Dermatology 1 Flashcards
What is your spot diagnosis for this patient?
Acanthosis nigricans
Acanthosis nigricans describes symmetrical, brown, velvety plaques that are often found on the neck, axilla and groin.
What is the pathophysiology?
insulin resistance → hyperinsulinemia → stimulation of keratinocytes and dermal fibroblast proliferation via interaction with insulin-like growth factor receptor-1 (IGFR1)
What may cause acanthosis nigricans?
obesity, T2DM
gastrointestinal cancer
PCOS
acromegaly
Cushing’s disease
hypothyroidism
Prader-Willi syndrome
drugs e.g. COCP
Acne is a common skin condition that involves inflammation of the pilosebaceous unit and is more common in adolescents.
What is the pathophysiology?
Multifactorial:
follicular epidermal hyperproliferation→ keratin plug → obstruction of the pilosebaceous follicle
colonisation by Propionibacterium acnes (anaerobic bacteria)
inflammation
How may acne be classified?
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
How should mild-moderate acne be managed?
a 12-week course of topical combination therapy should be tried first-line:
topical adapalene with topical benzoyl peroxide
topical benzoyl peroxide with topical clindamycin
topical tretinoin with topical clindamycin
topical benzoyl peroxide may be used as monotherapy if the person wishes to avoid using a topical retinoid or an antibiotic
How should moderate to severe acne be managed?
a 12-week course of one of the following options:
topical adapalene with topical benzoyl peroxide
topical adapalene with topical benzoyl peroxide + either oral lymecycline or oral doxycycline
topical tretinoin with topical clindamycin
COCP
Oral isotretinoin (secondary care)
What are the potential side effects of isotretinoin?
Dry skin and lips
Photosensitivity of the skin to sunlight
Depression, anxiety, aggression and suicidal ideation
Patients should be screened for mental health issues prior to starting treatment
Rarely Stevens-Johnson syndrome and toxic epidermal necrolysis
Which acne treatments are contraindicated in pregnancy?
tetracyclines (give erythromycin instead)
topical and oral retinoid treatment
What are the important points to remember about oral abx prescribing for acne?
Topical and oral antibiotics should not be used in combination
a topical retinoid or benzoyl peroxide should always be co-prescribed with oral antibiotics to reduce the risk of antibiotic resistance developing
only continue a tx option that includes abx for > 6 months in exceptional circumstances
tetracyclines should be avoided in pregnant/ breastfeeding women (use erythromycin instead) and in children <12
Which patients with acne should be referred to dermatology?
patients with acne conglobate acne: a rare and severe form of acne found mostly in men that presents with extensive inflammatory papules, suppurative nodules and cysts on the trunk
patients with nodulo-cystic acne
consider for patients with scarring and pigmentary changes
What are the possible complications associated with acne?
Gram-negative folliculitis: may occur as a complication of long-term antibiotic use for acne - give high-dose oral trimethoprim
Scarring
Progression to acne fulminans (emergency)
Psychological complications and social withdrawal
What type of scars may be caused by acne?
Ice pick scars : small indentations in the skin that remain after acne lesions heal
Hypertrophic scars: small lumps in the skin that remain after acne lesions heal
Rolling scars: irregular wave-like irregularities of the skin that remain after acne lesions heal
What is acne fulminans?
very severe acne associated with systemic upset (e.g. fever)
Hospital admission is often required and the condition usually responds to oral steroids
What is your spot diagnosis?
Actinic keratoses
Actinic keratoses is a common premalignant skin lesion that develops as a consequence of chronic sun exposure.
Describe the key features of these lesions
small, crusty or scaly, lesions
may be pink, red, brown or the same colour as the skin
typically on sun-exposed areas e.g. temples of head
How may actinic keratoses be managed?
prevention of further risk: e.g. sun avoidance, sun cream
fluorouracil cream: 2 to 3 week course
skin will become red and inflamed - sometimes topical hydrocortisone is given following fluorouracil to help settle the inflammation
cryotherapy
curettage and cautery
What is your spot diagnosis?
Alopecia areata
Alopecia areata is a presumed autoimmune condition causing hair loss.
Describe the pattern of hair loss seen
localised, well demarcated patches of hair loss
at the edge of the hair loss, there may be small, broken ‘exclamation mark’ hairs
How may alopecia areata be managed?
Hair will regrow in 50% of patients by 1 year, and in 80-90% eventually.
