DERMATOLOGY Flashcards
chronic dry and very itchy skin?
Eczema
management of mild eczema?
generous emollients
mild topical steroids considered on inflamed areas (1% hydrocortisone)
management of moderate eczema?
generous emollients
moderately potent topical steroids (0.025 betamethasone valerate or 0.05% clobetasone butyrate)
use mild topical steroid in delicate areas
sever itch/urticaria = oral 1 month non-sedating antihistamine trial
management of severe eczema?
generous emollients
inflamed skin = potent topical steroids (0.1 betamethasone valerate)
moderate potency topical steroid for delicate areas
severe itch/urticaria = one month trial of antihistamine
sleep disturbance = sedating antihistamine
severe, extensive eczema = oral prednisolone
lesions are erythematous, vesicles, crusting, scaling
sharp margins confined to site of exposure
rapid onset/within ours of exposure
may occur in everyone
Irritant contact dermatitis
lesions erythematous, papules, vesicles, erosions, crusts and scaling
initially sharp margins which eventually spread out over time
onset after 12-72hrs of exposure
occurs only in sensitized
Allergic Contact dermatitis
management of contact dermatitis
best Tx = avoid contact and decontaminate using soap and water
aveeno baths. calamine lotions. cool compress and oral antihistamines
mild to high potency topical steroids
severe reactions = oral prednisolone - can taper over 7-21 days
clustered erythematous papules, papulovesicular
and papulopustules
more common around the mouth but can form around eyes and nose
typically in females 20-45yrs and associated with steroid use
peri-oral eczema
management of peri-oral eczema?
mild = topical metronidazole/erythromycin severe = Oral ABx e.g. lymecycline/doxycycline
avoid irritants, alcohol and spicy foods and steroids
symmetric coin shaped lesions
vesicles and papules merge to form a plaque
itchy/pruritic
nummular/discoid eczema
management of nummular/discoid eczema?
adv to moisturize
moderate to potent steroid
sedating antihistamine if sleep disturbance
hyperpigamented plaques on anterior/medial aspects of lower legs
erythema, ulcers and some oedema
ulceration usually above medial malleolus
may have hx of varicose veins, HF, thrombophlebitis, trauma/surgery to limb or above 50yrs
venous stasis eczema
how is venous stasis eczema investigated
ABPI - <0.9 = arterial disease
management of venous stasis eczema?
compression
elevation and walking
topical steroids or ABx if indicated
tx the ulcers accordingly
fever swollen lymph nodes extremely painful blistering rash monomorphic punched-out erosions, circular depressed ulcertaed lesions ~ 1-3cm
eczema herpitcum
investigations for eczema herpiticum?
clincial diagnosis - viral swabs can be taken
management of eczema herpiticum?
oral/IV acyclovir 400-800mg 5x day
severe/systemically affected = hospital admission and IV antiviral preferred.
eczematous lesions in sebum rich areas
(usually scalp, under eye, near ears and around nose)
associated otitis externa or blepharitis
seborrheic dermatitis
management of seborrheic dermatitis
scalp = OTC zin pyrithin = head n shoulders
or OTC tar = Tgel shampoo
+ ketoconazole
face and body
topical ketoconazole
short term topical steroids
isolated red/brown macule/papule with rough yellow-brown scale over it
usually on temples
may be more than one
actinic keratosis
management of actinic keratosis
sun avoidance/sun cream
cryotherapy/surgical removal
diclofenac gel = solarase
5-fluorouracil cream = 2-3 week course
others include
tretinon (retin A)
acid peels
round lesion on scalp
surrounding alopecia
can form spongy/boggy mass (leronion)
tinea capitis
management of tinea capitis?
topical ketoconazole and
oral griseofulvin for adults or
oral terbinafine for children
well-defined annular erythematous lesion withpapules and pustules and clearer central area
tinea corporis
management of tinea corporis?
