Dermatology Flashcards by Charlotte Colling

A 52 year old woman presents with a painful irregular keratinous nodule on her forearm. She states that she noticed it 2 months ago and it has already doubled in size. She is currently a smoker with a 20 pack year hx.

PMH: diabetes, renal transplant 9 years ago

What is the most likely diagnosis?

What is the management of this condition? (2)

Squamous cell carcinoma

Urgent referral to dermatology
+ efudix cream (5-fluorouracil)

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B..

Name the term used for the following description:

“A blister (greater than 5mm in diameter) consisting of clear fluid accumulated within or below the epidermis”

Bulla

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Herpes virus (simplex/zoster) is treated with which antiviral?

Acyclovir

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Stevens-johnson syndrome forms a spectrum with toxic epidermal necrosis.

What is the difference (by definition) of the 2 conditions?

SJS: < 10% body surface affected

TEN: > 30% body surface affected

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Which type of melanoma is the most aggressive and thus carries the worst prognosis?

Describe what this may look like:

Nodular melanoma

Red nodule that often bleeds easily

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A 6-year-old girl is brought into the general practice by her father. He is concerned about a new, itchy rash that has developed around his daughter’s mouth. Apart from this rash, she is well in herself.

What is the diagnosis?

How would you manage this condition currently? If it spreads further, how would you manage it then?

What advice would you give the father regarding personal hygiene around their house and attending school?

Impetigo

Topical hydrogen peroxide 1% cream / fusidic acid, extensiuve disease = oral flucloxacilin

School: stay off school under either all the lesions have crusted over OR it has been 48h since starting antibiotics (topical fusidic acid)

Hygiene: don’t share towels!

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U..

Name the term used for the following description:

“A circumscribed area of skin loss extending through the epidermis into the dermis”

Ulcer

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C..

Name the term used for the following description:

“A nodule consisting of an epithelial-lined cavity filled with fluid or semi-solid material”

Cyst

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P..

Name the term used for the following description:

“A palpable, plateau-like elevation of the skin, usually more than 2cm in diameter”

Plaque

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Describe the

1. inflammatory (3)

2. non-inflammatory (2)

lesions that may be seen in acne vulgaris:

Which parts of the body are the above features usually found on? (4)

inflammatory:
~ papules
~ pustules
~ nodules
non-inflammatory:
~ comdomes
~ pseudocysts

Face, neck, chest, back

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List 3 common features seen in a patient presenting with atopic eczema:

What is the every-day management atopic eczema? (2)

What is the management of acute atopic eczema flares:
1. mild severity

moderate severity
severe severity

Dry skin
Itchy skin
Erythema

Emollients & avoid triggers that cause flares

Mild flare: hydrocortisone

Moderate flare: eumovate

Severe flare: betnovate

All once daily for 7-14 days

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What is the name of the sign seen below?

What condition is this a common feature of?

Lichenification

Atopic eczema (longstanding disease)

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V..

Name the term used for the following description:

“A small blister (less than 5mm in diameter) consisting of clear fluid accumulated within or below the epidermis”

Vesicle

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A mother brings in her 6 year old child with a rash in his armpits that you diagnose as molluscum contagiosum.

She is asking whether she needs to keep him off school until the rash had cleared. What advice should you give her?

He can still go to school as normal

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Name the 2 commonest bacteria that cause cellulitis:

Strep pyogenes (60%)

Staph aureus (30%)

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What is the management of:
1. uncomplicated cellulitis (eg, without systemic illness)

complicated cellulitis (eg, with systemic illness)
cellulitis in a patient with a penicillin allergy

Name 3 complications associated with unresolved cellulitis:

Uncomplicated: oral flucloxacillin

Complicated: IV co-amoxiclav

Penicillin allergy: clarithromycin

Complications:

~ sepsis

~ necrotising fasciitis

~ gas gangrene

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A 23 year old man presents to the GP with intense itching, especially at night.

It is noted there is a polymorphic symmetrical rash on his wrists, elbows and in the webs of his fingers.

He notes that he has recently been travelling and staying in hostels for the past two months.

What is the most likely diagnosis?

