DERM Revision 2

Question 2

Describe the pathophysiology of acne vulgaris [3]

Answer 2

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

Question 3

How do you differentiate acne to rosacea? [2]

Answer 3

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

Question 4

Describe what is meant by acne fulminans [1]

Answer 4

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

Question 5

Describe how you treat mild [3], moderate [3] or severe acne [1]

Answer 5

NB can also use: antiandrogens e.g. spironolactone, cyproterone acetate

Question 6

What is important to note about using abx to treat acne vulgaris? [1]

Answer 6

Topical AND oral antibiotics should not be used in combination in the treatment of acne

Question 7

Alternative to repeated courses of isotretinoin = ? [2]

Answer 7

oral contraceptives e.g. microgynon

antiandrogens e.g. spironolactone, cyproterone acetate

Question 8

Describe the clinical manifestatio of acne vulgaris [3]

Answer 8

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

Question 9

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]

Answer 9

• 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.

Question 10

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?

Answer 10

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.

Question 11

Describe the mangement of mild, moderate and severe acne vulgaris [+]

Answer 11

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)

Question 12

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]

Answer 12

Nodulocystic acne
Acne conglobata
Acne fulminans
Acne at risk of permanent scarring

Question 13

Name a side effect of using tetracylines for acne treatment if used in children under 8 years of age or in pregnant women? [1]

Answer 13

permanent teeth discolouration

Question 14

What risks occur with isotretinoin prescription? [5]

Answer 14

Teratogenicity
hyperlipidaemia
hepatotoxicity
Sexual side effects: erectile disfunction, loss of libido, vaginal dryness
Photosensitivity
Depression & ? suicide ideation

Question 15

What monitoring should you perform when prescribing isotretinoin? [3]

Answer 15

Liver function tests
Lipids
Pregnancy tests in female patients

Question 16

Name this type of melanoma [1]
What sign is shown here? [1]

Answer 16

Subungual melanoma

Question 17

Name this type of melanoma [1]

Characteristics? [+]

Answer 17

Amelanotic Melanoma
- no melanin
- firm
- grow fast
- look harmless

Question 18

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]

Answer 18

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

Question 19

Describe the characteristics of Basal Cell Carcinoma (BCC)

Answer 19

• 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

Question 20

Which type of skin cancer is most common? [1]

Answer 20

Basal Cell Carcinoma (BCC) (75%)

Question 21

Which genetic conditions are a risk factor for BCC? [2]

Answer 21

Genetic disease:
* Gorlin syndrome
* Xeroderma pigmentosum

Question 22

Describe test often perform in clinic to test for BCC [1]

Answer 22

Question 23

Describe this type of BCC [1]

Answer 23

Morphoeic BCC
- sclerotic (scarred)

Question 24

Describe the Dx [2] and Mx [3] of BCC

Answer 24

Diagnosis
History
Skin biopsy from ulcer edge

Management
Excision
Radiotherapy
Superficial BCCs – 5-flourouracil or imiquimod cream

Question 25

Describe the characteristics of SCC [+]

Answer 25

* **Enlarging scaly/crusted lump**s * 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

Question 26

Dx? [1] Describe this [1]

Answer 26

**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

Question 27

Superficial form of SSC = ? [1]

Answer 27

**Bowens Disease**

Question 28

# H Describe the characteristics of Seborrheic Keratoses [+]

Answer 28

* 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

Question 29

Name and describe this type of skin condition [3]

Answer 29

**Junctional Naevi** * Mole * Flat * Pigmented * Regular, symmetrical, static appearance | GO over

Question 30

What are solar lentigo?

