DERM Revision 1 Flashcards
A strong genetic link with which gene is associated with atopic eczema? [2]
Fillagrin
- Filaggrin is a protein present in normal epidermis. Following processing from its precursor protein, profilaggrin, it binds and condenses the keratin cytoskeleton - therefore is important in skin barrier formation
SPINK-5
- involved with the regulation of desquamation within the epidermis
Patients with atopic eczema are particularly susceptible to a number of cutaneous infections, of which [] is the most common
Patients with atopic eczema are particularly susceptible to a number of cutaneous infections, of which Staphylococcus aureus is the most common
Which diagnostic factors / characterisitic features are associated with acute [3] subacute [1] and chronic [3] flares of eczema?
Acute:
- Scaling
- Vesicles
- Papules
Subacute:
- Represent an intermediate stage where acute lesions begin to resolve; characterized by erythematous scaling plaques with possible crusting.acacu
Chronic:
- Lichenification
- Hyperpigmentation or hypopigmentation
- Fissures
Name and describe this secondary condition associated with eczema [2]
Lichen Simplex Chronicus
- secondary to chronic scratching or rubbing in response to pruritus
- well-demarcated plaques with lichenification, hyperpigmentation, and scaling.
Name and describe this secondary condition associated with eczema [2]
Prurigo nodularis:
- Chronic skin condition characterised by very itchy firm lumps
- Characterized by multiple firm, itchy nodules that result from repeated scratching or picking at eczematous lesions.
PN can occur at any age but is more common in the elderly. When PN occurs in younger patients, it is more likely to be associated with inflammatory skin diseases, usually eczema (also called atopic dermatitis).
Describe the characteristics needed for a diagnosis of eczema
An itchy skin condition in the last 12 months
Plus three or more of
* Onset below age 2 years’
* History of flexural involvement’’
* History of generally dry skin
* Personal history of other atopic disease’’’
* Visible flexural dermatitis
‘not used in children under 4 years
‘‘or dermatitis on the cheeks and/or extensor areas in children aged 18 months or under
‘'’In children aged under 4 years, history of atopic disease in a first degree relative may be included
Describe the treatment regime for an acute flare of atopic dermatitis / eczema [6]
- Emollients (warn patients about fire hazard risk)
- Consider topical steroid cream / ointment. Start on low to medium potency and go up
- Consider topical calcineurin inhibitor; tacrolimus; pimecrolimus. Useful for long term tx of pruritis without giving steroids for long time
- Consider Phototherapy: Narrow Band UVB (NB-UVB) small part of the UVB light spectrum is used to tx; where UVA radiation is combined with a chemical called psoralen that increases the effect of UVA on the skin). PUVA (UVA + psoralen)
- Systemic therapies: methotrexate (1x week medication, given with folic acid); ciclosporin (shorter time for treatment to work; can only use for 1 or 2 years before moving to biologics
- Biologics: JAK inhibitors - Baricitinib, Upadacitinib; IL-13/4 – Dupilumab, Tralokinumab.
State an example of low, mid, high and very high potency corticosteroids used in the tx of eczema
Low-potency: hydrocortisone, desonide
Mid-potency: fluticasone, triamcinolone, fluocinolone
High-potency: mometasone, betamethasone, desoximetasone
Very high-potency: clobetasol, ulobetasol, diflorasone.
What are the common side effects of topical calcineurin inhibitors? [4]
About 50% of patients develop some local skin irritation or a burning or itching sensation when these treatments are started, particularly with tacrolimus ointment.
Small increased risk of developing cold sores (herpes simplex infection) on the treated skin during the first few weeks of treatment.
Due to suppressesion of the immune system, one possible consequence of immune suppression is an increased risk of non-melanoma skin cancer and lymphoma.
