Dermatology Flashcards
What should be included in a dermatological history?
History of presenting complaint
Past medical history: systemic disease, history of atopy (triad: asthma, hayfever eczema), history of skin cancer or pre cancer (seborrheic keratosis), history of sunburn/sunbeds/sunvathing, skin type
Social history: work, hobbies, smoking, alcohol (sun exposure, irritants, aggrevating facotrs, LATEX ALLERGY), lived abroad?
Drug history and allergies- regular and recent, systemic and topical - get specific (where/how much/how long for/strength/dosage/hand washing/using other creams at same time (disrupts absorption))
Family hx: autoimmune (inc. vitilligo), skin cancers, atopy
Impact on quality of life: pain, cosmetic appearance -> mental health, treatments (skin thinning, changes to pigmentation)
Presenting complaint: nature - rash vs. lesion
Site
Duration - acute (infection)
Initial appearance and evolution (rash may start with single lesion and spread)
Symptoms (itch/pruritis, pain)
Aggravating and relieving factors - triggers (washing powder, medication, cosmetics)
Previous and current treatments (effective or not) - what, how long, why hasn’t it work (child gets distressed, job is obstructive, treatment causes itching)
How to approach dermatological examination?
Inspect, palpate,systemic check (whole skin, hair nails mucous membranes), describe
SCAM:
S- site, size, shape - distrubition (photosensitive, flexural, extensor, genralised) )
C- colour (pigmented (hypo/hyper/de), eryythematous, blanching, purpura) hand configuration (discrete, confluent, linear (psorias, follows line of prev injury), target lesions,))
A - associated changes (e.g. surface features) (exudate/crust, scale, excoriation marks, erosion, ulceration)
M - morphology (raised/flat, fluid filled)
ABCD
Asymmetry
Border (irregular, blurred)
Colour
Diameter
What is a commodome?
A comedone is a small black (open) or white (closed) coloured spot which often occur as part of an acne outbreak and develops on the face, neck, chest and back as a result of sebum and keratin blockage of the pilosebaceous unit.
What is alopecia?
Ariarta - patchy
Or diffuse
Hair loss
What is hypertrichosis?
Excessive hair growth over and above the normal for the age, sex and race of an individual, in contrast to hirsutism, which is excess hair growth in women following a male distribution pattern.
What is hirsuitism?
Hirsutism (HUR-soot-iz-um) is a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern — face, chest and back. With hirsutism, extra hair growth often arises from excess male hormones (androgens), primarily testosterone
What is koilonychia?
Spoon shaped nail
Associated with iron def. aneamia
What is onycholysis?
Thickened nails lifting off the nail bed
Associated with psoriasis
What is clubbing?
Clubbing is a physical sign characterized by bulbous enlargement of the ends of one or more fingers or toes
Associated with lung cancer
What is pitting?
Small dots in the nail
Associated with psoriasis
What is a macule?
Flat, small lesion <1cm,
Discolouration: brown, blue, red or hypopigmented
What is a papule?
Superficial elevated solid lesions (<0.5cm)
Varies in colour
What is a vesicle?
CIrcular collection of free fluids <1cm
What is a patch?
Flat lesion larger than a macule (>1cm)
Circumscribed
Discoloured
What is a plaque?
Superfiical lesion which is elevated, solid and flat.
Topped lesion >1cm
What is a nodule?
Circular, elevated, solid lesion (>1cm) - larger than a papule
What is a bulla?
Circumscribed collection of free fluid >1cm (greater than a vesicle)
What is a pustule?
A vesicle containing puss (inflammatory cells)
What is meant by annular?
Ring shaped lesion
What is meant by a wheal/urticarial lesion?
Odematous, transitory plaque, may last a few hours
May be round, annular or polycyclic
May be associated with angiodema or anaphylaxis
May require bloods and urinalysis to exclude a systemic cause
What is meant by scale?
Epidermal thickening, consists of flakes or plates of compacted desquamated layers of stratum corneum
What is meant by crust?
Dried exudate on skin
What is erythoderma?
Confluent erythema
Erosion
Palpable purpuric papules
Telangiectasia
Ulcer
Petechiae
Scaly papules
Annular non scaling plaque
Cyst
Patch
Erythema
Gangrene
Vesicles
Macules
Patch
Bulla
Crust (in impetigo)
Eschar
Erythoderma
Sclaey plaque
Pustules
Papules
Nodule
Ecchymosis seen in vasculitis
What is the standar exicisonal shape for removal of a skin lesion?
Elliptical shape including saftey margin of normal skin to allow for closure
Risk factors for melanoma?
MORE THAN 5 EPISODES OF SUNBURN UNDER 10 YEARS OF AGE
Sun exposure
Sun beds
Immunosupression
Burns easily
Multiple moles (>100)
Atypical naevus syndrome moles
Family history of melanoma
Skin type 1
Previous history of melanoma
Large congenital melanocytic naevus
What do multiple pinpoint bleeding points on a painful callus suggest?
Warts
How can a verruca be managed?
Duct tape
Topical therapies
Cryotherapy
What is molluscum contagiosum?
Shiny smooth papules with central dimple secondary to viral infection . Self limiting but can us antiseptic wash +/- abx if appear infected
How might scabies present?
Multiple household members with same condition.
Linear burrows (may be tortuos), rubber nodules, papules, excoriations,
Scabies presents with incredibly itchy small red spots, possibly with track marks where the mites have burrowed.
The classic location of the rash is between the finger webs, but it can spread to the whole body.
History of contact with symptomatic individuals, puritus worse at night
Common sites include fingers, finger webs, wrists, elbows, ankles, feet, nipples and genitals
How long after treatment of scabies will the itchy persist
One month
How does bullous phemigoid present?
Erythematous rash
Itchy
Papules and plaques
Some annular/targetoid leisions
Tense blisters/bulla on an erythematous base
Preceded by a non-specific itchy rash
Usually effects the trunk and limbs (Mucosal involvement less common)#
Often affecting elderly patients
How does shingles distribute and how does it appear?
In a dermatomal distribution
Erthymatous, erosions, crust
How does SSC present?
Fast growing
Ulcerated lesion
May have shiny edges and telangiectasia
Bleeding and crust present
What is Bowen’s disease?
Type of early skin cancer
Bowen’s Disease appears as an irregular, red, keratinised, scaly plaques classically located on areas of sun exposed skin
How to use steroids in eczema?
The general rule is to use the weakest steroid for the shortest period required to get the skin under control. Steroids are very good for settling down the immune activity in the skin and reducing inflammation, but they do come with side effects. They can lead to thinning of the skin, which in turn make the skin more prone to flares, bruising, tearing, stretch marks and enlarged blood vessels under the surface of the skin called telangiectasia. Depending on the location and strength of the steroid there may be some systemic absorption of the steroid. The risks of using steroids need to be balanced against the risk of poorly controlled eczema.
The thicker the skin, the stronger the steroid required. Only weak steroids used very cautiously should be applied to areas of thin skin such as the face, around the eyes and in the genital region. It is best to completely avoid steroids in these areas in children.
How should steroid cream be applied?
Emollient should be applied first
Use fairly genourously when active and thinner when improving
What is acne?
A chronic inflammatory condition, with or without localised infection disorder of the pilosebaceous units (containing hair follicles and sebaceous glands) causing comedones, papules and pustules to form.
Commodomal - less severe,
Pustular more severe
How might secondary syphillis manifest dermatologically?
Secondary syphilis develops as a maculopapular rash covering the torso and limbs as well as the palms and soles.
Patients generally feel very unwell and have lymphadenopathy.
What is the first line treatment of plaque psoriasis?
Potent topical corticosteroid + topical vitamin D is the first line treatment for plaque psoriasis.
What psychiatric drug is a common trigger of psoriasis?
Lithium
What is contact dermatitis?
Contact Dermatitis is a type of Eczema which occurs following exposure to a causative agent.
The rash is typically eczematous and commonly located on the hands in an asymmetrical distribution.
What is Bullous Pemphigoid?
