Dermatology Flashcards by Sheryl O'Hare

Melanoma in situ - what is the treatment (and margins)

Excision with 5mm clearance

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Melanoma <1mm past basement membrane - what is the treatment (and margins)

Excision with 1cm clearance

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Melanoma >1mm past basement membrane - what is the treatment (and margins)

Excision with 2cm clearnance

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melanocytes proliferate and form clusters of cells at the DE junction - what does this suggest

Junctional nevus

childhood

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BCC arises from _____cytes in the ____ layer of the epidermis/dermis

BCC

arises from keratinocytes
basal layer of epidermis

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Non healing ulcer, telangectasia, rolled out edges, central ulceration - what does this suggest

BCC

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If you remove the entire BCC lesion, the patient is cured. True or false?

True

- there is no risk of recurrence (in that area)

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SCC arises from _____cytes in the ____ layer of the epidermis/dermis

SCC

arises from keratinocytes
supra basal layer of epidermis

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there is no risk of recurrence with SCC. True or false?

False

- there is risk of recurrence.

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Name 2 precancerous skin lesions for SCC

bowen’s disease

- actinic keratosis

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Where does bowens disease typically present?

Legs

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Where does actinic keratosis typically present?

Head and neck

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Explain morphology of seborrhoeic keratosis

Stuck on appearance
Greasy hyperkeratotic surface (looks like a muffin)
Warty surface
Well defined border
Can be muti-coloured

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Describing PIGMENTED skin lesions

ABCD

Asymmetry

shape and colour
think of horizontal and vertical axis

Border

well differentiated?
regular or irregular?

Colour

Diameter

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Management of actinic keratosis?

Cryotherapy (if small) 
Imiquimod cream 
5-FU cream 
Photodynamic therapy 
There is no need to excise

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bowens disease: partial/full thickness dysplasia of epidermis?

Full thickness

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Name 2 aggressive areas for SCC?

Lips

Ears

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Melanoma growth - initial

Horizontal (radial growth)

grows flat
has good prognosis
no danger of metastasising

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Melanoma - vertical growth phase

Measure the breslow thickness

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If breslow thickness over 1mm, what is the management

Wide local excision

Sentinal node biopsy (done under GA)

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BCC type: raised, well defined

Nodular BCC.
This is the typical BCC you would imagine
Tx: eliptical excision

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Superficial BCC

Flat, well defined

Tx: non-surgical management (cryotherapy, imiquimod, 5-FU)

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What is moh’s surgery used for?

BCC

Poorly defined lesion on difficult body site

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Contact allergic dermatitis is which type of hypersensitivity reaction?

Type IV

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Soap, detergent, cleaning prodcuts are common causes of - contact allergic dermatitis - irritant contact dermatitis

Irritant contact dermatitis

'monomorphic punched out lesions'

Eczema herpeticum

Treatment of mild atopic eczema

Emollients | mild potency topical steroids

Treatment of moderate atopic eczema

emollients moderate-potency topical corticosteroids topical calcineurin inhibitors bandages