Answer 30

**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**

Question 31

Name and describe this type of skin condition [3]

Answer 31

* **Compound Naevi** Mole **Central raised area** Surrounded by flat pigmentation

Question 32

On palm of hands or feet Dx? [1]

Answer 32

Acral Naevi

Question 33

Name and describe this type of skin condition [1]

Answer 33

**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**

Question 34

https://www.passmedicine.com/menu.php#

Question 35

What are risk factors for malignant melanoma? [5]

Answer 35

**UV Radiation** - UVB causes direct DNA damage **Skin Type** - (Fitzpatrick Skin types I & II) **Melanocytic naevi** - **multiple (>100) or giant (>20 cm) naevi** - **Congenital melanocytic naevi** (moles present from birth, or that develop within the first few months after birth, are called congenital melanocytic nevi) - **Atypical mole syndrome** (AMS): >1 pigmented lesions on the iris; >1 naevi on buttocks or instep naevi on anterior scalp; ≥2 atypical naevi; >100 naevi **Genetics** - CDK4, xeroderma pigmentosum, melanocortin 1 receptor **Previous skin cancer** - Previous melanoma **Immunosuppression** - HIV/AIDS - Organ transplant recipient - Lymphoproliferative disease - Anti-TNF treatment

Question 36

Which is the most common place to get MM in men? Skin of lower limb Skin of trunk Skin of upper limb Head or neck

Answer 36

Which is the most common place to get MM in men? Skin of lower limb **Skin of trunk** Skin of upper limb Head or neck

Question 37

Which is the most common place to get MM in women? Skin of lower limb Skin of trunk Skin of upper limb Head or neck

Answer 37

Which is the most common place to get MM in women? **Skin of lower limb** Skin of trunk Skin of upper limb Head or neck

Question 38

Histologically, melanomas are divided into five major subtypes. What are they? [5]

Answer 38

Superficial spreading (70%) Nodular (15%) Lentigo maligna (10%) Acral lentiginous (< 5%) Desmoplastic melanoma (< 1%)

Question 39

Superficial spreading Nodular Lentigo maligna Acral lentiginous Desmoplastic melanoma

Answer 39

Superficial spreading Nodular Lentigo maligna **Acral lentiginous** Desmoplastic melanoma

Question 40

Superficial spreading Nodular Lentigo maligna Acral lentiginous Desmoplastic melanoma

Answer 40

Superficial spreading Nodular Lentigo maligna **Acral lentiginous** Desmoplastic melanoma

Question 41

Superficial spreading Nodular Lentigo maligna Acral lentiginous Desmoplastic melanoma

Answer 41

**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.

Question 42

Superficial spreading Nodular Lentigo maligna Acral lentiginous Desmoplastic melanoma

Answer 42

Superficial spreading **Nodular** Lentigo maligna Acral lentiginous Desmoplastic melanoma

Question 43

Superficial spreading Nodular Lentigo maligna Acral lentiginous Desmoplastic melanoma

Answer 43

**Superficial spreading** Nodular Lentigo maligna Acral lentiginous Desmoplastic melanoma

Question 44

Which of the following are typically more seen at a more advanced stage. Superficial spreading Nodular Lentigo maligna Acral lentiginous Desmoplastic melanoma

Answer 44

Which of the following are typically more seen at a more advanced stage. They transition immediately into the vertical growth phase. Because of this, it is usually diagnosed at a more advanced stage. Superficial spreading **Nodular** Lentigo maligna Acral lentiginous Desmoplastic melanoma

Question 45

**[]** occurs in the elderly on chronically sun-exposed sites. Superficial spreading Nodular Lentigo maligna Acral lentiginous Desmoplastic melanoma

Answer 45

**[]** occurs in the elderly on chronically sun-exposed sites. Superficial spreading Nodular **Lentigo maligna** Acral lentiginous Desmoplastic melanoma

Question 46

How do you investigate for MM? [1]

Answer 46

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

Question 47

Management is complex and guided by the **Melanoma Multidisciplinary Team (MDT)**. Describe the different treatment options

Answer 47

**Surgical**: - **WLE** represents the standard treatment for primary melanoma. Involves removal of the biopsy scar with a surrounding margin of ‘healthy’ skin, with fat, down to muscular fascia. This margin is determined by the Breslow thickness. - **Sentinel Lymph Node Biopsy (SLNB)** - **Electrochemotherapy** is a relatively new therapy for patients with locally advanced melanoma. **Medical** (typically adjuvant therapy) - Chemotherapy - Radiotherapy - Immunotherapy

Question 48

Which factors determine if a MM prognosis? [5]

Answer 48

**Breslow thickness** **Clark level** **Ulceration** - . It is suggestive of an aggressive tumour phenotype with greater likelihood for invasion and metastasis. **Mitotic index** (an indicator of cell turnover) is also an important histological finding.

