dermatology Flashcards
define pressure sores
damage to skin over bony prominence as a result of pressure
aetiology/risk factors of pressure sores
risk factors:
- immobility
- alzheimer’s
- diabetes
constant pressure limits blood flow to skin -> skin damage
occur as a result of pressure, friction, and shear stress
presenting signs and symptoms of pressure sores
most commonly located at sacrum and heel
staged from 1-4
very tender
can become infected
- fever
- erythema
- foul smell
investigations for pressure sores
none
clinical dx
Waterloo score used to predict risk of pressure sores
management of pressure sores
document and categorise ulcer
nutritional support
pressure redistributing devices
negative pressure wound therapy
debridement
abx and antiseptics
documentation of pressure sores
document surface area with validated measurement technique
document estimated depth
categorise ulcers using validated classification tool
nutritional support for pressure ulcers
- assessment by dietician
- supplements if nutritional deficiency
- education
pressure redistributing devices for pressure ulcers
- high specification foam mattress
negative wound pressure therapy for pressure ulcers
- not routinely offered unless necessary to reduced number of dressing changes
debridement of pressure ulcers
consider:
1. amount of necrotic tissue
2. category, size, and extent of ulcer
3. patient tolerance
4. comorbidities
use autolytic debridement with appropriate dressing
consider sharp debridement if autolytic will take longer and prolong healing
consider larval therapy is sharp debridement contraindicated or if associated vascular insufficiency
define psoriasis
- chronic systemic inflammatory skin disease causing scaly red plaques
- chronic relapsing/remiting disease
*can include psoriatic arthritis
clinical diagnosis of psoriasis
- red, itchy, scaly patches
- distribution- elbows, knees, trunk, scalp, face
- colour- red/pink patches with some silvery scale
- +/- joint or nail involvment
- PMHx: IBD, obesity
- systemic illness
- FHx
risk factors for psoriasis
strong:
- genetic
- trauma (scratching, tattoos, piercings)
- infection (Streptococcal, HIV)
weak:
- drugs (corticosteroid withdrawal)
- stress
- alcohol
- smoking
- hormonal changes (puberty, menopause)
- high UV exposure
types of psoriasis
- chronic plaque- scaly plaque (most common)
- pustular - pus filled lesions (palms/soles) widespread=emergency
- guttate- tear drop patches after bacterial infection
- nail
- erythodermic - severe inflammed skin peeling in long sheets
- inverse- rash in skin folds
signs of plaque psoriasis on physical examination
- raised inflamed plaque lesions
- superficial silver white scaly eruption
- friable skin underneath
Auspitz’s sign (pinpoint bleeding points)
signs of guttate psoriasis on physical examination
- widespread, erythematous, fine, scaly papules
- on trunk, arms, and legs
- lesions often erupts after URTI
pustular psoriasis
- rare, sever, and urges
- palmoplantar pustulosis affecting palms and soles
- chronic
erythrodermic psoriasis in physical examination
- generalised erythema with fine scaling
- associated with pain, irritation, sometimes severe itching
investigations for psoriasis
clinical Dx
consider skin biopsy
management for psoriasis
- lifestyle changes (weight loss, stop smoking/alcohol, reduce stress/anxiety)
- emolients (moisturisers)
- topical corticosteroids with Ca2+ (short term), vitamin D analogues
- salicylic acid (lift off scales)
- short-contact dithranol (large plaque psoriasis)
Severe / >10% skin/ nail involvement/ resitant to steroids
- refer to dermatology => calcineurin inhibitors, PUVA/phototherapy, biologic therapy, immunosuppressants (methotrexate,anti-TNF)
Plaque:
- mild- topical therapies
- moderate to severe:phototherapy, methotrexate, apremilast, biological agent, oral retinoid
Guttate:
- phototherapy => methotrexate => oral retinoid =>ciclosporin
Pustular:
- oral retinoid
- re-PUVA
- methoxsalen + uv-A + oral retinoid
- acitretin administered before PUVA therapy to enhance efficacy
- * inconvenient scheduling
- * phototoxicity
- * burning in dose not adequately controlled
conditions associated with psoriasis
- psoriatic arthritis (+ joint pain/swelling/stiffness)
- Crohn’s
- anxiety/depression
- metabolic syndrome
Define urticaria (Hives)
Superficial swelling of the skin causing a raised, red itchy rash
- acute (<6 weeks)
- chronic (>6 weeks)
- spontaneous - unknown cause
- autoimmune - IgE mediated allergy (food), high levels of IgG
- chronic inducible urticaria (CINDU)- urtiaria in response to physical stimulus (cold, water, pressure)
Causes of urticaria
increased histamine release into skin => vasodilation of vessels + leaking => redness + swelling
- Allergy- food, insect bite/sting
- Cold/heat exposure
- Infection- cold, hepatitis
- Drugs - NSAIDs, antibiotics
Hx taking for urticaria
HPC:
- onset
- Duration (<6 weeks = acute/chronic)
- Rash symptoms (shape, size, distribution, itchy, painful)
- severity (urticaria activity score)
- recent infections (fever, cough)
- check for GI symptoms (H.pylori?)