Bullous Pemphigoid is an autoimmune blistering skin condition which affects the elderly. It is more common in those with neurological diseases such as Parkinson’s Disease or dementia. Bullous Pemphigoid is caused by autoantibodies against antigens between the epidermis and dermis, resulting in a sub-epidermal split. Initially, it presents as pruritic, tense, fluid-filled bullae (large blisters) on an erythematous base. In the image shown, some of the bullae have ruptured, leaving post-inflammatory hyperpigmentation. The lesions can be localised or widespread, often occurring in skin folds.
What is impetigo and what causes it?
Impetigo is a superficial bacterial skin infection, usually caused by the staphylococcus aureus bacteria.
A “golden crust” is characteristic of a staphylococcus skin infection. It is also less commonly caused by the streptococcus pyogenes bacteria.
It occurs when bacteria enter through a break through the skin and is highly contagious.
It can be classified as non-bullous or bullous
How does non-bullous impetigo present?
Occurs around the nose or mouth
Exudate from the lesions dries to form a golden crust
Pt not unwell
Common in children
What can be used to treat non-bullous impetigo?
- Topical fusidic acid, antiseptic cream (hydrogen peroxide 1%)
- Oral flucloxacillin in more wide spread or severe impetigo
How to prevent spread of impetigo?
Advise not to touch or scratch lesions
Hand hygine
Avoid shairing face towels and cutlery
Stay off school until lesions have healed (crusted over) - usually 7 to 10 days - or treated with antibiotics for at least 48hrs
If bullous patients should be isolated
How does bullous impetigo occur?
Staphylococcus aureus only.
These bacteria can produce epidermolytic toxins that break down proteins that hold skin cells together, causing 1-2cm fluid filled vesicles to form on the skin.
How does bullous impetigo present?
Painful ithcy lesions: 1-2cm fluid filled vesicles form, growing in size and then bursting forming a ‘‘golden crust’’
More common in under 2s
Systemic symptoms may occur: fever, lethargy
How is bullous impetigo treated?
Flucloxacillin - oral or IV if very unwell or at risk of complications
What is staphylococcus scaled skin syndrome?
Complication of bullous impetigo - severe infection with widespread lesions
How can bullous impetigo be investigated?
Swabs of the besides can confirm diagnosis bacteria and antibiotic sensitivities
What are the potential (but rare), complications of impetigo.
Cellulitis if the infection gets deeper in the skin
Sepsis
Scarring
Post streptococcal glomerulonephritis
Staphylococcus scalded skin syndrome
Scarlet fever
What is folliculitis, how does it present and what causes it?
Inflammation of a hair follicle resulting in papules or pustules (pimples).
Most commonly caused by a staphylococcus aureus infection (gram negative folliculitis can occur after prolonged antibiotic treatment for acne)
What is eosinophillic foliculitis? How is it diagnosed and treated?
Eosinophilic folliculitis is a sterile folliculitis that is caused by immunosuppression, most commonly due to HIV.
Diagnosis is by skin biopsy, which reveals eosinophils in the skin surface.
Treatment is with HAART and topical corticosteroids.
What is cellulitis?
Bacterial soft tissue infection of the dermis and deep subcutaneous tissue
Risk factors for cellulitis?
Advancing age
Immunocompromised e.g. diabetic
Predisposing skin condition e.g. ulcers, pressure sores, trauma, lymphoedema
What organisms typicall cause cellulitis?
Generally caused by Streptococcus and/or Staphylococcus organisms.
Clinical features of cellulitis?
Erythema
Calor (heat)
Swelling
Pain
Poorly demarcated margins
Systemic upset: fever, malaise
Lymphadenopathy
Often evidence of breach in skin barrier e.g. trauma, ulcer, etc
How is cellulitis managed?
Blood tests including culture
Skin swab for culture
Oral or IV antibiotics depending on severity - flucloxacillin first line
Mark the area of erythema to aid in detection of rapidly spreading cellulitis
Elevate if possible
Wound debridement may be necessary
Sterile dressing, analgesia
Folliculitis
Cellulitis
HSV 1
What is the genital lesion
HSV 2
Chicken pox
Shingles
Viral wart
Name the viral lesion
Molluscum contagiosum
dermatophytosis (ring worm)
What skin infection could this be
candidiasis
Candidal intertrigo
Scabies
Types of herpes simplex virus?
HSV-1 - most common cause of oral herpes (and genital)
HSV-2 causes genital herpes, more likely to cause recurrent anogenital symtpoms
How might genital herpes present?
May be entirely asymptomatic
Multiple painful genital ulcers
Dysuria
Vaginal or urethral discharge
Lesions typically crust and heal, at which point virus ceases to be shed from the lesions.
In some cases may have symptoms of fever, malaise, headache and urinary retention.
Recurrent episodes are usually less severe than a primary episode. There may not be a clearly identifiable trigger. The recurrent episode may have a prodromal phase, such as tingling.
Most effective method to diagnose a lesion as HSV
The most effective method of diagnosis is to obtain a swab from the base of the ulcer and analyse using nucleic acid amplification tests (NAATs).
How is HSV transmitted?
HSV is transmitted from skin-to-skin.
The virus can be shed in the prodromal phase and during phases of recurrence or when displaying clinical symptoms for the first time. Virus can also be shed when the patient is asymptomatic
The current guidance advises patients to abstain from sex during clinical recurrence or when they are experiencing prodromal symptoms. In the case of oral HSV kissing or any skin to skin contact with the lesion should be avoided until completely healed.
There is a risk of transmission to the eye if contact lenses become contaminated
How is genital HSV treated and when should it start?
Oral antivirals are the primary treatment for genital herpes simplex infection — treatment should commence within 5 days of the start of the episode, or while new lesions are forming for people with a first clinical episode of genital herpes simplex virus (HSV).
Aciclovir, Valaciclovir, Famciclovir
How is oral HSV-1 infection managed?
Usually self limiting
Can reccomend soft diet if eating is painful
NICE advises against prescribing topical anaesthetic or analgesic preparations, mouthwash or lip barrier preparations.
Paracetamol, ibuprofen
Choline salicylate gel for pain control of cold sores can be bought over the counter (this is contra-indicated under the age of 16 due to Reye’s syndrome).
Topical antiviral agents are minimally benificial but can be used if initiated at the onset of symptoms before vesicles appear purchased OTC
Aciclovir 5% (age range is not specified by the manufacturer),
When should oral antiviral agents be considered for oral HSV-1?
For immunocompetent individuals, oral antivirals are not routinely indicated for the treatment of cold sores but may be indicated in severe episodes. If possible this should be done from the time of the prodrome - ie before vesicles appear.
Seek specialist advice for people who are immunocompromised (including people with HIV), antivirals may be warrented or even admission.
Aciclovir is active against herpes viruses but does not eradicate them. It can be used as systemic and topical treatment of herpes simplex infections of the mucous membranes and is used orally for severe herpetic stomatitis.
Valaciclovir is an ester of aciclovir. It is licensed for herpes simplex infections of the skin and mucous membranes.
Complications of HSV infection?
Dehydration, especially in children.
Recurrent lesions at the same site may occasionally cause atrophy and scarring.
Secondary bacterial infection, including impetigo, can occur.
Eczema herpeticum can complicate atopic eczema.
Bell’s palsy is possibly a complication of herpes simplex infection.
Rare complications include dissemination, herpes encephalitis, meningitis, corneal dendritic ulcers (ocular herpes simplex) and erythema multiforme.
What is Eczema herpeticum?
Eczema herpeticum is a rare and serious skin infection caused by one of the herpes viruses. It causes a blistery, painful skin rash. It most often affects children who have eczema
Herpes simplex virus 1 (HSV-1) is the most common causative organism
The eczema causes breaks in the skin which allows the virus in
Considered an emergency as it can spread quickly
Often mistaken for chickenpox, however differes as spots are smaller and closer together
A typical presentation is a patient who suffers with eczema that has developed a widespread, painful, vesicular rash with systemic symptoms such as fever, lethargy, irritability and reduced oral intake. There will usually be lymphadenopathy (swollen lymph nodes).
Eczema Herpeticum management?
Antiviral medicine such as aciclovir is usually very successful for treating eczema herpeticum. It may be given as a liquid or a tablet (mild to moderate). For people who are too unwell to take it as a liquid or a tablet, it can be given by a drip intravenously (severe)
Viral swab of vesicles to confirm diagnosis
STEROID CREAM WILL WORSEN
How does eczema herpeticum present?