oral fluconazole
usually asymtpomatic but may itch
found mainly on trunk, neck and arms
patches are a copper/brown in colour and scaly
may become non-scaly and white once resolved
early 20s
durations months/years
tinea versicolor
investigations to confirm tinea versicolour diagnosis?
woodlamp
microscopy
fungal culture
skin biopsy
management of tinea versicolour
selenium sulphide 2.5% lotion/shampoo used daily for 7-10/7
topical miconazole for 14/7
pruritic superficial rash - large scaly, well-demarcated red/brown plaques
mainly around the groin and adjacent skin
gentials spared
hx of wearing tight underwear, living in tropical climate
obese
athletic
male
tinea cruris
management of tinea cruris?
topical azole = ketoconazole, clotrimazole or miconazole
young adults
herald patch
erythematous, oval scaly patches with a longitudinal distribution often described as ‘fir tree appearance’
may have has a prodromal viral infection
pityriasis rosea
management of pityriasis rosea?
self-limiting = usually resolves in 6 weeks
what are the 5 main drug eruptions?
morbilliform urticarial fixed hyperpigmentation chemo-induced acral erythema
often 7-10 days after exposure
maculopapular rash which become confluent
itchy
usually spares the face
morbilliform
management of morbilliform eruption?
antihistamines and cooling lotion
hives mins-hrs after intiating medication
urticarial eruption
management of urticarial eruption?
antihistamines and cooling lotion +/- epinephrine
round. rythematous plaques mins-hrs after medication initiation
any part of body affected but common in glans penis
fixed eruption
tingling in the palms. soles and then swelling/erythema after several days
chemo-induced acral erythema
well demarcated, read/silver rash that is ring-shaped
appearing on stratus coneum, hair/follicles and on nails.
dermatophyte infections
diagnosis of demratophyte infections?
KOH microscopy
management of dematophyte infections?
clotrimazole, miconazole & terbinafine
Pruritic, purple polyglonal papules
can merge into plaques
usually on the wrist, ankles, shins, mucous membranes and penis
‘ white lines on surface/wickham’s striae’
oral/buccal mucosa - white lacey pattern
often an eruptiosn due to gold, quinine or thiazides
lichens planus
management for lichens planus
potent topical steroids (oral/IM injection considered)
sedating antihistamine
monitor mucous membranes - benzydamine mouthwash
UV therapy
sharply marginated erythematous papule with silvery white scale
scales loose and easily removed from scatching
papules grow sharply maginated plaques which merge with each other
can happen on scalp, palms/soles, nails, extensor surfaces and lower back and anterior tibial surface
can lead to joint pain/arthritis
usually in teens/childhood or older pts in 50s
family history present
psoriasis
management of psoariasis?
- potent corticosteroid + vitamin D (tacalcitol or calcipotriol) - OD
- increase vit D analgoue to BD dose
- if no imporvement in 8-12 weeks = increase steroid to BD dose or start coal tar O/BD
- short acting diathanol/anthralin
commonly on shins
pain, redness, warmth and swelling
macular
usually associated with systemic upset = fever
can be linked with venous stasis
cellulitis
management of mild cellulitis?
first line - flucloxacillin - doxycycline in allergy and macrolide as alternative in pregnancy
if traumatic consider tetanus prophylaxis and outpatient wound check in 24-48hrs
management of severe cellulitis?
clindamycin, vancomycin
co-amoxiclav or ceftriaxone
moxifloxacin
inflammation of small vessels
itching/burning rash
1-3mm lesions which may coalesce
often on legs
recent initiation of medication?
autoimmune disorder hx
vasculitis
management of vasculitis?
treat underlying cause if identified
compression stockings and elevation
sedating antihistamine
if systemic involvement = high dose steroid
no systemic involvement = colchicine or dapsone
bright red/fiery red lesion on skin superficial layers affects painful, raised and well-demarcated plaques malaise often on face and lower extremities
erysipleas
management of erisipleas?
supportive care and analgesia
flucloxacillin
if on face co-amoxiclav and admit to hospital
‘golden’ crusted skin lesions typically around the mouth
commonly in children and warmer weather
impetigo
management of limited/localized impetigo?
