Dermatology Flashcards
What are the CF of acne vulgaris?
- Closed and open comedones
- Pustules and papules
- Cysts
- Atrophic scars
What is the pathophysiology of acne?
Androgens increase sebum production
There is keratinocyte proliferation
Cutibacterium acnes allowed to colonise
Inflam of pilosebaceous unit
What is the topical management of acne?
- Keratolytics - benzoyl peroxide, retinoids eg. adapalene , salicylic acid
- Abx - clindamycin and erthromycin
What are the oral drugs can GPs prescribe for acne?
Systemic abx:
- Oxytetracycline - 500mg BD
- Lymecycline - 408mg OD
- Erythromycin and trimethoprim more rarely
Cyproterone acetate = dianette COCP, anti androgen
What is the final option for acne management?
Isotretinoin = roaccutane. Vit A derivative, decreases sebum.
90% of peoples skin clears and is a cure in 50%.
What are the SEs of isotretinoin?
- Teratogenic, women must be on effective contraception
- Hyperlipidaemia and liver dysfunction = bloods
- Myalgia
- Depression
- Reduced concentration
What are the clinical features of atopic eczema?
- Erythematous, dry skin, often in flexures
- Itchy and hx of scratching
- Excoriations and bleeding/weeping
- Associated infection
- Lichenification
What is the management of atopic eczema?
- Emollients - as often as possible, in direction of hair growth to all skin
- Steroid use
- Calcineurin inhib
- Systemics
What are the different steroids that can be used in eczema management?
Mild - hydrocortisone 0.5%, 1% and 2.5%
Mod - eumovate
Potent - betnovate
Very potent - dermovate
They can all come in creams or ointments, ointments don’t sting and are more moisturising so preferred if pt willing to use.
What are the different calcineurin inhibitors and what do you need to know?
Tacrolimus 0.03% >2 yo
Tacrolimus 0.1% >16 yo
Pimecrolimus
Used when steroids haven’t controlled sx and steroid sparing
- Sting
- Avoid in HSV infection
- Need sun protection as there is a theoretical increase in skin cancer
- Can be used prophylactically
What systemics can be used in eczema management?
- UV light - UVB
- Ciclosporin
- Methotrexate
- Dupilumab
What are some additional advice and options are there for eczema?
- Garments - keep ointments on and cause rapid improvement in eczema
- Soap substitutes and bath oils
- Baths to wash off flakes and cream residue
- Swab infections
- Sedating antihistamines but no evidence for histamine in eczema
What are the complications of eczema?
- S.aureus infection - crusty, oozing rash = impetiginized eczema
- Eczema herpeticum = disseminated HSV infection = fever and clusters of itchy blisters/punched out erosions life threatening
What are the clinical features of psoriasis?
- Plaques
- Silver scaling - hyperproliferation of the epidermis
- Scalp, extensors, trunk
- Not really itchy
- Nail changes
- Joint pain - psoriatic arthritis - exam joints and nails
What is guttate psoriasis?
Small raindrop scales, usually no bigger than 1cm. Triggered by streptococcal throat infection.
What are the nail changes in psoriasis?
- Nail pitting
- Onycholysis
- Hyperkeratosis
What is the management of psoriasis?
- Emollients
- Steroids
- Vit D analogues
- Calcineurin inhib
- Systemic treatments
- Tar preps and dithranol not used anymore really
What are the systemics used in management of psoriasis?
- Phototherapy - UVB and PUVA in comincation w psoralen
- Ciclosporin
- Methotrexate
- Acitretin = retinoid
- Biologicals eg. adalimumab
What is impetigo?
Staph infection around the peri oral facial area - golden crust. Can be bullous or non bullous.
Can have systemic features - lethargy, fever, diarrhoea.
Is contagious so need to advice no school/work until lesions crusted or 48 hours abx.
What is the treatment of impetigo?
Localised - fusidic acid, 4 times a day for 2 weeks
Widespread - fluclox/penicillin or erythromycin
What are the CF of cellulitis?
- Infection reaching the hypodermic layer
- Commonest on the legs - can be caused by tinea pedis in toes of affected limbs
- Poorly defined margin
- Red, hot, swollen, painful
- Normally a portal of entry
- Systemically unwell - fever and malaise
What is the treatment of cellulitis?
Oral/IV penicillin
10-14 days - stay as inpatient, normally elderly people
Erysipelas vs cellulitis
Cellulitis affects the deeper skin and erysipelas is a superficial infection.
Erysipelas has a well defined margin.
