Dermatology Flashcards
Melanoma in situ - what is the treatment (and margins)
Excision with 5mm clearance
Melanoma <1mm past basement membrane - what is the treatment (and margins)
Excision with 1cm clearance
Melanoma >1mm past basement membrane - what is the treatment (and margins)
Excision with 2cm clearnance
melanocytes proliferate and form clusters of cells at the DE junction - what does this suggest
Junctional nevus
childhood
BCC arises from _____cytes in the ____ layer of the epidermis/dermis
BCC
- arises from keratinocytes
- basal layer of epidermis
Non healing ulcer, telangectasia, rolled out edges, central ulceration - what does this suggest
BCC
If you remove the entire BCC lesion, the patient is cured. True or false?
True
- there is no risk of recurrence (in that area)
SCC arises from _____cytes in the ____ layer of the epidermis/dermis
SCC
- arises from keratinocytes
- supra basal layer of epidermis
there is no risk of recurrence with SCC. True or false?
False
- there is risk of recurrence.
Name 2 precancerous skin lesions for SCC
- bowen’s disease
- actinic keratosis
Where does bowens disease typically present?
Legs
Where does actinic keratosis typically present?
Head and neck
Explain morphology of seborrhoeic keratosis
- Stuck on appearance
- Greasy hyperkeratotic surface (looks like a muffin)
- Warty surface
- Well defined border
- Can be muti-coloured
Describing PIGMENTED skin lesions
ABCD
Asymmetry
- shape and colour
- think of horizontal and vertical axis
Border
- well differentiated?
- regular or irregular?
Colour
Diameter
Management of actinic keratosis?
Cryotherapy (if small) Imiquimod cream 5-FU cream Photodynamic therapy There is no need to excise
bowens disease: partial/full thickness dysplasia of epidermis?
Full thickness
Name 2 aggressive areas for SCC?
Lips
Ears
Melanoma growth - initial
Horizontal (radial growth)
- grows flat
- has good prognosis
- no danger of metastasising
Melanoma - vertical growth phase
Measure the breslow thickness
If breslow thickness over 1mm, what is the management
Wide local excision
Sentinal node biopsy (done under GA)
BCC type: raised, well defined
Nodular BCC.
This is the typical BCC you would imagine
Tx: eliptical excision
Superficial BCC
Flat, well defined
Tx: non-surgical management (cryotherapy, imiquimod, 5-FU)
What is moh’s surgery used for?
BCC
Poorly defined lesion on difficult body site
Contact allergic dermatitis is which type of hypersensitivity reaction?
Type IV
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