hydrogen peroxide 1% cream if not systemically unwell
topical ABx = fusidic acid or topical mupirocin
management of extensive impetigo?
oral flucloxacillin
or alt = macrolide
school exclusion till lesions have crusted ove/ 48hrs after Abx initiation
excessive pruritis either in hair or around pubic regions
lice
management of lice?
permethrin cream - apply at night and wash off in the morning
widespread pruritis
linear burrows on the sides on fingers, iterdigital webs or on flexor ascpects of wrists
typically in children/young adults
scabies
management of scabies
first line = premethrin 5% cream - apply from neck down at night and wash off 8-12hr later
second line = melathion 0.5%
treat any bacterial superinfections
treat entire household
early features include
erythema migrans/’bulls eye rash’
usually painless
headaches, lethargy, fever and arthralgia
later features
CVS - heart block or peri/myocarditis
neuro = facila palsy, meningitis
MSK = joint effusions
lyme disease
lyme disease investiagtions?
ELISA antibodies and western blot
management of lyme disease
- doxyxyline 100mg BC 21/7
- Amoxicillin 1g TDS 14-21/7
- azithromycin 500mg 17/7
refer for any neuro involvement
management of animal bites
control bleeding and irrigate thoroughly with germicisal
consider tetanus and rabies prophylaxis
Give prophylactic Abx = co-amoxiclav - Doxycycline +metronidazole if allergic
refer if systemic illness
human bites management?
co-amoxiclav as abx prophylaxis
doxycycline and metronidazole if allergic
management of skin lacerations
assessment of the injury
heamolysis - elevation, pressure and tourniquet
analgesia = systemic or local
skin prep = irrigate debride ragged edges
closure = primary, delayed, secondary
dressings = either non-adherent, lubricated or dry
infection prevention if high risk
follow up in 48-96hrs
red and painful burn?
first degree
pale pink, painful and blistered
epidermal second degree
white patches of non-blanching erythema, reduced sensation
dermal second degree
white/brown or balck in colour, no blisters, no pain
3rd degree
burn extending to subcut fat, muscle, nerves, major blood vessels or bone
4th degree
epidermal second degree initial management
initial first aid/ clear skin tetanus immunisations topical Abx = silver sufadiazine with bulky occlusive dressing hydration (oral preferred) analgesia elevate limbs to control oedema
dermal second degree initial management
cleanse wound
leave blisters intact - sterile + protective
non-adherent dressing and avoid topical creams
review in 24hrs
third degree burn management
usually surgical repair or grafting
fourth degree burn management
often requires amputation or extensive reconstructive surgery
refer to burns unit when?
dermal 2nd degree 3rd/4th degree inhalation injury electrical/chemical burn paediatric chronic illness or mental illness in pt
management of needlestick injuries?
first aid
discuss with healthcare profressional - consider prophylaxix eg: pep
investigations = virology, LFTs and hCG
documentation
prevention is key emphasis on prophylaxis
well-raised, circumscribed irregularly shaped areas of erythema and oedema
affects both dermal and epidermal layers
very pruritic/itchy
urticaria
management of urticaria?
- H1/H2 blockers = benydryl, hydroxyzine or ranitidine
- steroids = prednisolone
- consider epinephrine if any airway compromise is present
continue Tx for 5 day
well-demarcated patches of depigmented skin
peipheries affected more
trauma may precipitate new lesions/areas of depigementation
linked to T2DM, Addisons, thyroid disorders, penicious anaemia and alopecia
vitiligo
management of vitiligo?
topical corticosteroids
topical tacrolimus
photo/UV light therapy
sunscreen
camouflage makeup
initially manifests as recurrent, painful and inflamed lumps
commonly in the axilla
nodules may rupture to release mucopurulent, malodourous discharge
merging of nodules may for plaques, sinus tracts or ‘rope-like’ scarring
double comedomes = form fistulae
commonly affects adults under 40 and women more
FHx, smoker, obesity, diabetic, PCOS
hidradenitis supperativa
management of hidradenitis supperativa?