Other than reassurance, treatment options include:
topical or intralesional corticosteroids
topical minoxidil
phototherapy
dithranol
contact immunotherapy
wigs
Antihistamines (H1 inhibitors) are of value in the treatment of allergic rhinitis and urticaria.
Give some examples of sedating and non sedating anti-histamines.
Examples of sedating antihistamines:
chlorpheniramine
As well as being sedating these antihistamines have some antimuscarinic properties (e.g. urinary retention, dry mouth).
Examples of non-sedating antihistamines:
loratidine
cetirizine
What is your spot diagnosis?
Athlete’s foot - tinea pedis
Athlete’s foot (tinea pedis) is caused by which organism?
How does it present?
How may it be managed?
Trichophyton fungi
scaling, flaking, and itching between the toes
topical imidazole or terbinafine first-line
What is your spot diagnosis?
basal cell carcinoma - BCC
BCC is one of the 3 main types of skin cancer.
What are its main features?
mostly found on sun-exposed sites e.g. H+N
initially a pearly, flesh-coloured papule with telangiectasia
may later ulcerate leaving a central ‘crater’
What are the risk factors for developing a BCC?
Family hx
Increasing age
Male sex
Exposure to UV radiation, esp. in childhood
Fitzpatrick skin types I and II
Immunosuppression
Arsenic exposure
How may BCC be managed?
if a BCC is suspected, a routine referral should be made
Management options:
surgical removal
curettage
cryotherapy
topical cream: imiquimod, fluorouracil
radiotherapy
What are the standard surgical excision margins for a BCC?
4-5mm
What factors suggest increased risk of recurrence of BCC?
Tumour site (lesions on the central face)
Increasing tumour size
Poorly defined clinical margins
Histological features of aggression (perineural and ⁄ or perivascular involvement)
Failure of previous treatment
Immunosuppression
What is your spot diagnosis?
Bowen’s disease
What is Bowen’s disease?
a type of precancerous dermatosis that is a precursor to SCC
more common in elderly patients
5-10% chance of developing invasive skin cancer if left untreated
What are the key features of Bowen’s disease lesions?
red, scaly patches
often 10-15 mm in size
slow-growing
often occur on sun-exposed areas such as the head (e.g. temples) and neck, lower limbs
How can Bowen’s disease be managed?
topical 5-fluorouracil:
BD for 4 weeks
often results in significant inflammation/erythema
Topical steroids are often given to control this
cryotherapy
excision
What is your spot diagnosis?
Bullous pemphigoid
an autoimmune condition causing sub-epidermal blistering of the skin
Bullous pemphigoid is more common in elderly patients.
Features include:
itchy, tense blisters typically around flexures
the blisters usually heal without scarring
there is stereotypically no mucosal involvement (i.e. the mouth is spared)
What will be seen on skin biopsy of bullous pemphigoid?
immunofluorescence shows IgG and C3 at the dermoepidermal junction
How is bullous pemphigoid managed?
referral to a dermatologist for biopsy and confirmation of diagnosis
oral corticosteroids are the mainstay of treatment
topical corticosteroids, immunosuppressants and antibiotics are also used
What is your spot diagnosis?
cherry hemangioma
Cherry haemangiomas (Campbell de Morgan spots) are benign skin lesions which contain an abnormal proliferation of capillaries.
What are the key features of these lesions?
erythematous, papular lesions
typically 1-3 mm in size
non-blanching
not found on the mucous membranes
As they are benign no treatment is usually required
What are the 2 main types of contact dermatitis?
Irritant contact dermatitis: COMMON
non-allergic reaction due to weak acids or alkalis (e.g. detergents)
Often seen on the hands
Erythema is typical, crusting and vesicles are rare
Allergic contact dermatitis: UNCOMMON
type IV hypersensitivity reaction
seen on the head following hair dyes, acute weeping eczema which predominately affects the margins of the hairline
Topical treatment with a potent steroid is indicated
How can irritant contact dermatitis be managed?
avoid the trigger
emollients
topical corticosteroids
What is your spot diagnosis?
Dermatitis herpetiformis
autoimmune condition associated with coeliac disease
Dermatitis herpetiformis is an autoimmune blistering skin disorder associated with coeliac disease.
What is it caused by?
What are its key features?
How can it be investigated?
deposition of IgA in the dermis
itchy, vesicular skin lesions on the extensor surfaces (e.g. elbows, knees, buttocks)
skin biopsy: direct immunofluorescence shows deposition of IgA in a granular pattern in the upper dermis
How may dermatitis herpetiformis be managed?
dapsone
gluten free diet
What is your spot diagnosis?
Dermatofibroma