Dermatology Flashcards
1
Q
What is the pathophysiology of Acne Vulgaris?
A
Multifactorial
Follicular epidermal hyperproliferation forms a keratin plug which obstructs the pilosebaceous follicle
Colonisation with P acnes
Inflammation
2
Q
Outline the difference between a whitehead and a blackhead regarding the pilosebaceous unit.
A
Whitehead is when the top is closed thus no [O] cf blackhead is when it is open thus [O] occurs
3
Q
What is the management for Acne fulminans?
A
Hospital admission
Oral steroids
4
Q
What are the clinical features of drug-induced acne?
A
Monomorphic lesions
Steroid use
5
Q
How would you classify acne?
A
Mild (<34 lesions + <1 nodule): open + closed comedones ± inflammatory lesions
34+ lesions + >2 nodules
Moderate: wide-spread lesions + numerous plaques/papules
> 3 nodules
Severe: Extensive inflammatory lesions with nodules, pitting and scarring
Actually mild-to-moderate or moderate-to-severe
Acne Conglobata: Inflammatory nodulocystic with interconnecting sinuses and abscesses -> Severe scarring
Acne fulminans: Severe form of acne conglobata with systemic features of fever, arthralgia and lymphadenopathy
6
Q
Outline the Acne treatment ladder.
A
Supportive: Face wash (with neutral pH cleanser); avoid oil-based products; reduce make up; try not to scratch/pick
1st: Topical therapy (Retinoid/BPO/ ABX)
2nd: Topical combination therapy
3rd: Oral ABX
Tetracyclines for 3 months
If pregnant, use Macrolides
7
Q
Which management is contraindicated in a pregnant woman with acne?
A
Tetracyclines
Isotretinoin
Note: Ceiling of care is essentially Erythromycin for 3 months
8
Q
A 27 year old chap presents with severe acne. He says he has had it since he was 17. He reports a fever and lymphadenopathy.
O/E you see multiple communicating nodules which are inflamed.
What is your management?
A. Oral tetracycline for 3 months
B. Oral tetracycline for 6 months
C. Hospital admission and Oral steroids
D. Oral steroids
A
C - This is Acne Fulminans, a severe form of Acne Conglobata with systemic features requiring hospital admission and oral steroids
9
Q
What are the contraindications of Oral Isotretinoin?
A
Pregnancy/no contraception Hyperlipidaemia Hypervitaminosis A Liver dysfunction Allergies to constituents
10
Q
Describe atopy.
A
Atopy refers to a predisposition to an abnormally exaggerated IgE response to allergen exposure.
11
Q
What are the clinical features of Atopy?
A
Atopic eczema
Allergic rhinitis
Asthma
12
Q
What gene is responsible for the heritability of atopy?
A
MZ 80% concordance
Mutation in FLG gene which codes for Filaggrin protein used to form an effective barrier.
Therefore deficiency allows the access of antigens to penetrate, picked up by CD4+ T helper cells which differentiate and cause an exaggerated IgE response
13
Q
What are the clinical features of atopy?
A
Early onset
Eczema - flexural, scaly, itchy, erythematous patches
Rhinitis
Asthma
Note: Afro-Carib ethnicity may have a different distribution with extensor prevalence and pigmentation changes
14
Q
How may atopic eczema be classified?
A
Mild: areas of dry skin with infrequent itching
Moderate: areas of dry skin with frequent itching
Severe: widespread areas of dry skin with itching and extensive skin thickening, bleeding, oozing or cracking
15
Q
How is Atopic Eczema managed?
A
Supportive: Stop triggers; bathing in gentle soaps; food diaries/trigger diaries;
+
Medical: Stepwise approach used
1st: Emollients (vehicle-only) via lotion > cream > ointment or gel/spray
2nd: Topical steroids
Hydrocortisone < Clobetasone 0.05% < Betamethasone 0.1% < Clobetasol 0.05%
In moderate-severe
3rd: Calcineurin inhibitors e.g. Tacrolimus
16
Q
Outline the Atopic Eczema treatment ladder.
A
Mild:
Emollient
Mild potency topical corticosteroids
Moderate:
Emollient
Moderate potency steroids
Topical calcineurin inhibitors
Severe: Emollients Potent topical corticosteroids Topical calcineurin inhibitors Bandages/Phototherapy/Systemic therapy
17
Q
Does Atopic Eczema ever?
A
Atopic eczema has a tendency to improve as children grow older and transition into adolescence and adulthood.
75% gone by age of 16 years old
18
Q
Which of the following is not a risk factor for Psoriasis?
A. MHC gene
B. Streptococcal infection
C. Trauma to skin
D. IV Drugs
A
D - IV drugs
Other risk factors include
Iatrogenic: ß-blockers, Lithium, ACEi, Chloroquine
HIV
Smoking
Alcohol
Stress
19
Q
What is the pathophysiology of Psoriasis?
A
Antigen stimulates immune response which causes myeloid dendritic cells to be attracted and produce IL-23 which stimulates T cells. This results in hyperproliferation of keratinocytes
20
Q
What appears first in Psoriatic arthritis?
A
Psoriatic plaques with arthritis following skin disease 5-10 years later
21
Q
You notice raised, scaly, well-demarcated plaques which are symmetrically distributed on the extensor surfaces, trunk and gluteal cleft. Lesions are itchy and fissured.
What type of skin condition is this?
A. Guttate psoriasis
B. Chronic plaque psoriasis
C. Atopic eczema
D. Inverse psoriasis
A
B - Chronic plaque psoriasis
Features: Symmetrical distribution, extensor surfaces, gluten, knees, elbows Colour: opposite to natural skin colour Thickened plaques (hypertrophic) Itchy or painful
22
Q
You notice raised (onycholysis), thickened nail plates with plaques underneath (subungual hyperkeratosis). They appear white (leukonychia) and you see oil drop discolouration.
What type of skin condition is this?
