Dermatology Flashcards
How would Lupus Erythmatosus present
Proteinuria, High ESR/CRP, dsDNA positive, pancytopenia, has fever and fatigue
Photodistributed erythematous rash
Chilblains: itchy swelling
Livedo reticularis: net like redness
Cutaneous vasculitis: inflamed blood vessels
Alopecia
What are the two types of Lupus
Systemic LE:
Cutaneous/Discoid LE
How is SLE dignosed
Mucocutaneous: cutaneous lupus- spiderlike rash, oral ulcers
Haematological: haemolytic anaemia, thrombocytopenia, leukopenia
Immunological: ANA, anti-dsDNA, anti-SM
How can SLE and CLE be diffrentiated between
CLE causes scarring , SLE doesnt
What type of lupus is present in children and what antibody is present and what test should be done
Neonatal lupus
Ro positive
Test ECG as risk of heart block
What is the autoimmune connective tissue disease which caused proximal extensor inflammatory myopathy, a photodistributed pink violet rash on the extensors, eyes and scalp
Dermatomyositis
What signs are seen in dermatomyositis
High ALT, high CK, antinuclear antibody(ANA) and lots of other antibodies,
weakness, weight loss, fatigue
Heliotrope rash: on eyelids
Gottrons papules: papules on interphalangeal and metacarpal joints
Ragged cuticles
Shawl sign: rash on upper back
Photosensitive erythma
How would a patient with vasculitis present
IgA vasclitis
abdominal pain, GI bleeding,
Small vessel problems:
purapura - macular and palpable, non blanching
Medium vessel problem:
Digital necrosis
Retiform purapura ulcers
Subcutaneous nodules along blood vessels
What is the name of the systemic granulomatous disorder
Sarcoidosis
How does sarcoidosis present
Affects many systems: lungs, skin. LUNGS: cough with ?
Reactive oxygen species, joint pain
Red to brown violaceous papules
lupus pernio: blue to violet nodules and papules
disfiguring lesions on nose, lips,
Ulcerative
scar sarcoid
Granulatomous plaques
What symptoms does DRESS cause and what does DRESS stand for
Drug reaction with eosinophilia and systemic symptoms: taken an antibiotic, anti epileptic, ibuprofen or medication 2-6 weeks before
multiple myeloma
Rash, fever, tachycardia, renal (interstitial neprhitis), heart (myocarditis) and liver (hepatitis) starting to fail
Lymphadenopathy, high eosinophils
RASH: widespread papules, maculopapular, erythroderma, head/neck oedema
How is DRESS treated
take away the cause, corticosteroids
What is graft versus host disease
if face involvement, acral involvement and diarrhoea then GvHD rather than DRESS
Reaction to stem cell transplant or new drugs: a multiple organ disease. Donor T lymphocyte activity against antigens.
Skin, liver, GI tract
Erythmatous macules and papules, scleral icteus
what is the condition called when it is a constant itch without a rash
Pruritus
What is pruritus suggestive of and what investigations should be done
Renal failure, iron deficiency, Hep, HIV, cancer
GBC, rnal tets, LFT, ferritin, XR chest, BLoods for Hep ABC and HIV
What skin sign can occur in pruritis
Nodular prurigo: chronic scratichin causing nodules to form
What causes scurvy
Vit C (ascorbic acid) deficiency
What are the symptoms of scurvy
Spongey gingivae with bleeding and erosion
Petechiae, ecchymoses, follicilar hyperkaratosis, corkscrew hairs with perifollicular haemorrhage
What is the name of the protein deficiency and what are the skin signs
Kwashiorkor
Sparse dry hair
soft thin nails
cheilitis- inflam of lips
desquamation (peeling skin) large areas of erosion
How doe zinc deficiency present
dermatitis, diarhhoea, depression
perioral, acral and perineal skin with scaly erosive erythmea
What is carcinoid syndrome and how does it present
Metastases of malignant carcinoid tumour, 5HT secretion.
