Dermatology

Question 1

How should we describe a skin lesion systematically?

Answer 1

• Site and distribution
• Configuration
• Colour
• Morphology/primary lesions
• Surface features/secondary lesions (evolved from primary lesions)
• Hair and nail findings

Question 2

What are some common skin conditions?

Answer 2

• Atopic eczema
• Acne vulgaris
• Psoriasis
• Urticaria
• Molluscum contagiosum

Question 3

Outline atopic eczema

Answer 3

• Characterised by pruritis and inflammation
• Epidermal changes e.g. papules, vesicles
• Can occur anywhere but often flexural
• Exogenous vs endogenous causes
• Acute vs chronic
• Clinical diagnosis including: personal or family history of atopy e.g. hay fever, asthma

Question 4

How is eczema treated?

Answer 4

• Treatment
• Education and support
• Avoidance of exacerbating factors
• Topical therapies e.g. emollients, use of soap substitute, steroids/calcineurin inhibitors
• Phototherapy
• Systemic therapies

Question 5

How might eczema present?

Answer 5

• Generalised
• Hyperpigmented
• Patches
• Scaly
• Lichenification

Question 6

How might acne present?

Answer 6

• Localised
• Well defined
• Discrete
• Erythema
• Papules
• Vesicles
• Pustules
• Crusts
• Comedones

Question 7

Outline acne vulgaris

Answer 7

• Found mostly in skin of face, neck and upper body (back or chest)
• Chronic skin disease due to blockage of hair follicles in skin
• Clinical diagnosis

Question 8

What are the causes of acne vulgaris?

Answer 8

• Increased sebum production (androgen influence)
• Excessive deposition of keratin in pores
• Overgrowth of Cutibacterium acnes (skin commensal)
• Pro-inflammatory chemicals released into skin

Question 9

How is acne vulgaris treated?

Answer 9

• Topical
• Non-antibiotic treatments e.g. benzoyl peroxide, retinoids etc
• Antibiotic treatments e.g. erythromycin, tetracycline, clindamycin
• Systemic treatments such as antibiotics, oral contraceptive pill, isotretinoin

Question 10

How might psoriasis present?

Answer 10

• Extensor
• Well-defined
• Hyperpigmented
• Plaque
• Scaly
• Can be symmetrical
• Can be erythematous

Question 11

Outline psoriasis

Answer 11

• Chronic skin condition
• Occurs equally in men and women
• Often occurs between 20-30 years old and 50-60 years old
• Strong genetic predisposition
• Has a relapsing and remitting course
• Most common type is plaque psoriasis

Question 12

What can cause psoriasis?

Answer 12

• Immune mediated inflammatory disease
• T cells cytokine production is stimulated
• Causes keratinocyte proliferation
• Identify any triggers or iatrogenic causes (including medications such as ACEi, B blockers, NSAIDs, Lithium, anti-malaria)

Question 13

How is psoriasis treated?

Answer 13

• Topical e.g. emollients, corticosteroids, vit D analogues, calcineurin inhibitors, salicylic acid, vit A, tar preparations
• Phototherapy broad-band or narrow-band UV B light
• Oral systemic medication e.g. acitretin, ciclosporin, methotrexate
• Injectable systemic medication e.g. TNF antagonists, monoclonal antibodies

Question 14

Outline urticaria

Answer 14

• Transient (<24 hours) +/- angioedema
• Acute vs. chronic (persists for over 6 weeks)
• Mast cell degranulation and histamine release
• Leads to increased capillary permeability and leakage of fluid into surrounding tissue

Question 15

How is urticaria treated?

Answer 15

• Suppress symptoms
• H1 anti-histamines (fexofenadine, cetirizine, loratadine)
• H2 anti-histamines (cimetidine, ranitidine)
• Steroids, ciclosporin, montelukast

Question 16

Outline molluscum contagiosum

Answer 16

• Pox virus infection
• 2-6 week incubation period
• More common in atopic and immunocompromised patients
• Most self-resolve within 6-9 months
• No treatment required

Question 17

How do we take a dermatological history?

