Dermatology Flashcards
What is eczema? what is the diagnosis?
Eczema, also known as atopic dermatitis, is a chronic inflammatory skin condition that affects millions of adults worldwide. It is characterized by dry, itchy, and red patches on the skin, which can be exacerbated by environmental triggers such as stress, allergens, and irritants. The condition can significantly impact patients’ quality of life, causing discomfort, sleep disturbance, and psychological distress.
The diagnosis of eczema is based on clinical presentation and history, and management involves a combination of lifestyle modifications, topical treatments, and systemic therapies.
What is the diagnosis of eczema?
UK Working Party Diagnostic Criteria for Atopic Eczema
An itchy skin condition in the last 12 months
Plus three or more of
Onset below age 2 years* History of flexural involvement** History of generally dry skin Personal history of other atopic disease*** Visible flexural dermatitis
not used in children under 4 years
**or dermatitis on the cheeks and/or extensor areas in children aged 18 months or under
**in children aged under 4 years, history of atopic disease in a first degree relative may be included
What are the 8 different management areas to think about in eczema?
Patient Education
Educating patients about their condition and its management is essential for optimal outcomes. This includes information on the chronic nature of eczema, potential triggers, and the importance of adherence to treatment regimens.
Emollients
Emollients are the cornerstone of eczema management and should be used regularly regardless of disease severity. They provide symptomatic relief by hydrating the skin, reducing transepidermal water loss and restoring the skin barrier function. Patients should be advised to apply emollients liberally and frequently (at least twice daily) even when their skin appears clear. Emollient choice should be tailored to individual preferences (e.g., creams, ointments or lotions) to improve adherence.
Topical corticosteroids
Topical corticosteroids are indicated for acute flares and moderate-to-severe eczema. Topical corticosteroids potency should be selected based on disease severity and body site; lower potency topical corticosteroids (e.g., hydrocortisone 1%) can be used on delicate areas such as the face or genitals, whilst higher potency topical corticosteroids (e.g., betamethasone valerate 0.1%) may be required for more severe cases or thicker skin areas like palms or soles.
Topical calcineurin inhibitors
Topical calcineurin inhibitors, such as tacrolimus and pimecrolimus, are an alternative to steroids for eczema management. They are particularly useful in areas where long-term steroids use is contraindicated, such as the face or skin folds. Topical calcineurin inhibitors should be initiated by a specialist dermatologist in cases of severe eczema or when other treatments have failed.
Antimicrobials
In cases of secondary bacterial infection (e.g., impetigo), a short course of topical or oral antibiotics may be necessary. Topical antiseptics can also be used as adjunctive therapy to reduce bacterial colonisation and prevent infection.
Phototherapy
Narrowband ultraviolet B (NB-UVB) phototherapy can be considered for patients with moderate-to-severe eczema who have not responded adequately to topical therapies. This treatment should be supervised by a dermatologist and requires regular monitoring for potential side effects such as erythema, burning, and an increased risk of skin cancer.
Systemic Therapies
Systemic immunosuppressive agents such as ciclosporin, azathioprine or methotrexate may be indicated for severe refractory eczema under the guidance of a specialist dermatologist. These medications require close monitoring due to their potential side effects and interactions with other medications.
Biologic Therapy
Dupilumab, a monoclonal antibody targeting IL-4 and IL-13 pathways, has been approved for use in adults with moderate-to-severe atopic dermatitis unresponsive to conventional therapies. This biologic agent should only be prescribed by specialist dermatologists experienced in managing severe eczema.
How is itch managed?
Management of Itch
Pruritus is a significant symptom associated with eczema that can lead to sleep disturbance and impaired quality of life. The use of sedating antihistamines, such as hydroxyzine or chlorphenamine, can be considered for short-term relief of itch and sleep disturbance. Non-sedating antihistamines (e.g., cetirizine or loratadine) are less effective for itch control but may be useful for managing concomitant allergic symptoms.