Pt generally unwell with fever
Usually children w history of atopic eczema
Fluid filled vesicles - usually on face or neck
Spreads
Vesicles may weep or become crusted over
Lymphandopathy may be present
What is chickenpox?
Chickenpox is caused by the varicella zoster virus (VZV). It causes a highly contagious, generalised vesicular rash. It is common in children. Once a child has had an episode of chickenpox, they develop immunity to the VZV virus and will not be affected again.
When does chicken pox stop being contagious?
When the lesions scab over
When does chicken pox start being contagious?
A couple of days before rash appears
Clinical features of chickenpox?
Widespread, erythematous, raised, vesicular blistering lesions
Rash usually starts on trunk or face and spreads outwards affecting the whole body over 2-5 days
Fever is often the first symptom
Itch
General fatigue and malaise
Intubation period of chicken pox?
10 days to 3 weeks
How is chickenpox spread?
Chickenpox is highly contagious and spread through direct contact with the lesions or through infected droplets from a cough or sneeze.
Potential complications of chickenpox?
Bacterial superinfection
Dehydration
Conjunctival lesions
Pneumonia
Encephalitis (presenting as ataxia)
After the infection the virus can lie dormant in the sensory dorsal root ganglion cells and cranial nerves reactivate later in life as shingles or Ramsay Hunt syndrome.
Advice for pregnant women exposed to chicken pox (and the reasoning behind it)?
If they are not immune, varicella zoster immunoglobulins can be given to protect them against the virus after exposure.
Before 28 weeks: potential for congenital varicella syndrome - developmental problem in fetus
Around time of delivery: can lead to life threatening neonatal infection, requires treatment with varicella zoster immunoglobulins and aciclovir
Management of chickenpox?
Chickenpox is usually a mild self limiting condition that does not require treatment in otherwise healthy children.
Aciclovir may be considered in immunocompromised patients, adults and adolescents over 14 years presenting within 24 hours, neonates or those at risk of complications.
Complications such as encephalitis require admission for inpatient management.
Symptoms of itching can be treated with calamine lotion and chlorphenamine (antihistamine).
Patients should be kept off school and avoid pregnant women and immunocompromised patients until all the lesions are dry and crusted over. This is usually around 5 days after the rash appears.
What is shingles and which patients is it expected and not expected in?
Shingles is a reactivation of the varicella zoster virus which can lie dormant in nerve ganglia following primary infection (chickenpox).
It commonly occurs in the elderly and shingles in young adults should prompt investigation for an underlying immune condition.
How does shingles present?
Tingling feeling in a dermatomal distribution
Progression to erythematous papules occuring along one or more dermatones within a few days, which develop into fluid dilled vesicles which then crus over and heal
Fever
Headache
Malise
Potential complications of shingles?
Secondary bacterial infection of skin lesions
Corneal ulcers, scarring and blindness if eye involved
Post-herpetic neuralgia
- Pain occurring at site of healed shingles infection
- Can cause neuropathic type pain (burning, pins and needles)
- Can cause allodynia (perception of pain from a normally non-painful stimulus e.g. light touch)
Management of shingles?
Oral antiviral (e.g. valaciclovir 1g three times per day for 7 days) if eye involvement or if immunocompromised.
IV antiviral if severe disease
Advise avoiding contact with pregnant women, babies and those who are immunocompromised until the lesions are fully crusted over, as transmission can occur via skin contact
Who should be offered the one off shingles vaccine?
Patients in their 70s
What virus causes viral warts?
human papillomavirus (HPV)
How can viral warts be classified?
Cutaneous (verruca, papiloma)
Mucosal
Who is at increased risk of viral warts?
School aged children
Patients with dermatitis (defective skin barrier)
Immunosupressed patients: azathioprine, ciclosporine, HIV
How are viral warts (HPV) spread?
Skin to skin contact or autoinoculation (picking or scratchin a ward may cause a subungal wart (under nail) or a wart being spread to another area of skin.
Autoinoculation of the virus in a scratch can result in a line of warts (pseudo-koebnerisation)
HPV incubation period?
Up to 12 months depending on amount of virus inoculated
How do cutaneous viral warts appear?
Cutaneous viral warts have a hard, keratinous surface.
Tiny red or black dots visible in the wart are papillary capillaries.
How do common warts present?
Common warts (verruca vulgaris) present as cauliflower-like papules with a rough, papillomatous and hyperkeratotic surface ranging in size from 1 mm to 1 cm or more. They may be solitary or multiple. Common warts are found most often on the knees, backs of fingers or toes, and around the nails (periungual).
Plantar wart presentations
Plantar warts (verruca plantaris) include tender inwardly growing myrmecia on the sole caused by HPV 1, and clusters of superficial less painful mosaic warts due to HPV 2. Myrmecial warts are typically tender with lateral and direct pressure, are surrounded by yellow hyperkeratotic callus-like skin showing accentuated skin markings, but with discontinuation of the skin lines through the actual wart.
Plane wart presentation (verruca plana)
Plane warts are typically multiple small flat-topped skin-coloured papules located most commonly on the face, hands, and shins. On the shins and beard-area of the face the virus is often spread by shaving resulting in numerous warts. Plane warts are mostly caused by HPV types 3 and 10.
What is a filiform wart
A filiform wart is a cluster of fine fronds emerging from a narrow pedicle base usually found on the face. They are also described as digitate (finger-like).
Complications of cutaneous viral warts
Viral warts are infectious to the patient and others
Cutaneous warts can have significant psychosocial effects such as teasing at school, embarrassment, permission refused for swimming lessons.
Periungual warts can cause nail dystrophy and destruction.
Pain due to plantar warts (myrmecia type) interferes with walking and sporting activities, causing knee or hip pain.
In epidermodysplasia verruciformis (rare autosomal recessive condition suscepitable to skin infection) the specific HPV types involved can cause cutaneous squamous cell carcinomas.
Callus vs wart
Pinpoint red or black dots (papillary capillaries) are revealed when the wart is pared down. Patent capillaries cause pinpoint bleeding. Plantar corns lack the papillary capillaries.
Location of a plantar wart is not restricted to pressure sites whereas a plantar callus or corn is always at a pressure site.
Tenderness is maximal with lateral pressure for a plantar wart whereas a corn or callus is more tender with direct pressure.
Differential diagnoses for a cutaneous viral wart?
Seborrhoeic keratosis
Squamous cell carcinoma
Plantar corn and callus.
Treatment of viral warts?
Work by removing virus containing skin - HPV infects the basal cell layer of the epidermis so wards can recur rapidly if the virus has not been eradicated
Topical: salicylic acid or podophyllin containing treaments (remove surface skin cells). Most resolve within 12 weeks of daily applications.
Cryotherapy with liquid nitrogen at one to two week intervals to cause peeling of surface layers for 3-4 months
Electosurgery for large resistant warts
Complications of cataract surgery
Endophthalmitis is the most dangerous complication and the first thing any doctor should rule out when
presented with a patient complaining of visual symptoms following intraocular surgery. Patients typically
present within days of surgery with severe pain, loss of vision and hyperaemia. They should be admitted
and seen immediately by an ophthalmologist.
Posterior lens capsule pacification is a relatively common complication of cataract surgery that usually
occurs a few weeks following the operation. The typical patient complains of blurry vision as if their
cataract has returned, and a white opacity may be visible on observation. The condition can be treated
easily with a simple laser procedure which can be carried out as an outpatient.
Other rare complications to be aware of are:
• Retinal detachment
Macular oedema
Glaucoma
• Corneal oedema
Eczema herpeticum
The Hazards of Ultraviolet Radiation
UV B: sunburn, DIRECT DNA DAMAGE AND CARCINOGENESIS
UV A: Photo ageing! Potentiates UV-B carcinogenesis, Immunological effects
What is an Acquired melanocytic naevus?
A melanocytic naevi is a benign skin lesion due to a local proliferation of pigment cells (melanocytes), occuring in childhood.
Evolves in three steps:
Junctional: flat + pigmented (due to melanocytes at the basal layer of the epidermis) - small, flat, and black
Compound: raised + pigmented, hyperkerratotic, and/or hairy (due to melanocytes at the basal layer of the epidermis + deep in the dermis)
Intradermal: raised + pale - usually dome-shaped papules or nodules (due to melanocytes deep in the dermis)
Typical mole appearance
What are congenital naevi?
