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Dermatology 1 Flashcards

1
Q

What is your spot diagnosis for this patient?

A

Acanthosis nigricans

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2
Q

Acanthosis nigricans describes symmetrical, brown, velvety plaques that are often found on the neck, axilla and groin.

What is the pathophysiology?

A

insulin resistance → hyperinsulinemia → stimulation of keratinocytes and dermal fibroblast proliferation via interaction with insulin-like growth factor receptor-1 (IGFR1)

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3
Q

What may cause acanthosis nigricans?

A

obesity, T2DM
gastrointestinal cancer
PCOS
acromegaly
Cushing’s disease
hypothyroidism
Prader-Willi syndrome
drugs e.g. COCP

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4
Q

Acne is a common skin condition that involves inflammation of the pilosebaceous unit and is more common in adolescents.

What is the pathophysiology?

A

Multifactorial:

follicular epidermal hyperproliferation→ keratin plug → obstruction of the pilosebaceous follicle

colonisation by Propionibacterium acnes (anaerobic bacteria)

inflammation

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5
Q

How may acne be classified?

A

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

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6
Q

How should mild-moderate acne be managed?

A

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

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7
Q

How should moderate to severe acne be managed?

A

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)

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8
Q

What are the potential side effects of isotretinoin?

A

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

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9
Q

Which acne treatments are contraindicated in pregnancy?

A

tetracyclines (give erythromycin instead)
topical and oral retinoid treatment

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10
Q

What are the important points to remember about oral abx prescribing for acne?

A

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

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11
Q

Which patients with acne should be referred to dermatology?

A

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

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12
Q

What are the possible complications associated with acne?

A

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

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13
Q

What type of scars may be caused by acne?

A

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

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14
Q

What is acne fulminans?

A

very severe acne associated with systemic upset (e.g. fever)

Hospital admission is often required and the condition usually responds to oral steroids

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15
Q

What is your spot diagnosis?

A

Actinic keratoses

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16
Q

Actinic keratoses is a common premalignant skin lesion that develops as a consequence of chronic sun exposure.

Describe the key features of these lesions

A

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

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17
Q

How may actinic keratoses be managed?

A

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

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18
Q

What is your spot diagnosis?

A

Alopecia areata

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19
Q

Alopecia areata is a presumed autoimmune condition causing hair loss.

Describe the pattern of hair loss seen

A

localised, well demarcated patches of hair loss

at the edge of the hair loss, there may be small, broken ‘exclamation mark’ hairs

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20
Q

How may alopecia areata be managed?

A

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

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21
Q

Antihistamines (H1 inhibitors) are of value in the treatment of allergic rhinitis and urticaria.

Give some examples of sedating and non sedating anti-histamines.

A

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

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22
Q

What is your spot diagnosis?

A

Athlete’s foot - tinea pedis

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23
Q

Athlete’s foot (tinea pedis) is caused by which organism?

How does it present?

How may it be managed?

A

Trichophyton fungi

scaling, flaking, and itching between the toes

topical imidazole or terbinafine first-line

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24
Q

What is your spot diagnosis?