What are the different dermatophytes and what areas do they affect?
Tinea corporis - trunk
Tinea cruris - groin folds
Tinea pedia - feet
Tinea capitis - scalp
Tinea unguim - toes
What are the features of a tinea lesion?
- Asymmetrical
- Central sparing
- Annular
- Irregular border = active border but well defined
- Scaly border
What is an eczematous ID reaction?
Hypersensitivity reaction to fungal antigens - eczema like lesions all over the body
What is the management of dermatophyte skin infections?
Topical miconazole, can add topical steroid if super itchy. Apply anti fungal at least 2cm margin around lesion and cover whole area.
Tinea capitis - oral terbinafine, get LFTs
Tingea unguium - 3-6 months terbinafine
What is actinic keratoses?
Dry scaly patches of skin caused by sun damage. Confined to the basal layer of the epidermis and are a precursor for SCC.
Found on face ears and hands commonly (sun exposed sites).
What is the treatment of actinic keratoses?
- 4-16 weeks imiquimod cream
- 2-4 weeks 5-fluorouracil cream - chemo cream and makes things worse before better
- Cryotherapy
What is Bowen disease?
SCC in situ - slowing enlarging erythematous scaly plaques. In the epidermis w/o invasion through the basement membrane.
What is the treatment of Bowen’s?
- Surgical excision
- Cryotherapy
- Fluorouracil cream
- Imiquimod cream
What are some differentials for SCC?
- BCC
- Bowen’s disease
- Keratocanthoma
- Actinic keratosis
- Cutaneous horn
What are the features of a SCC?
- Nodular
- Frequently ulcerating - described as never healing
- Growing a lot and quickly
- Itchy/painful
- Bleeding
- Poorly differentiated
What is the treatment of SCC?
- Surgical excision w wide margins
- When hard to find the depth can do Moh’s micrography
- Radiotherapy
What are the RF of SCC?
- Sun exposure
- Pre malignant skin conditions
- Chronic inflam
- Immunosuppression
- FH
What are the RF for BCC?
- Increasing age
- Previous BCC
- Sun damage and sunburn
- Type 1 skin type
- FH
What are the features of a lesion that is a BCC?
- Nodular
- Slow growing - years
- Pearly rolled edge
- Surface telangiectasia
- Pink/skin colour
- Can ulcer/bleed
What are the features of superficial BCC?
- Slightly scaly, irregular plaque
- Thing translucent rolled border
- More common BCC in younger people
What is the treatment of BCC?
- Excision w 3-5mm margin of normal skin
- May require skin graft
- Moh’s micrography for high risk ares eg. around nose lips and eyes
- Curettage, cautery, cryotherapy
- Imiquimod for superficial BCC
What is advise to pt who have been treated w BCC and SCC?
- Avoid the sun in the middle of the day
- Shade and covered clothing
- SPF50+ every day
- Avoid sun beds
- Regularly check for new lesions
What is melanoma?
Uncontrolled growth of melanocytes w the potential to metastasise
What are the RF of melanoma?
- Increasing age - 45-64 most common age group
- Previous skin cancer of any time
- Many naevi
- FH
- Type 1 skin
What are the features of melanoma?
- Most commonly on skin but can also grow on eye, brain, mouth, vagina
- Change in colour - black, brown, red, blue
- Begins flat but can become thickened and raised
- Change in size and shape
- Itchy or tender, can bleed and crust
What is Breslow thickness?
Measuring the thickness of an invasive melanoma:
Vertically in mm from top of granular layer to deepest point of tumour involvement - indicates how likely tumour is to spread
What is the treatment of melanoma?
- Excision w wide margin, up to 20mm
- If local LM enlargement due to mets = removal, if not enlarged = sentinel node biopsy
- Immunotherapy, other monoclonal ab
- Chemo for met disease
What is shingles?
Localised, dermatomal, painful blistering rash caused by reactivation of varicella sozter virus.
Have chicken pox and the virus then remains dormant in the dorsal root ganglia for years before reactivated.
What are the CF of herpes zoster/shingles?
- 1st sign = localised pain w/o tenderness or skin change
- Fever and headache
- Lymphadenopathy
- Blistering rash - red papules and blisters/pustules
- Recover is complete w/i 2-4 weeks normally
What are the complications of herpes zoster?
- Eye complications - if tip of the nose has a rash more likely to get eye involvement - trigeminal nerve involvement (Hutchingson’s sign), causes keratitis and corneal damage
- Ramsay Hunt syndrome - facial nerve palsy w vesicles in the ear
- Post herpetic neuralgia
What is the treatment of herpes zoster?