Moles present from birth, tend to be large, pigmented and hairy monitor but not of much concern
What is a dysplastic naevus?
An atypical naevus that may resemble a melanoma, by having ‘ABCDE’ features. (ie. Asymmetry, colour changes)
Asymettrical shape
Border irregularity
Colour irregularity
Diameter over 7mm
Evolution of lesion
Symptoms (bleeding, itching)
They may be part of a syndrome called Familial Atypical Multiple Mole-Melanoma (FAMMM) syndrome, where there are multiple naevi (>50) many of which are atypical and an increased risk of melanoma.
What to look for when examining a mole?
• A is for asymmetrical shape. Look for moles with irregular shapes, such as two very different-looking halves.
• B is for irregular border. Look for moles with irregular, notched or scalloped borders — the characteristics of melanomas.
• C is for changes in colour. Look for growths that have many colours or an uneven distribution of colour.
• D is for diameter. Look for new growth in a mole larger than about 6mm.
• E is for evolution. Look for change in the mole, includes changes in shape, size and elevation.
Significance of colour in SUPERFICIAL SPREADING MALIGNANT MELANOMA?
Black: stratum corneum
Brown: loss of pigment may mean regression, immune system attacking lesion
Grey: papillary dermis
Blue: pigment invading into the deep melanin - concern
Melanoma mimics?
Multi component haemangioma
Intracorneal haemorrhage
Subungual haematoma
Benign longitudinal melanonhchia
Pigmented sebkeratosis
What melanoma mimic is this?
Multi component haemangioma
What melona mimic is this
Intracorneal haemorrhage
T
Bowens disease vs Actinic keratosis?
Actinic keratosis partial dysplasia, Bowens complete
Actinic keratosis has much lower mallignant potential
Typical appearance of seborrheic keratosis?
Seborrheic keratosis are typically dull and darkly pigmented, round or oval in shape, and often
appear like a scab of a healing wound. They can be flat or slightly raised. Typically reported as a new skin lesion
Most common dermatological conditions?
Eczema
Psoriasis
Acne
Actinic keratosis
Melanoma
SCC
BCC
Lichen planus
Sebhorric warts
Urticaria
What topical treatment can be used to treat acitinic kerratosis or superficial BCC?
Efudix
Treatments for moderate acne?
Start topical abx: treclin gel, epidura
Topical treatments: benzy peroxide acid
Oral abx: doxycyline - 3 months
Side effects of oral retinoids?
Note requires baseline bloods
Dry skin and lips
Dry mucous membranes
Photosensitivity of the skin to sunlight
Depression, anxiety, aggression and suicidal ideation. Patients should be screened for mental health issues prior to starting treatment.
Rarely Stevens-Johnson syndrome and toxic epidermal necrolysis
Teratogenic Fragile skin (avoid waxing)
Slower wound healing
Headaches
Joint pains
Hyperlipidemia
When can oral retinoids be trialed in acne?
failure of 3 month course of oral abx
Potential complications of eczema?
Eczema herpeticum (rare but serious medical emergency, treated with acyclovir)
Secondary bacterial infection (impetigous eczema)
How should topical steroids be used in eczema flares?
Moderate to strong for 5 days
Weaker for 1-2 weeks following
Complications associated with psoriasis?
Metabolic syndrome
Nail psoriasis describes the nail changes that can occur in patients with psoriasis. These include nail pitting ( punctate depressions of the nail plate), Onychomycosis (thickening), discolouration, ridging and onycholysis (separation of the nail from the nail bed).
Psoriatic arthritis (occurs in 10 – 20% of patients with psoriasis and usually occurs within 10 years of developing the skin changes. It typically affects people in middle age but can occur at any age)
Psychosocial implications of having chronic skin lesions, which may affect mood, self esteem and social acceptance and cause depression and anxiety.
Other co-morbidities that increase the risk of cardiovascular disease are associated with psoriasis, particularly obesity, hyperlipidaemia, hypertension and type 2 diabetes.
What is basal cell carcinoma?
Basal cell carcinoma is the most common form of skin cancer, slow growing, locally invasive mallignant tumour of the EPIDERMAL KERATINOCYTES
Typically presenting as a slow-growing tumour, most commonly of the head or neck. Nodular BCC is the most common subtype, presenting as a shiny nodule with associated telangiectasia, central ulceration and ‘pearly, rolled edges’.
Tend to occur in older individuals
They are associated with a history of sun exposure
What is pyoderma gangrenousum?
Pyoderma gangrenosum is a neutrophil dermatosis characterised by the formation of enlarging ulcers, usually on the lower limbs, with a characteristic yellow purulent surface and black/ blue outer edge.
This condition is commonly associated with several systemic diseases (e.g. inflammatory bowel disease); however, it can also be drug-induced (cocaine)
Excisional margin for BCC?
4mm
What kind of rash does toxic shock syndrome (staph aureus) present with?
Sunburn like
What is impetigo?
Impetigo is a contagious bacterial infection that is most commonly seen in the paediatric population. The infection is classically caused by group A Streptococcus and Staphylococcus aureus. Children living in warm, humid climates are most commonly affected.
Skin lesions typically begin as papules and vesicles which eventually break down to give a characteristic golden or honey-coloured crusted appearance. Lesions typically occur on the face and limbs and systemic manifestations are minimal.
Topical treatment can be used for localized disease, however, an oral antibiotic like flucloxacillin should be prescribed for severe infections.
Management of lichen sclerosis?
The gold standard management for this condition is topical steroids. A very potent topical steroid is often prescribed as first-line therapy (e.g. clobetasol propionate). In conjunction with this treatment, other conservative measures are often used, including washing the affected area a couple of times per day with water, avoiding restrictive clothing, prompt management of incontinence if present and the application of emollients to alleviate the itch.
How does phemigus vulgaris typically present
Easily-burst faccid bullous lesions appear first in the mouth before later appearing on the skin, forming eroisions and crusts. Lesions are often painful. Usualy affecting mucosal areas. It is an autoimmune disease with a peak incidence in the 6th decade that is more prevalent in Ashkenazi Jews. Be aware that it is a medical emergency that is treated with steroids and supportive measures. positive Nikolsky sign
What is positive Nikolsky sign
If the test result is positive, the very thin top layer of skin will shear off, leaving skin pink and moist, and usually very tender. A positive result is usually a sign of a blistering skin condition. People with a positive sign have loose skin that slips free from the underlying layers when rubbed.
What is infantile haemangioma
infantile haemangioma or ‘strawberry haemangioma’. Strawberry naevi may be present at birth or develop in the first few weeks after birth, they are the most common tumours of infancy. They typically begin as small flat red areas and then develop into raised dimpled lesions. The lesions continue to grow until the child reaches 3-4 years, at which point they begin to regress spontaneously.
What is acne rosacea and how is it managed?
This is a condition that typically affects fair-skinned people and is characterised by erythema, telangiectasia, papules and pustules on the forehead, nose, cheeks and often chin. It typically begins with flushing and is often worse after alcohol ingestion, as in this case.
The first-line treatment for acne rosacea is topical metronidazole. Topical azelaic acid can be used if topical metronidazole is not tolerated or fails to improve the condition.
Oral abx (tertracyclines) may be used, topical brimonidine for temporary vasoconstirction may be used, for rhinophyma - surgery or laser ablation.
Advise patients to avoid triggers (spicy food, heat, sunlight, wind, alcohol, hot foods and liquid), wear sun protection and to use bland emollients to mositurise to wash with
How can a topical vitamin d analogue treat psoriasis
Increases skin turnover
First line treatment of mild to moderate roseacea
Topical Azeliac acid or topical antibiotic such as metronidazole
Most common subtype of BCC?
Nodular BCC
Nodular lesion, erythematous with pearly white rolled out lesion, ulcerated center
Spreads into the dermis usually extends over 1mm into the skin
may be well defined, may be symmetrical
Duration - long history, 1-2mm per year, slow growing
What subtype of BCC might be mistaken for a chronic skin condition such as eczema or psoriasis?
Superficial-type BCC
Appears as a patch
May have crusting
Erythematous
Serpentine vessels
Superficial BCCs often appear as pink or red dry, scaly spots. They slowly enlarge and may develop a raised edge. Often, people mistake a superficial BCC as a dry patch of skin or a non-itching rash that won’t go away. This subtype of BCC is most often found on the trunk (chest or upper back), arms, or legs.