Treatment of severe atopic dermatitis

``` emollients potent topical corticosteroids topical calcineurin inhibitors bandages phototherapy systemic therapy. ```

areas of rapidly worsening, painful eczema clustered blisters consistent with early-stage cold sores punched-out erosions (circular, depressed, ulcerated lesions) usually 1 mm to 3 mm that are uniform in appearance (these may coalesce to form larger areas of erosion with crusting) possible fever, lethargy or distress. What diagnosis does this make you think of? And what would the treatment be?

Eczema herpeticum | Tx: aciclovir (oral or systemic)

Eczema often starts in the flexor/extensor surfaces then becomes more prominent in the flexor/extensor surfaces?

Starts in extensors | Then becomes apparent in flexors

What is the main cause of atopic dermatitis

Break down of the skin barrier loss of water molecules in the skin barrier means pathogens can get through and cause irritation and inflammatory reaction

Side effects of topical corticosteroids (4)

Thinning of skin Reduced growth Increased skin infections Striae

What is the main mode of action of using topical corticosteroids for eczema?

Anti-inflammatory | Vasoconstrictive

Hydrocortisone 1% - mild - moderate - potent - very potent

Mild

Betnovate 0.1% - mild - moderate - potent - very potent

Potent

Eumovate - mild - moderate - potent - very potent

Moderate

Dermovate - mild - moderate - potent - very potent

Very potent

Name 2 calcineurin inhibitors

Tacrolimus | Pimecrolimus

Which calcineurin inhibitor is for adults only?

Tacrolimus

Step 1 eczema managmenet

Emollients alone

Step 2 eczema management

Emollients + mild topical corticosteroid (hydrocortisone)

Step 3 eczema management (moderate)

Emollients + moderate topical coticosteroid (eumovate) | + calcineurin inhibitors

Step 4 eczema management (severe)

Emollients + potent/very potent corticosteroid (betnovate/dermovate) Specialist help

patient who suffers with eczema that has developed a widespread, painful, vesicular rash with systemic symptoms such as fever, lethargy, irritability. The rash is usually widespread and can affect any area of the body. It is erythematous, painful and sometimes itchy, with vesicles containing pus. The vesicles appear as lots of individual spots containing fluid. After they burst, they leave small punched-out ulcers with a red base.

Eczema herpeticum

What is the main feature of Seborrhoeic dermatitis in infants?

Cradle cap

Treatment of Seborrhoeic dermatitis of the scalp in adults?

Ketoconazole shampoo

Name a systemic drug that may be used in severe eczema?

Ciclosporin

Child with fever, corzyal symptoms and conjunctivitis. a few days later develops rash which starts on face and then spreads to rest of body. Erythematous and macular rash with flat lesions. What condition is this describing?

Measles

red-pink, blotchy, macular rash with rough “sandpaper” skin that starts on the trunk and spreads outwards. Patients can have red, flushed cheeks. Other features: ``` Fever Lethargy Flushed face Sore throat Strawberry tongue Cervical lymphadenopathy ```

Scarlet fever

What is the treatment of scarlet fever

Phenoxymethylpenicillin

What is the main complication of roseola infantum?

Febrile convulsions | - high temperature

Which drug is used in the management of chronic urticaria?

Fexofenadine

Cocksackie A virus causes which skin condition?

Hand foot and mouth disease

Molluscum contagiosum requires no treatment. True or false?

True

What is topical fusidic acid?

Topical antibiotic

Which condition is associated with a herald patch (and what is a herald patch)

Pityriasis rosea | - faint pink scaly oval lesion usually occuring on torso

Onychomycosis - what is this

Fungal nail infection

In ring worm, the centre/edge of the lesion is darker in colour?

Edge | - giving it a well demarcated border

How do you treat non bullous impetigo

Topical fusidic acid

HOw do you diagnose impetigo?

Swab the vesicles

Streptococcal throat infection -> many small raised papules across the trunk and limbs (looks like raindrops). The papules are mildly erythematous and can be slightly scaly

Guttate psoriasis

WHat is the Koebner phenomenon

development of psoriatic lesions to areas of skin affected by trauma

What is a treatment option for severe acne?

``` Oral isotretinoin (roacutane) - highly teratogenic ```

What is the commonest causacian skin cancer?

BCC

Solar urticaria is a type X hypersensitivity reactio?

Type 1

What is the most common hepatic porphyria?

Porphyria cutanea tarda

Management of porphyria cutanea tarda

Chloroquine | Venesection

How do porphyrias arise?

