Dermatology Flashcards
Covers chronic skin conditions and common ones: Psoriasis Acne vulgaris Rosacea Eczema Seborrhoeic dermatitis contact dermatitis Skin cancers- BCC, SCC, Melanoma vs premalignant conditions (e.g. bowens, kerathoacanthoma etc, benign naevus) vitiligo
Define psoriasis
Psoriasis is a chronic autoimmune & inflammatory skin condition characterised by well demarcated red scaly plaques.
Quick overview of the pathophysiology of psoriasis?
autoimmune and T cell mediated disease, inflammatory cells produce cytokines, this leads to infiltration of other inflammatory cells leading to redness, and keratinocyte proliferation - leading to scale as as stratum corenum is shed from the skin.
Risk factors for psoriasis?
- genetics
- caucasian
- equal between M & F
- infections - streptococcal & guttate psoriasis
- hormonal changes (puberty and menopause) & post partum period (often improves during pregnancy)
- change of medications - beta blockers, lithium, chloroquine and ACEi worsen, withdrawal of steroids
- trauma/ sunburn - koebner phenomenon
- smoking and alcohol
- HIV
- psychological stress
relieving factor for psoriasis?
sunlight improves symptoms (psoraisis better in summer vs winter)
In a small number of patients it can be an exacerbating factor
Types of psoriasis?
5 main types:
1) chronic plaque psoriasis –> commonest type, symmetrical plaques on extensor surfaces of the limbs - knees and elbows, scalp and lower back.
2) flexural psoriasis –> smooth red plaques without scale in flexures and skin folds
3) guttate psoriasis –> multiple small tear drop shaped red plaques on the trunk after streptococcal infection in young adults
4) pustular psoriasis –> multiple petechiae and pustules on the palms and soles
5) generalised erythrodermic psoriasis –> rare but serious form characterised by redness and systemic illness
Key features of a history of psoriasis?
symptoms
other key features on the history?
Symptoms of psoriasis:
- pruritic lesion
- typically erythematous, circumscribed scaly plaque
often elbows, knees, extensors, scalp, less commonly nails, ears, umbilical region
pain or burning sensation around lesion
joint pain and stiffness in psoriatic arthritis (affects 20%)
family history common
check medications - lithium, beta blockers, ACEi or steroid cessation
Type of psoriasis with this sign?
Nail pitting is common with psoriasis and psoriatic arthritis
What is the type of psoriasis?
Plaque psoriasis affecting the knee
Type of psoriasis?
Guttate psoriasis
widespread erythematous fine scaly papules with a water drop appearance often on trunk arms and legs. Often erupts after URTI
Type of psoriasis?
Pustular psoriasis - acute generalised pustular psoriasis, rare severe and urgent, affects palms and soles and is chronic
What type of psoriasis is this?
Eythrodermic psoriasis with generalised erythema and fine scaling, often associated with pain, irritation and sometimes severe itching
It is a rare but severe form of psoriasis which can occur acutely as first presentation or may evolve from chronic psoriasis. Widespread inflammation of the skin leads to significant fluid loss, resulting in dehydration, electrolyte loss, peripheral oedema and rarely hypothermia & HF. It requires hospital admission for inpatient mx.
Clinical examination features of psoriasis?
Psoriatic lesions are:
Well demarcated
erythematous
plaques
assocaited with overlying scale
auspitz’s sign - if you remove the scale the lesion bleeds
koebner phenomenon- new lesions at sites of damage
on extensor surfaces mostly, elbows, knees and scalp
if on flexural surfaces may be shiny and moist
usually discrete by may coalesce
nail changes - pitting, onycholysis, yellowing and ringing (associated with more severe disease if nail changes are present)
How do we diagnose psoriasis?
usually no investigations are necessary it is a clinical diagnosis.
Psoriasis area and severity index PASI is a clinical tool to assess the severity.
You can order a skin biopsy where there is doubt in diagnosis.
What are some of the associated conditions with psoriasis?
- Psoriatic arthritis –> chronic seronegative inflammatory arthritis, estimated one third develop psoriatic arthritis
- onset normally follows skin disease by 5-10 yrs but occasionally arthritis develops before skin changes
- psoriatic nail changes occur in 90%
- Other conditions associated include –> IBD, metabolic syndrome, CV disease, other autoimmuen conditions, eye pathologies including uveitis, blepharitis and conjunctivitis.
Management of chronic plaque psoriasis?
