Dermatology Flashcards
Anti-dsDNA and Anti-smith
Systemic Lupus Erythematosus (SLE)
The initial test for SLE is ANA
Anti-histone
Drug induced lupus (hydralazine)
Anti-scl70
Systemic Sclerosis
Anti-centromere
Limited sclerosis/CREST syndrome
Anti-Jo1
Polymyositis
Anti-Ro, Anti-La
Sjogren’s disease
Anti-mitochondrial
Primary biliary cirrhosis
Anti-smooth muscle
Autoimmune hepatitis
pANCA
Churg Strauss (Eosinophilic Granulomatosis with Polyangiitis)
cANCA
Wegener’s Granulomatosis (Granulomatosis with Polyangiitis)
Anti-tissue transglutaminase and IgA, Anti-gliadin, Anti-endomysial
Celiac disease
ANA
Rheumatoid Arthritis (RA), initial test for SLE, other auto-immune diseases.
What is cellulitis?
Typically due to…?
Inflammation of the skin and subcutaneous tissues.
G +ve like Streptococcus pyogenes and Staphylococcus aureus
Features of cellulitis
Commonly on the shins
Erythema, pain, swelling
May be associated with systemic upset such as fever
Management of cellulitis
1st line Fucloxacillin
Allergic to penicillin> Clindamycin or Clarithromycin (clindamycin if failed to respond to flucloxacillin like MRSA)
Severe cellulitis and MRSA skin infection management
Severe cellulitis> IV benzypenicillin + flucloxacillin
MRSA skin infeciton> Vancomycin
4Ps + F and LP for lichen planus
Pruritic Purple Papular Polygonal rash on the Flexor surfaces
White LACY PATTERN on the buccal mucosa
Management of lichen planus
topical steroids
Benzydamine mouthwash or spray is recommended for oral lichen planus
Extensive lichen planus may require oral steroids or immunosuppression
ABCDE of malignant melanoma (when to suspect?)
Asymmetry- the 2 halves of the mole look different in shape
Border- Irregular edges
Color- Different shades of black, brown and pink
Diameter- >6mm
Evolves- Enlarge, grows upwards, downwards, outwards as a flat lesion
Management of a benign mole?
A benign mole that does not bleed or interfere with life can be referred to a PRIVATE dermatology clinic.
NHS does not provide Cosmetic Services
Depth of invasion is important as a …… factor for malignant melanoma
Prognosis
bad prognosis factor
What is the most important prognostic factor indicator in a malignant melanoma that was excised?
Breslow thickness
The depth in mm
Most common melanomas in the UK?
70% are superficial spreading melanomas.
More common in people with pale skin and freckles, less common in darker skinned people.
They initially grow outwards rather than downwards, so don’t pose a problem. If they grow downwards into deeper skin layers then they can spread to other parts of the body.
Melanomas that usually appear as a changing lump on the skin which might be black to red in colour.
Nodular melanomas, they develop faster and can quickly grow downwards into deeper layers of the skin if not removed.
They often grow on previously normal skin and most commonly occur on the head and neck, chest or back. Bleeding or oozing is a common symptom
What is SLE (systemic lupus erythematosus)
Multisystem autoimmune disorder.
Presents early in adulthood and is more common in women and Afro-Caribbean origin.
General Features of SLE (systemic lupus erythematosus)
atigue, fever, lymphadenopathy
Mouth ulcers (large, multiple and painful)
Remitting and relapsing illness
Skin features of SLE (systemic lupus erythematosus)
Malar (butterfly) rash (spares nasolabial folds)
Discoid rash- scaly, erythematous, well demarcated rash in sun-exposed areas. They may progress to become pigmented and hyperkeratotic before becoming atrophic
Photosensitivity
Raynaud’s phenomenon (1/5th of the pxs but often mild)
Musculoskeletal, cardiovascular and respiratory features of SLE (systemic lupus erythematosus)
Arthralgia and non-erosive arthritis
Pericarditis (the most common cardiac manifestation)
and myocarditis
Pleurisy and fibrosis alveolitis
Renal and neuropsychiatric features of SLE (systemic lupus erythematosus)
Proteinuria and glomerulonephritis (diffuse proliferative glomerulonephritis is the most common type)
Anxiety and depression
Psychosis
Seizures
SLE immunology
99% is ANA positive (screening= sensitive but not specific)
20% are rheumatoid factor positive
anti-dsDNA is highly specific (>99%) but less sensitive (70%)
anti-Smith is the most specific (>99%) but very low sensitivity (30%)
The initial screening for SLE is …?