A. Guttate psoriasis
B. Chronic plaque psoriasis
C. Nail psoriasis
D. Inverse psoriasis
A
C - Nail psoriasis
Subungual hyperkeratosis Onycholysis Leukonychia Nail pitting Splinter haemorrhages
23
Q
You notice thick plaques which have a pink/white pigmentation, thickening and fissures present. The distribution is within the intertriginous areas.
What type of skin condition is this?
A. Guttate psoriasis
B. Chronic plaque psoriasis
C. Atopic eczema
D. Inverse psoriasis
A
D - Inverse Psoriasis
24
Q
You notice small, discrete plaques with a truncal distribution 2 weeks ago, this patient had a sore throat.
What type of skin condition is this?
A. Guttate psoriasis
B. Chronic plaque psoriasis
C. Atopic eczema
D. Inverse psoriasis
A
A - guttate psoriasis
‘Raindrop’ Psoriasis which have multiple small circular plaques forming 2 weeks after streptococcal sore throats
25
You notice sterile pustules on reddened skin present in a truncal distribution.
What type of skin condition is this?
A. Localised pustular psoriasis
B. Chronic plaque psoriasis
C. Generalised pustular psoriasis
D. Inverse psoriasis
C - Pustules present widespread on a background of erythema
26
What is the management ladder for Psoriasis?
1st line: Potent corticosteroid OD + Vitamin D analogue OD
- apply separately, once in morning, once at night
2nd line: Vitamin D analogue BD
- 8-12 weeks
3rd line: Potent corticosteroid BD OR Coal tar OD/BD
- 4 weeks
Hospital: Phototherapy
- UVB; PUVA
Hospital: Systemic therapy
- Methotrexate
- Ciclosporin
27
What is a potential side effect of Psoralen + UVA?
Skin ageing
Squamous cell cancer
28
What is the management for scalp psoriasis?
Potent corticosteroids OD for 4 weeks
29
What is the management for face psoriasis?
Mild/moderate potency for 2 weeks
30
When may you begin to notice systemic side effects from topical steroids?
>10% BSA
Using more than 1-2 weeks per month
Not keeping to a 4 week break before starting another course of topical corticosteroids
31
What is the MOA of Calcipotriol?
Vitamin D analogue
Reduce cell division and differentiation to reduce epidermal proliferation
32
What is the side effect of Dithranol?
Stains skin
33
What are the potential complications of Psoriasis?
Psychosocial difficulties
Systemic upset - from GPP or EP or medications
Medication related side effects
34
Which is the causative pathogen of Lyme disease?
Borrelia burgdorferi
B. burgdoferi
35
What are the clinical features of Lymes disease?
Erythema migraines: Bulls eye rash which develops 1-4 weeks after bite; >5cm diameter
Systemic features:
- Headache
- Lethargy
- Fever
- Arthralgia
Late features:
CV:
- Heart block
- Peri/myocarditis
Neurological:
- Facial nerve palsy
- Radicular pain
- Meningitis
36
How is Lyme disease diagnosed?
A. Clinically based on fever and headache after walking in the woods
B. Clinically based on erythema migraines present
C. ELISA with B burgdoferi Abs
D. PCR test
B - Erythema migrans present is enough for ABX
37
What is the management of asymptomatic tick bites?
Supportive: Remove tick; ABX if Sx develop
38
What is the management for suspected/confirmed Lyme disease?
Doxycycline 200mg OD 21 days
Doxycycline 100mg BD 21 days
39
Following treatment with Doxycycline for a rash which appeared following a suspected tick bite, a 37 year old patient presents with headache and muscle ache.
He is orientated, has no new rashes but has a regularly regular HR of 90bpm and a blood pressure of 100/65mmHg.
What is your diagnosis?
A. Allergy to antibiotic
B. Jarish-Herxheimer reaction
C. Drug exanthem
D. SJS
B
40
What is VZV also known as?
A. HHV-1
B. HHV-6
C. HHV-8
D. HHV-3
D - HHV-3
HHV-1 = oral lesions
HHV-6 = Pityriasis rosea
HHV-8 = Kaposi's sarcoma
41
Explain the pathophysiology of Shingles.
Following primary infection of VZV resulting in a generalised vesicular rash within 14 days of exposure, the VZV lies dormant in the dorsal root ganglia.
This can reactivate and present in a dermatomal distribution years later as Shingles
42
A patient who is on Azathioprine presents, concerned that their brother-in-law who he has just seen, has presented with chickenpox. The patient is unsure if he has ever had chickenpox.
How do you manage this?
Check VZV Abs and give VZIG
43
A 24 week pregnant woman who is G3P2 presents worried she may have caught chickenpox. She is asymptomatic however her youngest child has been at school with an individual who has chickenpox.
She is unsure if she has had chickenpox when she was younger.
What is your management?
>20 weeks and unsure...
Check VZV Abs
If not, give Oral Aciclovir at 7-14 days post-exposure
OR
VZIG
44
A 14 week pregnant woman who is G3P2 presents worried she may have caught chickenpox. She is asymptomatic however her youngest child has been at school with an individual who has chickenpox.
She is unsure if she has had chickenpox when she was younger.
What is your management?
<20 weeks and unsure...
Check VZV Abs
Give VZIG STAT
45
How long is someone infective for when they have chickenpox?
4 days before rash, 5 days after rash
"4 before, 5 after"
46
What medication should be avoided when chickenpox is present and why?
NSAIDs - increase risk of bacterial infection
47
Who should receive the VZV vaccine?
Healthcare workers unexposed
Contacts of immunocompromised individuals
48
How long should a child be away from school following a chickenpox infection?
All lesions crusted over - "4 before, 5 after"
49
How long should a child be off school following a sore throat and a sandpaper like rash?
24 hours from ABX
This is Scarlet Fever
50
How long should a child be off school following whooping cough?
2 days from ABX or 21 days from symptoms
51
How long should a child be off school following spots on the oral mucosa, fever and a maculopapular rash?
This is measles and it is 4 days
52
How long should a child be off following a maculopapular rash, lymphadenopathy and positive Rubella Abs?
5 days
53
Which of the following is not a typical feature of Varicella Zoster Syndrome?
