shades of black, brown and pink
- Diameter - most melanomas are at least 6mm in diameter
- Evolving - if in doubt, check it out! (some sources may show this as evolution of shape, size or colour)
types of melanoma
isional vs excisioal biopsies in melanoma
Incisional biopsies are currently recommended for the histopathologic diagnosis of large tumors in facial, mucosal, and acral locations. Complete excisional biopsies are the generally recommended standard for melanoma surgery. Incisional biopsies of malignant melanoma do not negatively influence prognosis.
what is the diagnosis?
Wart - HPV
- Surface layer of skin paired off with a scalpel, multiple pin point bleeding point suggests wart
- Management: duct tape/topical therapies/cryotherapy
what is the diagnosis?
Molluscum
* Umbilicated papules -> centrally eroded with crust
* Children with eczema
* Self limiting virus – poxvirus
* Antiseptic wash if concerned infected
* Do not share towels, flannels or clothes, avoid squeeing spots and sharing baths
A 33-year-old woman reports severe itching (particularly at night) over the previous 4 weeks. She has no history of atopy. She lives with her husband and baby daughter. Her husband has no history of itch. Her daughter has a rash on the trunk (see photograph above). Examination reveals excoriated papules on the wrists, hands and feet.
What si the likely aetiology?
- Scabies – esp itchy at night with multiple household members affected
o Look for linear burrows on the anterior wrist
management of scabies
- permethrin 5% is first-line
- malathion 0.5% is second-line
treat whole household/ close contacts
apply twice (a week apart)
what is this?
rusted (Norwegian) scabies
- seen in patients with suppressed immunity, especially HIV
- treat with ivermectin
A 70-year-old man has a 2-week history of a generalised itchy rash with numerous tense blisters arising from urticated lesions on the trunk and limbs.
What is this?
- Bullous Pemphigoid
Bullous pemphigoid vs pemphigus vulgaris
- Bullous pemphigoid- very tense bulla
- no mucosal involvement
A 58-year-old woman has a 5-day history of a tender rash over her left mid back. She developed discomfort in the area prior to the rash appearing. The rash is made up of crusted vesicles.
What is the likely aetiology?
Shingles
- Arises from reactivation of the VZV
- After this would cause chicken pox in initial infection, the virus then lays formant in the dorsal root ganglion
- If reactivated this would cause lesions in the distortion of the associated dermatome only -> should not cross the midline
A 78-year-old man says this lesion first appeared 6 weeks ago and is continuing to grow.
What is the likely aetiology?
- Squamous cell carcinoma
- Quick growth
- Central ulceration
skin cancer locations men vs women
women- legs
men- trunk
A 64-year-old woman complains of patches of rough skin over her lower legs.
what is the likely aetiology?
This is a case of Bowen’s disease, also called Squamous cell carcinoma in situ as malignant cells are confined to the epidermis.
Akintinc keratosis -> Bowens -> SCC
whos at highest risk of SCC
Immunosuppressed e.g. if organ transplant
diagnosis?
venous eczema
- compression stockings
what is this?
Acne rosacea
- flush easy esp after alcohol
- gritty dry eyes
management of acne rosacea
First line: topical ivermectin (same as scabies) and lymecycline
what is this characteristic of?
target lesion- Lyme disease
tinea capitis vs seborrheic dermatitis (dandruff)
Tinea capitis
- bold patch
- very itchy
- trichophytum
- management: oral terbinafine
Seborrheic dermatitis
- flakiness
- no alopecia
what is this?
Meningococcal septicaemia
Management
- Community: Benzylpenicillin IM STAT
- IV antibiotics -> Ceftriaxone
- Steroids
what is this?
lichen planus
- non infectious
lichen sclerosus
penile, vulval, and perianal areas
- topical steroids
what is this?
Erythroderma- rash covering >95% of body
Causes
- eczema
- psoriasis
- drugs e.g. gold
- lymphomas, leukaemias
- idiopathic
steroid ladder
Finger tip rule
1 finger tip unit (FTU) = 0.5 g, sufficient to treat a skin area about twice that of the flat of an adult hand