acute flares = steroids or flucloxacillin, surgical I&D may be needed
long term = topical clindamycine or oral clindamycin, doxycycline or rifampicin
reinforce good hygiene, loose clothing, smoking cessation and weight loss if obese
patches of bilateral macular areas of hyperpigementation with irregular borders
typically on face
use of contraceptive, recently pregnant or lots of sun exposure
melasma (chioasma)
management of melasma?
opaque sunblock/avoid sun exposure
topical hydroquinolone
tretinoin
smooth, rounded, mobile and non tender lump
average 3-5cm
commonly on neck, upper chest or arms
lipoma
management of lipoma
watchful waiting
surgical excision if large or symptomatic
discrete nodules, usually mobile often with punctum
common on head, neck and trunk
if inflamed = eythematous and can rupture to release foul-smelling discharge
epithelial inclusion/sebaceous cyst
management of epithelial inclusion/sebaceous cyst
abx if inflamed
surgical excision = entire cyst wall/capsule to prevent recurrence
persistently red, broken skin often extending to underlying surfaces
usually over bony prominence
history of lack of mobility
decubitus ulcers/pressure sores
management of decubitus ulcers/pressure sores
reposition and pressure support products
wound management dressings - hydrocolloid dressings
pan relief
Abx if appears infected
dark, thick, velvety skin in body folds/creases
often in axilla, neck or groin
skin looks dirty
Hx of T2DM, GI tumours, endocrine disorder or obesity
acanthosis nigricans
management of acanthosis nigricans
treat underlying cause
GI tumour = surgical exclusion
ammonium lactate - 12% PRN to soften skin
aqua glycolic acid BD
more common in elderly patients
itchy, tense blsiters around flexures
erythematous, papular or urticarial bullae in inflammatory plaques
no mucosal involvement - doesn’t spread to mouth
bullous pemphigoid
diagnosis/Ix for bullous pemphigoid
Immunofluorescence - IgG and C3 at dermo epidermal junction
management of bullous pemphigoid
topical or systemic steroids = oral mainly
+/- immunosuppressants
sometime Abx used
target lesion/iris lesions vesicles/bullae form in the centre initially seen on the back of hands or feet before spreading to the torso upper limbs more common mild pruritis
recent infection, or intiation of drug
erythema multiforme
management of eythema multiforme
treat underlying cause
antihistamine, paracetamol, cool compress and steroids
seen in older people males>females FHx stuck to the skin appearance brownish papule, grasy/spongy appearance commonly on sun exposed areas - back keratotic plugs on the surface
seborrheic kertoses/ senile keratosis
management of seborrheic keratoses
have low threshold for melanoma = bisopsy if suspicious
cryotherpay
curettage
routine exams to watch for melanoma
found on sun-exposed sites mainly the head and neck
initially pearly, flesh-coloured papule
telangiectasia
may later ulcerate forming a crater and crusting
colour red-pink with a pearly translucent border
basal cell carcinoma
investigation and diagnosis for BCC
biopsy
management for BCC?
surgical removal, curettage , cyoptherapy
moh’s surgery and radiation therapy
patient ed = avoid sun exposure and self exam
slowly evolving isolated keratotic papule or plaque
if highly differentiated = kertainised surface, firm on palpation
if poorly differentiated = no keratinisation, fleshy, granulomatous and soft on palpation
more common in fair skinned blondes and red-heads
may be immunosupressed, smoker, longstanding ulcers, sunlight exposure
squamous cell carcinoma
investigation for SCC?