A. Skin scarring
B. Limb hypoplasia
C. Macrocephaly
D. Chorioretinitis
C - Microcephaly occurs
Mnemonic: E-NHS
Eyes: Chorioretinitis, Cataracts, Microphthalmia
Neurological: Microcephaly; learning difficulties; bladder and bowel dysfunction
Hypoplasia of limbs
Scarring of skin
54
Why should aspirin be avoided in children with Chickenpox?
Reye's syndrome may occur with encephalopathy and liver impairment
Features:
- Confusion
- Seizures
- Cerebral oedema
- Hypoglycaemia
- Fatty infiltration of kidneys, liver and pancreas (steatosis)
55
Which of the following is not a risk factor for the development of Shingles?
A. Age above 85 years old
B. CKD
C. Taking Salbutamol
D. Transplant recipients
C - Salbutamol is not a risk factor for Shingles.
```
Risk factors:
Immunocompromised
Transplant recipients
Autoimmune conditions
HIV
Co-morbidites: CKD; COPD; Diabetes;
```
56
What is the term for a vesicular eruption along the tip of the nose?
What does this suggest?
Hutchinson's sign
CN V1 dermatome infected §with VZV thus increased risk of Herpes zoster ophthalmic
57
What are the indications for anti-viral therapy in Shingles?
Facial distribution (Ramsay-Hunt or Herpes Zoster Ophthalmicus)
Pregnancy
Immunocompromised
Patients >50 years old
Severe pain
58
What are the potential complications of Shingles?
```
Secondary bacterial infection
Dissemination
Ramsay Hunt Syndrome
Herpes Zoster Ophthalmicus
Post-herpetic neuralgia
CNS involvement
```
59
How is Post-Herpetic neuralgia managed?
Paracetamol/Co-codamol
If uncontrolled:
Neuropathic analgesia: Amitriptyline; Gabapentin; Pregabalin
60
What is the typical distribution of Erythema nodosum?
Anterior legs (shins)
61
What is the pathophysiology of erythema nodosum?
Hypersensitivity reaction resulting in panniculitis
62
Give 5 causes of Erythema nodosum.
```
Idiopathic
Pregnancy
Streptococcal infection
TB
Sarcoidosis
HIV
Hepatitis B
Parasitic infection
Crohn's Disease
Ulcerative colitis
Malignancy
COCP
Penicillins
```
63
What is the management for Erythema Nodosum?
Identify cause: Bloods, XR, ASO, Mantoux test
Supportive: NSAIDs; Rest; Compression stockings
64
Which of the following is not a cause of erythema nodosum?
A. Streptococcal infection
B. Behcet's disease
C. Lymphoma
D. Metformin
D - metformin
65
What are the clinical features of Erythema multiforme?
Hypersensitivity reaction of the skin, secondary to infection or drugs.
Discoid lesions - central blister and surrounding pallor
66
Give 5 causes of Erythema multiforme.
Idiopathic
M pneumoniae
HSV
Streptococcus
```
Drugs: Penicillin; Sulphonamides; Carbamazepine; Allopurinol; NSAIDs; COCP
CT disease
Sarcoidosis
TB
Malignancy
```
67
What is the difference between Erythema multiforme and Erythema multiforme major?
Becomes major when involves oral mucosa.
68
How long does it take for Erythema multiforme to resolve?
Spontaneously resolves over 2 weeks
69
What is the causative pathogen of Impetigo?
S aureus
70
For how long should children be excluded from school following impetigo?
48 hours after ABX or lesions healed
71
What is the management for Impetigo?
Localised
Fusidic acid
Mupirocin
Widespread/Bullous
Oral Flucloxacillin
```
Severe disease (systemic upset)
Hospital admission
```
72
What are the potential complications of Impetigo?
```
Cellulitis
Staphylococcal scalded skin syndrome
Lymphangitis
Osteomyelitis/septic arthritis
Scarlet fever (GAS)
Acute glomerulonephritis (1-2 weeks post-infection)
```
73
What are the clinical features of Impetigo?
Depigmented macules (<1cm) or patches (>1cm)
Koebner phenomenon
Distribution: Dermatomal (segmental) or Non-segmental: Focal; Acrofacial; Mucosal; Generalised; Universal; Follicular; Mixed (segmental and non-segmental forms)
74
What is the management of Vitiligo?
Supportive: Psychosocial interventions; Patient education; Skin camouflage service; Dermatology referral
+
Medical: Topical steroids (segmental/localised); Systemic steroids (widespread); Phototherapy (UVB)
± Refractory to Tx
Surgical: Skin grafts
75
Give 5 RFs for BCC.
Sun-exposure
Increasing age
Genetics: p53; Albinism; Gorlin Syndrome
PMHx
Immunosuppression
Carcinogens: Ionising radiation; Arsenic; Hydrocarbons
76
What is the inheritance of Gorlin-Goltz Syndrome?
PCTH1 gene inherited in autosomal dominant manner q
77
What are the clinical features of Gorlin-Goltz syndrome?
```
BCCs
Hypertelorism
Bifid ribs
Odontogenic keratocysts
Calcification of faux cerebri
```
78
What are the clinical features of a BCC?
Telangiectasia
Ulceration
Rolled edges
Pearly border
Mnemonic: TURP
79
A 56 year old lady presents with a skin lesion on her cheek.
O/E it is fleshy and well-defined, about 5mm, circular. There is an large area of central ulceration seen with telangiectasia noted.
What is your DDx?
A. Nodular BCC
B. Infiltrative BCC
C. Basosquamous BCC
D. Superficial BCC
A - Rodent ulcer described
80
A 76 year old lady presents with a plaque on her arm. She noticed it 3 months ago and it has not grown much since.
O/E it is a 3mm lesion, fairly regular, it is dry with some crusting. It has a blue-tinge to it.
What is your DDx?
A. Superficial BCC
B. Infiltrative BCC
C. Basosquamous BCC
D. Actinic keratosis
A - features of a Superficial BCC
81
A 78 year old male presents with a skin lesion on his face. The shape is irregular, with a scar-like tissue around it. You see a roughly spherical lesion which has a central area and some telangiectasia.