And the confirmatory test for SLE is…?
Anti-nuclear antibody (ANA) is the most sensitive
Anti-dsDNA is the most specific (confirmatory)
Immunology in drug-induced lupus and drug examples
Anti-histone antibodies
Hydralazine
Procainamide
Isoniazid (TB drug!)
Drug induced lupus is just like SLE
True or false?
FALSE
Not all typical features are seen
Renal and nervous system involvement is rare
Resolves on its own after stopping the causative drug
Features of drug induced lupus
Arthralgia
Myalgia
Skin (malar rash) and pulmonary involvement (pleurisy) are common
Immunology of drug induced lupus
ANA positive in 100%
dsDNA negative
Anti-histone antibodies are found in 80-90% (usually the answer in exams)
Urticaria
Wheals (central itchy white papules or plaques surrounded by erythema)
Variable in size and shape
± swelling of soft tissues (eyelids, tongue, lips) > angioedema
Here today, gone tomorrow> come and go within a few minutes or hours
Acute and chronic urticaria
Acute <6 weeks
Chronic >6 weeks
Why aspirin and opiates cause urticaria?
Aspirin and opiates may elicit the release of histamine from mast cells > urticaria
Management of urticaria
Tx the cause and aggravating factors
(Stop aspirin, opiates, overheating, stress, alcohol, caffeine)
Non-sedating H1 anti-histamines (cetirizine or loratadine)
In pregnant, give sedating anti-histamine like chlorphenamine
Psoriasis main features
Itchy, scaly, well demarcated, circular, reddish, elevated lesions (plaques)
Overlying white or silvery scales
It can be on elbows, knees, scalp etc.
NOT contagious
On the extensor surfaces and scalp
Strong genetic basis
Vigorous scrapping> pinpoint bleeding> Auspitz’ sign
New lesions appear at sites of injury of the skin> Kobner’s reaction
Family Hx is often given as a hint
± nail changes (pitting, onycholysis)
Psoriasis Rx
Topical steroids
Vitamin D analogues
Tar preparations
Eczema main features
Chronic, relapsing Inflammatory skin condition
Itchy red rash
Affects skin creases (flexures like wrist, elbow folds, behind knees)
Triggered by environmental irritants and allergens. Also URTIs (upper respiratory tract infection) can cause a flare up eczema
Family history of atopic diseases like asthma and hay fever
Eczema treatment
1st line> emollients
Topical steroids
Seborrheic dermatitis main features
Scaling rash
Affects sebaceous glands
Found on face, scalp and chest
Inflammatory reaction to yeast
Presents as inflamed greasy areas with fine scaling
Can present as dandruff when on scalp.
Seborrheic dermatitis management
Regular antifungal
Intermittent topical steroids
Px with hx of immunosuppression and smoking, with thick white marks ± inflamed mouth/tongue that can be rubbed out.
Oral thrush (candidiasis)
Plaques might enlarge and become painful, causing discomfort while eating and swallowing.
It might also present with inflamed painful sore mouth angles.
Management of oral thrush
Stop smoking
Good inhaler techniques, spacer device, rinse mouth with water after use.
Oral fluconazole 50mg OD for 7 days or fluconazole oral suspension
Px with hx of smoking, with white oral lesion with raised edges, bright white patches, sharply well-defined edges and cannot be rubbed out.
Leukoplakia
Rx stop smoking and biopsy! (they are premalignant)
Oral lichen planus…
Lace (ornamented) like appearance lesions.
Remember the 4Ps+F
Purple, pruritic, polygonal, papular rash on flexor surfaces
Eczema in infants and children affect which part of the body?
(infants, young children and older children)
Infants> face and trunk then extremities
Younger children> on extensor surfaces
Older children> typical distribution with flexor surfaces affected and the creases of the face and neck.
Eczema occurs in around 15-20% of children and is becoming more common
It typically presents before the age of 6 months but clears around 50% of children by 5 years of age and in 75% of children by 10 years of age.
Management of Eczema in infants and children
1st line> emollients (at least BID= twice daily) + washing, bathing (moisturising)
2nd line> topical steroids (for eczema itself)
Hydrocortisone acetate is a mild, moderate, potent or very potent strength steroid?
Mild
Comes topical 0.5%, 1% or 2.5%
To be used in mild eczema or a new case that is not responding to emollients.