Flushing, diarrhoea, wheezing, dizziness, usually started on amlodipine, hypotension
What skin illness begins with flu, sore eyes and oral ulcers and develops into an extensive painful rash
Stevens Johnson Syndrom/ Toxic Epidermal Necrolysis
How does Stevens Johnson Syndrome develop into Toxic epidermal Necrolysis
flu like, abrupt lesions on trunk first then face and limbs. Get macules, blisters and erythme. blisters then merge to make sheets of skin detatchment (wet wallpaper)
Full thickness epidermal necrosis in less than 2-3 days
called TEN when more than 30% skin detachment
How does Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis occur
cell mediated cytotoxic reaction against epidermal cells
Drugs usually cause anti epileptics, NSAIDs, ABs,
What score is used to assess severity of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis
SCORTEN: over 40yrs, % epidermal detatchment, serum urea glucose and bicarbonate, malignancy
What are the complications of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis
Death, blindness
How does erythroderma present
Erythema affecting more than 90% of body
can get oedema, loss of fluid and proteins, sepsis risk, tachy
What is the cause of erythroderma
Drug reactions
Psoriasis
Atopic eczema
How is erythrodema treated
Treat underlying cause
restore fluid and electrolytes and body temp
Emollients to help skin barrier
Topical steroids and Abs
What are the different signs of chronic kidney disease
Excoriations/prurigo
Xerosis: dryness
Half and half nails
Calciphylaxis: cow print looking
Anaemia
Signs to the primary cause like SLE or immunosuppression like viral warts
What are the different signs of chronic liver disease
Excoriations/prurigo
Jaundice
Muehrckes lines of nails
Terrys nails ( white nail then a line of normal coloured nail right before the white)
Palmar erythema
Spider telangiectasia: red blob with spider capillary lines as legs
Clubbing
How may Diabetes mellitus manifest cutaneously
Necrobiosis Lipoidica: plaques with red-brown raied edge, a yellow/brown atrophic centre
Teerys nails, Xerosis, Xanthelesma and xanthom, Granuloma annulare (ring of pink), skin infection, neuropathic ulceration
How does graves disease present cutaneously
Pre tiial myxoedema
How may acromegaly manifest cutaneously
Cutis gyrata verticis: scalp lines
Acne
How may HIV manifest cutaneously
Morbilliform rash
Urticaria
Erythema multifome: red round marks looks like a target
oral/genital ulceration
How does GI disorders affect the skin
Orofacial granulomatosis- swelling in mouth/face lips
panniculitis
psoriasis
How does celiac disease manifest
Dermatitis herpetiformis : blistering vesicles on skin
What sign is associated with IBD, obesity and smoking
Hidradenitis superitiva: inflamed nodes- sterile absecces, hypertrophic scars : underarms, genitals and inframammory
What is the name for skin folds
Intertriginous areas
What is the sign associated with IBD, leukaemia, seronegative arthritis
Pyoderma gangrenosum: pustule on erythmatous base which ulcerates and extends with a necrotic border, is painful
looks like a chunk of fat and skin has been taken out
What test would you do for SLE
FBC, U&E, ANA, anti-dsDNA, complement an urinalysis
When would you do a lipid panel
Xanthelesma
What presentation is associated with scurvy
Corkscrew hairs and perofillicular purapura
What symptoms is associated with crhonic kidney disease
calciphylaxis
What is he difference between nail changes in chronic kidney and chronic liver disease
Chronic liver: Terrys nails, Muerches nails
Chronic kidney: Half and half, terrys
What is melanoma
malignant tumour from melanocytes
Pigmented, asymmetrical lesion, colour variation, irregular border
What are the risk factors of melanoma
FHx, fair skin, red hair
Sun exposure, subeds, immunosuppressed
What is the pathogenesis of melanoma
MAP kinase messaging pathways that are important for cell migration during embryogenesis but are also important in melanoma generations. MAP kinase pathway can lead to NRAS and BRAf mutations which can can lead to activation of the pathway leading to melanocyte reproduction leading to melanoma
How does the body respond to melanoma formation
CD8 Tcell recognise mealnoma antigens and are able to kill
CTLA-4 inhibits T cell abctivation by removing B7 on APC so T Cells CD28 has nothing to bind to
What immunotherapy is based on blocking CTLA-4 so that T cells can be activated
Ipilimumab
What are the subtypes of melanoma
Superficial spreading
Nodular
Lentigo maligna : o face
Acral lentiginous : on elbows
Unclassifyale
How does superficial spreading melanoma present
fair skin, trunk of men and womens legs, (sometimes white/depigmentation in centre as immune cells fight)
Symmetry, border irregularity, large diameter because of Horizontal/radial growth phase then Vertical/downwards (nodule like if goes downwards)
How do nodular melanomas present
in fair skinned individuals, trunk head and neck
blu to black or pink to red nodule
Only vertical growth which makes it more aggressive
How does lentigo maligna melanoma present
over 60 yrs, chronicall sun damaged skin, usually face
slow growwing, asymmetric brown/black macule, irregular border
How does acral lentiginous melanoma present
palms and soles or around nails
deep pigmentation can get ulceration
What sign on the nails can be indicative of melanoma
Melanonychia
What is the name of the melanoma that doesnt produce pigment
Amelanotic melanoma
What is indicative of a poor prognosis in melanomas
Inc breslow thickness
ulceration
age
men
lymph node
How are melanomas nvestigated
Dermoscopy
Biopsy
How are melanomas managed
Excision to subcutaneous fat , 2mm peripheral margin unless lentigo maligna.