- Conservatively –> avoid exacerbating factors, smoking cessation, reduce alcohol consumption and maintain optimal weight
- Medical:
- topical therapy first line - they reduce itch and clear plaques
- regular emollient to reduce scale and itch
- potent corticosteroid applied OD plus vitamin D analogue applied OD (calcipotriol)
- applied separately one in the morning and one in the evening
- up to 4 weeks as initial tx
- 2nd line if there is no improvement
- vitamin D analogue twice daily
- 3rd line if no improvement
- potent corticosteroid twice daily or coal tar prep
Secondary care:
- phototherapy UVB 3x/ wk
- adverse effects include ageing and SCC
Systemic therapy
- oral methotrexate used 1st line especially if assocaited joint disease
- other immunosuppressants e.g ciclosporin, retinoids, biologics
Complications of psoriasis?
chronic plaque psoriasis is a lifelong condition and is frequently resistant to treatment.
Therefore it is associated with significant psychosocial burden, screen regularly for anxiety and depression.
Systemic upset e.g. erythrodermic psoriasis and generalised pustular psoriasis are lifethreatening and severe.
medication used to tx psoriasis often has troubling or severe side effects:
E.g. steroids with skin atrophy, striae and rebound symtoms, aim for 4 week break before starting another course of topical corticosteroid
Vitamin D analogues e.g. calcipotriol can be used long term, reduce scale and plaques not erythema but avoid in pregnancy
what are the differentials for a scaly rash?
- Pityriasis rosea
- Tinea
- Seborrhoeic dermatitis
- discoid eczema
- bowen’s disease
- discoid lupus
- scabies
What are the potencies of topical steroids?
What are important points to communicate to patients with steroids?
Topical corticosteroids are available in 4 different potencies - “Help Every Budding Dermatologist”
Hydrocortisone (mild)
Eumovate (moderate)
Betnovate (potent)
Dermovate (very potent)
- Potent topical corticosteroids should not be used on the face or genitals
- very potent topical steroids should not be used in primary care only by dermatologists
Define acne vulgaris
common condition in adolescence resulting from inflammation of the pilosebaceous unit, leads to the development of comedones, pustules and papules.
cause of acne vulgaris
- Due to increased sebum production
- & increased androgenic hormones at adolescence that cause hyperplasia of the sebaceous glands
- bacterial colonisation ( P acnes) leading to inflammation of the pilosebaceous unit.
- hyperactive immune response
risk factors of acne vulgaris
- Typically related to natural hormonal shifts that occur during puberty or excess androgens - PCOS, congenital adrenal hyperplasia, exogenous steroid
- exacerbated by steroids & antiepileptics
- worsened by topical skin products e.g. cosemetics and shaving products
Clinical features of acne
non inflammatory comedones - closed and open comedones. Closed comedones (whiteheads) are plugged follicles, open comedones (black heads)
inflammatory papules, pustules, nodules and cysts.
Papules and pustules are small raised lesions < 5mm
Nodules and cysts are deeper larger lesions > 5mm
often located in face chest and back with many pilosebaceous units.
Chronic disease may lead to scarring due to healing of lesions.
Definitions of derm terminology with acne:
Comedone
Papule
Pustule
Comedone = dilated sebaceous follicle in the skin (pore) which can be open (blackhead) or closed (whitehead) due to accumulation of bacterial and cellular debris
Papule = solid raised lesion less than 0.5cm in diameter
Pustule = a lesion less than 0.5cm in diameter that contains pus
Definitions of derm terminology in acne:
Nodule
Cyst
Nodule = solid raised lesion less than 0.5cm in diameter but with a deeper component
Cyst = thin walled closed capsule or sac containing fluid
What are some of the classifications of acne vulgaris?
- Mild –> prescence of non inflammatory lesions, sparse inflammatory lesions
- Moderate –> widespread non inflammatory lesions, numerous papules and pustules
- Severe –> extensive inflammatory lesions including nodules, pitting and scarring
what is the difference between inflammatory lesions vs non inflammatory lesions in acne?
- Non inflammatory lesions are the comedones- either open (blackhead) or closed (white head).
- Inflammatory lesions include the papules, pustules, nodules and cysts. Papules and pustules are less than 5mm whereas the nodules and cysts are deeper larger lesions > 5mm
typical features on the history of acne?
- onset usually around adolescence 12-17yrs
- females may notice worsening and improvement around the menstrual cycle
- open and closed comedones, papules, pustules, nodules and cysts may be described
- post inflammatory hyperpigmentation and scarring may occur
- skin tenderness
- thorough history of lifestyle factors e.g. skincare, makeup, shaving, diet, medications needed
- family history
- ascertain what the patient has tried before
- depression and social isolation are common, screen for anxiety and depression
Features on examination of acne vulgaris
- non inflammatory lesions include white heads (closed comedones) and blackheads (open comedones)
- inflammatory lesiosn include papules, pustules, nodules and cysts
- often fount face, chest, back, upper arms
- post inflammatory hyperpigmentation and atrophic scars
What is a commonly associated condition with acne?