What is your DDx?
A. Nodular BCC
B. Infiltrative BCC
C. Basosquamous BCC
D. Superficial BCC
B - scar-like lesion with BCC features
82
You see a skin lesion that is very dark, purple with an area of central necrosis and a pearly border.
What is your DDx?
A. Nodular BCC
B. Infiltrative BCC
C. Basosquamous BCC
D. Pigmented BCC
D
83
A patient presents with what he says is a large, cut like skin lesion. He reports no history of injury.
O/e you see a 5cm, irregular lesion with crusting and telangiectasia.
What is your DDx?
A. Nodular BCC
B. Infiltrative BCC
C. Basosquamous BCC
D. Superficial BCC
C - features of both BCC and SCC
84
How is a BCC managed?
Surgical: Wide-local excision (low-risk lesions); Moh's Micrographic Surgery (high-risk lesions)
Destructive (cryotherapy; curettage)
Non-surgical: Radiotherapy; Imiquimod cream
85
Which of the following is not a feature of a high-risk BCC?
A. Size >2cm
B. Subtype
C. Poorly defined margins
D. Diabetes
D
86
Which of the following is not a feature of a high-risk BCC?
A. Perivascular invasion seen
B. Previous Tx failure
C. Poorly defined margins
D. Size of 1cm
D - size must be above 2cm
87
What are the clinical features of a Melanoma?
Mnemonic: ABCDE
```
Asymmetry
Border (irregular)
Colour (2+ pigments)
Diameter (>6mm)
Evolving lesion
```
88
What investigation is required in a suspected melanoma?
Excisional biopsy with 2mm margin
89
What are the causes of Melanoma?
UV Exposure
Severe sun burn in childhood (blistering)
Immunosuppression
Multiple naevi (>100)
Fitzpatrick skin type I and II
FH (cdk ∆s)
Genetic mutations (CDK4; xeroderma pigmentosum; melanocortin 1 receptor)
90
What is the pathophysiology of melanoma?
uncontrolled proliferation of melanocytes in the basal epidermis.
91
What are the subtypes of Melanoma?
```
Superficial spreading (70%)
Nodular (vertical growth)
Lentigo maligna (chronic sun-exposure)
Acral lentiginous (under nails, hands and feet)
Desmoplastic melanoma
```
Any of these could be amelanotic melanomas (pigment lacking)
92
What is the most common subtype of melanoma?
Superficial spreading (70%)
93
What classification systems can be used in melanomas?
Breslow thickness (mm)
Ulceration
Mitotic index (mitoses per mm2)
94
What investigations may be done in a melanoma?
Excision biopsy with 2mm margin
FBC
U+Es
LFTs
LDH
FNA - if believed to have spread to lymph nodes
95
What are the stages of melanoma?
AJCC Cutaneous melanoma staging
Stage 0 = in situ
Stage I = melanoma <0.8mm thick
Stage II = 1-2mm thick ± ulceration
Stage III = lymph node involvement
Stage IV = metastatic spread
96
How is a Melanoma managed?
Surgery: Wide-local excision (remove fat down to muscular fascia - determined by Breslow thickness)
±
SNLB (staging tool)
±
Adjuvant therapy: Chemo/Radio/Immunotherapy
97
What are the clinical features of Rosacea?
```
Affects nose, cheeks and forehead
Flushing
Telangiectasia
Develops into persistent erythema with papules and pustules
Rhinophyma
Ocular involvement e.g. Blepharitis
Sunlight and spicy food can worsen
```
98
Manegement of Rosacea?
```
Mild symptoms (limited number of pustules and papules)
Topical Metronidazole
```
Resistant/Systemic
Orał tetracycline e.g. Doxycycline
Prominent telangiectaisa
Laser therapy
99
What are the layers of the Epidermis?
Mnemonic: BSG LC
Stratum basale - mitosis of keratinocytes
Stratum spinosum - keratinocytes join desmosomes
Stratum granulosum - cells secrete lipids and hydrophobic molecules
Stratum lucidum - cells anucleate + keratin production
Stratum corneum - cells lose organelles + produce keratin
100
What epidermal structures determine the fingerprint?
Fingerprint determined by stratum basale and stratum spinosum pushing epidermal ridges (rete ridges) into underlying dermis between dermal papillae of papillary layer which is augmented by dermal ridges
101
What are the layers of the dermis?
* Papillary layer: loose; cellular arrangement; highly innervated
* Reticular layer: deeper; less cellular; thicker ECM (collagen fibres + elastin fibres) organised into regular, structured lines called Langer’s Lines. May have smooth muscle in the reticular area e.g. Dartos Fascia in Penis and Scrotum
102
In which layer of the skin to Langer's lines lay?
Langer's lines are thick collagen and elastin arrangements in the reticular layer of the dermis
103
Explain the difference between apocrine and eccrine glands.
Eccrine
Independent units in dermis with long ducts opening into skin
Throughout the body
Involved in thermoregulation and excretion
Apocrine
Coiled, tubular gland opening into hair follicle
Hair covered areas
Release pheromones in proteinaceous sweat, encourages bacterial growth
104
How can you assess the extent of burns?
Use Wallace's Rule of Nines
Head + Neck = 9%
Each arm = 9%
Anterior leg = 9%
Posterior leg = 9%
Anterior abdomen = 9%
Posterior abdomen = 9%
105
What is the immediate first aid of a heat burn?
Remove source
| Irrigate burn with cool water for 10-30mins
106
What is the immediate first aid of a electrical burn?
Switch off power supply
Remove person from source
107
What is the immediate first aid of a chemical burn?
Brush off chemical
Irrigate with water
Do not try to neutralise the chemical
108
Describe a first degree burn?
Think of burns in layers...
1st degree is the superficial epidermis
Appears red and painful
109
Describe a second degree burn which is of the deep dermis.
Second degree burn
White with patches of non-blanching erythema.
