dermatology Flashcards

Question

Type eczema

Answer 1

Varicose eczema

Answer 2

* Internal organ systems - lots of symptoms, limite dphysical signs * Skin - many physical signs, few symptoms * Diagnostic process - General medical (8% symptoms, 20% physical signs) and skin diagnosis (80% physical signs, 20% histroy)

Answer 3

* Same history as surgical lump * Where * How long been there * Precedign abnormality * UV exposure history: Tendency to tan/burn, fair/dark skin, freckling, sun-lover/hater, lived or worked abroad (armed services), sunbeds

Answer 4

* Where did the rahs begin * How has the rash evolved? * Previous skin diagnoses? * Does sun exposure worsen (lupes) or improve the rash (eczema/psoriasis) * Symptoms: (very few) - itch, pain, weeping (almsot always eczema) * Most PMH irrelevant - atopy (eczema?), family (psoriasis or eczema), itchy contacts (scabies) * contact with substances - allergic contact dermatitis * Occupation/hobies - allergic contact dermatitis * Drugs, including when started - drug eruption *

Answer 5

* **Level of the pathology**: Epidermis, Dermis, Subcutaenous. Touch and feel (texture-rough/smooth. thickness, elasticity) * **Derma**l - skin stays smooth, raised surface * Macule (little flat) * Patch (big flat) * Papule (little area raised, dome surface) * nodule (big raised area), dome surface * Plaque (raised area with flat surface), usually formed by adj papules merged * Vesicle (Filled papule, small blister) * Bulla (Fluid filled nodule, large blister) * **Epidermal** pathology - surface change - crust, scale * Thickness of skin - Absence (erosion, ulcer, lichenificatin), thickened ( hyperkeratosis, lichenification) * Colour change - papura/necrosis, pigmentation (haemosiderin v melanin) * Crust -- dried serum, orange/yellow, remove to reveal undelryign patho * Scale - abrnomal stratum corneum, accumulation abnormal eratin. Hyperkeratotic * Colour - blood leakage (purpura-non blanching, or dusky purple), viability (necrosus - green-\>black), pigent (pale brown -\> blue/black) * Pigmentation - haemosiderin (yellow/brown), melanin (depth pigment alters colour) * **Patterns of ras**h: Symmetry (external v internal causes). Some suggest diseases. Psoriasis extensor, eczema flexural, contact sensitivity, photodistribution

Answer 6

* End of bed - comment broadly, pattern/distribution/extent, internal or external process? * Approach patient and for each area: describe surface morphology, papules/plaques, other physical signs * CLues from relating structures - scalp/hair/nails/mucous membranes * Is rash epidermal or dermal

Answer 7

* Crust = dried serum, orange/yellow colour * May be confused with keratin (usually white/yellow) * Always remove crust to reveal underlying patho * Is crust obscuring key characteristics of a tumour (means area of tumour become inviable and maybe necrotic and seep serum and this crust then builds up and can obscure patho).

Answer 8

* Abnormal stratum corneum * Accumulation of abnormal keratin * Hyperkeratotic

Answer 9

Excoriations

Answer 10

* Blood leakage - purpura (non blanching), dusky purple * Viability - necrosis - green-\>black * Pigment - pale brown - blue/black

Answer 11

Palpable painful purpura- cutaneous vascultisi

Answer 12

Cutaneous vascultis progression purpura and necrosis

Answer 13

Necrosis green/black necrotic tissue also seen in ulcers eg, pressure sores

Answer 14

* Epidermal (kertainocyte- derived): 4 basic tumour: Seborhheic keratosis, acitinic keratosis, basal cell carcinoma, squamous cellc arcinoma * Melanocytic- malignant melanoma (MM)

Answer 15

* Benign, basal = basal cell papilloma - seborrheic keratosis. (Seb K) * Benign squamous = solar/actinic keratosis (AK) * Malignant basal - basal cell carcinoma (BCC) * Malignant squamous = squamous cell carcinoma (SCC)

Answer 16

Seb Ks - brown "Stuck on" plaques

Answer 17

Basal cell carcinoma - pale/opalescen/translucent (lacking blood) Telangiectasia on left of original image. Ulcerated hav little depressions.