Example of a moderate strength steroid for eczema
Betamethasone valerate (0.025%) or Clobetasone butyrate (0.05%)
for a moderate eczema with wide area of dryness, crackling and redness
Example of a potent strength steroid for eczema
Betamethasone valerate (0.1%)
or
Mometasone 0.1%
(For severe eczema that causes bleeding, intense itching that prevents sleeping, and not responding to emollients and hydrocortisone)
Hydrocortisone butyrate
Very potent strength steroid for eczema
Clobetasol propionate
What should be done if emollients and steroids are to be given together?
Apply emollient 1st, then wait 30 minutes, then apply the topical steroid.
Also, avoid irritants and stress
Tx bacterial infection if present (flucloxacillin is 1st line)
If eczema awakens the patient at night then consider a sedative antihistamine (chlorphenamine)
Clotrimazole is a…..
used for….
Antifungal agent
Used for athlete’s foot, fungal groin infections, fungal nappy rash
What should be administered in a patient referring an insect bite with itching skin and no signs and symptoms of anaphylaxis?
What if he develops a severe reaction?
Oral anti-histamine
If a severe reaction develops (affects breathing) then give IM adrenaline
One of the 3 main types of skin cancer
Lesions known as Rodent Ulcers
Characterized by slow-growth and local invasion
Metastases are extremely rare.
Basal cell carcinoma
BCC is the most common type of cancer in the western world.
Features of Basal Cell Carcinoma
Many types of BCC are present.
The most common type is nodular BCC
(Sun-exposed sites, especially the head and neck
Initially pearly, flesh-coloured papule with telangiectasia
May later ulcerate leaving a central “crater”)
Patient with white umbilicated ulcer with central depression….
Basal Cell Carcinoma
Rodent ulcers
Management of BCC
Surgical removal Curettage Cryotherapy Topical cream: imiquimod and fluorouracil Radiotherapy
White or pink papules with an umbilicated (depressed) central punctum. If squeezed they produce cheesy white material.
Molluscum contagiosum (pox virus)
Can be found anywhere on the skin
They resolve spontaneously in 6-24 months
Usually in children and immunocompromised patients. (consider AIDS if extensive pink umbilicated papules)
Golden crusted skin lesions commonly found around the mouth (honey coloured crust) in children.
Impetigo
Superficial bacterial skin infection usually caused by Staph aureus or Strepto pyogenes.
Can be primary or a complication of an existing skin condition like eczema, scabies or insect bites.
Incubation period of 4 to 10 days.
Lesions tend to occur on the face, flexures and limbs not covered by clothing.
Very contagious!
Rx of impetigo
Limited, localised, non-bullous disease
1st line hydrogen peroxide cream 1%
Fusidic acid 2% or mupirocin (2nd line)
If extensive non-bullous or bullous impetigo
Oral flucloxacillin
or Oral erythromycin if penicillin allergic.
What should be done with a child with impetigo?
They should be excluded from school until the lesions are crusted and healed.
Or 48 hrs after commencing the antibiotic treatment.
What if the rash is painful and associated with fever, especially in a child with Hx of eczema?
Consider eczema herpeticum and give aciclovir.
When to suspect Cold Sore of Herpes Simplex Virus and not Impetigo
Hx of recurrent episodes
Pain (tingling, itching, burning) before the onset of vesicles (prodromal pain)
Vesicles initially filled with clear fluids
More common in adults.
Patient that complains of flushing after alcohol or sunlight exposure. Telangiectasia can be seen in his nose, cheeks and forehead.
Acne Rosacea- a chronic skin disease of unknown aetiology
Telagiectasia is common
Later develops into persistent erythema with papules and pustules
Rhinophyma is a nose disfigurement
Ocular involvement: blepharitis
Rx of Acne Rosacea
Topical metronidazole may be used for mild symptoms (limited number of papules and pustules, NOT PLAQUES)
More severe disease is treated with systematic antibiotics like Oxytetracycline or tetracycline
What is Tinea Capitis?
A fungal infection involving hair follicles and causing hair loss (alopecia) very rapidly
Rx of Tinea Capitis
Because of the risk of scarring, Rx is with a systemic oral antifungal such as oral terbinafine, itraconazole, or fluconazole.
In children griseofulvin is used.
Dermatitis Herpetiformis is linked to which disease?
Px with bloating, loose stools, abdominal pain, iron deficiency anemia and folate deficiency with severly itchy rash distributed over scalp, sacrum, elbows and knees.
Celiac disease.
Tissue transglutaminase IgA and endomysial Abs are (+)ve
Indications of IM adrenaline in anaphylaxis
Hoarseness of voice Wheezes Shortness of Breath (SOB) Stridor Shock Facial, tongue or cheek swelling