Question 49

Describe what is meant by **Gorlin syndrome** [1]

Answer 49

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**.

Question 50

What are the clinical sub-types of BCC? [5] Describe how the present

Answer 50

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.

Question 51

Types of BCC: **[]** and **[]** BCCs are considered low-risk, whereas **[]** is high-risk due to their extensive local spread and high recurrence rate.

Answer 51

**Nodular** and **superficial** BCCs are considered **low-risk**, whereas **morpheaform** is **high-risk** due to their extensive local spread and high recurrence rate.

Question 52

Describe the different treatment options for low and high risk BCC [+]

Answer 52

The main goal of treatment is the **complete** **removal** of the **tumour** with **preservation** of the **function** and **cosmesis** of the **affected area.** The type of treatment depends on whether the BCC is **low or high risk** **Low risk:** - **complete** **surgical** **removal** or **electrodesiccation** and **curettage** **(ED&C)** - **Superficial BCCs** – 5-flourouracil or imiquimod cream **High risk** - **Mohs micrographic surgery** is a specialist removal method for non-melanoma skin cancers with high recurrence risk - As an alternative for high-risk lesions, **simple resection with adjunct radiotherapy** has been recommended

Question 53

Describe what is meant by Bowen's disease [1]

Answer 53

**Bowen’s disease** (also known as SCC in situ) occurs when the cancerous cells are c**onfined to the epidermis**.15 It can also progress into **invasive SCC,** so it is important to monitor and treat Bowen’s disease promptly.

Question 54

Describe the management of squamous cell skin cancer [3]

Answer 54

**Surgical excision** with **4mm** **margins** if lesion **< 20mm** in diameter. If tumour **>20mm** then margins should be **6mm.** **Mohs micrographic surgery** may be used in **high-risk patients** and in **cosmetically important sites.**

Question 55

Squamous skin cell cancer commonly mets to...[3]

Answer 55

The most commonly affected sites are **lungs, liver and brain.**

Question 56

Describe the differences in a good and bad prognosis for squamous skin cell cancer [4]

Answer 56

**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^*

Question 57

For Bowen’s disease, therapies such as **[]** or therapies like **[]** are first-line management

Answer 57

For Bowen’s disease, **destructive** **therapies** such as **cryotherapy** or topical therapies like **5-fluorouracil are first-line managemen**t.8

Question 58

Tx for serborrheic keratoses? [2]

Answer 58

* **reassurance** about the benign nature of the lesion is an option * options for removal include **curettage, cryosurgery and shave biopsy**

Question 59

Name and describe this type of skin condition [3]

Answer 59

**Junctional Naevi** Flat Pigmented Regular, symmetrical, static appearance

Question 60

Name and describe this type of skin condition [3]

Answer 60

**Intradermal Naevi** * Protrude from the skin surface * Pigmented or flesh coloured

Question 61

Name and describe this type of skin condition [1]

Answer 61

**Blue Naevi** - solitary, bluish, smooth surfaced macule, papule or plaque. They are generally round or oval in shape.

Question 62

Name and describe this type of skin condition [1]

Answer 62

**Dermatofibroma** - common benign fibrous skin lesions. They are caused by the abnormal growth of dermal dendritic histiocyte cells, often following a precipitating injury

Question 63

Describe the management options for Actinic Keratoses [4]

Answer 63

**Management options include**: - prevention of further risk: e.g. sun avoidance, sun cream - **fluorouracil cream**: typically a 2 to 3 week course. The skin will become red and inflamed - **sometimes topical hydrocortisone** is given following fluorouracil to help settle the inflammation - **topical diclofenac**: may be used for **mild AKs**. Moderate efficacy but much fewer side-effects - **Imiquimod** can be used for lesions on the face and scalp when cryotherapy or other topical treatments cannot be used.