Answer 18

Ulcerated basal cell carcinoma

Answer 19

* Key factor - Breslow thickness *

Answer 20

Flat lesion, no elevation or depression Change in colour

Answer 21

Raised so its a palpable lesion, less than 5mm in diameter

Answer 22

Plaque = flat topped lesion

Answer 23

Wheal = firm oedematous plaque/papule. Dermal oedema

Answer 24

Vesicle - fluid colleciton smaller than 5mm

Answer 25

Bull - fluid collection larger than 5mm

Answer 26

Crust - dried serum. Pustule, vesicle, bulla

Answer 27

Erosion - partial focal loss of epidermis. Heals without scarring

Answer 28

Lichenification

Answer 29

Excoriations

Answer 30

Fissure - vertical loss of epidermis and dermis with sharply defined walls. Crack in the skin

Answer 31

Telangiectasis- small dilated superficial blood vessels that blanch with pressure

Answer 32

Burrow - channel in the superficial epidermis

Answer 33

Target lesion

Answer 34

Koebnerization

Answer 35

* Site * Size and shape * Colour * Associated symptoms * Margin and morphology

Answer 36

Basal cell carcinoma

Answer 37

* MM - Breslow Thickness * Measured from the granular layer of the epidermis to the base of the tumour. * Reliable indicator of prognosis Tickness + approximate 5year survval * In situ = 95-100 * \<1mm 95-100 * 1-2mm 80-96 * 2.1-4mm 60-75mm * \>4mm 50

Answer 38

Squamous cell carcinoma

Answer 39

* Eczema = * Flexor surfaces * ill defined, excoriated, licenified, papular. * On the scalp - finer scale, loosely adherent, o undelrying well demarcasted plaque. * Nail changes - associated with hand dermatitis. Chronic paronychia (thickened proximal and laterla nail fold). Surrounding skin, dry, cracked, illdefined erythema. Horizontal nail ridging. * Psoriasis = * Extensor surfaces * salmon pink, well demarcasted, plaques, silvery adherence scales. * Check, scalp and behind ears * Nail changes - onycholysis, pitting, subingal hyperkeratosis * Summary - FH, ask about inflammatory arthritis, check nails and scalp, back of neck, check umbilicus.

Answer 40

◦Nail changes associated with hand dermatitis ◦Chronic paronychia (thickened proximal and lateral nail fold) ◦Surrounding skin, dry, cracked, illdefined erythema ◦Horizontal nail ridging

Answer 41

Discoid eczema

Answer 42

Take a bacterial swab

Answer 43

Eczema herpeticum is a disseminated viral infection characterised by fever and clusters of itchy blisters or punched-out erosions. Take viral swab

Answer 44

Red flag for psoriasis - infected ## Footnote **Pustular psoriasis**

Answer 45

Erythroderma is a severe and potentially life-threatening inflammation of most of the body's skin surface. It is also called generalized exfoliative dermatitis. It may be caused by a reaction to a medicine. Or it may be caused by another skin condition or cancer

Answer 46

Cellulitis: - Bacterial infection of lower dermis and subcutaneous tissue - Red, painful, swollen skin with poorly defined edge - Usually unilateral - Can be associated with systemic symptoms - Commonly caused by Strep pyogenes and Staph aureus - Discuss risk factors e.g. previous episode of cellulitis, diabetes, venous disease etc

Answer 47

Erysipelas: - Affects upper dermis - Usually caused by Group A beta haemolytic strep (Strep pyogenes) - Affected skin has sharp raised border (cellulitis less well demarcated, and does not have such marked swelling) - Red, firm and swollen, can be dimpled - Treatment – penicillin antibiotic of first choice

Answer 48

* Look for portal of entry * Swabs +/- bloods * Analgesia, fluid, elevation * Treat co-existing skin conditions * Uncomplicated cellulitis can be treated with oral antibiotics * If severe cellulitis or systemic symptoms, IV antibiotics are needed * Antibiotics based on local protocol or sensitivities * Prolonged course may be required