What type of BCC might be mistaken for a scar?
Infiltrative basal cell carcinoma
The cancer grows with a “root system” which is embedded into the dermis of the skin. Because of this root system, infiltrative basal cell carcinomas require certain procedures, including excision or Mohs surgery, to make sure that all of the roots are removed completely
This specific type presents differently than other basal cell skin cancers, in that it forms in thin, small clusters, making it more difficult to spot.
Isolated lesion, no history of trauma to explain a scar
Infiltrating or morpheaform BCCs tend to appear as scar-like growths on the skin. They can be slightly shiny, and sometimes have telangiectasias, sores (erosions), or scabs on their surfaces. These skin changes can be subtle.
Non surgical management of BCC? When would it be used?
Chemotherapy creams: Fluorouracil (efudix 5% BD for 4 week), Imiquimod cream (Aldara 5% used 5 days of a week OD for 6 weeks)
Cyrotherapy
Radiotherapy (curative, palliative, adjunct to surgery)
Phototherapy
Only curative for superficial BCC, but may be used if patient declines or is unsuitable for surgery
Small low risk lesions
What might Fluorouracil (efudix) be used to treat?
Superficial BCC
Bowens disease
Actinic keratosis
Bowens disease
Actinic keratosis
Superficial BCC
Nodular BCC
Infiltrive BCC
BCC surgical management
Surgical exision
Curettage and cautery
‘Mohs’ micrographic surgery (excision og the lesion and tissue borders are progressively excised until specimens are microscopically free of tumour) - for recurrent, high risk tumours
Direct closure if small (under 1cm) Elliptical excision/excision with flap formation/excision with graft from clavicle
Margin of safety 4mm
SCC typical timeline?
Appears in weeks to months (no longer than 6, usually up to 3-4)
Management of SCC?
Surgical excision, if not suitable can consider potential palliative or curative radiotherapy
Chemotherapy for large metastic disease
What are the most common skin cancers?
- BCC
- SCC
- Malignant melenoma
Most dangerous skin cancers?
- Malignant melanoma
- SCC
- BCC
What is an SCC?
Squamous Cell Carcinoma
A Cutaneous Squamous Cell Carcinoma (SCC) is a locally invasive malignant tumour of epidermal keratinocytes or its appendages.
SCCs can cause pain, tenderness or bleeding and grow over weeks or months.
SCCs sometimes metastasise, which can be fatal.
Subtypes of melenoma
Superficial spreading melenoma
Nodular melenoma
Lentigo maligna melanoma
Acral lentiginous melanoma.
What factors indicate a favourable melenoma prognosis?
Symeterical and minimal colour variation most key
Asymptomatic (no itching or bleeding)
Regular boarder
Depth of infiltration
Diameter does not indicate prognosis
How might a melenoma develop?
De novo melenoma - New mole in older patient - pleomorphic cells
Melanomas arising from common and congenital nevi - less common, congenital mole changes - composed of roundish, monomorphous cells
Surgical management of mallignant melenoma?
Excisional margin with 2mm (more can interfere with sentinel lymph node - false abnormalities)
Radiosensitive dye injected by the scar (entinel lymph node biopsy (SLNB))
Wide local exision potentially later surgery
Which layers of skin are removed when excising a skin cancer to ensure depth clearance?
Epidermis, dermis, hypodermis (fat)
Particularly important for SCC and melanoma
Management of melenoma?
Excision with 2mm margin and sentiel node biopsy
Second procedure after histology diagnosis if required
Based on the stage, a wider excision margin may be taken around the lesion to ensure the cancer has been removed:
Stage 0 = 0.5cm
Stage I = 1cm
Stage II = 2cm
Stage III and IV are metastatic, so adjuvant immunotherapy or chemotherapy is given.
What tool is used to classify and predict outcome in malignant melenoma?
Breslow thickness interpretation
Histology is used to diagnose melanoma and a Breslow thickness is established. The Breslow thickness is the depth of the tumour and is a strong predictor of outcome.
If the Breslow thickness is >1mm a sentinel node biopsy should be carried out, which can look for evidence of metastases and stage the cancer.
What is a superficial spreading melenoma?
Subtype of melenoma
Most common
Best prognosis
Typically begins as a dark spot that is asymettric, has irregular boarders, or changes colour
Spread horizontally
Doesn’t tend to infiltrate deeply
Common on lower limbs
Young and middle aged adults
Related to intermittent high intensity UV exposure
It is most likely to develop on the trunk in males, on the legs in females, and on the upper back in both sexes.
What is a nodular melenoma?
Subtype of melenoma, starting as a raised spot - dark or light - and grows vertically
Most aggressive form
Usually invasive at time of diagnosis
Common on the trunk
Young and middle aged adults related to intermittent high-intensity UV exposure
The bump is usually black, but it may be:
blue
gray
white
brown
tan
red
the same color as the surrounding skin
What is an acral lentiginous melenoma?
Subtype of melenoma
Appears as irregular growth or patch on palms of hands or sole of feet (pain when walking) or under nails
Changes colour and size
Only melenoma that doesn’t have a link to UV raditation
Occurs in the elderly population
An early sign might be an oddly shaped black, gray, tan, or brown mark with irregular borders.
When ALM begins in the nails, it may appear as a streak under the nail. Most cases of ALM on the nails occur on the big toe or thumb.
The surface may be flat, but there may be deep inward growth.
Some tumors involve a loss of color or no change in color.
ALM tumors often take on an irregular shape or color or a rough texture as they grow.
ALM may resemble a plantar wart or a fungal infection.
What is a lentigo maligna and lentio maligna melanoma?
Lentigo maligna is an early form of melanoma in which the malignant cells are confined to the tissue of origin, the epidermis, hence it is often reported as ‘in situ’ melanoma.
It occurs in sun damaged skin so is generally found on the face or neck, particularly the nose and cheek. It grows slowly in diameter over 5 to 20 years or longer.
Starts as an irregular shaped tan or brown spot growing slowly over years
Lentigo maligna melanoma is diagnosed when the melanoma cells have invaded into the dermis and deeper layers of skin. Lentigo maligna has a lower rate of transformation to invasive melanoma than the other forms of melanoma in situ (under 5% overall). However, the risk of invasive melanoma is greater in larger lesions, with up to 50% of those with diameter of greater than 4 cm being reported to have an invasive focus.
Common on the face in elderly population, related to long term cumulative UV exposure
May become raised or change colours, can be multipigmented
lentigo maligna/lento maligna melenoma
Acral lentiginous melanoma
Superficial spreading melenoma
Nodular melenoma
What features of a skin lesion should be reffered under the 2 week wait pathway for suspected mallignant melenoma?
Asymmetry
Border irregularity (melanoma often has a ‘scalloped’ border)
Colour variation (a variegated lesion is one that consists of many colours)
Diameter >6mm
Evolves over time
Additionally an ‘ugly duckling sign’ can be used to identify malignant lesions- any lesion that stands out from the rest should be suspected.
Basal cell carcinoma risk factors?
Type I or II skin (fair skin which always burns and never or rarely tans)
History of frequent or severe previous sun burn
Outdoor occupation or hobbies
Personal or family history of skin cancer
Immunosuppression
Increasing age
Male sex
Management of BCC?
Management of a BCC depends on its size, location, type and local guidelines - but the majority are managed surgically. Treatment options include;
Surgical excision with a 4mm margin
Curettage and cautery
Mohs micrographic surgery if the BCC is in a cosmetically sensitive area or appears ill-defined. This involves examining the excised tissue under the microscope as it is removed to ensure all the cancerous cells are removed whilst preserving the maximum amount of healthy tissue.
Cryotherapy
Photodynamic therapy
Radiotherapy is used as an adjunct or if surgery is inappropriate
Topical therapies such as Imiquimod or 5-Fluorouracil
What is Mohs micrographic surgery and when is it used?
Mohs micrographic surgery if the BCC is in a cosmetically sensitive area or appears ill-defined. This involves examining the excised tissue under the microscope as it is removed to ensure all the cancerous cells are removed whilst preserving the maximum amount of healthy tissue.