Scabies

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A 3m girl is brought to the GP as her parents are worried about a skin lump that has appeared on her neck. It is non-tender and isn’t bothering her, but it is growing in size.
On examination there is a 2 x 2cm firm, well demarcated lesion with visible telangiectasia. There are no other skin lesions.

What is the likely diagnosis? - what is this?

What would the treatment be here?

What would the treatment be if the lesion was near the eyes/ rapidly enlarging or was ulcerating?

Haemangioma - a vascular birth mark that isnt present at birth but appears from 6 weeks onwards. It will proliferate & grow up until 8m and then self resolve.

Treatment if asymptomatic: nothing - they will self resolve (involute)

Treatment if problematic: Oral propanolol

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What conditions are included in the atopic triad?

Asthma
Hayfever
Eczema

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W..

Name the term used for the following description:

“A transitory, compressible papule/ plaque of dermal oedema. It’s usually red or white in colour and signifies urticaria”

Wheal

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A 42-year-old woman presents to her GP with a rash on her wrist which she has had for about a week. She reports it is very itchy, especially at night. She reports that her 7-year-old son has also got a similar itchy rash but this is between his fingers and on his palms. Her husband and daughter are unaffected.

On examination, you can see a red spotty rash and the skin looks very excoriated. You can just make out some linear burrows.

What is the most likely diagnosis?

What would the management be?

Scabies

Treat WHOLE household with permethrin 5% for 7 days

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A 41 year old female presents to ED with a painful skin rash of sudden onset. The last few days she has felt unwell with a fever, sore throat, conjunctivitis and malaise.

On examination, she has a diffuse erythematous rash on her trunk, with macules, target lesions and blisters. When you rub one of the blisters, the top layer of skin slides off.

She also has painful ulcers on her lips and genitals.

She recently was treated for a UTI by her GP.

What is the diagnosis?

What is the name of the sign that is indicated here? (rubbing blister causes top layer of skin to slide off)

What is the likely cause of this condition in this example?

Stevens-johnson syndrome (EMERGENCY!!!)

Nikolsky sign

The cause in this woman is her recent trimethoprim use

~ trimethoprim is a common cause

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What condition should you think of if you see silvery white scales affecting the extensor surfaces?

Psoriasis

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Eczema herpeticum is caused by which virus?

List some of the presenting features seen in this condition: (include a description of the skin rash) (4)

What is the management of this condition?

Herpes simplex virus type 1 or type 2

fever
lymphadenopathy
blistering rash with punched out lesions
contains vesicles & pustules

Oral acyclovir

# S.. Name the term used for the following description: “An accumulation of thickened, horny layer keratin in the form of readily detached fragments”

Scale

What is the name given when **erythema** affects more than 90% of the skin?

**Erythroderma**

Describe the **A-E** method of identifying a **melanoma**:

**A:** asymmetry (of the lesion) **B:** border (an irregular border is suspicious **C:** colour (containing multiple different colours is suspicious) **D:** different (from other naevi) **E:** evolving (fast growing lesions are suspicious)

What investigations are performed if a melanoma is suspected? (2) Along with TNM, what other classification is used to stage a melanoma?

**Excisonal biopsy & histopathology** **Breslow thickness** of the lesion - *measures how deep the tumour has gone into the skin layers*

Having had a **renal transplant** previously is a risk factor for what type of skin cancer?

**Squamous cell carcinoma**

# P.. Name the term used for the following description: “A visible collection of free pus in a blister”

Pustule

A 43-year-old female presents to ED with painful lips. She mentions that her lips have been bleeding for the last day, along with multiple places within her mouth. She also reveals that she has a rash on her body that 'peels off' when she applies pressure. She mentions that 5 days before this, she felt like she'd had the flu and wonders whether the issues with her bleeding lips could be down to this. What condition does this woman have? What is the definitive investigation to diagnose this condition? What is the sign that she is describing by her skin ‘peeling off’?

Stevens-johnson syndrome Skin biopsy **Nikolsky sign**

# M.. Name the term used for the following description: “A localised area of colour or textural change in the skin - *no elevation present*"

Macule

A 46-year-old man presents to A&E with a rash over part of his body and mouth. He tells you that he has felt under the weather for the last few days but the rash came on today. His past medical history is quite unremarkable and the only time he has seen the GP this year was due to his first episode of gout for which he was started on a medication. On examination, the affected skin appears blistered and peeling in some areas. He also has a number of mouth ulcers and his lips are very swollen and sore-looking. What is the most likely diagnosis? In this example, what is the likely cause for the development of this condition?

