Derma (Skin disorder Associated malignancies)

Question 1

Skin disorder Associated malignancies

Answer 1

Acanthosis nigricans Gastric cancer
Acquired ichthyosis Lymphoma
Acquired hypertrichosis lanuginosa Gastrointestinal and lung cancer
Dermatomyositis Ovarian and lung cancer
Erythema gyratum repens Lung cancer
Erythroderma Lymphoma
Migratory thrombophlebitis Pancreatic cancer
Necrolytic migratory erythema Glucagonoma
Pyoderma gangrenosum (bullous and non-bullous forms) Myeloproliferative disorders
Sweet’s syndrome Haematological malignancy e.g. Myelodysplasia - tender, purple plaques
Tylosis Oesophageal cancer

Question 2

ALOPECIA

Answer 2

A- anticancer drugs like cycophosphamide, adriamycin
L- lithium
O- OCP withdrawal
P- PTU
E- ethionamide,
C- colchicine, carbimazole
I- interferons
A- anticoagulant like heparin, Vit A excess

Question 3

Squamous cell carcinoma of the skin
Prognostic factots

Answer 3

Good Prognosis
Well differentiated tumors
<20mm diameter
<2mm deep
No associated diseases

Poor prognosis
Poorly differentiated tumours
>20mm in diameter
>4mm deep
Immunosuppression for whatever reason

Question 4

Acne vulgaris: management

Answer 4

Acne vulgaris is a common skin disorder which usually occurs in adolescence. It typically affects the face, neck and upper trunk and is characterised by the obstruction of the pilosebaceous follicles with keratin plugs which results in comedones, inflammation and pustules.

Acne may be classified into mild, moderate or severe:
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

For people with mild to moderate acne:
a 12-week course of topical combination therapy should be tried first-line:
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
topical benzoyl peroxide may be used as monotherapy if these options are contraindicated or the person wishes to avoid using a topical retinoid or an antibiotic

For people with 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
important points about oral antibiotic usage:
tetracyclines should be avoided in pregnant or breastfeeding women and in children younger than 12 years of age. Erythromycin may be used in pregnancy
minocycline is now considered less appropriate due to the possibility of irreversible pigmentation
only continue a treatment option that includes an antibiotic (topical or oral) for more than 6 months in exceptional circumstances
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
combined oral contraceptives (COCP) are an alternative to oral antibiotics in women
as with antibiotics, they should be used in combination with topical agents
Dianette (co-cyprindiol) is sometimes used as it has anti-androgen properties. However, it has an increased risk of venous thromboembolism compared to other COCPs, therefore it should generally be used second-line, only be given for 3 months and women should be appropriately counselled about the risks
oral isotretinoin: only under specialist supervision
pregnancy is a contraindication to topical and oral retinoid treatment

To reduce the risk of antibiotic resistance developing the following should not be used to treat acne:
monotherapy with a topical antibiotic
monotherapy with an oral antibiotic
a combination of a topical antibiotic and an oral antibiotic

NICE referral criteria
the following patients should be referred to a dermatologist:
patients with acne conglobate acne: a rare and severe form of acne found mostly in men that presents with extensive inflammatory papules, suppurative nodules (that may coalesce to form sinuses) and cysts on the trunk.
patients with nodulo-cystic acne
referral should be considered in the following scenarios:
mild to moderate acne has not responded to two completed courses of treatment
moderate to severe acne has not responded to previous treatment that includes an oral antibiotic
acne with scarring
acne with persistent pigmentary changes
acne is causing or contributing to persistent psychological distress or a mental health disorder

Question 5

Rosacea Management

Answer 5

Rosacea (sometimes referred to as acne rosacea) is a chronic skin disease of unknown aetiology.

Features
nose, cheeks and forehead
flushing is often first symptom
telangiectasia are common
erythema with papules and pustules
rhinophyma
ocular involvement: blepharitis
sunlight may exacerbate symptoms

Management
simple measures:
-high-factor sunscreen
-camouflage creams may help conceal redness
predominant erythema/flushing:
-topical brimonidine gel
-brimonidine is a topical alpha-adrenergic agonist
mild-to-moderate papules and/or pustules:
-topical ivermectin is first-line
-alternatives include: topical metronidazole or topical azelaic acid
moderate-to-severe papules and/or pustules:
-combination of topical ivermectin + oral doxycycline

Referral should be considered if
-symptoms have not improved with optimal management in primary care
-laser therapy may be appropriate for patients with prominent telangiectasia
-patients with a rhinophyma

Question 6

Psoriasis: management

Answer 6

Chronic plaque psoriasis management
Secondary care management
-Phototherapy
-Systemic therapy
Scalp psoriasis management
Face, flexural and genital psoriasis management

Chronic plaque psoriasis management

NICE recommend a step-wise approach for chronic plaque psoriasis
>Regular emollients: may help to reduce scale loss and reduce pruritus
>1st line: potent corticosteroid + vitamin D analogue applied once daily
should be applied separately, one morning and the other in evening)
for up to 4 weeks as initial treatment
>2nd line: if no improvement after 8 weeks then offer: vitamin D analogue twice daily
>3rd line: if no improvement after 8-12 weeks then offer either: potent corticosteroid applied twice daily for up to 4 weeks, or
-coal tar preparation applied once or twice daily
-dithranol can also be used

Secondary care management

Phototherapy
narrowband ultraviolet B light is now the treatment of choice. If possible this should be given 3 times a week
photochemotherapy is also used - psoralen + ultraviolet A light (PUVA)
adverse effects: skin ageing, squamous cell cancer (not melanoma)

Systemic therapy
oral methotrexate is used first-line - particularly useful if there is associated joint disease
ciclosporin
systemic retinoids
biological agents: infliximab, etanercept and adalimumab
ustekinumab (IL-12 and IL-23 blocker) is showing promise in early trials

Scalp psoriasis management
-potent topical corticosteroids used once daily for 4 weeks
if no improvement after 4 weeks then either use a different formulation of the potent corticosteroid (for example, a shampoo or mousse) and/or a topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid

Face, flexural and genital psoriasis management
-mild or moderate potency corticosteroid applied once or twice daily for a maximum of 2 weeks