Deficiency in the enzymes involved in haem synthesis. | Leads to increased porphyrins

``` Young-middle aged female on OCP Following Symptoms come in attacks and in the meantime the patient is healthy - Abdominal pain - Nausea - Vomiting - Urine becoming darker in colour ``` What is the likely diagnosis? - porphyria cutanea tarda - acute intermittent porphyria - Erythropoeitic protoporphyria

Acute intermittent porphyria

Urine in acute intermittent porphyria

Dark brown/ red

Which porphyria causes bullous eruptions on exposure to sunlight?

Porphyria cutanea tarda

Investigation for porphyria cutanea tarda?

Woods lamp

Child crying in direct sunlight, which porphyria? - porphyria cutanea tarda - acute intermittent porphyria - Erythropoeitic protoporphyria

erythropoeitic protoporphyria

Port wine stain Neurological abnormalities Vision abnormalities (glaucoma)

Sturge Weber Syndrome

Cafe au lait spots in which condition | - how many do you need to have for it to be relevant

Neurofibromatosis type 1 | - need to have at least 6

Ash leaf macule is seen in which condition?

Tuberous sclerosis

Allergic contact dermatitis - type X hypersensitivity reaction

Type 4

What is the investigation of choice to confirm contact allergic dermatitis?

Patch testing

Outline how patch testing works

Day 1: Take Hx and apply patches Day 3: remover patches and note any reactions Day 5: record final readings

a common yeast infection of the skin which can affect melanocyte function leading to variable pigmentation

Pityriasis versicolor

ABPI measurements: 0.8-1.3 normal < 0.8 vascular disease >1.3 calcification When can you use compression stockings

if over 0.8 but probs below 1.3

Worsening psoriasis, currently managed on emollients. What is the next step? a. Refer for phototherapy b. Coal tar c. Topical retinoid d. Topical steroid + calcipotriol (vitamin D analogue) e. Topical salicylic acid

d. Topical steroid + calcipotriol (vitamin D analogue) - NICE recommend a potent corticosteroid applied once daily plus vitamin D analogue applied once daily for up to 4 weeks as initial treatment to reduce plaques.

management of lyme disease

2 weeks of doxycycline

a severe drug reaction with necrosis and loss of the epidermis affecting over 30% of body surface area

Toxic epidermal necrolysis

epidermal thickening, absence of granular layer, presence of parakeratosis and Munro microabscesses.. What condition does this suggest?

Psoriasis

BCC management ``` a. Urgent excision b. Imiquimod cream (Aldara) c. Diagnostic biopsy d. Cryotherapy e. Routine excision ```

Routine excision

Name 3 potential management options for vitilligo

Camoflague creams Topical steroids Phototherapy

What condition is vitilligo often confused with?

Pityrisis vesicolor | - yeast infection

What is the kobner phenomenon?

the appearance of new skin lesions of a pre-existing dermatosis on areas of cutaneous injury in otherwise healthy skin

Herald patch is associated with which condition

Pityrisis rosea

2-4cm patch on tummy then a few days later there is truncal eruption of small pink oval lesions with peripheral scale.

Pityrisis rosea

Violaceous (pink/ purple) flat-topped shiny papules Intensely itchy What does this suggest?

Lichen planus

Describe the pathophysiology of acne

Occlusion of the pilosebaceous unit - ductal hypercornification - blackheads or whiteheads - cosmetic occlusion

Increased/decreased sebum production in acne

Increased

There is a relationship between number of bacteria and acne severity. true or false?

False

Ice pick scars are common in which condition?

Acne

How is mild acne treated

Topical treatment only

How is moderate acne treated

Topical treatment + Oral antibiotics + Dianette (female)

How is severe acne treated

isotretinoin (Roaccutane)

Name 4 topical treatments for acne

Tretinoin Adapalene Nicotinamide Benzoyl peroxide

What are the 3 properties/functions of benozyl peroxide

Keratolytic - reduces duct occlusion, reduces comedones ANti-inflammatory Anti-microbial

What caution should you give to patients using benzoyl peroxide

Bleaches skin, clothes, hair

Which acne treatment should you not use in pregnancy?

Isotretinoin

name 4 oral antibiotics that can be used in moderate acne?

``` TETRACYCLINES - Doxycyclin - Lymecycline - Oxytetracycline Erythromycin (if pregnant) ```

Contraceptives can be useful in the treatment of acne for females. Why?

Decrease androgen production Eg: COCP Diannette

Contraceptives are as useful as oral antibiotics in the treatment of acne. True or false?