PCOS is the most common endocrinopathy in women. It leads to increased thecal ovarian androgen production which exacerbates acne.
differential diagnoses for acne vulgaris?
Acne rosacea - presents with papules and sometimes pustules, affecting central face. presents with more generalised erythema & telangiectasia.
Tends to affect older women 30-50s
Investigations for acne vulgaris?
Acne is diagnosed clinically and does not require any further investigation
If patients have persisten or unusual acne you can swab for M& Culture
In women with persistent acne then testing for underlying hormonal disorder may be required
Management of acne vulgaris?
Management for acne involves skincare advice, topical or oral therapies and support for any mental health disorder.
- Conservative:
- advise to use non alkaline, skin neutral cleansers twice daily
- advise to avoid oil based moisturisers and suncreams
- advise those using makeup to avoid oil based and remove it at the end of the day
- advise to avoid picking or scratching as this increases risk of scarring
- Medical:
- Need to adhere to treatment for at least 6-8 weeks before full effect will be seen
- Step up management:
- Single topical therapy - topical retinoids, benzoyl peroxide
- topical combination therapy - topical antibiotic plus retinoid or benzoyl peroxide
- oral antibiotics: tetracycline, oxytetracycline or doxycyline
- Avoid tetracyclines in pregnant / breastfeeding women (erythromycin may be used in pregnancy)
- Single oral antibiotic used for max of 3 months
- topical retinoid or benzoyl peroxide always co prescribed with oral abx to reduce abx resistance developing.
- COCP alternative to Abx
- Dianette (cocyrindiol) used as it has anti androgen properties (only given 3m as increased risk VTE)
- Oral isoretinoin only under specialist (pregnancy is CI to both topical and oral retinoid)
Specialist points for retinoid treatment?
- Oral retinoids are reserved for severe resistant cases of acne vulgaris and are only prescribed under a specialist
- they are thought to work by reducing sebum production and inhibiting bacterial growth
- highly teratogenic therefore CI in pregnancy
- common practice to prescribe two forms of contraception for women
- other SE:
- Dry mucus membranse
- headaches
- hairthinning or loss
- Avoid in hepatic impairment and liver function eeds ot be monitored due to risk of hepatitis
- increased risk of suicide and depression when taking retinoids, change in mood needs to be closely monitored.
explaining acne to a patient:
Key points
” Acne is a really common skin condition that often arises during your teenage years. It is characterised by the spots you have been describing that can affect your face, chest and upper back. It can range from being mild to severe and is not a serious condition from a medical point of view but can cause a lot of distress.
It is caused by the clogging of your pores by a substance called sebum, which your body produces naturally. It can cause a build up of a bacteria on the skin called P Acnes. It is improtant to know this is not because of being dirty or eating greasy foods, and is usually made worse by hormones called androgens that naturally increase during puberty. It can also run in your family.
To treat it:
- No change in diet will cyre acne
- important to only wash your face twice a day, do not overwash
- avoid picking which causes scarring
- cosmetics can worsen spots look for the word - noncomedogenic
- there are lots of treatments, if one does not work we can try another. But we need to try a treatment for at least 6-8 weeks to see if it has an effect.
- Treatments include topical creams that include antibiotics, benzoyl peroxide or retinoids (Differin).
- Next in line are oral antibiotics or the oral contraceptive pill known as diannette. (cannot use if migraines or history of VTE)
- Important to know these treatments will treat the spots but not scars, scars need time to heal.
- If the above treatments do not work we can refer to dermatology.
examination features of rosacea?
- papules and pustules in central face
- flushing - frequent or persistent flushing
- telangiectasia
- ocular manifestations - lid margin telangiectasia, conjunctival injection, scleritis, blepharitis
Key features of seborrhoeic dermatitis
- scalp itching
- scalp scaling
- glabella scaling
- nasolabial fold scaling
- post auricular scaling
- white flakes
- erythema
Examination features for eczema?
- Dry skin with erythema scaling, papules or vesicles in acute flares
- infancts- extensors and cheeks predominatly affected
- in older children and adults , usually fle_xural surfaces_
- affect areas may have hyper or hypo pigmentation
- excoriations
- chronic eczema - skin is thick and lichenified
Management of atopic eczema?
