DERM Revision 2 Flashcards
Describe the pathophysiology of acne vulgaris [3]
Increase in Sebum Production:
- Primarily driven by hormonal (particularly testosterone) changes - stimulate sebaceous glands to produce more sebum
Follicular Hyperkeratinisation:
- abnormal keratinocyte proliferation and differentiation within the pilosebaceous unit
- results in the formation of a keratinous plug known as a microcomedo
Colonisation with P. acnes:
- The lipid-rich environment created by increased sebum production also promotes overgrowth of anaerobic bacteria like P. acnes
How do you differentiate acne to rosacea? [2]
Acne have comedones
- open (blackheads)
- closed (whiteheads)
- Scarring common
Rosacea:
- Rosacea often includes symptoms of flushing and ocular involvement which are not seen in acne vulgaris.
- The absence of scarring is more typical for rosacea
Describe what is meant by acne fulminans [1]
Acne fulminans
- severe form of acne conglobata with systemic features such a fever, arthralgia and lymphadenopathy.
- Hospital admission is often required and the condition usually responds to oral steroids
Describe how you treat mild [3], moderate [3] or severe acne [1]
NB can also use: antiandrogens e.g. spironolactone, cyproterone acetate
What is important to note about using abx to treat acne vulgaris? [1]
Topical AND oral antibiotics should not be used in combination in the treatment of acne
Alternative to repeated courses of isotretinoin = ? [2]
oral contraceptives e.g. microgynon
antiandrogens e.g. spironolactone, cyproterone acetate
Describe the clinical manifestatio of acne vulgaris [3]
Comedone Formation
- Closed comedones (whiteheads) occur when the follicular opening is obstructed completely
- Open comedones (blackheads) form when there is partial obstruction with exposure to air causing oxidation of melanin or lipids within the sebum.
Papule and Pustule Development
- inflammation persists around a blocked follicle, it can evolve into papules—small raised bumps indicating underlying inflammation without pus formation.
Nodule and Cyst Formation
Scarring can occur
Folliculitis is an inflammation of the hair follicles caused by bacterial infection, most commonly Staphylococcus aureus. It can mimic acne vulgaris but there are several distinguishing characteristics.
What are they? [3]
- Folliculitis lesions tend to have a more uniform appearance
- Distribution of folliculitis can occur anywhere there is hair growth (face, chest and back as with acne vulgaris)
- The presence of pruritus (itching) is more common in folliculitis than in acne vulgaris.
Perioral dermatitis presents as small papules and pustules around the mouth area. This condition can be mistaken for acne vulgaris due to similar lesion types; however, it differs which ways?
Limited to the perioral area (around the mouth), periocular area (around the eyes) or nasolabial folds, whereas acne vulgaris commonly affects the face, chest and back.
No comedones
Perioral dermatitis may appear scaly or dry, unlike acne vulgaris.
Describe the mangement of mild, moderate and severe acne vulgaris [+]
Mild: 12 week topical combination of any of the following:
* a fixed combination of topical adapalene with topical benzoyl peroxide
* a fixed combination of topical tretinoin with topical clindamycin
* a fixed combination of topical benzoyl peroxide with topical clindamycin
Moderate to severe acne: a 12-week course of one of the following options:
* a fixed combination of topical adapalene with topical benzoyl peroxide
* a fixed combination of topical tretinoin with topical clindamycin
* a fixed combination of topical adapalene with topical benzoyl peroxide + either oral lymecycline or oral doxycycline
* a topical azelaic acid + either oral lymecycline or oral doxycycline
Severe - not responding to treament
- Oral isotretinoin (derived from vitamin A and is a powerful anti-inflammatory agent)
NICE guideline 198 (June 2021) advises considering oral isotretinoin use in those over the age of 12 who have failed treatment with topical therapies and systemic antibiotics.
Examples include [4]
Nodulocystic acne
Acne conglobata
Acne fulminans
Acne at risk of permanent scarring
Name a side effect of using tetracylines for acne treatment if used in children under 8 years of age or in pregnant women? [1]
permanent teeth discolouration
What risks occur with isotretinoin prescription? [5]
Teratogenicity
hyperlipidaemia
hepatotoxicity
Sexual side effects: erectile disfunction, loss of libido, vaginal dryness
Photosensitivity
Depression & ? suicide ideation
What monitoring should you perform when prescribing isotretinoin? [3]
Liver function tests
Lipids
Pregnancy tests in female patients
Name this type of melanoma [1]
What sign is shown here? [1]
Subungual melanoma
Name this type of melanoma [1]
Characteristics? [+]
Amelanotic Melanoma
- no melanin
- firm
- grow fast
- look harmless
What does the Breslow thickness (mm) of a MM mean? [1]
What does the Clark level (I-V) refer to? [1]
What thickness inidcates a thin [1] and thick melanoma [1]
Breslow thickness (BT) is based on the vertical thickness of the tumour in millimetres.
Clark level (I-V) is a histological classification with estimated prognosis based upon the anatomical level of invasion into the skin.