True | - can be used instead of oral antibiotics in women

Name 3 indications for using isotretinoin (roacutane)

inadequate response to conventional therapy significant scarring nodulo/cystic acne

List some side effects of using isotretinoin

``` Dry skin, lips, eyes (contact lenses) & nose(bleeds) Skin fragility Hyperlipidaemia Abnormal liver function Teratogenesis- contraception Mood alteration ```

Rosacea is more common in males / females?

Females

Prominent facial flushing exacerbated by sudden change in temperature , alcohol & spicy food

Rosacea

Which antibiotic can be used in the management of rosacea

Topical metronidazole

Rosaces has increased/decreased/normal sebum excretion rate?

NORMAL | - unlike acne which is increased

``` Presence of papules and pustules makes you think - mild - moderate - severe acne ```

Moderate

a topical retinoid (if not contraindicated) or benzoyl peroxide should always be co-prescribed with oral antibiotics. True or false?

True | - this reduces the risk of antibiotic resistance

There is a role for dietary modification in patients with acne. True or false?

False | - there is no role for dietary modification

Patients with rosacea with rhinophyma should be referred to dermatology. true or false?

True

which class of antibiotics are used in acne vulgaris?

Tetracyclines

Risk factors for skin cancer

``` Sun exposure Immunosuppressants occupation lived abroad any blistering sunburns in the past ```

Slow growing lesions, celtral ulceration, rolled pearly edge, telangectasia

BCC (nodular)

Superficial BCC treatment

Imiquimod 5-FU Cryotherapy

Actinic keratosis features

lots of scale

SCC grows quickly/slowly and is tender/non tender?

Quickly | Tender

partial/full thickness epidermal dysplasia in actinic keratosis

Partial

Bowens disease common location

legs

In the immunosuppressed patient, what is the most common skin cnacer?

SCC

Treatment of basal cell papilloma

Mainly nothing | Can do cryotherapy

Firm centre, small red spot

dermatofibroma

Acute dermatitis - what process is happening?

spongiosis | - fluid between the epidermal cells

full thickness epidermal thickening in histology of patient with eczema - what is this likely to be clinically

Lichenefication

Seborrhoeic dermatitis location of distribution

Paranasal folds | Hair line

Seborrhoeic dermatitis - treatment

emollients | anti fungal creams

In a child with eczema, the nappy area is usually involved/spared?

Spared

What does biopsy for Hishprung disease show

Absence of ganglion cells in the submucosa

Which type of murmur is pulmonary stenosis?

Ejection systolic

What is eisenmeiger syndrome?

When the pulmonary pressure is higher than the systemic pressure (occurs in ASD/VSD sometimes) and the L->R shunt seen in ASD/VSD reverses to R->L which is more worrying

What is folliculitis

Bacterial infection of hair follicles

Management of localised folliculitis

topical antibiotics

Management of impetigo

Don't go to school or nursery Topical fusidic acid Avoid sharing towels and bed sheets

Management of necrotising fasciitis

IV antibiotics | Surgical debridements

WHich virus causes viral warts

HPV (types 6 and 11)

Treatment options for viral warts?

Cryotherapy Salicylic acid imiquimod

viral warts around the nail. Which treatment should you not use?

Cryotherapy | - topical treatments are better

Treatment of shingles

Self limiting | Caught within 72 hours give aciclovir

You can catch ____ with someone who has shingles

chickenpox

How do you investigate fungal infections?

Skin scraping

When might terbinifine be used

Fungal infections

Name 2 causes of non-scarring hair loss

Alopecia | Tinea capitis

What is ptyriasis versicolor

Yeast infection which interferes with normal melanin production - can be hyper or hypo pigmented

Treatment of candidiasis

Cotrimaxazole

Describe staphylococal scalded skin syndrome

Superficial split in epidermis, split between dermosomes in the granular layer of the epidermis

staphylococal scalded skin syndrome more common in adults/children?

Children

staphylococal scalded skin syndrome - management

Hospitalisation and IV antibiotics

ERYSIPELAS - more deep/superficial than cellulitis

More superficial

How long should you take oral antibiotics for acne?

at least 4 months

Which pill should you give in acne? - COCP - POP

COCP

WHich antibiotic may be used in rosacea?

Metronidazole (topical)

Split is "at the junction between epidermis and dermis" this is true of - bullous pemphigoid - pemphigus vulgaris

Bullous pemphigoid

What is the first line management of sebhorroeic dermatitis?

Ketokonazole

Angiofibromas Peri-ungal fibroma Ash leaf macules

Tuberous sclerosis

Lisch nodules Cafe au lait macules makes you think

Neurofibromatosis

How to differentiate erisipylis and cellulitis

Erysipleas - sharp demarcation at the border, more firey looking

Satellite lesions makes you think which condition

Candidiasis

If you have necrobiosis, which condition is this associated with?

Diabetes

Acanthosis nigricans is associated with

Diabetes

What does scarring alopecia mean?

No hair follicles left

Heloptrope rash Grottons papules which condition

Dermatomyositis

WHat is the main cause of erythema multiforme?

Herpes simplex virus

What is livedo reticularis

Mottled skin exacerbated by the cold

Which type of cell is primarily responsible for the development of urticaria, angioedema and anaphylaxis, and in which layer of the skin is it found?