Gingival hyperplasia
Why can calcineurin inhibitors be useful on the face and neck and in the folds of the skin, particularly if the atopic eczema is very persistent at these sites? [1]
Topical calcineurin inhibitors do NOT cause skin thinning or stretch marks or some of other side-effects associated with using strong topical corticosteroids for a long period
Describe two bedside monitoring needs to be used when giving calcineurin inhibitors [2]
BP - know to cause hypertension (caused by ciclosporin vasoconstriction and salt retention)
Urine dipstick - has nephrotoxic effects
Describe two bedside monitoring needs to be used when giving calcineurin inhibitors [2]
FBC - bone marrow suppression (e.g., neutropenia, thrombocytopenia).
CXR - assess for TB
LFTs - methotrexate is renally excreted
Folate levels
Fibroscan
Name and describe an ophthalmological complication of eczema [1]
Keratoconus, the clear, protective outer layer at the front of the eye (called the cornea) becomes thinner and changes shape over time.
- cornea becomes thinner and weaker and begins to bulge, leading to blurred and distorted vision
- Instead of having a curved football shape, it becomes pointed like a rugby ball.
NB: due to vigorous and long term itching or rubbing of the eyes.
Name and give a brief overview of the the different types of eczema
Atopic dermatitis
Irritant contact dermatitis
- provoked by contact with water, detergents and other chemicals
Allergic contact dermatitis (Type 4 HS)
- occurs when there is sensitisation to a usually tolerated environmental contact such as nickel, fragrance, hair dye or preservatives.
Discoid eczema
- chronic eczema characterised clinically by papules or papulovesicles which coalesce into coin-shaped patches.
Seborrhoeic dermatitis
- most commonly occurs on the scalp and face secondary to toxic substances produced by yeasts.
Asteatotic eczema (also known as xerotic (dry) eczema)
- Distinctive crazy-paving appearance.
- Diamond-shaped plates of skin are separated from each other by red bands forming a network
Venous eczema:
- varicose or stasis eczema due to increase in pressure pushing blood and blood products from the veins into the surrounding tissue. This then triggers inflammation in the skin
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
Asteatotic eczema
- Asteatotic eczema often has a distinctive crazy-paving appearance.
- Diamond-shaped plates of skin are separated from each other by red bands forming a network
- There may also be scratch marks. It may start on one shin but soon spreads to affect the skin around both lower legs.
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
Seborrhoeic dermatitis
- Seborrhoeic dermatitis is a common, chronic, or relapsing form of eczema/dermatitis that mainly affects the sebaceous gland-rich regions of the scalp, face, and trunk.
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
Asteatotic eczema
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
Venous Eczema
- Venous eczema appears to be due to fluid collecting in the tissues and activation of the innate immune response.
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
Discoid eczema usually affects the limbs, particularly the legs, but the rash may be widespread.
- The majority of patches are round or oval. The plaques are usually very itchy. The skin between the patches is usually dry and irritable.
There are two clinical forms of discoid eczema:
- Exudative acute discoid eczema: oozy papules, blisters, and plaques
- Dry discoid eczema: subacute or chronic erythematous, dry plaques
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
How can eczema present differently according to ethnicity? [2]
White skin: often flexor surfaces
Asian and black children / adults: often on extensor. If you can see redness then usually a sign that is severe as skin tone normally will hide.
Describe this pattern of eczema [1]
Follicular eczema
What is the treatment for this manifestation of eczema? [2]
Eczema herpeticum - multiple punched out lesions
(1) Oral aciclovir 5 times daily for 10-14 days
Alternative: valaciclovir twice daily for 10-14 days
(2) If patient vomiting or unable to take tablets: IV aciclovir
Name this investigation and what type of HS it investigates [2]
Skin prick test (Type 1 HS)
Sk1n prick
Patch testing (HS type 4)
P4tch testing
What is this type of eczema? [1]
Pompholyx eczema
- Pompholyx eczema (also known as ‘dyshidrotic eczema’) is a type of eczema that affects the hands and feet. It involves the development of intensely itchy, watery blisters, affecting the sides of the fingers, the palms of the hands and soles of the feet.