BCC subtypes?
Nodular
Superficial spreading
Infiltrative
Pigmented
Cystic
Keratotic
SCC typical appearence?
SCCs typically appear as an irregular, ill-defined red keratotic (scaley and crusty) nodule which may ulcerate. They often occur on sun exposed areas of skin such as the face, scalp, ears, hands and shins.
Causes/risk factors of SCC?
SCCs are caused by DNA mutations following exposure to ultraviolet (UV) light, certain human wart viruses or other forms of skin damage such as burns. Genetic factors can predispose to these mutations.
Risk factors
Risk factors for the development of SCCs;
Type I or II skin (fair skin which always burns and never or rarely tans)
History of frequent or severe previous sun burn
Outdoor occupation or hobbies
Personal or family history of skin cancer
Immunosuppression, especially following an organ transplant
Smoking
Premalignant skin conditions such as Actinic Keratosis or Bowen’s Disease. (Bowen’s Disease is also known as Intraepidermal SCC or SCC in Situ. It is pre-malignant as tumour cells are confined to the epidermis.)
Increasing age
Male sex
SCC
What is Pyogenic Granuloma
A Pyogenic Granuloma is a reactive overgrowth of capillary blood vessels. It is a benign lesion, but can cause discomfort and frequent, easy bleeding. Pyogenic Granulomas are relatively common, occurring mostly in children and young adults and in females more often than males.
Pyogenic Granulomas appear as a single, shiny, red nodule of up to 1cm, often described as ““raspberry-like”. This nodule will have grown rapidly from a painless, small, discoloured spot. Pyogenic Granulomas are most commonly located on the fingers and hands.
Presentation of pyogenic granuloma
Pyogenic Granulomas appear as a single, shiny, red nodule of up to 1cm, often described as ““raspberry-like”. This nodule will have grown rapidly from a painless, small, discoloured spot.
Pyogenic Granulomas are most commonly located on the fingers and hands.
Causes of pyogenic granuloma?
Minor trauma, such as a pin prick
Infection, commonly Staphylococcus aureus
Pregnancy
Some medications, such as oral Retinoids
How are pyogenic granulomas managed and why?
The diagnosis of a Pyogenic Granuloma is clinical, but can be confirmed by biopsy and histological examination. This is required to rule out the more sinister differential diagnosis of an Amelanotic Melanoma.
Pyogenic Granulomas can be managed by;
Surgical excision
Laser surgery
Curettage and cautery
Cryotherapy
What gives a blue naveus its colour?
A naevus that is blue in colour because the melanocytes are very deep in the skin.
What is a becker naveus?
A becker naevus is an irregular, hyperpigmented patch usually affecting the shoulders of males.
During puberty it darkens and becomes hairy.
What is a halo naveus?
A halo naevus is melanocytic naevus that is surrounded by a white halo.
What is a spitz naveus?
A red, dome-shaped papule that is commonly found on the face of children.
Spitz naevus
Halo Nevus
Beckers Naevus
Congenital Melanocytic Naevus
Management of infantile sebhorric dermatitis
First line treatment is by applying baby oil, vegetable oil or olive oil, gently brushing the scalp then washing off.
When this is not effective, white petroleum jelly can be used overnight to soften the crusted areas before washing off in the morning.
The next step is a topical anti-fungal cream such as clotrimazole or miconazole, used for up to 4 weeks. Severe or unresponsive cases may need referral to a dermatologist.
Who is typically effected by sebhorric dermatitis and how does it present
Seborrhoeic dermatitis is an inflammatory skin condition that affects the sebaceous glands. The sebaceous glands are the oil producing glands in the skin. It affects areas that have a lot of these glands, such as the scalp, nasolabial folds and eyebrows. It causes erythema, dermatitis and crusted dry skin.
In infants it causes a crusted dry flaky scalp, often called cradle cap. It is thought that Malassezia yeast colonisation has a role to play in the development of seborrhoeic dermatitis, and the condition improves with anti-fungal treatment.
This condition most commonly affects babies under 3 months of age, young adults, the elderly and those with a combination of oily and dry skin. It is exacerbated by cold weather and partially relieved by sun exposure. It presents with diffuse scalp scale, blepharitis and scaly skin located in the facial folds (i.e. on either side of the mouth).
Erythema multiforme
Erythema multiforme is an uncommon skin rash that is thought to be a hypersensitivity reaction to some medications and infections. It characteristically causes ‘target lesions’ which consist of a central dusky or dark red area with peripheral pink ring and are demonstrated in the image shown. In practice, lesions can have a variable appearance and only a few ‘targets’ may be seen. It is often asymptomatic but can be pruritic. The most common cause is herpes simplex virus but multiple other infections such as typhoid, mycoplasma pneumonia and tuberculosis can trigger it. There are numerous other causes such as medications and inflammatory disorders. It is usually an asymptomatic and self-limiting condition and so treatment is often not needed, although investigations should be considered to investigate an underlying cause.
Mucosal involvement is either absent or limited to only one mucosal surface
What is the minimum length of time recommended to wait between the application of emollients and topical steroids?
20-30 mins as to avoid diluting the steroid and affecting its efficacy
What is contact dermatitis?
Contact dermatitis is an inflammatory skin condition induced by exposure to an external irritant or allergen. It is a type IV hypersensitivity reaction. The appearance of contact dermatitis is highly variable. It may affect any area of the body and may be any shape. It is often an erythematous and pruritic rash. Lighter skin can become red, and darker skin can become dark brown, purple or grey.
Diagnosis is made clinically or with patch tests in some cases. Type IV hypersensitivity is also known as delayed hypersensitivity, as the reaction typically occurs 24 to 72 hours after antigen exposure. Unlike types I to III, it is not antibody-mediated but T-cell-mediated. It is involved in the processes of contact dermatitis.
When might an infantile/strawberry haemangioma warrant refferal to paediatrics?
When strawberry naevi affect the visual axis, they will likely require a referral to paediatrics for further management.
Otherwise no management needed, should stop growing and begin to regress by ages 3-4
Molluscum contagiosum
Resolution of mollusom contagiosum?
The papules resolve by themselves without any treatment, however this can take up to 18 months. Once they resolve the skin returns to normal. Scratching or picking the lesions should be avoided as it can lead to spreading, scarring and infection.
When might molluscum contagisoum require treatment and what can be done?
Rarely, if bacterial superinfection infection occurs in the lesions as a result of scratching, this may require treatment with antibiotics. Options include topical fuscidic acid or oral flucloxacillin.
Immunocompromised patients and those with very extensive lesions or lesions in problematic areas such as the eyelid or anogenital area may require referral to a specialist. Specialist treatment options include:
Topical potassium hydroxide, benzoyl peroxide, podophyllotoxin, imiquimod or tretinoin
Surgical removal and cryotherapy (freezing with liquid nitrogen) is an option but can lead to scarring
Which patients are typically effected by molluscum contagiosum?
Children
How does molluscum contagisoum spread?
It is spread through direct contact or by sharing items like towels or bedsheets.
Which virus causes molluscum contagiosum?
Molluscum contagiosum is a viral skin infection caused by the molluscum contagiosum virus, which is a type of poxvirus.
Common fungal infections by region?
Ringworm is a fungal infection of the skin. It is also known as tinea and dermatophytosis. Fungal infections have specific names depending on the area they affect:
Tinea capitis refers to ringworm affecting the scalp (caput meaning head)
Tinea pedis refers to ringworm affecting the feet, also known as athletes foot (pedis meaning foot)
Tinea cruris refers to ringworm of the groin (cruris meaning leg)
Tinea corporis refers to ringworm on the body (corporis meaning body)
Onychomycosis refers to a fungal nail infection
Candidial intertrigo presentation?
Candidal intertrigo classically presents as erythematous and macerated plaques with peripheral scaling. There are often associated superficial satellite papules or pustules [2,5,6].
Which common skin condition is this?
Eczema
Lesions in acne vulgaris
Macules are flat marks on the skin
Papules are small lumps on the skin
Pustules are small lumps containing yellow pus
Comedomes are skin coloured papules representing blocked pilosebaceous units
Blackheads are open comedones with black pigmentation in the centre
Ice pick scars are small indentations in the skin that remain after acne lesions heal
Hypertrophic scars are small lumps in the skin that remain after acne lesions heal
Rolling scars are irregular wave-like irregularities of the skin that remain after acne lesions heal
What is psoriasis?