- Prevention - vaccine
- Conservative = rest, analgesia, abx for secondary infection
- Aciclovir 800mg 5 times daily for 7 days if start w/i 1-3 days of onset
What is the treatment of post herpetic neuraliga?
- Early use antiviral meds
- Local anaesthetic applications
- Topical capsaicin
- Amitriptylline
- Gabapentin and pregabalin
- Transcutaneous electrical nerve stim
- Botox
What are the CF of dermatitis?
- Inflammatory erythematous rash of papules, vesicles and plaques
- Swelling
- Can ooze, weep and bleed
- Normally a reactive rash made worse by application of what caused it
What are the CF of chronic eczema?
- Lichenification - skin thickening w accentuation of sin creases
- Hyperkeratosis
- Fissuring and excoriation
- Hyperpigmentation
How do you confirm a wart diagnosis?
Remove surface layer skin w a scalpel and multiple pin point bleeding points = wart.
What is the management of warts?
- Duct tape
- File off wart then salicylic acid
- Cryotherapy - commonly reoccurs
What are the CFs of molloscum contagiosum?
- Shiny, smooth umbilicated papule
- Common in children, esp if have pets
- Can erode and crust
- In adults affects immunocomp eg. HIV
- Transmission more common in wet conditions eg. swimming
What is the treatment of molloscum contagiosum?
Self limiting virus but advice:
- Antiseptic washes eg. hydrogen peroxide cream
- No sharing towels, clothing or baths
- Avoid squeezing spots
- Can give abx if suspect bacterial infection
- Cover affected areas
What are the CFs of scabies?
- Extreme itchy, worse at night
- Multiple household members w same sx
- Linear burrows
- Erythematous papules
- Excoriations
- Esp in interdigital spaces and wrists
What is the management of scabies?
- Permethrim cream everywhere and then wash off after 8-12 hours once and then again after a week
- Treat whole household, close friends and sexual contacts
- Wash bedlinen
- Itch will remain for a few weeks after treatment
What is bullous pemphigoid?
Autoimmune subepidermal blistering disease, most common in elderly people.
More prevalent in pt w neurological disease eg. dementia, stroke and IPD
What are the CF of bullous pemphigoid?
- Erythematous non specific itchy rash precedes blisters
- Annular lesions
- Vesicles and bullae
What are the ix into bullous pemphigoid?
- Skin biopsy of skin adjacent to blister - direct immunoflourescence = ab along BM
- Indirect immunoflourescence for circulating ab
What is the management of bullous pemphigoid?
- Potent topical steroids eg. clobetasol
- Emollients to help relieve itch
- Systemic steroids
- Tetracycline abx can be better steroid sparing
- Abx for secondaring bacterial infection
- Analgesia
- Immunosuppressants eg. methotrexate, azathioprine
What is a chancre?
Treponema pallidum or primary syphilis infection.
Painless ulcer that is self limiting
What does pityriasis rosea look like? What are the sx of the rash?
1st = large circular or oval herald patch, on chest abdo or back
2nd = ~2w later = smaller scaly oval red patches over chest and back
Itchy!
Flu sx a few days before get the rash
What causes pityriasis rosea?
HSV, vaccines, drug induced reactions
What is the management of pityriasis rosea?
Self limiting in 6-10w
Control itching = moisturiser, soap substitute
Sun light can help
Can try steroids and antihistamines but not always needed
Calamine lotion and zinc oxide for severe itching
What is rosacea?
Chronic inflam condition affecting central face = persistent facial redness, telangiectasia, inflam papules and pustules
30-60 years
What is the management of rosacea?
Lifestyle - avoid triggers eg. hot, spicy food, sun, cosmetic products, vasodilators, alcohol, dairy
Moisturise ++
Suncreams
Avoid topical steroids - make it worse
A adrenergic agonists eg. topical brimonidine and oral B blockers stop flushing
What are the CF of lichen planus?
Violaceous skin lesions, purple, shiny papules often over wrist
Oral - lacy reticulated pattern
Vulval - white lacy pattern in mucous membrane
Relapses and remits
What is the treatment of lichen planus?
Can be self limiting but topical steroids, calcineurin inhib and retinoids
If widespread = systemic steroids and DMARD
What is the management of guttate psoriasis?
Treat associated strep infection w abx
PUVB
Emollients
Normally clears w/i 3-4 months without treatment
25% becomes chronic plaque psoriasis : (