A

basal cell carcinoma - BCC

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25
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'
26
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
27
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
28
What are the standard surgical excision margins for a BCC?
4-5mm
29
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
30
What is your spot diagnosis?
Bowen's disease
31
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
32
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
33
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
34
What is your spot diagnosis?
Bullous pemphigoid an autoimmune condition causing sub-epidermal blistering of the skin
35
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)
36
What will be seen on skin biopsy of bullous pemphigoid?
immunofluorescence shows IgG and C3 at the dermoepidermal junction
37
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
38
What is your spot diagnosis?
cherry hemangioma
39
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
40
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
41
How can irritant contact dermatitis be managed?
avoid the trigger emollients topical corticosteroids
42
What is your spot diagnosis?
Dermatitis herpetiformis autoimmune condition associated with coeliac disease
43
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
44
How may dermatitis herpetiformis be managed?
dapsone gluten free diet
45
What is your spot diagnosis?
Dermatofibroma
46
Dermatofibromas (also known as histiocytomas) are common benign fibrous skin lesions. What are they caused by? What features do they present with?
They are caused by the abnormal growth of dermal dendritic histiocyte cells, often following a precipitating injury. Features: solitary firm papule or nodule, typically on a limb typically around 5-10mm in size overlying skin dimples on pinching the lesion
47
What is your spot diagnosis?
Eczema herpeticum
48
What is eczema herpeticum?
severe primary infection of the skin by HSV 1 or 2 presents as a rapidly progressing painful rash, most commonly in children with atopic eczema
49
How does eczema herpectium present on examination? How should it be managed?
OE: monomorphic punched-out erosions usually 1-3 mm in diameter lymphadenopathy systemic symptoms such as fever, lethargy, irritability and reduced oral intake viral swabs, admission for IV aciclovir
50
What is the potential complication of eczema herpeticum?
Bacterial superinfection can occur, leading to a more severe illness - requires abx
51
What is your spot diagnosis?
Atopic eczema
52
What is atopic eczema? How does it present?
a chronic atopic condition caused by defects in the normal continuity of the skin barrier, leading to inflammation in the skin dry, red, itchy and sore patches of skin over the flexor surfaces (the inside of elbows and knees) and on the face and neck
53
How can atopic eczema be managed?
Maintenance: avoiding allergens and irritants soap substitutes emollients Flares: thicker emollients topical steroids “wet wraps” antihistamines if very itchy treating any bacterial infections
54
Why may you advise a patient with eczema to use a cream during the day time and an ointment at night?
creams soak into the skin faster than ointments, they are lighter and feel more comfortable
55
Which emollients can be used in the mx of eczema?
Thin creams: E45 Diprobase cream Cetraben cream Epaderm cream Thick, greasy emollients: 50:50 ointment (50% liquid paraffin) Hydromol ointment Diprobase ointment Cetraben ointment Epaderm ointment
56
What steroids may be used in the management of eczema? (mild-very potent)
Mild: Hydrocortisone 0.5%, 1% and 2.5% Moderate: Eumovate (clobetasone butyrate 0.05%) Potent: Betnovate (betamethasone 0.1%) Very potent: Dermovate (clobetasol propionate 0.05%)
57
What is the finger tip rule for steroid tx of eczema?
1 finger tip unit (FTU) = 0.5 g, sufficient to treat a skin area about twice that of the flat of an adult hand
58
What are the potential side effects of long term topical steroid use for eczema? What should you do to reduce risk?
skin thinning and telangiectasia Only weak steroids used very cautiously should be applied to areas of thin skin such as the face, around the eyes and in the genital region. It is best to completely avoid steroids in these areas in children.
59
What practical advice can you give people for applying topical eczema treatments?
emollients can become contaminated with bacteria - fingers should not be inserted into pots (many brands have pump dispensers) if a topical steroid is also being used the emollient should be applied first followed by waiting at least 30 minutes before applying the topical steroid
60
What is the most common cause of secondary bacterial infection of eczema? How is this managed ?
staphylococcus aureus tx = oral antibiotics, particularly flucloxacillin
61
What is your spot diagnosis?
Erythema ab igne
62
What is erythema ab igne?
a skin disorder caused by over exposure to infrared radiation characteristic features include reticulated, erythematous patches with hyperpigmentation and telangiectasia classic hx = elderly lady who sits by open fire, hot water bottle placed directly on skin e.g. for cramps
63
What is your spot diagnosis?
Erythema multiforme
64
What is erythema multiforme? What features may it present with?
a hypersensitivity reaction that is most commonly triggered by infections minor and major forms Features: target lesions initially seen on the back of the hands / feet before spreading to the torso upper limbs are more commonly affected pruritus is occasionally seen and is usually mild
65