Psoriasis is a chronic autoimmune condition that causes recurrent symptoms of psoriatic skin lesions. There is a large variation in how severely patients are affected with psoriasis. There appears to be a genetic component but no clear genetic inheritance has been established. Around a third of patients have a first degree relative with psoriasis. The symptoms start in childhood in a third of patients.
What chronic condition is this?
Psoriasis
What is plaque psoriasis?
Plaque psoriasis features the thickened erythematous plaques with silver scales, commonly seen on the extensor surfaces and scalp. The plaques are 1cm – 10cm in diameter. This is the most common form of psoriasis in adults.
Plaque psoriasis
What condition is this (hint, peadiatric patient post strep throat infection)
Guttate psoriasis
What is guttate psoriasis?
Guttate psoriasis is the second most common form of psoriasis and commonly occurs in children.
It presents with many small raised papules across the trunk and limbs.
The papules are mildly erythematous and can be slightly scaly.
Over time the papules in guttate psoriasis can turn into plaques.
Guttate psoriasis is often triggered by a streptococcal throat infection, stress or medications. It often resolves spontaneously within 3 – 4 months.
What is pustular psoriasis?
Pustular psoriasis is a rare severe form of psoriasis where pustules form under areas of erythematous skin. The pus in these areas is not infectious. Patients can be systemically unwell. It should be treated as a medical emergency and patients with pustular psoriasis initially require admission to hospital.
What rare but serious skin condition is this?
Pustular psoriasis
What is erythrodermic psoriasis?
Erythrodermic psoriasis is a rare severe form of psoriasis with extensive erythematous inflamed areas covering most of the surface area of the skin. The skin comes away in large patches (exfoliation) resulting in raw exposed areas. It should be treated as a medical emergency and patients require admission.
What rare severe dermatological condition is this?
Erythrodermic psoriasis
Characteristic of pustular psoriasis?
Generalised pustular psoriasis is characterised by recurrent acute flares.
Initially, the skin becomes dry, fiery red and tender.
Within hours, 2–3 mm pustules appear.
After a day, the small pustules coalesce to form lakes of pus
These dry out and peel to leave a glazed, smooth surface on which new crops of pustules may appear.
Successive crops of pustules may appear and erupt every few days or weeks.
What nail change associated with psoriasis is this?
Onychomycosis (thickening)
What psoriatic nail change is this?
onycholysis (separation of the nail from the nail bed)
What psoriatic nail change is this?
Pitting
What is urticaria?
Urticaria are also known as hives.
Swelling involving the superficial dermis, riasing the epidermis, itchy wheals
They are small itchy lumps that appear on the skin. They may be associated with a patchy erythematous rash. This can be localised to a specific area or widespread. They may be associated with angioedema and flushing of the skin. Urticaria can be classified as acute urticaria or chronic urticaria.
What serious condition is this?
Staphylococcal scalded skin syndrome
What is Pityriasis rosea?
Pityriasis rosea a generalised, self limiting rash that has an unknown cause. It often occurs in adolescents and young adults. It may be caused by a virus such as human herpes virus (HHV-6 or HHV-7), but no definitive causative organism had been established.
This patch appears two days preceeding a more widespread rash of faint red or pink, slightly scaly, oval shaped lesions, usually less than 2 cm in diameter. What is it called and whatt conidtion is it a feature of?
Herold patch
Pityriasis Rosea
How does DRESS syndrome present?
Drug hypersensitivity syndrome usually develops over several days, with onset 2-8 weeks after starting the responsible medicine.
A high fever of 38–40 C is usually noticed first. This is quickly followed by a widespread skin rash. Characteristics of the rash are diverse.
Morbilliform eruption affects 80% of cases, with varying morphology including targetoid lesions, blisters and pustules
Erythroderma or exfoliative dermatitis (involving > 90% body surface area) may follow in about 10%
Facial swelling affects 30%
Mucosal involvement affects 25% (lips, mouth, throat, genitalia)
The rash can last many weeks.
What very serious derm condition is this?
Drug erruption in DRESS syndrome?
Cutaneous features of erythema multiforme?
Cutaneous lesions develop at the peripheries before spreading centrally.
Distribution is usually symmetrical with a preference for extensor surfaces.
May be painful, pruritic, or swollen.
Early lesions present as round, erythematous papules which later develop into target lesions.
Target lesions consist of three concentric rings of colour variation:
A central, dusky area of epidermal necrosis
Surrounded by a lighter oedematous area
With a peripheral erythematous margin.
Atypical lesions may be present with typical lesions. Atypical lesions are raised with poorly defined borders and/or fewer zones of colour variation.
In severe disease, up to hundreds of lesions may be present in different developmental stages, at times making it difficult to identify characteristic lesions.
Erythema multiforme mucosal features?
Lesions develop as blisters, which then break to reveal shallow erosions with a white overlying pseudo-membrane.
Erythema multiforme favours oral membranes, but may also present with urogenital and, rarely, ocular lesions.
Mucous membrane involvement can be painful and significantly limit oral intake; lesions may precede or follow cutaneous lesions.
Acute generalised exanthematous pustulosis
Acute generalised exanthematous pustulosis, or AGEP, is an uncommon pustular drug eruption characterised by superficial pustules.
Over 90% of cases of AGEP are provoked by medications, most often beta-lactam antibiotics (penicillins, cephalosporins and quinolones)
Typically, AGEP starts on the face or in the armpits and groin and then becomes more widespread. It is characterised by the rapid appearance of areas of red skin studded with pinhead-sized sterile pustules. There tends to be more disease in skin folds. Facial swelling often arises.
Oral lesions affect about 20% of patients with AGEP.
The onset of AGEP is usually within 2 days of exposure to the responsible medication.
Can lead to severe systemic symptoms (10%)
Presentation of necrotising fasciitis?
Patients present with rapidly spreading cellulitis and are systemically very unwell - fever, tachycardia.
Blistering and necrotic skin
Severe pain
There is often a history of risk factors i.e. a cutaneous portal of entry for the bacteria (trauma/surgery(abdominal)/co-morbidities(diabetes and malignancy).
On physical examination the affected region will be blistering and erythematous. In early stages mild oedema may be the only sign. There will either be severe pain or anaesthesia over the site of cellulitis. In advanced cases, the skin may be grey, with overlying crepitus (subcutaneous emphysema). The patient is typically pyrexial, tachycardic, tachypnoeic, and hypotensive.
X-ray may show soft tissue gas
Erythema nodosum
Erythema nodosum is an uncommon skin condition that causes dusky red/blue tender nodules due to inflammation of the underlying subcutaneous tissue. It is most commonly found on the shins and calves and is frequently symmetrical. The image shown demonstrates the typical features of erythema nodosum with poorly demarcated edges and the dusky blue/red colouration. Erythema nodosum has many causes including some infections, malignancies and inflammatory bowel disease. It can also occur in pregnancy, as in this case in this scenario. It is usually self-limiting.
Discrete tender nodules which may become confluent, appear for 1-2 weeks and leave a bruise-like discoloration as they resolve.
Lesions do not ulcerate and resolve without atrophy or scarring
Erythema nodosum
What is acute meningococcemia?
A serious communicable infection transmitted via respiratory secretions, bacteria get into the circulating blood.
Gram negative doplococcus Neisseria meningitdis is the causative organism.
Presents with features of menigitis, septicemia (hypotension, fever, myalgia) and a typical rash:
Non blanching purpiric rash on the trunk and extermities which may be preceded by a blanching maculopapular rash, and can rapidly progress to ecchymoses, hemorrhagic bullae and tissue necrosis
What is erythroderma, its causes, presentation, management, complications?
Exfoliative dermatitis involving at least (90% of the skin surface.
Caused by previous skin disease (e.g. eczema, psoriasis), lymphoma, drugs (e.g. sulphonamides, gold, suphonylureas, penicillin, allopurinol, captopril) and idiopathic
Presents with inflamed skin, edematous and scaly, systemically unwell with lymphadenopathy and malaise
Managed by treating the underlying cause, where known, emollients and wet-wraps to maintain skin moisutre, topical steroids may help to relieve inflammation
Complications can include secondary infection - fluid loss and electrolyte imbalance, hypothermia, high-output cardiac failure, capillary leak syndrome
What is erysipelas and how is it distinguishable from cellulitis?