- Conservatively
- stepped approach with emollients forming the base of treatment
- identify triggers - detergents, soaps, clothes, foods
- diaries to identify temporal relationships between triggers and flares
- Medical
- emollients are moisturising agents that help soothe smooth and hydrate skin, strengthen the barrier between your skin cells to prevent allergens and irritants and bacteria entering
- effects are short lived therefore they need to be used regularly and liberally even between flares of the disease
- used first if a corticosteroid is also to be used, in a ratio of 10:1
- come in multiple forms e.g. lotions, creams, gels, sprays and ointments
- emollients can be used as soap substitures
- Topical steroids are used and categorised based on potency (help every budding dermatologist - hydrocortisone, eumovate, betnovate, dermovate)
- more potent steroids are used only be specialists
- come in multiple forms e.g. lotions, creams, gels, sprays and ointments
- specialist:
- if topical steroids have failed then topical calcineurin inhibitors (tacrolimus and pimecrolimus) may be used
- Phototherapy for moderate to severe eczema (not in children)
- last line is systemic immunosuppression
What is skin cancer divided into?
What is the most lifethreatening?
What is the most common?
What is the single most important risk factor?
- Skin cancer is divided into melanoma and non melanomas. Non melanomas include basal cell carcinoma and squamous cell carcinoma.
- Malignant melanoma is the most life threatening and affects the younger population.
- Basal cell carcinoma is the most common.
- sun exposure is the sinlge most preventable risk factor for skin cancer.
Define basal cell carcinoma
Key features
Basal cell carcinoma is a slow growing locally invasive malignant epidermal (basal layer) skin tumour.
- Typically slow growing over months to years
- occurs on sun exposed sites of the body
- commonest form of skin cancer
- generally affects middle aged to elderly
- locally destructive and rarely metastasise, the centre can become necrotic or ulcerated therefore sometimes referred to as the “Rodent ulcer”
- Typically TURP features –> telangiectasia, ulcerated, rolled edges, pearly or pink coloured.
Key risk factors for BCC
- UV radiation and sunburn history
- outdoor occupation or hobbies
- xray exposure, arsenic exposure
- male
- increasing age
- immunosuppression - transplants and HIV
- Fitzpatrick skin types 1 and 2 (always burn, never tan)
- Genetics - xeroderma pigmentosum, gorlin goltz syndrome
- family history or personal history of skin cancer
features on the history for BCC
- Clinical features of BCC : TURP
- Telangiectasia - contains small blood vessels on the surface, when compressed and released they refill with blood.
- Ulcer (central ulceration occurs later hence known as rodent ulcer)
- Rolled edges
- Pearly or pink (shiny)
- Slow growing over months to years
- appear on sun exposed sites e.g. scalp, face, lower legs
- two main types: nodule BCC (most common) and superficial plaque like
- Ask about UV and sun exposure
- Xrays or arsenic
- Family history or personal history of cancer
- Skin type and how they react in the sun
examination features BCC
- Pearly papule or plaque
- non healing scab
- small crust non healing wound
- plaque or nodule with rolled borders
- papules with telangiectasia
Sub types of BCC?
- 5 common variants of BCC
- The most common type is nodular BCC
- Next most common is superficial BCC
- Others include basosquamous BCC, pigmented BCC and morphoeic BCC.
- Nodular BCC are red or flesh coloured, have well defined borders with overlying telangiectasia and as they grow develop central ulceration. Commonly arise on the face, can develop on mucosal surfaces
- Superficial BCCs are slow growing erythematous plaques that can be dry/crusted/ blue tinged. Hard to distinguish between dermatitis or SCC
- Morphoeic BCC - scar like lesions or indentations, deeply invasive
- Pigemented BCC - hard to distinguish from a melanoma, pigmentation from melanin production, often excised with 2mm margin as any pigmented lesion suspicious of melanoma
- basosquamous - rare but aggresive form of BCC with increased risk recurrence and metastasis
examination features of SCC?
- Examination via dermoscopy
- Type of SCC:
- Bowens disease
- invasive scc
- metastatic scc
- Presents as:
- usually head, neck or upper limbs
- bowens disease –> presents as thin flesh coloured or red plaque with scale or crust
- SCC:
- Keratotic with scaly, crusty surface arising from keratinocytes
- ill defined borders
- non healing
- nodular
- may be friable and bleed easily
- may be ulcerated
- fast growing over weeks to months
- on sun exposed sites e.g. scalp, face, ears, lower legs
Management of SCC?