Reduced sensation
110
Describe a second degree burn affecting the superficial dermis?
Pale pink, painful and blistered
111
Describe a full thickness burn.
White/brown/black in colour; no blisters; no pain
112
Which burns should be referred to hospital?
>3% (adults) and >2% (children) superficial burns
Deep dermal and full thickness burns
Burns involving the face, hands, feet, perineum, genitalia, flexure, circumferential burns of limbs, torso or neck
113
How do you manage a severe burn?
Supportive: Assess extent of burns; Intubation (if smoke inhalation/neck involvement); IV fluids if BSA >10% (children) or >15% adults); administer half of the fluids needed in first 8 hours; Analgesia; Urinary catheter
± Circumferential burns
Surgery: Escharotomy (division of burnt tissue to improve ventilation/relieve compartment syndrome)
114
How are IV fluids calculated in a burns patient?
Parkland formula
BSA x weight x 4 = mL
Give half of fluids in first 8 hours
115
When should a patient be transferred to a burns centre?
BSA > 5% (children)
BSA >10% (adults)
116
What is the difference between a petechiae and an ecchymosis?
Size, based on 2mm width
117
What is the difference between a macule and a patch?
Both flat but size.. macule is smaller cf patch (1.5cm)
118
What is the difference between a papule and a plaque?
Both solid, raised lesions - but papule (<0.5cm) cf papule (>1cm)
119
What is the difference between a vesicle and a bulla?
Size, bulla > 0.5cm - both raised, clear-fluid filled lesion
120
What is the difference between a pustule and an abscess?
Pustule = pus-filled lesion <0.5cm
Abscess = localised pus accumulation
121
Outline the pathological sieve.
Stone (metabolic changes)
Infection (pathogen-mediated)
Tumor (cancer)
Tubercle (chronic inflammation)
Trauma (injury)
122
How would you examine a rash?
Adequate introductions
General inspection
```
Distribution
Size
Colour
Associated changes
Morphology
```
Inspect hands
Inspect eyes
Inspect mouth
Inspect elbows
Inspect head
Thank patient
Wash hands
Summarise findings
Suggest investigations
Suggest differentials
123
What is the difference between lotion, cream and ointment?
Lotion - large water based
Cream - more lipid
Ointment - high lipid content ± urea
124
Outline the topical steroid ladder.
Hydrocortisone 1% (mild)
Clobetasone 0.05%
Betamethasone 0.1%
Clobetasol 0.05% (very potent)
125
What are the side effects of topical steroids?
Systemiceffects
Skin atrophy
Spread of infection
Secondary infection
Acne rosacea
126
What are the compounds in Trimovate cream?
TRI = THREE
Clobetasone
Oxytetracycline
Nystatin
127
What are the components of Flucidin H cream?
Fusidic acid 2%
Hydrocortisone 1%
128
You see a patient with psoriasis. When scratching and removing scales, light bleeding is observed. What is this termed?
Auspitz sign
129
What are the types of Psoriasis?
```
Psoriasis
Guttate distribution of psoriasis
Flexural
Psoriatic
Pustular
Nail psoriasis
```
130
Outline the pathophysiology of urticaria.
Stimuli (autoimmune/infection/ACEi/NSAIDs/penicillin/food) results in Th2 cells secreting IgE via mast cells which increases the permeability of capillaries resulting in wheal formation and erythema.
131
What are the clinical features of Urticaria?
Wheals
Pruritus
Oedema of deeper tissues
Swelling of soft tissues
132
Which virus is associated with Erythema Multiforme?
HSV-2
CMV
EBV
133
In bullous pemphigoid, where are antibodies directed against?
PemphigoiD = Deep
Abs directed against hemidesmosomal proteins between epidermis and dermis resulting in inflammatory cell infiltrate and bullous lesions
134
How is bullous pemphigoid managed?
Supportive: Dress; monitor signs of infection
+
Topical steroids
±
Oral ABX if infected
135
Where are autoantibodies directed in pemphigus vulgaris?
PemphiguS = Superficial
Autoantibodies directed against desmogleins in epidermis thus intra-epidermal split in the skin
136
You examine a patient with pemphigus and notice the top layer is fragile, breaking under lateral pressure. What is the name of this sign?
Nikolsky's sign
137
How is Pemphigus vulgaris managed?
Supportive: Dressings; monitor for infectious signs; good oral care
+
High dose steroids: Prednisolone
138
How is SJS categorised and differentiated from TEN?
Skin sloughing and blistering due to mucocutaneous complications
SJS <10% BSA
TEN >30% BSA
139
Give 5 causes of SJS.
```
Recent infections
Recent vaccinations
AIDS
SLE
Genetic predisposition
Anticonvulsants
Sulfonamides
Penicillins
Cephalosporins
COCP
Allopurinol
```
140
What tool can be used in SJS to assess severity and mortality?
SCORETEN
Mnemonic: CAABBS as in SJS you call a CAB to the hospital
```
Cancer
Age >40
Area (Wallace's rule of 9)
BUN >20mg/dL
Bicarbonate <20mEq/L
BPM >20bpm
Sugar >250mg/dL
```
141
What are the clinical features of erythroderma?
Constitutional symptoms
Lymphadenopathy
Erythema
Hot skin
```
Keratoderma
Haemodynamic instability (HR up, BP down)
```
142
How is erythroderma managed?
Supportive: Tx cause; wet wraps; heavy emollient
±
Medical: ABX if needed
143
A 24 year old man presents 7 days after starting Penicillin for a throat infection. He is hot and reports a rash across his trunk.
O/E you see a widespread red rash with small bumps within. The rash is itchy.
What is your differential?
A. Widespread Exanthematous Drug Reaction
B. Drug Rash with Eosinophilia and Systemic Symptoms (DRESS)
C. Acute Generalised Exanthematous Pustulosis
D. Acute Generalised Pustular Psoriasis
A - Widespread Exanthematous Drug Reaction
144
A patient presents with a high temperature and tiredness. They report facial swelling also. They say they are generally well and only take Lamotrigine which they commended 4 weeks ago.