**Stevens-johnson syndrome** **Allopurinol** (he was recently diagnosed with gout!)

An 8 year old girl is brought into the GP by her father with a rash. On examination there is a papular rash on the palmar aspect of the wrist and in the finger webs. Her father reports that the rash is intensely itchy and is *more* itchy at night. What is the diagnosis? How should she be treated? What advise should you give to the father?

Scabies **Permethrin 5%** - *treat the WHOLE household!* *Advise to wash ALL bedding and towels!*

# P.. Name the term used for the following description: “A small, solid elevation of the skin that is *less* than 5mm in diameter”

Papule

**Eczema herpeticum** is caused by the *herpes simplex virus.* Describe the rash that this would present with: What is the management of this condition?

*Rash:* **Blistering** rash with **punched out lesions** (contains vesicles/pustules) Management: oral **acyclovir** (*IV if unwell)*

A **19** year old boy presents to his GP complaining of a condition affecting this **chest**, **back** and **face**. Upon examination, the GP notes that a mixture of **comdomes**, **papules** and **pustules** are seen around the face and back. What is the most likely diagnosis? What is the management of this condition? 1. **1st line** 2. **2nd** **line** 3. **3rd** **line**

**Acne vulgaris** 1st line: **topical benzoyl peroxide** (or topical retinoids) 2nd line: *add in* oral **tetracyclines** (eg, doxycycline) 3rd line: **oral** **isotretinoin** _under dermatology guidance!!!!_ ~ can cause depression!!

Which body surfaces are affected in **atopic eczema**? (flexors/extensors) Which season of the year is atopic eczema usually worse in? What is a common feature of **longstanding** atopic eczema? ~ describe what this looks like..

**Flexor** surfaces **Winter** months **Lichenification**

A 56 year old man presents with a couple of hard, scaly lesions on his nose and cheeks. You notice that the lesion has a yellow scale. What is the diagnosis? What is the management of this condition? (2)

**Actinic keratosis** Management: cryotherapy + efudox (5-fluorouracil)

Name the commonest bacteria to cause **impetigo:**

Staph aureus

Which condition (eczema/ psoriasis) involves: 1. flexure surfaces 2. extensor surfaces

**Flexures:** eczema **Extensors:** psoriasis

A mother brings her 2-year-old son to the GP with a lesion on his chin. She says it started two days ago and appears to be getting bigger. She says that he has never had any skin problems previously. On examination there is a single golden crusty lesion on the child's face. What is the most likely diagnosis? If you were unsure of the diagnosis, what investigation would you do? What is the management of this condition? If this management hasn't worked and the rash has spread across his face, what would be the next best management option?

**Impetigo** Swab the lesion for MC&S **Topical fusidic acid/hydrogen peroxide 1% cream** → oral **flucloxacilin** if rash is extensive (2nd line management after fusidic acid)

If a patient presents with a *rapid onset*, *painful* rash that has blisters, macules and *target lesions*, with a *flu-like* ilness several days before the rash presented - what condition should you be thinking of? What sign would you expect to be positive in this condition? What is the definitive investigation to diagnose this condition?

**Stevens-johnson syndrome** **Nikolsky sign** (when you rub a blister and the top layer of skin slides off) Skin biopsy

If someone presents with **hypo** or **hyperpigmented** patches of skin after recent travel to a **hot country**, what condition should you think of?

**Pityriasis versicolor** (also known as tinea versicolor)

# N.. Name the term used for the following description: “A solid elevation of the skin that is *greater* than 5mm in diameter”

Nodule

A 68 year old woman presents to your clinic after having noticed a nodule on her back 8 months ago. The nodule has been slowly getting bigger in size and has raised pearly edges with central ulceration. The woman is naturally pale with ginger hair. Whilst chatting to her you find out that she frequently holidays to Turkey as she loves the hot weather but admits to often getting sunburnt. What is the diagnosis? How is this condition managed? (2)

**Basal cell carcinoma** (slow growing nodule with raised pearly edges and ulceration. She has type 1 skin and a history of sun exposure & frequent sunburn!) Management: ~ Surgical excision of nodule (depending on site/size) +/- cryotherapy / efudox (*5-fluorouracil*)

List some nail changes that may be seen in someone with **psoriasis**: (3) What is the 1st line management of **psoriasis**? ~ how long would this tried for before moving on to 2nd line management?