An acute superfical form or cellulitis and involves ther dermis and UPPER (as opposed to deep) subcutaneous tissue
Well-defined, red raised border
Patients more likely to be systemically unwell
erysipelas
How does staphylococcal scalded skin syndrome present?
Develops within a few hours to a few days, and may be worse over the face, neck, axillae or groins
A scald like skin appearence is followed by a large flaccid bulla
Perioral crusting is typical
There is intraepidermal blistering in this condition
Lesions are very painful
Sometimes the eruption is more localised
Recovery is usally 5-7 days
Tinea corporis appearance
Tinea infection of the trunk and limbs - itchy, circular or annular lesions with a clearly defined raised and scaly edge is typical
Tinea cruris
Tinea infection of the groin and natal cleft - very itchy, similar to tinea corporis (itchy circular or anullar lesions with a clearly definied raised and scaley edge)
Tinea pedis
Atheletes foot - moist scailing and fissuring in the toewebs, spreading to the sole and dorsal aspect of the foot
Tinea mannum
Tine infection of the hand - scailing and drying in the pamar creases
Tinea capitis
Scalp ringworm
Patches of broken hair, scailing and inflammation
Tinea incognito
Inappropriate treatment of tinea infection with topica; or systemic corticosteroids - ill defined and less scaly lesions
Candidiasis
White plaques on mucosal areas, erythema with satellite lesions in flexures
Pityriasis/Tinea versicolor
Infection with Malassezia furfur
Scaly pale brown patches on upper trunk that fail to tan on sun exposure
Usually asymptomatic
Vitiligo
An aquired depigmenting disorder where there is a complete loss of pigment cells (melanocytes)
Thought to have autoimmune aetiology, where the innate immune system causes destruction of loss of melanocytes, leading to loss of pigment formation in the skin
Presentation: any age, single or multiple patches or depigmentation, often symettrical
Common sites are exposed areas such as face hands and feet, as well as body folds and genitalia
Favours sites of injury - Koebner phenomenon
Mx: Minimise skin injury, topical treatments such as steroids and calcineurin inhibitors, phototherapy such as UVB therapy, oral immunosupressants such as methotrexate, ciclosporin, mycophenolate mofetil
Melasma
An aquired chornic skin disorder where there is increased pigmentation in the skin
Thought to be due to genetic predisposition and triggered by factors such as sun exposure, hormonal changes such as pregnancy and contraceptive pills
The pigmnetation is caused by and overproduction of pigment (melanin) by pigment cells (melanocytes)
Presents with brown macules (freckle like spots) or larger patches with an irregular border
Symettrical distribution
Common sites include forhead cutaneous upper lips and cheeks
Mx: Lifelong sun protection, discontinuation of hormonal OCP, cosmetic camouflage, topical treatments that aim at inhibiting the formation of new melanin such as hydroquinone, azelaic acid, kojic acid, vit C
Venous ulcers
Often painful, worse on standing
History of venous disease (varicose veins, DVT)
Typically occur in the malleolar area (more common over the medial than lateral malleolus)
Lesions are large, shallow, irregular ulcers with exudative and granulating bases
Associated features include warm skin, normal peripheral pulses, leg oedema, haemosiderin and melanin deposition (brown pigment), lipodermatoclerosis, and atrophie blanche (white scarring with dilated capillaries)
ABPI withh be normal 0.8-1
What type of ulcer is this and what features suggest it?
VENOUS
-Malleolar areas
- Large
- Shallow
- Irregular
- Exudative and granulating base
- Surrounding hyperpigmentation (haemosiderin and melanin deposition)
- Skin appears hard surrounding (lipodermatosclerosis)
- White scarring with dilated capilaries (atrophie blanch)
What type of ulcer is this and which features suggest that?
ARTERIAL
At pressure area, distal point
Relatively small
Sharply defined
Deep
Partially necrotic base
Shiny pale skin surrounding
Hair loss surrounding
What type of ulcer is this and what features suggest this?
NEUROPATHIC ULCER
Occuring at a pressure site
Granulating base
Surrounded by hyperkeratotic lesion (e.g. callus)
What is meant by lichen nitidus pattern?
Lichen nitidus is an uncommon inflammatory skin condition that usually presents with tiny skin-coloured bumps
Can be the pattern which eczema presents in darker skin
Associated features - lichen planus?
Nail changes and hair loss
Lacy white streaks on the oral mucosa and skin lesions (Wickham’s striae)
Seborrheic warts
Warty greasy papules or nodules
Stick on appearence with well definied edges
Commonly occur on the face ad trunk in middle aged or elderly patients
Often multiple, asymptomatic, may be managed if symptomatic with:
Curette and caturey, cryotherapy
What is this lesion?
Sebhorric wart
What are senile purpura?
Non-palpable purpura with surrounding atrophic thin skin, occuring on the extensor surfaces of hands and forarms in the elderly population (with sun damaged skin)
Such skin is easily traumatised
Patients are systemically well
Bloods, urinalysis, skin biopsy may be undertaken
No treatment is needed
Vasculitis (in context of derm)
Painful lesions
Dependent areas (e.g. legs, buttocks, flanks)
Palpable purpura (often painful)
Systemic illness
Bloods and urinalysis, skin biopsy, may be performed
Requires treatment of underlying cause (not skin lesions) such as steroids and immunosuppressants if there is skin involvement
Disseminated intravascular coagulation (derm context)
History: trauma, malignancy, sepsis, obstertic complications, transfusions, or liver failure
Common sites: Spontaneous bleeding from the ear, nose and throat, GI tract, respiratory tract and wound site
Lesion: Petechiae, ecchymoses, haemorragic, bullae and/or tissue necrosis
Associated features; Systemically unwell
Management: Treat underlying cause, transfuse for coagulation deficiencies, anticoagulants for thrombosis
KELOID SCARS
Overgrowth of scar tissue which tends to be larger than the original wound itself
Thought to be due to overproduction of the collagen during wound healing after: minor injuries, insect bites, skin surgery, acne spots in generically predispostiioned individuals
More common in darker skin types
Presents as firm, smooth hard nodule which may be itchy and/or painful
Topical treatments such as steroids and silocone gel can potentially flatten the scar and improve symptoms - intralesional steroid injection if not effective, surgery as last resort as may result in largery keloid scar
Fungal scraping of pityriasis versicolor on microscopy?
Fungal hyphae and spores in a distinctive ‘spaghetti and meatball’ appearence
Dermatofibroma
A Well circumscribed pink nodule with peripheral pigmentation with smooth surface with lack of scaling suggesting a dermal lesion.
The lesion will be firm on palpation and when gently pressed on the lateral edges will demonstrate central dimpling
This is a benign lesion with no malignant potential. Treatment is therefore not routinely required. On occasions lesions may become itchy, tender or bleed if traumatised (e.g. by shaving). Excision under local anaesthetic can be considered.
Plantar pustulosis
Plantar pustulosis. There is usually involvement of the palms too, and this disorder is generally known as palmoplantar pustulosis or palmoplantar pustular psoriasis.
The presence of pustules should always prompt consideration of infection, particularly by Staphylococcus aureus or (here) dermatophyte infection (Trichophyton species) causing tinea pedis. If in doubt, burst a pustule with a sterile needle and take a swab of pus for bacteriological investigation or take a skin scraping for mycology.
In this case, the presence of multiple 2-5mm pustules, which evolve to leave brown macules on red, scaly palms and soles is typical of
palmoplantar psoriasis. These pustules are sterile. This condition may occur in isolation, or there may be psoriasis
What is this and when is it seen?
Typical palpable purpura of Henoch Schönlein Purpura
Henoch-Schonlein Purpura
Henoch-Schonlein purpura (HSP) is a small vessel vasculitis that usually affects children.
It is an IgA mediated disease that is thought to be triggered by a viral upper respiratory tract infection.
HSP usually presents with a classical triad of purpura over the extensor surfaces of the lower limb, abdominal pain and arthritis. Renal involvement is often present- usually haematuria, proteinuria, nephritic syndrome or nephrotic syndrome. In young children, intussusception may also occur.