What is your differential?
A. Widespread Exanthematous Drug Reaction
B. Drug Rash with Eosinophilia and Systemic Symptoms (DRESS)
C. Acute Generalised Exanthematous Pustulosis
D. Acute Generalised Pustular Psoriasis
B - DRESS Syndrome
Hypersensitivity reaction which occurs 2-6 weeks following medication
Constitutional symptoms
Maculopapular rash
Facial oedema
Lymphadenopathy
145
Following beginning erythromycin for a throat infection due to a penicillin allergy, a young man presents with a rash.
O/E the rash consists of sterile pustules on oedematous erythema which is present in the flexural regions.
What is your differential?
A. Widespread Exanthematous Drug Reaction
B. Drug Rash with Eosinophilia and Systemic Symptoms (DRESS)
C. Acute Generalised Exanthematous Pustulosis
D. Eczema Herpeticum
C - Acute Generalised Exanthematous Pustulosis
146
A 7 year old presents to the A+E department with a fever and clusters of itchy blisters. The itchy blisters wheep when itched and you can see some yellow crusting. They have a past medical history of Asthma and Dermatitis.
What is your differential?
A. Widespread Exanthematous Drug Reaction
B. Drug Rash with Eosinophilia and Systemic Symptoms (DRESS)
C. Acute Generalised Exanthematous Pustulosis
D. Eczema Herpeticum
D
147
What is your infective pathogen causes Eczema herpeticum?
HSM
148
What is the management for Eczema herpeticum?
Oral Acyclovir
Oral Flucloxacillin
149
What is Bowen;s disease a precursor to?
Squamous cell carcinoma
150
What is the chance of developing Squamous cell carcinoma when having Bowen's disease?
5-10%
151
What are the clinical features of Bowen's diseasE?
Red, scaly patches 10-15mm in size
Sun exposed areas
152
Give 5 RFs for Squamous Cell Carcinoma.
* Sun exposure
* Older age
* Immunosuppression
* Fair skin
* Human Papillomavirus
* Hereditary skin conditions
* Ionising radiation
* Environmental toxins: Arsenic or Tar
* Actinic keratosis
* Male Sex
153
What are the clinical features of a squamous cell carcinoma?
```
Keratotic, scaly
Bleeding/crusting
Non-healing wound
Erythematous plaques/papules
Dome-shaped nodules
```
154
What is the management for a SCC?
<2cm
Wide-local excision
>2cm or sensitive area
Mohs Micrographic Surgery
± Metastases
Chemo/Radiotherapy
155
What is the difference between a keratoacanthoma and actinic keratosis?
Actinic keratoses: scaly/crusty papule/plaque with skin colour changes
Keratoacanthoma: arises from hair follicle which rapidly grows, well demarcated, firm, hyperkeratotic plug
156
What is Lofgren Syndrome?
* Bilateral hilar lymphadenopathy
* Migratory polyarthritis (symmetrical arthritis 1º affecting ankles)
* Erythema nodosum (extensor surface of lower legs)
157
What is Heerfordt Syndrome?
* Parotitis
* Uveitis
* Facial palsy
158
State 5 types of Sarcoidosis.
```
Neuro
Ocular
Cardiac
Cutaneous
Pulmonary
Systemic
```
159
A patient presents with a skin lesion which is growing. O/E you see a purple, ulcerated area.
What is your DDx?
Pyoderma gangrenosum
160
A patient presents with a widespread rash on the torso. He has been under the care of Oncology recently for his long-standing Lung cancer.
O/E you see concentric rings with a wood-grain appearance. The rash is itchy.
What is your DDx?
Erythema Gyratum Repens
161
What are the clinical features of Acute Febrile Neutrophilic Dermatosis?
```
Fevere
Sore eyes
Mouth ulcers
Arthralgia
Headache
```
Tender and painful papules/vesicles on the neck, limbs and mucosa
Biopsy confirms neutrophils
162
What are the clinical features of Dermatomyositis?
Constitutional symptoms
Heliotrope rash
Periorbital violaceous erythema
Macular violaceous erythema
Gottron papules (purple dusty red flat topped papules on bony surfaces)
Proximal muscle weakness
163
What is the difference between Cellulitis and Erysipelas?
Cellulitis is an infection of the deep tissues, dermis and subcutaneous tissue whilst erysipelas is a distinct form of superficial cellulitis - it is well demarcated
164
What is the management of Cellulitis?
Mild (no systemic signs/systemically unwell)
Oral Flucloxacillin
Severe (significant systemic upset/unstable comorbidity/sepsis)
IV Flucloxacillin
165
What are the risk factors of cellulitis?
```
Animal bite
Diabetes mellitus
Immunocompromised
Venous insufficiency
Oedema
Lymphodema
Eczema
```
166
Which pathogen causes Necrotising fasciitis?
```
GAS
S aureus
E coli
Klebsiella
Proteus
```
167
What types of Necrotising Fasciitis exist?
Type 1 = polymicrobial
Type 2 = mono microbial
Type 3 = V vulnificus
Type 4 = Fungal pathogens
168
What are the clinical features of necrotising fasciitis?
Systemic features: Fever/ Nausea/ Vomiting
```
Grey discolouration of skin
Necrosis
Palpitations
Tachycardia
Hypotension
```
169
What is the management of Necrotising fasciitis?
Supportive: Fluids; Admission; Obs
+
Medical: Vancomycin + Pip/Taz + Clindamycin
+
Surgery: Debridement and resection ± Skin graft
170
What pathogen causes Gas gangrene?
C perfringens
171
What is the antibiotic given in Neutropenic sepsis?
A. Ceftriaxone
B. Piperacillin/Tazobactam
C. Flucloxacillin
D. Vancomycin
B - Tazobactam inhibits beta lactase so that piperacillin remains present to eradicate bacterial infection
172
What is the antibiotic given in MSSA sepsis?
A. Ceftriaxone
B. Piperacillin/Tazobactam
C. Flucloxacillin
D. Vancomycin
C
173
What is the antibiotic given in MRSA sepsis?