Answer 49

Impetigo - Superficial bacterial skin infection - Pustules and honey-coloured crusted erosions - Most often caused by S aureus , also caused by group A strep (Strep pyogenes) - Most common in children - Usually affecting face and hands - Single or multiple irregular crops - Bullous vs non-bullous - bullous due to staph exfoliative toxins

Answer 50

Furuncle (boil) - S aureus - May be associated cellulitis - 10-20% Staph carriers – nose, armpits, groin - Topical antiseptic / compress / oral abics / be aware of sepsis - Carbuncle = collection of interconnecting boils.

Answer 51

* Antibiotic ointment eg, mupirocin or fusidic acid * oral antibiotics

Answer 52

* Meningococcal rash * Neisseria meningitidis * Spreads to blood and brain causing meningocccemia and/or meningococcal meningitis * Petechia and purpura, may be extensive * Dx-blood culture and LP * Rx-Penicillins

Answer 53

Chancre - primary syphilis. Small firm red papule which ulcerates to form painless ulcer (chancre) Treponema pallidum

Answer 54

**Secondary syphilis** Widespread rash and flu like symptoms Rough, red, or reddish brown spots both on palms and soles Wart like sores in mouth or genital area **Tertiary syphilis** Can affect multiple organ symptoms e.g neurosyphilis Syphillis known as ‘The Great Pretender’, as can mimic many other diseases

Answer 55

* Lupus vulgaris (cutaneous TB) * Mycobacterium Tuberuclosis * Rare * Reddish brown lesions with gelatinous consistency (apple jelly nodules)

Answer 56

* Viral exanthem * -Exanthem * Widespread rash accompanied by systemic symptoms * Common in childhood – e.g. chicken pox, measles, rubella, parvovirus b19 can present as such * Various other viruses * Drug reactions an important differential

Answer 57

HSV- herpes simplex virus * Type 1 – usually orofacial * Type 2 – usually anogenital * After primary infection, recurrent infections can occur * Recurrent Type 1 HSV occurs most frequently on face esp lips – herpes simplex labialis * Dx – viral swabs for PCR * Rx – mild cases do not required Rx, severe cases may require antivirals e.g. aciclovir

Answer 58

**Eczema herpeticum** - Dissemination viral infection - Most cases due to HSV - Fever, clusters of painful, itchy blisters and punched out erosions - Commonly a complication of atopic eczema - Complicated by secondary bacterial infection - Antiviral treatment, IV antivirals required if patient unwell or immunocompromised

Answer 59

Herpes zoster

Answer 60

Varicella zoster

Answer 61

* Herpes zoster opthalmicus * Opthalmic nv ( first division of trigeminal nv) * Ask for ophthalmology review!

Answer 62

**Viral wart aka veruca** - Caused by HPV - Common in children and in immunocompromised - Hard keratinous surface - Tiny dot can be seen at centre of each scaly spot – intracorneal haemorrhage - Common on backs of fingers and toes - Rx-salicylic acid, cryo

Answer 63

* Superficial (common) and deep (rare, tropical) * Superficial - dermatophytes (Tinea), candida, yeasts

Answer 64

**Tinea corporis**: demonstrate how to take a skin scraping - Dermatophyte skin infection - Name depending of body part affected - Prefix tinea +body site

Answer 65

Tinea pedis

Answer 66

Tinea capitis

Answer 67

**Fungal infection of nails- onychomycosis** - Can be caused by dermatophytes, yeasts, moulds - commonly due to T Rubrum - Ix-nail clippings for microscopy and culture - Rx- topicals antifungals if limited usually needs oral

Answer 68

Nail psoriasis

Answer 69

**Candidal intertrigo** - Intertrigo describes rash in body folds - Candida often affects intertriginous areas typically inframammary - Pink to bright red moist patches +/- satellite papules and pustules

Answer 70

**Pitryriasis versicolor:** * Common eyast ifnection fo the skin * Pityriasis 0 scale appears similar to bran * ersicolour - multiple colours * Masselezia fungus * Affects trunks, neck, arms * Brown or pink patches, pale patches common in darker skin * Asymptomatic, sometimes mildly itchy * Microsocpy - spaghetti and meatballs appearance, yeast ad hyphae

Answer 71

**Seborrhoeic dermatitis** - Not infection - Associated with proliferation of commensal Malassezia - Its metabolites cause an inflammatory reaction - Infantile seb derm - Adult seb derm - scalp, face (creases around the nose, behind ears, within eyebrows) and upper trunk.