Answer 17

• Presenting complaint
• History of presenting complaint
• Past medical history
• Family history
• Social history
• Drug history and allergies
• Impact on quality of life/ICE

Question 18

What information do we need to ascertain when a patient presents with a skin problem?

Answer 18

• Nature e.g. rash vs lesion
• Site
• Duration - how long has it been there? how rapidly did it appear?

Question 19

How do we find out the history of presenting complaint of a skin problem?

Answer 19

• Initial appearance and evolution
• Symptoms (particularly itch and pain)
• Aggravating and relieving factors (triggers)
• Previous and current treatments - effective or not
• Which treatments have worked before? Which treatments have not? Why did they stop taking treatment?

Question 20

What past medical history should we obtain from a patient with a skin problem?

Answer 20

• Systemic diseases
• History of atopy (asthma, hay fever, eczema)
• History of skin cancer or pre-cancer
• History of sunburn/sunbathing/sun-bed use
• Skin type

Question 21

What family history should we obtain from a patient with a skin problem?

Answer 21

• Family history of skin disease
• Family history of atopy
• Family history of autoimmune disease

Question 22

What social history should we obtain from a patient with a skin problem?

Answer 22

• Occupation
• Sun exposure
• Contactants
• Improvement in skin condition when away from work

Question 23

What drug history should we obtain from a patient with a skin problem?

Answer 23

• Regular and recent
• Systemic and topical
• Get specific with topical treatments (find out what treatment is, find out what strength it is)
• Where?
• How much?
• How long for?

Question 24

How do we examine the skin?

Answer 24

• Inspect
• Palpate
• Describe
• Systemic check (whole skin, hair, nails, mucous membranes)

Question 25

How do we describe skin problems?

Answer 25

• S - site, distribution (rash) or size and shape (lesion)
• C - colour and configuration
• A - associated changes e.g. surface features
• M - morphology

Question 26

How do we describe pigmented lesions?

Answer 26

• Asymmetry
• Border (irregular or blurred)
• Colour
• Diameter

Question 27

How can we describe the site and distribution of a skin rash/lesion?

Answer 27

• Generalised
• Flexural
• Extensor
• Photosensitive

Question 28

How can we describe the configuration of a skin rash/lesion?

Answer 28

• Discrete (separate little lesions)
• Confluent (spots merge into each other)
• Linear
• Target (darker centre with a lighter border)

Question 29

How can we describe the colour of a skin rash/lesion?

Answer 29

• Erythematous (red and blanching)
• Purpuric (red or purple and non-blanching)
• Brown or black (pigmented or hyperpigmented)
• Hypo pigmented (depigmented if total loss of colour)

Question 30

How can we describe the surface features of a skin rash/lesion?

Answer 30

• Scale (built-up keratin)
• Crust (dried exudate)
• Excoriation (erosion from scratching)
• Erosion/ulceration (partial or full thickness loss)

Question 31

How can we describe the morphology of a skin rash/lesion?

Answer 31

• Macule (flat and small)
• Patch (flat and bigger)
• Papule (raised and little)
• Plaque (raised and extensive)
• Nodule (large solid lump)
• Vesicle (small fluid-filled blister e.g. chickenpox)
• Pustule (skin blister filled with pus)
• Bulla (large fluid-filled blister)
• Annular (ring-shaped e.g. fungal skin presentation)
• Wheal (lesions become raised due to oedema in dermis of skin)
• Discoid/nummular
• Comedones

Question 32

How can we describe hair findings?

Answer 32

• Alopecia (patchy or diffuse)
• Hypertrichosis
• Hirsutism

Question 33

How can we describe nail findings?

Answer 33

• Koilonychia (spoon shaped nails)
• Pitting
• Onycholysis
• Clubbing