biopsy
management for SCC
excision, mohs surgery or radiation therpay
a ‘growing mole’
evolving, enlarging or has become elevated
mean diamete 8-12mm
more common in caucasians
family hx or fair skin and chronic sun exposure
melanoma
investigation for melanoma
biopsy
management for melanoma
2wwr
total excision with margins
stage 1-2 = interferon a
chemo/immunotherapy for metastatic disease
smaller blisters on the palms & soles - vesicular eruptions and pruritic
can have a burning sensation
rupture of blister leaves behind dry cracked skin
precipitated by humidity and high temps
dyshidrosis/pompholyx
management of dyshidrosis/pompholyx
topical steroids
emollients
cool compress
burrow’s solution - 10% aluminum acetate dilution
well-demarcated, round, oval or linear plaques of confluent papules
thickened skin
accented skin markings
dull red-dark brown/black
usually due to repetitive rubbing/scatching/itching
lichen simplex chronicus
management of lichen simplex chronicus
must stop itching/scratching
occlusive dressing nocte
topical steroids
sedating antihistamines
fever malaise
headaches
widespread rash
may have a infection or initiated a drug
exanthems
management of exanthems
treat underlying cause/infection
acute, unilateral painful blistering rash - can be erythematous and doesn’t cross the midline
initial prodromal feature include a burning pain over the affected dermatome, fever lethargy and headache
commonly in T1-L2
shingles
management of shingles
NSAIDS/paracetamol - or amitriptyline
if within 72hrs = aciclovir
small fleshy warts on the genitals or rectum
may itch or bleed
genital warts or condyloma acuminata
management of genital warts
topical podophyllum or cryotherapy
imiquimod topical cream
trichloroacetic acid
electrocautery laser
pinkish or pearly white papules with a central umbilication
usually appear in clusters on the trunk or in flexors
anogenital lesions can occur
molluscum contagiosum
management of molluscum contagiosum
treatment not recommended unless troublesome or unsightly
simple trauma, cryotherapy
small rough raised or flattened lumps occur ocer the pressure of areas of the feet
verrucae/plantar warts
management of verrucae
salicylic acid - apply daily for 3/12
freezingtx/cryotherapy
maculopapular rash with target lesions which may develop into vesicles or bullae
mucosal involvement
fever and arthralgia
recently started a new medication
stevens-johnsons syndorme
systemically unwell - pyrexia and tachycardia
scalded appearance over an extensive area
+nikolsky’s sign = epidermis seperated with mild lateral pressure
toxic epidermal necrolysis
management of toxic epidermal necrolysis
stop the precipitating factor
supportive care
IVIG first line
immunosuppressive agents and plasmapheresis
presence of whiteheads or blackheads
papules or pustules
modules or cysts
usually in teens/young adults
acne vulgaris
management of acne
- good skin hygiene and a single topical agent - retinoid, benzoyl peroxide or steroid, then try combine two single agents
- oral abx on a daily basis or oral COC
- oral isotretinoin (roacutane)
typically affecting the nose, mouth and forehead
flushing/heat on face
telengiestasia
persistent erythema - sometimes with pustules and papules
maybe associated with conjunctivitis, stye.chalazions and blepharitis
rhinophyma
usually 30-50s and more common in females
rosacea
management of rosacea
- daily topical metronidazole
- oral Abx = tetracyclines
last resort = isotretinoin or private laser tx
reduce exposure to alcohol and hot beverages
pt with rhinophyma - refer
itchy, erythematous pustules - often clustered and by hair follicles
folliculitis
management of folliculitis
topical aseptic wash = chlorhexidine
oral Abx = flucloxacillin for s.aureus
ciprofloxacin for pseudomonas
eythematous painful swollen lateral or proximal nail fold
might have purulent/abscess
paronychia
management of paronychia
warm socks
flucloxacillin
consider I&D
bitemporal recession of hair often spared at the occiput and a thin band around the sides
horse-shoe shape
in males mainly
in females = loss of oestrogen = thinning
androgenic alopecia
management of androgenic alopecia
minoxidil (2% or 5% in males)
finesteride in males only
yellow white nail separates from nailbed
distal or lateral subungual
nail soft dry powdery and adherent to bed and not thick
superficial white
nail surface intact
debris causes nail to seperate
proximal subungual
thick nail plate
yellow/brown colour
candida nail infection