A. Ceftriaxone
B. Piperacillin/Tazobactam
C. Flucloxacillin
D. Vancomycin
D
174
What is the antibiotic given in early onset sepsis?
A. Benzyl Penicillin + Gentamicin
B. Piperacillin/Tazobactam
C. Flucloxacillin
D. Vancomycin
A
175
What is the antibiotic given in GBS sepsis?
A. Ceftriaxone
B. Piperacillin/Tazobactam
C. BenPen + Gen
D. Vancomycin
C
176
What is the antibiotic given in L monocytogenes sepsis?
A. Amoxicillin + Gentamicin
B. Piperacillin/Tazobactam
C. BenPen + Gentamicin
D. Vancomycin
A
177
What is the management of Scarlet Fever?
Penicillin
178
What is tinea cruris?
Dermatophyte infection of groin
179
What is tinea pedis?
Dermatophyte infection of foot
180
What is tinea corporis?
Dermatophyte infection of the body
181
What is the management for a Dermatophyte infection?
Topical fluconazole
Oral ketoconazole
182
What is the management of Genital warts?
Podophyllotoxin
OR
Cryotherapy
183
How is Scabies managed?
Permethrin
184
What pathogen causes Scabies?
Sarcoptes scabiei
185
What is the management for an animal bite?
Supportive: Saline/Iodine
+
ABX: Co-amoxiclav
±
Rabies vaccine + Rabies Ig
+
Tetanus vaccine + Tetanus IG
186
When would a patient not require Tetanus prophylaxis in an animal bite?
Patient had course of tetanus vaccine within last 10 years
187
When would a patient need a tetanus vaccination following an animal bite?
Not vaccinated
Tetanus prone wound (puncture; foreign body; systemic sepsis occurring)
High risk wound (heavy contamination; extensive devitalised tissue; requires surgical intervention)
187
When would a patient need a tetanus vaccination following an animal bite?
Not vaccinated
Tetanus prone wound (puncture; foreign body; systemic sepsis occurring)
High risk wound (heavy contamination; extensive devitalised tissue; requires surgical intervention)
188
What are Campbell de Morgan spots?
Benign skin lesions due to abnormal proliferation of capillaries
Non-blanching
1-3mm in size
189
What pathogen causes Pityriasis Versicolor?
Malassezia furfur
190
What are the clinical features of Pityriasis versicolor?
most commonly affects trunk
patches may be hypopigmented, pink or brown (hence versicolor). May be more noticeable following a suntan
scale is common
mild pruritus
Follows sun exposure
191
A 21-year-old female has been suffering from well demarcated red, scaly lesions on her elbow and knees for the past few years. She is treated for her condition with corticosteroids and vitamin D.
Which drugs would most likely exacerbate her underlying condition?
```
Lithium
Beta-blockers
NSAIDs
ACEi
TNF-alpha inhibitors
Anti-malarials
```
192
What are the clinical features of Erythrasma?
Flat, scaly pink/brown rash in groin/axillae
193
What's the management of Erythrasma?
Topical miconazole or Erythromycin
194
A 40-year-old woman visits the GP with a two-month history of unintentional weight loss. She reports feeling more fatigued than usual but otherwise has no localising signs or symptoms. On examination, hyperpigmentation and thickening of the skin in her groin and axilla are noted; the patient believes this has also been present for approximately 2 months.
Which malignancy is most associated with this presentation?
Gastric adenocarcinoma
195
What are the clinical features of Pellagra?
Mnemonic: 4 Ds
Diarrhoea
Dermatitis
Dementia
Death
196
What are the clinical features of Lemierre's syndrome?
Thrombophlebitis of IJV
Secondary to F necrophorum infection with peritonsillar abscess
```
Bilateral are throat
Neck pain
Stiffness
Fevers and rigors
Septic pulmonary emboli
```
197
What is the difference in TIBA between anaemia of chronic disease and iron deficiency anaemia?
TIBA is high in IDA
TIBA is low in AOCD
198
Where do keloid scars typically form?
Sternum
Extensor surfaces
Trunk
199
A 30-year-old man is trapped in a house fire and sustains 30% partial and full thickness burns to his torso and limbs. Three days following admission he has a brisk haematemesis. Which of the following is the most likely explanation for this event?
Curling's ulcers
200
A 30-year-old woman with known polycystic ovary syndrome presents with excessive hair growth of the chest, back and face. She reports her symptoms first developed around the time of puberty, with the hair continuing to remain prominent, growing back despite removal via waxing and shaving.
The underlying skin is normal and the patient is otherwise well with no other medical conditions.
What topical agent is the treatment of choice for the facial features of this patient’s condition?
Topical eflornithine
201
Which drugs may cause Gynaecomastia?
Mnemonic: DISCO
```
Digoxin
Isoniazid
Spironolactone
Cimetidine
Oestrogens
```
Oestrogens
202
How do you estimate the risk of bleeding in a patient with AF?
ORBIT Score
```
Age >74
Bleeding risk
Coagulation
Dick? (Sex)
eGFR <60
```
203
What are the clinical features of Aortic Stenosis, GI bleeding and angiodysplasia referred to?
Heyde's Syndrome
204
Stroking skin in atopic eczema to elicit a white line is termed?
White dermographism
205
What is meant by Besnier's Prurigo?
Chronic inflammatory changes regarding pigmentation and scarring which lead to pruritic nodules overlying eczematous areas
206
Which infections are patients with eczema particularly prone to?
Bacterial sepsis
Molluscum contagiosum
Herpes simplex (Eczema Herpeticum)
207
What are the clinical features of Wiskott-Aldrich Syndrome?
Atopic eczema + thrombocytopenia
Atopic eczema features
Epistaxis
ICH
Haematochezia
Recurrent bacterial infections
Autoimmune phenomena susceptibility
208
What is Job's Syndrome?