* **nail pitting** * **yellowing** of the nails * **onycholysis** (separation of the nail from the nailbed) Topical *potent* **corticosteroids & vitamin D analogue** + emollients ~ try this for **4-8 weeks** before stepping up management

What type of skin cancer should you think of if you see: ~ **slow growing nodule** ~ **raised pearly edges** ~ telangiectasia ~ ulceration

**Basal cell carcinoma**

List the common presenting features of **psoriasis**: *(include a description of the skin rash & nail changes)* (6) Which body surfaces are affected in **psoriasis**? (flexors/extensors) Which areas of the body does psoriasis usually affect? (3)

* symmetrical red, scaly plaques * **silvery white scales** * itchy * nail pitting * yellowing of the nails * onycholysis (separation of the nail from the nailbed) **Extensor surfaces** **Knees, elbows, scalp**

A woman who is 31 weeks pregnant presents with a rash on her abdomen and thighs. The rash is very itchy and she is having difficulty sleeping at night. What is the most likely diagnosis? How is this condition treated? (2)

Atopic eruption of pregnancy Emollients & topical corticosteroids

What is the 1st line treatment for **tinea** fungal infections? 1. topical 2. systemic

1. **imidazole** 2. **terbinafine**

**Guttate psoriasis** usually only presents following what illness?

**Post-strep infection!**

A 26 year old presents to the GP with flaky, hypopigmented skin on her back since returning from her holiday to Greece. She denies getting sunburnt on holiday and wants to know why her skin is looking like this. What is the diagnosis? What is the management of this condition in: 1. minor disease 2. extensive disease

**Tinea vesicolor** (also known as pityriasis vesicolor) Minor disease: **topical imidazole** (eg clotrimazole) Extensive disease: **ketoconazole shampoo**

A** 70**-year-old man is seen in the clinic with a **red skin lesion** on his right **hand** that has **slowly been growing** over the last year. He denies any itchiness, pain, or changes in sensation. His past medical history includes **multiple sunburns** throughout his lifetime, and he does **not regularly use sunscreen.** On examination, a **10 mm erythematous, scaly patch** is seen at the base of the thumb of the right hand. It is **well-demarcated **and there is **no telangiectasia.** What is the likley diagnosis? Given the above diagnosis, what is the treatment of choice? If this lesion is left untreated, what may it transform into?

**Bowens disease** (aka SCC in situ) Treatment: **5-fluorouracil cream** If left untreated, it can transform into **SCC**

Which **GI condition** is associated with developing **Pyoderma gangrenosum**?

**IBD**

A 28-year-old man undergoes an ileocaecal resection and end ileostomy for **Crohn's disease**. One year later he presents with a **deep painful ulcer** at his stoma site. What is the most likely diagnosis?

Pyoderma gangrenosum (associated with IBD, ulcers can form anywhere on the body)

A **22**-year-old man is investigated for **weight loss**. A duodenal biopsy taken as part of his investigations shows **total villous atrophy and lymphocytic infiltrate**. He has a skin lesion that has **small itchy papules**. Which skin disease would you expect to see in this man?

Dermatitis herpetiformis

A **5**-year-old boy presents to GP with his mum. He has a** PMH including atopic eczema**, but today is presenting with a **rapidly progressing painful rash** on his **cheek**. What is the most likely diagnosis? What organism causes this? How should this child be managed?

**Eczema herpeticum** Caused by **herpes simplex virus**! As it is potentially life-threatening, children should be **admitted for IV aciclovir.**

A 45-year-old man presents to his GP with a one-week history of a **rash**. He has **recently returned from a holiday in *Spain***. He does not have any significant past medical history and does not take any regular medications. On examination, there is a rash affecting his trunk, consisting of **multiple hypopigmented patches**, which are **slightly scaly**. What is the most likely diagnosis? How is this condition treated?

**Pityriasis versicolor** Treatment: topical ketoconazole (shampoo)