``` Mast cell (releases histamine) - layer = dermis ```

Histamine release results in vasoconstriction/vasodilation?

Vasodilation

prodrome of respiratory symptoms, followed up to 14 days later by erosions of at least 2 mucosal surfaces with a variable degree of cutaneous involvement. Varying degree of cutaneous involvement with target-like lesions / dusky red macules / blistering / desquamation what does this suggest?

Steven johnston syndrome

Name 4 classes of drugs which can cause stevens johnston syndrome

NSAIDs Anticonvulsants - lamotrigine Antibiotics Sulphonamides

``` Parakeratosis Absence of granular layer expanded prickle cell layer munro micro-abscesses pathology of which condition ```

Psoriasis

Management of necrotising fasciitis

IV antibiotics | Surgical debridement

Nikolsky sign +ve in - pemphigus - pemphigoid

Pemphigus

immunofluoresence shows linear/chicken wire IgG in pemphigoid

Linear = pemphigoid

treatment of localised pemphigoid

Topical steroids

Treatment of generalised pemphigoid

Oral steroids tetracyclines azathioprine

Lysis of intercellular adhesion sites in - pemphigus - pemphigoid

Pemphigus

Dermatitis herpitiformis is associated with which condition?

Coeliac disease

linear IgG at basement membrane - pemphigus - pemphigoid

Pemphigoid

ABPI over 1.5 suggests

Claudication

Males vs females psoriasis

Equal

Hyperproliferation of epidermal cells makes you think

Psoriasis

Psoriasis is often symetrical / asymetrical?

Symetrical

What is koebner phenomenon

Wound / trauma causes psoriasis

What is autzpitz sign and which condition is it associated with?

Small pinpoint bleeding spots, associated with psoriasis

In flexural psoriasis, scale is a predominant feature?

False, scale is not a predominant feature in FLEXURAL psoriasis

Name 6 potential topical treatments for psoriasis

``` Emollients Coal tar Vitamin D analogue (calcipotriol) Topical steroids Dithranol Salicylic acid ```

Which topical treatment for psoriasis causes staining

Dithranol

What is the function of salicylic acid

Keratinolytic agent (removes hyperkeratosis)

Typically use low dose / high dose steroids in the management of psoriasis?

Low dose | - if you use high dose then there can be rebound flare up

Apart from topical treatment, what else can be used in management of psoriasis?

Phototherapy

Management options for arterial leg ulcers

``` Pain relief Lifestyle factors Aspirin Crepe bandaging Refer for vascular surgery if appropriate ```

Psoriasis treatment ladder

Topical treatments - once you get to high dose steroid (dermovate) then move on to - phototherapy - systemic therapy (methotrexate, retinoids)

Which type of phototherapy penetrates deep? - UVB - PUVA

PUVA

Outline the growth phases for melanoma

radial growth phase (confined to epidermis) | then later get vertical growth phase (metastasis can occur here)

Which type of melanoma is vertical growth phase from the outset

Nodular melanoma

Which type of melanoma is most common on facial skin, especially chronically sun exposed sides

Lentigo maligna

Which type of melanoma is most common in dark skin types

acral

Urticaria is swelling of which layer of skin

Dermis

Which 3 histamine receptors are relevant in urticaria

H1, H2, H4