Hyper-IgE syndrome with marked reactions to microbes / pathogens
Eczema
Recurrent infections - recurrent cold abscesses of skin; PNA; cysts; restrictive lung disease
Bony changes: hypertelorism; hyperostosis; scoliosis; osteoporosis
209
What are the clinical features of Kaposi's varicelliform eruption?
HSV infection
Umbilicated vesicles on b/g of erythema
Viraemia
210
What is the MOA of Tacrolimus?
IL-2 inhibitor on T cells - dampens T cell mediated inflammatory response
211
What supportive changes may be made for eczema management?
Think about vehicle (ointment > cream)
Antihistamines
Diet (oligoallergen theory of Atherton "avoid eggs and milk")
Bedding (reduce allergen exposure)
Bandaging
Psychological input
212
What is the distribution exhibited in Seborrheic dermatitis?
What is it associated with?
Sebaceous gland areas
Scalp; face; flexures
Pityrosporum ovale (Malassezia ovale)
213
Why is discoid eczema referred to as nummular?
Nummular is latin for coin e.g. No mullar
214
What is lichen simplex?
Eczematous response to scratching of an isolated area of the skin
Histologically caused by acanthosis and hyperkeratosis
215
Describe lichen striatus.
Linear distribution of eczema occurring in children and young adults
216
What form of eczema has a predilection for the base of the feet and has linear cracks and fissures?
Plantar dermatosis
217
Discuss asteatotic eczema.
Eczema craquele
Dry, superficial fissured skin in the elderly; usually present on the shins
Related to the cold, excessive washing and high humidity
218
What are the types of contact dermatitis?
Can be thought of as allergy (Type 4 mediated) or irritant
- Irritant
- Allergic
- Eczema craquele (asteatotic)
- Berloque dermatites (bergamot in colognes and UV light)
- Plant irritant dermatitis (allergen and UV light)
219
What are the main differences between pomphlyox and pustular psoriasis?
Pomphylox is tiny, fluid-filled vesicles in a b/g of eczema/atopy which may coalesce to form tense bullae
- Any age
- Sensation of heat/prick
Pustular psoriasis is small, yellow-filled sterile pustules on b/g erythema
- Adults
- Scaly
220
A patient presents with a sterile pustule on the tip of the finger. Nail dystrophy is observed.
They have a b/g of dermatitis.
What is your differential?
Acrodermatitis continua of Hallopeau
221
When does guttate psoriasis tend to occur?
3-4 weeks post-infection presenting with drop like eruption of papules which are deep-red
Based on trunk, limbs and sparing of face, palms and soles
222
What are the clinical features of Reiter's Syndrome?
Post-infectious...3-4 weeks later; HLA-B27
Urethritis
Uveitis
Arthralgia
Mucocutaneous features e.g. Psoriasiform rash: well-demarcated, serpiginous, white and ragged border
Soles
Distributed on penis (25% patients) e.g. Balanitis circinata sicca
Oral lesions
223
What is the term for the patch which precedes the widespread eruption in Pityriasis rosea?
Herald patch
224
What are the clinical features of lichen planus?
```
Purple
Polygonal
Pruritic
Planar
Plaques
Papules
```
225
What is Wickham's striae?
White lacey lines on the syurface of a lichen planus lesion
226
How may you distinguish between an epidermoid cyst and a dermoid cyst?
Epidermoid cyst is derived from squamous epithelial cells in the epithelium cf dermoid cysts are derived from embryological epithelium at sites of fusion.
Epidermoid:
- develop
- smooth, mobile, central punctum
- appear more superficial
- present on face
Dermoid:
- present at birth
- mobile, fleshy
- appear deeper
- face
227
What is the distribution and clinical features of acanthoma fissuratum?
Behind the ear
Acanthosis, hyperkeratosis
Small plaque, linear groove
228
What are the clinical features of skin tags?
Pedunculated, skin coloured
occur with age, pregnancy, IGT/DM; malignant acanthosis nigricans
229
What are the clinical features of an eccrine poroma?
Asymptomatic lump on volar surface
Solitary, pink/red plaque/nodule with thickened rim of epidermis ('moat')
230
What are the clinical features of a syringoma?
Benign tumour of sweat duct
Asymptomatic blemishes on the skin
Distributed symmetrically, around the eyes
Flesh coloured
231
What are the clinical features of a dermatofibroma?
Benign tumour occurring on legs
Tender
Raised papule on skin with smooth surface, moveable lateral but adherent to underlying skin. Dimples on lateral pressure
232
What are the clinical features of a neurofibroma?
Benign tumours of nerve sheath origin
Flesh coloured, firm or soft; variable size
Buttonhole sign: invaginated with finger tip
233
What are the clinical features of a lipoma?
Benign tumour of adipose tissue
Soft, fluctuant, can be lobulated
Variable size
Discrete lesion
Painless
Note: Angiolipomata may be painful as these are vascularised
234
What are the clinical features of a pyogenic granuloma?
Benign tumour of vascular origin
Post-injury
Sudden onset
Can bleed
Friable papule/nodule which is red or purple in colour
235
What are the clinical features of solar lentigo?
Increased melanocyte number without proliferation along basement membrane
'Age' spots
Macules which are pigmented in sun exposed areas
Hyperkeratosis and hypermelanosis
236
What are the clinical features of solar elastosis?
'Wrinkles' due to sun damage and ageing
| Skin can appear yellow/orange
237
What are the clinical features of a cutaneous horn?
Outgrowth of skin
Keratinised
Normally a sequalae of another condition
238
What are the clinical features of a solar keratosis?
Chronically sun exposed areas
Begins s small and grows to well-defined, red papule/plawue with rough yellow/brown scale
Pre-malignant, becoming squamous cell carcinoma
239
What are the clinical features of Bowens disease?
Solar exposure and HPV infection-16 and HPV-18 infection
```
Solitary rough patch
Well-defined
Slightly raised
Red plaque
Adherent scale
```
240
What are the clinical features of keratoacanthoma?
Rapidly growing tumour simulating squamous cell carcinoma however indented with keratin crater
Resolves SPONTANEOUSLY
Begins as a spot
Grows quickly
Sun exposed area distribution