Answer 72

Insec tbite reaction - note the linear distribution

Answer 73

- Sarcoptes scabiei - Parasitic mite that burrows under skin - Causes an intensely itchy rash - Worse at night disturbing sleep - Burrows – grey irregular tracks - Look in webspaces of fingers and toes, palms, wrists - Also found on elbows, nipples, buttocks, penis, soles - Rarely involves face and scalp - Can develop a generalised rash which is a hypersensitivity reaction few weeks after

Answer 74

* 5% permethrin cream applied all over skin and left on for 8-10 hours * Oral ivermectin 200mcg/kg * Treatment repeated a week later to kill newly hatched mites * Identify and treat contacts * Launder bed linen, towels, clothing and clean rooms * Seal items that cannot be washed in plastic bag for a week * Itching may persist up to 6 weeks. If itching persists after 6 weeks – consider if treatment has been applied properly, if there is reinfestation or if initial diagnosis is incorrect

Answer 75

Pubic lice

Answer 76

* Creams: * Pros - easy to rub in, dont rub off on clothes, will rub into weepy skin * Cons - not the best moisturisers, contain preservativw (an cause contact allergy) * Lotions: mainly water based * Cons - poor moisturisers * Pros - easy to apply to hairy areas eg, scalp * Ointments: Greasy, form waterproof barrier * Pros - better moisturisers than creams, better for eczema/dry skin * Cons - dont rub in as easily as creams, can be more unwieldy, can make clothes/sheets messy * Soap substitue emmolients. * In eczema (impaired skin barrier) - frequent and coopious emmolient use essential for dry itchy skin

Answer 77

* Range ptoencies * Essential for all but mildest eczema - effective and safe with appropriate use * Toxicity - atrophy, acne, rarely adrenal suppression * In order potency - Betamethasone valerate (top), hydrocortisone, dermovate ointment, betnovate RD ointment). * Many eczema patients dont use enough topical steroids due to unfoudned fears about atorphy * S/E topical steroids = Skin thinning (atorphy) usually only with storng steroids, prolonged period, at certain sites like face and skn creases. Also acne * Rules for steroid use - dont use storng on eif weaker steroid is effective, stronger steorids safe in short blasts and use ointment base rather than creams.

Answer 78

1. General measures - time needed to discuss condition, give patient info leaflet, advise on prepayment certificate 2. Topical treatment - emollients, topical treatments 3. Assess for relate docnditions - arthritis, mental health, CV disease and RFs * Always start with emollients. Soap substitute as moisturixer. Prescribe large quantities \>500g. This is to soften scale, allows scale ot life, allows acitve topical treatment to be more effective and encourage use even in quiescent periods. * Triggers - can be stress, smoking, skin injury, infectiosn etc. * Lifestyle advice on managin triggers. * Trunk and limbs - calcpotriol/betamethasone * Scalp - descale if needed with coconut oil etc then tres tongoign inflammation with topical steroids and maintainence therapy * Flexures and genetalia - cream/ointment silikis * Face - eumovate ointment * Guttate psoriass (most torso and limbs).- refer for light therapy and lotion itnerim * Palmoplantar pustular - stop smoking, dermovate ointment, moisturiser and referral hand and foot pIVA/Acitretin * Nails - practicle tips, dovobet gel * Psoriatic arthris - refer dermatology

Answer 79

* Calcipotriol cream- 2x daily * Calcitriol - 2x daily * Tacalcitol (curatoderm) * Vit D analogue. betamethasone combo - stops keratinocytes from dividing and allows them to differentiate. Enstilar cutaneous foam * Less messy, free fron odour, less irritant than dithranol, synergistic effect with phototherapy (dose sparing effect) * A/E - skin irritation in around 20% with calcupotriol, avoid face and flexures with calcipotriol/dovob etc. Hypercalcaemia, avoid in inflammatory . erythrodermic psoriasis. * Silkis - inhibits proliferation fo t lymhocytes and normalises the production of various inflammation factors.

