DERMATOLOGY

Question 1

Systemic Sclerosis

Define Limited cutaneous systemic sclerosis (LcSSc) and Diffuse cutaemous systemic sclerosis (dSSc)?

Answer 1

• ** LcSSc is characterized by skin fibrosis limited to the hands, forearms, feet, legs, and the head and neck, and is also known as CREST syndrome.**
• dSSc presents with widespread skin involvement and early visceral involvement.

Question 2

Systemic Sclerosis

Describe the clinical features of LcSSc and DcSSc?

Answer 2

LcSSc:
* Patients are usually female, aged between 30 and 50, and have a long history of Raynaud’s phenomenon
* Skin fibrosis is limited to the hands and forearms, feet and legs, and the head and neck
* Calcinosis
Raynaud’s phenomenon
Oesophageal dysmotility – dysphagia/gastro-oesophageal reflux disease
Sclerodactyly (bright shiny skin of the hands and feet) – fingers can be swollen and painful with reduced mobility and function; patients are unable to put palm to palm in a prayer sign
Telangiectasia
There is often also a family history of the disease

DcSSc
* Diffuse systemic sclerosis is a multisystem autoimmune disease – Key features are abnormalities of blood vessels and fibrosis of the skin and internal organs
* onset of diffuse systemic sclerosis is often abrupt and patients may present with swollen hands and feet, with a new onset of Raynaud’s phenomenon

Features in the history and examination include:
* Family history of systemic sclerosis
* Raynaud’s phenomenon
* Digital pits or ulcers that can be painful and lead to functional disability
* Skin thickening, sclerodactyly and loss of function of the hands
* Telangiectasia

Question 3

Systemic Sclerosis

Describe systemic manifestations of systemic sclerosis?

Answer 3

Dermatological:
Skin fibrosis (thickened plaques), sclerodactyly, microstomia, telangiectasia, calcinosis
Cardiovascular:
Raynauds Phenomenon, pericarditis with effusion, myocardial fibrosis
GI:
Oesophogeal dysmotility, bowel hypomotility, malabsorption, diffuse disease (gastric antral vascular ectasia)-vasculopathy (upper GI bleed)
Respiratory:
Pulmonary fibrosis, pulmonary arterial HTN (RHF-exertional dyspnoea, fatigue, weakness, signs of RHF (raised venous pressure, peripheral oedema, cardiac heave)
Renal:
scleroderma renal crisis (rapid progressive renal failure with HTN, headaches and seizures)

Question 4

Systemic Sclerosis

Describe the auto-antibodies raised in systemic sclerosis?

Answer 4

Most patients are ANA positive
* Anticentromere Ab: LcSSc (assoc with increased risk of pulmonary arterial HTN)
**Anti-Scl-70 Ab: DsSSc (assoc with progressive intersitial lung disease)
Anti-RNP**-Polymerase III: increased risk of scleroderma renal crisis and malignancy

Question 5

Systemic Sclerosis

Describe the managment of systemic sclerosis?

Answer 5

1. Management of Raynauds Phenomenon- smoking cessation, wearing gloves, avoid cold temp, oral vasodilators (CCB + Phosphodiesterase inhibitors), IV vasodilators (prostacyclin) in severe disease like digital ischaemia
2. GI management: PPI for reflux, antibiotics for small bowel bacterial overgrowth
3. Resp management: immunomodulatory agents for interstitial lung disease, Pulmonary arterial HTN (prostacyclins-iloprost, phosphodiesterase inhibitors-sildenafil, endothelin blockers-bosentan)
4. Renal management: ACE inhibiots to prevent renal crisis

Question 6

What dermatological condition has an acute onset of tear-drop scaly papules on trunk and limbs?

Answer 6

Guttate Psoriasis: commonly affects teenagers following a streptococcal throat infection

Question 7

Describe what combination of medication is given for severe rosacea?

Answer 7

Combination of topical ivermectin and oral doxycycline (1st line for severe papules/pustules)

Question 8

Cellulitis

Define and describe cellulitis?

Answer 8

• bacterial infection-affects the dermis and deeper subcutaneous tissues
• diagnosed clinically
• commonly caused by infection with Streptococcus pyogenes or less commonly S.Aureus
• most cases resolve with oral antibiotics

Question 9

Cellulitis

Describe the clincial features of cellulitis?

Answer 9

• Commonly occurs on the shins: usually unilateral
• erythema: generally well-defined margins (can be diffuse erythema)
• blisters and bullae: seen in more severe disease
• swelling
• systemic upset: fever, malaise and nausea
• Diagnosis: clinically (bloods and cultures if septicameia susepected)

Question 10

Cellulitis

Desceib the Eron classification criteria for management of cellulitis?

Answer 10

Class 1: no signs of systemic toxicity/person has no uncontrolled co-morbidities
Class 2: person is either systemically unwell/systemically well with a co-morbidity (like PAD, chronic venous insufficiency or obesity)-complicates/delays infection resolution
Class 3: significant systemic upset such as acute confusion, tachycardia, tacnypnoea, hypotension, unstable co-morbidities that may interfere with treatment response, limb-threatening infection due to vascular compromise
Class 4: Sepsis syndrome/severe life-threatening infection: necrotising fasciitis

Question 11

Cellulitis

Describe the following criterias for admitting a patient with cellulitis for IV antibiotics?

Answer 11

1. Eron Class III or Class IV cellulitis
2. Severe or Rapidly deteriorating celllulits
3. very young (<age of 1) or frail
4. immunocompromised
5. significant lymphodema
6. facial cellulitis or periorbital cellulitis
7. Eron Class II cellulitis: admission may not be neccessary if community can give IV antibiotics

Question 12

Cellulitis

Describe the management of cellulitis regarding each class?

Answer 12

Eron Class 1: Oral antibiotics
Oral Flucloxacillin: 1st line treatment for mild/moderate cellulitis
Oral Clarithromycin/Erythromycin (pregnancy) or Doxycycline in penicillin allergies

Eron Class II: NICE recommend: ‘Admission may not be necessary if the facilities and expertise are available in the community to give intravenous antibiotics and monitor the person - check local guidelines

Eron Class III-IV
admit
NICE recommend: oral/IV co-amoxiclav, oral/IV clindamycin, IV Cerufoxime and IV ceftriaxone