Breslow Thickness and Clark level
Thin melanoma: < 0.8mm
Thick melanoma: >0.8mm
Describe the characteristics of Basal Cell Carcinoma (BCC)
- Shiny pink/red lump
- Slow growing, over months to years
- Sometimes red flat patches
- Form a recurrent crust that doesn’t heal
- Over time bleed/ulcerate in the middle, but may not be painful
- Usually sun-exposed sites: face, ears, scalp, hands, upper trunk
- Rarely metastasise
TURP: Telangiectasia Ulceration Rolled edges Pearly edges
Which type of skin cancer is most common? [1]
Basal Cell Carcinoma (BCC) (75%)
Which genetic conditions are a risk factor for BCC? [2]
Genetic disease:
* Gorlin syndrome
* Xeroderma pigmentosum
Describe test often perform in clinic to test for BCC [1]
Describe this type of BCC [1]
Morphoeic BCC
- sclerotic (scarred)
Describe the Dx [2] and Mx [3] of BCC
Diagnosis
History
Skin biopsy from ulcer edge
Management
Excision
Radiotherapy
Superficial BCCs – 5-flourouracil or imiquimod cream
Describe the characteristics of SCC [+]
- Enlarging scaly/crusted lumps
- Grow rapidly over weeks
- May ulcerate
- Often tender/painful/bleed (except in IC ptx)
- Usually arise within pre-existing actinic keratosis or intraepidermal carcinoma
- Commonly face, lips, ears, hands and limps
- Rarely metastasises
- Often have hyperkerotic horn / no rolled border
Dx? [1]
Describe this [1]
Actinic Keratoses
- hyperkeratotic papules on a background of sun-damaged skin
- Actinic keratosis involves the formation of precancerous scaly lesions on the skin
- Actinic keratoses have around a 10% risk of developing into an SCC, therefore monitoring and treatment are important
Superficial form of SSC = ? [1]
Bowens Disease
H
Describe the characteristics of Seborrheic Keratoses [+]
- Very common
- Present in >90% of people over 60
- Increase in number with time
- Often develop in middle aged
- Waxy or warty surface
- Flat or plaques
- Stuck on appearance
Name and describe this type of skin condition [3]
Junctional Naevi
* Mole
* Flat
* Pigmented
* Regular, symmetrical, static appearance
GO over
What are solar lentigo?
Solar lentigo
- is a harmless patch of darkened skin. It results from exposure to ultraviolet (UV) radiation, which causes local proliferation of melanocytes and accumulation of melanin within the skin cells (keratinocytes)
- aka sun spots
Name and describe this type of skin condition [3]
-
Compound Naevi
Mole
Central raised area
Surrounded by flat pigmentation
On palm of hands or feet
Dx? [1]
Acral Naevi
Name and describe this type of skin condition [1]
Naevus Spilus
- Nevus spilus, also known as speckled lentiginous nevus, is a light brown or tan birth mark, speckled with small, dark spots or small bumps.
- Malignant change very rare
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Desmoplastic melanoma
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Desmoplastic melanoma
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Desmoplastic melanoma
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Desmoplastic melanoma
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Desmoplastic melanoma
Lentigo maligna
- Lentigo maligna is an early form of melanoma in which the malignant cells are confined to the tissue of origin, the epidermis
, hence it is often reported as ‘in situ’ melanoma. It occurs in sun damaged skin so is generally found on the face or neck, particularly the nose and cheek. It grows slowly in diameter over 5 to 20 years or longer.
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Desmoplastic melanoma
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Desmoplastic melanoma
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Desmoplastic melanoma
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Desmoplastic melanoma
[] occurs in the elderly on chronically sun-exposed sites.
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Desmoplastic melanoma
[] occurs in the elderly on chronically sun-exposed sites.
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Desmoplastic melanoma
How do you investigate for MM? [1]
All patients require a careful skin and lymph node examination.
- ALWAYS send for histology
- Suspicious lesions should be excised with a narrow (2mm) margin
- NEVER shave or curette a suspected melanoma
Describe what is meant by Gorlin syndrome [1]
A rare autosomal dominant condition that occurs as a result of gene mutation, specifically the PTCH1 gene. Individuals with Gorlin syndrome typically begin to develop BCCs during adolescence or early adulthood.
What are the clinical sub-types of BCC? [5]
Describe how the present
There are several clinical sub-types of BCC, including:
nodular
- red / flesh-coloured and have well-defined borders with overlying telangiectasias. As they grow, they may develop central ulceration (Rodent ulcer).
superficial
- slow-growing erythematous plaques that may be dry or crusted or have a slight bluish tinge
morphoeic
- scar-like lesion or indentation; they commonly occur on the upper trunk or face.
pigmented
- Pigmented BCCs may be difficult to distinguish from melanoma.
basosquamous:
- A rare, but aggressive form of BCC with increased risk of recurrance and even metastasis.
Describe what is meant by Bowen’s disease [1]
Bowen’s disease (also known as SCC in situ) occurs when the cancerous cells are confined to the epidermis.15 It can also progress into invasive SCC, so it is important to monitor and treat Bowen’s disease promptly.
Describe the differences in a good and bad prognosis for squamous skin cell cancer [4]
High-risk features include:
Size: >2mm deep or >20mm wide
Site: face, ear, genitals, hands, feet
Recurrence
Immunosuppressed individual
Poor differentiation (histologically)
Perineural invasion (histologically)
High tumour budding
Geeky medics^
Tx for serborrheic keratoses? [2]
- reassurance about the benign nature of the lesion is an option
- options for removal include curettage, cryosurgery and shave biopsy
Name and describe this type of skin condition [3]
Junctional Naevi
Flat
Pigmented
Regular, symmetrical, static appearance
Name and describe this type of skin condition [3]
Intradermal Naevi
* Protrude from the skin surface
* Pigmented or flesh coloured
Name and describe this type of skin condition [1]
Blue Naevi
- solitary, bluish, smooth surfaced macule, papule or plaque. They are generally round or oval in shape.
Name and describe this type of skin condition [1]
Dermatofibroma
- common benign fibrous skin lesions. They are caused by the abnormal growth of dermal dendritic histiocyte cells, often following a precipitating injury