Answer 80

* Several creams and shampoos * Some preps have been combined with topical steroids for synergistic effect and ease of patients use * Epidemiological studies have not confirmed any carcinogenci potential * MOA - not really known but thought to have anti-prolfierative effects: * Inhibit DNA synthesis of kaeratinocytes * Limit keratinocyte proliferation * Slows down the abnormal cycle * (Also anti-inflammatory effects) * Benefits - Effective, synergistic with phototherapy, certain preps can be used on face * A/E- odour, messty, stain clothing, can be irritant in higher doses, avoid in inflammatory/erythrodermic psoriasis.

Answer 81

* Derivative of tree bark * SHort contact (apply, then wahs off after 20min). Dithrocream-micanol * Over 24hours in Lassars paste (zinc and salicyclic acid) * Wash off with oliver oil * Respond within 20days of treatment * Relapse rate of 10% per month. * MOA - anti-proliferative effect on keratinocytes - inhibit DNA replciation, inhibit cellular respiration. Induce apoptosis in keratinocytes * Outpatient or inpatient treatment. Messy, staining, smelly * Safe and effective * Short contact - washed off plaques after 20-30mins * ingrams regime - combined with UVB, left on skin for 24hours. * Pros - inexpensive, effective, synergistic with phototherapy * A/E - irritant (burns- avoid on face and flexures), stains (fabrics and bathroom fitting irreversibly and skin reversibly), avoid in inflammatory/erythrodermic psoriasis

Answer 82

* Different strengths, often combined with coal tar or calcipotriol * Use on limited areas, useful in flexures (trimovate), face * Rotate topical corticosteroids with alternative non-corticosteroid preparations * Avoid long term use as sole topical treatment- skin atrophy, tolerance * Rebound phenomenon. * Can transform to unstable pustular psoriasis.

Answer 83

* Keratolytic * useful for hyperkeratotic areas = palms, soles, scalp * Available in: various strengths in emulsifying ointment. Also in combo with other preps (corticosteroids, coal tar, sulphur). * Higher strengths can be irritant

Answer 84

**Children:** * Calcipotriol from age 6 * DovoBet and silkis from age 12 * Coal tar - upto 6% from 1month, up to 10 from age 2 * Dithranol not recommended in infants/young children * Salicylic acid - can be used topically from age 2 Pregnant women: * Vit D analogues- avoid * Low potency topical steroids * Coal tar - intermittend use, low conc, on small percentage body and avoid 1st trimester * Dithranol - no A/E reported

Answer 85

* ldiagnostic uncertainty * lextensive disease, if unresponsive to initial therapy or difficult to self-manage * lneed for increasing amounts or potencies of topical corticosteroids * linvolvement of sites which are difficult to treat, e.g. face, palms and soles, genitalia, if unresponsive to initial therapy * lneed for systemic therapy, phototherapy (e.g. guttate psoriasis), day treatment or inpatient admission * lgeneralised erythrodermic or generalised pustular psoriasis (emergency referral is indicated); acute unstable psoriasis (urgent referral may be justified) * lrequest for education including demonstration of topical treatment * lfailure of appropriately used topical treatment for a reasonable time (e.g. 2–3 months)

Answer 86

* History: * DUration * Extensive * Rate of relapse if chronic * Exacerbants * FH * Arthrpathy * Exam: Nails, palms, body, scalp, flexures, feet * Explaind iagnosis * Topical treatment - emollient, active treatment * Explain how it is used

Answer 87

Actinic keratosis: Treatment = Liquid nitrogen cryotherapy, 5-fluorouracil cream, efudix

Answer 88

UV effect on the skin