Describe the clinical presentation of psoriasiss
- Erythematous, circumscribed scaly papules and plaques on elbows, knees, extensor surfaces of limbs, scalp, and, less commonly, nails, ears, and umbilical region. Silvery scale with well demarcated plaques
- Symmetrical
- Most commonly on extensor surfaces
- Well defined plaques (compared to eczema) with matching morphology
- Gets better when exposed to sun
- FHx
- 20% have psoriatic arthritis: joint pain, tendinitis etc. In most cases arthritis presents after the onset of cutaneous psoriasis
The appearance of punctate, bleeding spots when psoriasis scales are scraped off is called? [1]
Auspitz sign
Describe the tx algorithm for plaque psoriasis
Topical treatments:
- Emollients
- Steroids - dont use alone - combine with vitamin D analogue e.g. Dovabet (combination tx)
- Salicylic acid - breaks down keratin
- Coal tar - effective anti-inflam
Phototherapy: 3x week for 3 months
- NB-UBV
- PUVA
Systemics - Oral immunosuppression
- Methotrexate
- Ciclosporin
Systemics - retinoids:
- Acitretin - Its use is restricted, generally only for those who have failed other systemic options or in whom they are inappropriate.
Biologics
Describe the tx algorithm for guttate psoriasis [5]
- Most cases resolve spontaneously within 2-3 months
- Phototherapy
- Ciclosporin
- Methotrexate
- Acitretin
Describe what is meant by generalised pustular psoriasis [2]
Subdivided into acute GPP and generalised annular pustular psoriasis
The pustules may coalesce forming ‘lakes of pus’. They tend to resolve over days leaving the erythema and scaring. It can represent a dermatological emergency and patients are often systemically unwell with fever, malaise and arthralgia.
In erythroderma (erythrodermic psoriasis), there is generalised erythema with fine scaling. It is often associated with pain, irritation, and sometimes severe itching.[2]
Name this manifestation of psoriasis [1]
Describe why this an derm emergency
Erythroderma
Complications include:
* Dehydration
* Heart failure
* Infection
* Hypothermia - inability to regulate temperature
* Protein loss and malnutrition
* Oedema (swelling), particularly of lower legs
* Death
Describe how you differentiate guttate psoriasis to pityriasis rosea with regards to:
prodrome [1]
appearance [1]
treatment [1]
Guttate psoriasis:
- Precieded by streptococcal infection 2/4 weeks ago
- Tear drop scaly papules
- Most resolve spontaneously with 2-3 months.
PR:
- Ptx report recent resp. infection but not common in qs
- Herald patch followed 1-2 weeks later by multiple erythematous, slightly raised oval lesions with a fine scale confined
- Self limiting (~6 weeks)
Describe the clinical manifestation of pustular psoriasis [2]
Pustular psoriasis is a rare severe form of psoriasis where pustules form under areas of erythematous skin.
The pus in these areas is NOT infectious
Patients can be systemically unwell
It should be treated as a MEDICAL EMERGENCY and patients with pustular psoriasis initially require admission to hospital.
How would you differentiate psoriasis vs lichen planus?
Lichen Planus: is an ongoing (chronic) inflammatory condition that affects mucous membranes inside your mouth.:
- Flat-topped, polygonal papules that often have a violaceous hue.
- Wickham’s striae (fine white lines) may be visible on the surface.
- Oral or genital involvement is more common in lichen planus than psoriasis.
ACE inhibitors
The following factors may exacerbate psoriasis:
* trauma
* alcohol
* drugs: beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab
* withdrawal of systemic steroids
Describe clinical imaging of PsA?
X-ray of affected joints:
- may show erosion of the small joints. Classic findings are erosions of the DIP with periarticular bone formation (osteophytes). In advanced disease, there may be “pencil in cup deformity” at the DIP
X-ray of the sacroiliac joints (SIJ):
- usually normal in the initial stages, but it is important to obtain a baseline radiograph for assessing disease progression
- Periostitis (inflammation of the periosteum, causing a thickened and irregular outline of the bone)
MRI of SIJ:
- looking for joint oedema (not routinely performed due to low specificity)
TOMTIP: The classic x-ray finding in the digits is a “pencil-in-cup” appearance.