What may cause erythema multiforme?
idiopathic viruses: herpes simplex virus (most common cause) , mycoplasma pneumoniae bacteria: Mycoplasma, Streptococcus drugs: penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, COCP connective tissue disease e.g. SLE sarcoidosis malignancy
66
How may erythema mutiforme be managed?
clear underlying cause, for example a recent coldsore or treatment with penicillin = managed supportively no clear underlying cause = further investigations e.g. CXR to look for mycoplasma pneumonia major form = IV fluids, analgesia and steroids
67
What is your spot diagnosis?
Erythema multiforme major
68
What is erythema multiforme major?
more severe form of erythema multiforme, associated with mucosal involvement
69
What is your spot diagnosis?
Erythema nodosum
70
What is erythema nodosum?
inflammation of subcutaneous fat typically causes tender, erythematous, nodular lesions usually occurs over shins, may also occur elsewhere (e.g. forearms, thighs) usually resolves within 6 weeks lesions heal without scarring
71
Give some common causes of erythema nodosum
NODOSUM Normal (idiopathic) Oncology (malignancy) Drugs (e.g. penicllin) Oral Contraceptives Sarcoidosis Ulcerative colitis/Crohns Microbiology - Tb, Viral, Bacterial, Fungal
72
What investigations would you do to look for the underlying cause of erythema nodosum?
Inflammatory markers (CRP and ESR) Throat swab for streptococcal infection Chest xray for mycoplasma, TB , sarcoidosis and lymphoma Stool microscopy and culture for campylobacter and salmonella Faecal calprotectin for inflammatory bowel disease
73
How is erythema nodosum generally managed?
managed conservatively with rest and analgesia and treating the underlying cause Steroids may be used to help settle the inflammation Most cases will fully resolve within 6 weeks
74
What is your spot diagnosis?
Erythroderma (also known as exfoliative dermatitis)
75
What is erythroderma?
when more than 95% of the skin is involved in a rash of any kind Causes of erythroderma: eczema psoriasis lymphomas, leukaemias idiopathic drugs
76
How can erythroderma be managed?
hospitalisation may be required for patients with severe erythroderma due to the risk of complications such as dehydration, temperature dysregulation, and sepsis withdrawal of any offending drugs consider high dose systemic steroids if underlying skin condition
77
What is your spot diagnosis? What are the most common causative organisms?
fungal nail infection - thickened, rough, opaque nails are the most common finding dermatophytes: 90% of cases mainly Trichophyton rubrum yeasts: 10% of cases e.g. Candida
78
What are the risk factors for developing fungal nail infections?
increasing age diabetes mellitus psoriasis repeated nail trauma
79
How should fungal nail infections be investigated and managed?
Investigations: nail clippings +/- scrapings of the affected nail microscopy and culture Management: limited involvement = topical treatment with amorolfine 5% nail lacquer; 6 months for fingernails and 9 - 12 months for toenails extensive involvement, dermatophyte infection = oral terbinafine extensive involvement, candida infection = oral itraconazole
80
What is your spot diagnosis?
Guttate psoriasis
81
Guttate psoriasis is more common in children and adolescents. What can trigger it? What features does it present with?
may be precipitated by a streptococcal infection 2-4 weeks prior to the lesions appearing Features tear drop papules on the trunk and limbs tends to be acute onset over days
82
How may guttate psoriasis be managed?
most cases resolve spontaneously within 2-3 months there is no firm evidence to support the use of antibiotics to eradicate streptococcal infection tonsillectomy may be necessary with recurrent episodes topical agents as per psoriasis, UVB phototherapy
83
How can you differentiate between guttate psoriasis and its main ddx, pityriasis rosea?
guttate psorasis usually preceeded by streptococcal infection, pityriasis doesn't necessarily have a specific trigger guttate psoriasis = 'tear drop', scaly papules on the trunk and limbs pityriasis = herald patch followed 1-2 weeks later by multiple erythematous, slightly raised oval lesions
84
What is your spot diagnosis?
Hidradenitis suppurativa - also known as acne invertus
85
Hidradenitis suppurativa (HS) is a chronic, painful, inflammatory skin disorder. What are the risk factors for developing it?
Family history Smoking Obesity, diabetes, PCOS Mechanical stretching of skin
86
How does Hidradenitis suppurativa (HS) present?
recurrent, painful, and inflamed nodules occurs most commonly on intertriginous skin axilla is the most common site nodules may rupture = smelly purulent discharge coalescence of nodules = plaques, sinus tracts and 'rope-like' scarring
87
How can HS be managed?
Encourage good hygiene and loose-fitting clothing Smoking cessation Weight loss in obese Acute flares can be treated with steroids or flucloxacillin Long-term disease can be treated with topical or oral antibiotics Surgical incision and drainage may be needed in some cases
88
What are the potential complications of HS?
Sinus tracts, fistulas Comedones Scarring - severe scarring can lead to dense, rope-like bands in the skin with strictures and lymphedema Contractures Lymphatic obstruction
89
DDx for HS?
Acne vulgaris - primarily occurs on the face, upper chest, and back, whereas HS primarily involves intertriginous areas Follicular pyodermas (folliculitis, furuncles, carbuncles) - Unlike HS, follicular pyodermas are transient and respond rapidly to antibiotics Granuloma inguinale (donovanosis) - STI caused by Klebsiella granulomatis. Suspect donovanosis if there is an enlarging ulcer that bleeds in the inguinal area