Acute Triggers
- stresss levels
- last thing you ate before rash/ usual diet (Food allergy- IgE-mediated)
- any recent insect bites/stings
- any new medication/drugs
- work/home exposure to pets, chemicals, latex gloves
- any recent foreign travel
- CHRONIC RASH: medicine/ alcohol/caffeine/stress levels
PMHx:
- Allergies
- Autoimmune
- psychiatric illnesses
FHx:
- Allergies, urticaria
DHx:
- started any new medication
differentials for urticaria
- urticarial vasculitis (painful, non-blanching, palpable rash with systemic features fever, arthralgia) - caused by infection Hep B/C, autoimmune, drugs
- atopic eczema (dry/scaly skin, redness, lasts >24hrs)
- contact dermatitis (eczema rash after repeated exposure to allergen, lasts >24hrs)
- insect bites/stings (small papules)
- chronic pruitus (itching)
- erythema multiforme minor- rash has target like appearance
Examination findings of urticaria
- central swelling (red/white) with surrounding area of redness
- itchy rash +/- burning sensation
- fleeting rash (within 24hrs)
Investigations for urticaria
Only if cause isn’t identified/ exclude differentials
Bedside:
- stool culture (check for intestinal parasites)
Bloods:
- FBC - high neutrophils (urticarial vasculitis), low Hb (anaemia)
- ESR/CRP - exclude infection/ vasculitis
- LFTs- exclude viral hepatitis (high ALT/AST)
- TFTs - high thyroid autoantobodies linked with autoimmune urticaria
- H-pylori test
- antibody levels
Other:
- skin prick tests (check for allergies - food/drug)
Managament of urticaria
Usually don’t need treatment as resolves in a few days
- itchiness => Antihistamines
- oral corticosteroids (anti-inflammatory) for more severe symptoms
- peristant urticaria => refer to dermatologist
Complications of urticaria
- angiodema - swelling of deeper tissues (around eyes/lips/genitals/hands/feet)
- anaphylaxis (EMERGENCY)- swelling of eyes/face, wheezing, lightheaded, nausea, collapse
- chronic urticaria => emotional impact (stress, depression, anxiety)
define eczema and types of eczema
eczema = group of inflammatory conditions that cause dry, itchy, red skin
Types of eczema
- atopic dermatitis
- contact dermatitis
- Seborrhoeic dermatitis
- follicular eczema
causes/triggers of atopic dermatitis
- genetic susceptibility
- environmental triggers
- impaired immune system
- weak skin barrier
- stress
Triggers:
- synthetic clothing
- cold weather
- stress
- animal hair
- soaps/detergents
Presenting symptoms of atopic dermatitis
- itchy, red rash
- common in children/infancy and episodic in nature
- common sites in adults= hands, flexures of elbows, wrists, backs of knees
- common sites in infants = scalp, face
Examination findings of atopic dermatitis
- itching, dry skin
- acute flares - poorly demarcated areas of redness, scaling, crusting
- chronic- thickened skin (long-term scratching)
management for atopic dermatitis
mild
- emolients
- mild topical steroids (hydrocortisone)
- dermol (soap substitute)
- anti-histamines for itching (mainly for urticaria)
severe
- strong oral corticosteroid (prednisilone)
Complications of atopic dermatitis
- infected eczema => treat with fluoxacillin (antibiotics)
- eczema herpeticum (HSV infection due to steroid use + rash)
- stop steroids, oral acylcovir (for HSV) and fluoxacillin (for secondary bacterial infections)
define cellulitis
- acute bacterial infection of dermis and subcutaneous tissue causing unilateral leg swelling
- Staph. aureaus + strep, pyogenes most common bacteria
symptoms + signs of cellulitis
- ACUTE onset
- painful, red, WARM SWOLLEN limb
- usually unilateral + affects lower legs
- redness/swelling gets bigger in size
- can have fever, malaise, rigors
- can have blisters/ bullae
Investigations for cellulitis
- usually clinical diagnosis
- If ulcer/dishcarge/open wound => skin swab
Management for cellulitis
- Class 1 (minimal symptoms) - oral antibiotics in outpatient
- Class II (cormorbidities)- oral/IV antibiotics in outpatient
- Class III (limb threatening/ severe confusion) - IV antiboitics in hospital
- Class IV (SEPSIS)- urgent hospital referral + intensive treatment
Review after 2 days, advise patient to elevate, mositurise, take painkillers