- All suspected SCC need a 2WW referral to dermatology
- Patients undergo either excisional biopsy or punch biopsy
- Punch biopsy usually in areas without excess skin/ aesthetically challenging
Surgical:
- surgical excision biopsy with 4 mm border for those < 2cm or 6mm if > 2cm
- excisional biopsy is done with histological examination of the tumour and margins to ensure adequate removal
- adjuvant radiotherapy if there are affected LNs
- Mohs surgery in cosmetically challening locations, tumour removed layer by layer
- curettage and cautery
non surgical options include radiotherapy and cryotherapy
What is actinic keratosis?
What are the features?
Management?
- AK = common premalignant skin lesion develops after chronic sun exposure
- features:
- small crusty or scaly lesions
- often multiple lesions may be present
- can be pink, red brown or skin coloured
- typically sun exposed sites e.g. temples
- Management:
- Malignant transformation is common therefore treatment is required
- prevent further risk - sun avoidance and sun cream
- fluoroacil cream 2- 3 week course
- topical diclofenac - for milk AKs
- topical imiquimod
- crytherapy
- curettage and cautery
what is bowens disease?
What are the features
Management?
Bowens disease also known as SCC in situ is where the SCC has yet to breach the basement membrane
More common in elderly females
Can arise de novo or from preexisting actinic keratoses.
Features:
- Erythematous scaly plaque with sharp borders
- sun exposed sites e.g. LL
Management: 10% undergo malignant transformation therefore tx required
- surgical excision
- cryotherapy
- topical treatment - fluoroacil cream & topical hydrocortisone
What is the diagnosis?
What is the lesion and its features?
Management?
Keratoacanthoma
Benign epithelial tumour that occurs in sun damaged skin.
More common with increasing age
Appears similar to SCC therefore usually referred and treated surgicallyh
Features –> dome shaped papule, rapidly grows to become centrally filled with keratin
Management –> often spontaenously resolve within 3 months leaving a scar. As they look similar to SCC, 2WW often occurs with surgical removal.
What are the types of melanomas?
- Superficial spreading melanoma most common. Typically begins as asymmetrical dark spot with irregular borders or colour change. Related to intermittent high intensity UV exposure
- Nodular melanoma - starts as a raised spot the grows rapidly vertically, high rate metastasis
- acral lentiginous melanoma - found on palms soles or nailbeds. Hutchinsons sign on the nail bed - dark line is characteristic.
- Lentigo maligna- an in situ melanoma confined to the epidermis
history of melanoma?
Examination features
-
Altered pigmented lesion with ABCDE signs:
- Asymmetry
- irregular border
- colour alterations
- diameter > 6mm
- evolving lesion
- symptomatic - itching, bleeding or pain
- Melanomas mostly arise de novo but can arise from a congenital naevus
- if melanocytic naevi do not resemble other naevi, regardless of ABCDE criteria then also treat this as suspicious “ugly duckling sign”.
- spontaenous bleeding or ulceration
- nail signs - hutchinsons sign with subungal melanoma
- lymphadeopathy
- weight loss, fatigue, night sweats, headache or cough in metastatic
- in transit metastases - subcutaenous masses between the primary site and draining LNs
Investigations melanoma
2WW referral to dermatologist that inspects the lesion with dermatoscope.
If it is suspected to be a melanoma then excision biopsy occurs.
Or in cases of a large melanoma or close to vital structures e.g. eyes ears nose then incisional or punch biopsy
All patients need careful skin and lymph node examination
in cases of suspicous LN then FNA and cytology should be done
For high risk lesions total body CT or PET CT should be done
LDH - useful marker of cell turnover can risk stratify
If asked to explain management Melanoma in OSLER
- Complex and guided by the MDT
- Divided into surgical and medical
- Initially you need to confirm histologically that it is a melanoma therefore 1st line an ellipsoidal excisional biopsy is done, taking the entirety of the skin down to subcutaenous fat with a 2mm border. Punch or incision only in difficult areas.
- Plus sentinel lymph node biopsy - injection of radiolabelled dye into the lesion prior to surgery to identify any affected nodules with a gamma probe. These are also excised and sent for histological analysis.
- This is then histologically analysed giving three things:
- 1) breslow thickness - vertical depth of the tumour
- 2) ulceration - break in epidermis correlates with poorer prognosis
- 3) mitotic index - indicator of cell turnover
- Wide local excision is the standard treatment for primary melanoma which involves removal of biopsy scar with a surrounding margin of healthy skin which is determined by the breslow thickness.
- If in situ 0.5 cm thickness
- If less than 2mm then 1cm thickness
- If more than 2mm then 2cm thickness
- Additional medical therapy includes chemotherapy, radiotherapy and immunotherapy