wide excision : 5mm if in situ , 10mm for 1mm breslow depth
Sentinel lymphoma node biopsy: pT1b (less than 0.8mm but ulcerated)
Imaging in stage 3 or 4 (2-4mm,>4mm)
PET-CT, MRI
Prognostic factor for metastatic melanoma
LDH
If a melanoma is metastatic or unresectable what is the next step
Immunotherapy
CTLA-4 inhibition Ipilimumab (in BRAF negative)
PD-L1 Nivolumab
together is better
Mutated oncogene targeted therapy
BRAF and MEK inhibitor
What types of keratinocyte dysplasia are there
Actinic keratoses : some dysplastic cells in the epidermis
Bowens disease: SCC in situ (same place)
Squamous cell carcinoma: SCC (mets likely)
Basal cell carcinoma: locally invades no mets
Pathogenesis of basal cell carcinoma (3 points)
Basal Cell carcinoma:
- UV radiation, receptors for PDGF upregulated in mesencyhmal cells of stroma, PDGF upregulated in tumour cells.
- Proteolytic activity (metalloproteinases, collagenases) that degrade dermal tissue so can spread
- Chromosome 8q loses function (PTCH gene), p53 mutations usually there too
Pathogenesis of squamous cell carcinoma and how it may present
-UV radiation is a risk factor
- addition of genetic alterations - alterations in p53 and CDKN2A
- NOTCH1 and NOTCH2
present: erythmematous/skin coloured, papule or plaque, exophytic (mushroom looking), hyperkeratotic, ulcers
What are the risk factors of keratinocyte carcinomas
BCC more common than SCC
pale ppl
men
old - 68
RF: UV (PUVA), fair skin, genetic syndromes, immunosuppresant drugs, non-healing wounds,
What is actinic keratosis
Atypical keratinocytes confined to epidermis
sundamaged skin
macules (flat) or papules (raised)
red or pink
scale
(looks like scaley sundamage that older people have)
What is bowens disease
SCC in situ
erythmatous scaly pathc/ elevlated plaque
looks like actinic keratoses, eczema, psoriasis
What is the treatment of actinic keratoses and bowens disease
5-fluorouracil
cryotherapy
imiquimod cream
photodynamic therapy
curettage and cautery (scrape and burn)
excision
What are some high risk factors of SCC
more than 1cm on head and neck
more than 2cm on trunk and lim
in immunosuppressed or ppl whove had radiotherapy
poorly differentiated
PERINEURAL( around a nerve) LYMPHATIC OR VASCULAR INVASION
A patient presents with a rapidly enlargeing papule, a circumscribed crateriform nodule with a keratotic core what is the diagnosis and how is it managed
Keratoacanthoma
will go away by itself
How is SCC investigated
clinical diagnosis, biopsy if uncertain, US of lymph nodes if think mets
How is SCC treated
Excision
radiotherapy if unresectable or perineural invasion
Cemiplimab if metastatic
skin monitoring and sun protection advice
What are the types of BCC and how to identify
Nodular : pearly papule, shiny
Superficial : pink flat lesions, plaque, thin papule
Morphoeic: light pink to white colour, elevated or depressed area
Infiltrative
Basisquamous : combination of both
Micronodular: nodular but destructive and usually spreads
How to diagnose BCC
biopsy
How to treat BCC
surgical excision
mohs micrographic surgery (if recurrent, aggressive or in critical site)
can do topical 5-Fluorouraci or Imiquimod, or photodynamic therapy all the same things as SCC
What are cutaenous T cell lymphomas
Neoplasms of T cells that attack skin
What are the two types of cutaenous T cell lymphomas
Sezary syndrome : erythroderma, generalised lymphadenopathy, neoplastic T cells
Mycosis fungoides: looks like patch then plaque at first, may take 4-6 years to become a tumour.
What is kaposi sarcoma
HHV8 : bruised coloured noduled/papules,
systemic disease
may be related to immunosuppression
What is merkel cell carcinoma
Cells that resemble merkel cells
highly anaplastic
rapidly growing nodule, pink to red to violet, firm and domed shaped