90
What is the difference between hirsutism and hypertrichosis?
Hirsutism is often used to describe androgen-dependent hair growth in women, with hypertrichosis being used for androgen-independent hair growth
91
What is the most common cause of hirsutism?
PCOS Other causes: Cushing's syndrome congenital adrenal hyperplasia androgen therapy obesity: thought to be due to insulin resistance
92
How can hirsutism be managed?
advise weight loss if overweight cosmetic techniques such as waxing/bleaching - not available on the NHS consider using COCP such as Yasmin facial hirsutism: topical eflornithine - contraindicated in pregnancy and breast-feeding
93
What is hyperhidrosis?
excessive sweat production
94
What are the mx options for hyperhidrosis?
topical aluminium chloride preparations are first-line. Main side effect is skin irritation iontophoresis: particularly useful for patients with palmar, plantar and axillary hyperhidrosis botulinum toxin: currently licensed for axillary symptoms surgery: e.g. Endoscopic transthoracic sympathectomy. Patients should be made aware of the risk of compensatory sweating
95
What is your spot diagnosis?
impetigo
96
What is impetigo?
a superficial bacterial skin infection, usually caused by staphylococcus aureus - golden crust is characteristic can be classified as non-bullous or bullous
97
Describe non-bullous impetigo. How should it be managed?
typically occurs around the nose or mouth. The exudate from the lesions dries to form a “golden crust”. They do not usually cause systemic symptoms or make the person unwell. antiseptic cream (hydrogen peroxide 1% cream) topical fusidic acid Oral flucloxacillin is used to treat more widespread or severe impetigo
98
Describe bullous impetigo. How should it be managed?
always caused by staphylococcus aureus 1 – 2 cm fluid filled vesicles form on the skin exudate dries into golden crust may be systemically unwell with fever confirm dx with swabs, can manage with flucloxacillin
99
How long should children with impetigo be off school for?
children should be excluded from school until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment - highly contagious!!!
100
Complications of impetigo?
Cellulitis if the infection gets deeper in the skin Sepsis Scarring Post streptococcal glomerulonephritis Staphylococcus scalded skin syndrome Scarlet fever
101
Keloid scars are tumour-like lesions that arise from the connective tissue of a scar and extend beyond the dimensions of the original wound. What are the risk factors for developing these?
ethnicity: more common in people with dark skin occur more commonly in young adults common sites (in order of decreasing frequency): sternum, shoulder, neck, face, extensor surface of limbs, trunk
102
How can keloid scars be managed?
early keloids may be treated with intra-lesional steroids e.g. triamcinolone excision is sometimes required but careful consideration needs to given to the potential to create further keloid scarring
103
What is your spot diagnosis? How should this be managed?
Keratoacanthoma a benign epithelial tumour, more common with advancing age will often spontaneously regress within 3 months, but should be urgently excised to exclude SCC
104
What is the Koebner phenomenon?
describes skin lesions that appear at the site of injury. It is seen in: psoriasis vitiligo lichen planus, lichen sclerosus molluscum contagiosum warts
105
What is your spot diagnosis?
Leukoplakia - a premalignant condition
106
How does leukoplakia present? How can leukoplakia be diagnosed?
white, hard spots on the mucous membranes of the mouth premalignant condition, more common in smokers diagnosis of exclusion candidiasis and lichen planus should be considered, especially if the lesions can be 'rubbed off' biopsies often taken to exclude SCC
107
What is the risk of leukoplakia?
1% undergo malignant transformation to SCC
108
What is your spot diagnosis?
Squamous Cell Carcinoma
109
Give some risk factors for developing SCC of the skin
excessive exposure to sunlight / psoralen UVA therapy actinic keratoses and Bowen's disease immunosuppression e.g. following renal transplant, HIV smoking long-standing leg ulcers (Marjolin's ulcer) genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism
110
What features may SCC present with?
typically on sun-exposed sites such as the head and neck or dorsum of the hands and arms rapidly expanding painless, ulcerate nodules may have a cauliflower-like appearance there may be areas of bleeding
111
How can SCC be managed?
lesion <20mm in diameter: surgical excision with 4mm margins tumour >20mm : surgical excisions with 6mm margins Mohs micrographic surgery may be used in high-risk patients and in cosmetically important sites.
112
What factors confer poor prognosis of SCC?
Poorly differentiated tumours >20mm in diameter >4mm deep Immunosupression for whatever reason
113
What is Stevens-Johnson syndrome?
a severe systemic reaction affecting the skin and mucosa that is almost always caused by a drug reaction causes: PLANS penicillin lamotrigine, carbamazepine, phenytoin allopurinol NSAIDs sulphonamides
114
What features does Stevens Johnson syndrome present with? How would you manage a patient who presented like this?
the rash is typically maculopapular with target lesions may develop into vesicles or bullae Nikolsky sign is positive in erythematous areas - blisters and erosions appear when the skin is rubbed gently mucosal involvement systemic symptoms: fever, arthralgia Mx: hospital admission for supportive care

Y4 Neuro and Special Senses (21 decks)

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