List the steroids from mild - very potent
Hydrocortisone
Eumovate (clobetasone butyrate 0.05%)
Cutivate (futicasone proprionate)
Dermovate (Clobetasol propionate 0.05%)
Betnovate (Betamethasone valerate 0.1%)
Betnovate RD (betamethason valerate 0.025%)
Mild Potent Very potent
Hydrocortisone 0.5-2.5%
Moderate
Betamethasone valerate 0.025% (Betnovate RD)
Clobetasone butyrate 0.05% (Eumovate)
Potent
Fluticasone propionate 0.05% (Cutivate)
Betamethasone valerate 0.1% (Betnovate)
Very Potent
Clobetasol propionate 0.05% (Dermovate)
How many fingertip doses per:
Hands and fingers
A foot
Front of chest and abdomen
Bakc and buttocks
Face and neck
An entire arm and hand
An entire leg and foot
Hand and fingers (front and back) 1.0
A foot (all over) 2.0
Front of chest and abdomen 7.0
Back and buttocks 7.0
Face and neck 2.5
An entire arm and hand 4.0
An entire leg and foot 8.0
What amount of steroid should you prescribe for a single daily app for 2 weeks:
Face and neck
Both hands
Scalp
Both arms
Both legs
Trunk
Groin and genitalia
Area Amount
Face and neck 15 to 30 g
Both hands 15 to 30 g
Scalp 15 to 30 g
Both arms 30 to 60 g
Both legs 100 g
Trunk 100 g
Groin and genitalia 15 to 30 g
What is discoid eczema?
Discoid eczema is sometimes referred to as nummular eczema, meaning coin-shaped.
Features
typically present as round or oval plaques on the extremities the lesions are extremely itchy central clearing may occur giving a similar appearance to tinea corporis
What is eczema herpeticum? who is this most commonly seen in?
Eczema herpeticum describes a severe primary infection of the skin by herpes simplex virus 1 or 2.
It is more commonly seen in children with atopic eczema and often presents as a rapidly progressing painful rash.
What is seen on examination of eczema herpeticum? What is the management?
On examination, monomorphic punched-out erosions (circular, depressed, ulcerated lesions) usually 1–3 mm in diameter are typically seen.
As it is potentially life-threatening children should be admitted for IV aciclovir.
What is pompholyx? What may this be precipitated by?
Pompholyx is a type of eczema which affects both the hands (cheiropompholyx) and the feet (pedopompholyx). It is also known as dyshidrotic eczema.
Pompholyx eczema may be precipitated by humidity (e.g. sweating) and high temperatures.
Give 5 features of pompholyx
Features
-small blisters on the palms and soles
-pruritic
-often intensely itchy
-sometimes burning sensation
-once blisters burst skin may become dry and crack
What is the management of pompholyx? 3
Management
-cool compresses
-emollients
-topical steroids
What is psoriasis?
Psoriasis is a common (prevalence around 2%) and chronic skin disorder. It generally presents with red, scaly patches on the skin although it is now recognised that patients with psoriasis are at increased risk of arthritis and cardiovascular disease.
Describe the pathophysiologt of psoriasis
Pathophysiology
multifactorial and not yet fully understood genetic: associated HLA-B13, -B17, and -Cw6. Strong concordance (70%) in identical twins immunological: abnormal T cell activity stimulates keratinocyte proliferation. There is increasing evidence this may be mediated by a novel group of T helper cells producing IL-17, designated Th17. These cells seem to be a third T-effector cell subset in addition to Th1 and Th2 environmental: it is recognised that psoriasis may be worsened (e.g. Skin trauma, stress), triggered (e.g. Streptococcal infection) or improved (e.g. Sunlight) by environmental factors
what are 4 subtypes of psoriasis?
Recognised subtypes of psoriasis
plaque psoriasis: the most common sub-type resulting in the typical well-demarcated red, scaly patches affecting the extensor surfaces, sacrum and scalp
Flexural psoriasis: in contrast to plaque psoriasis the skin is smooth
guttate psoriasis: transient psoriatic rash frequently triggered by a streptococcal infection. Multiple red, teardrop lesions appear on the body
pustular psoriasis: commonly occurs on the palms and soles
What are 5 complications of psoriasis?
Complications
psoriatic arthropathy (around 10%) increased incidence of metabolic syndrome increased incidence of cardiovascular disease increased incidence of venous thromboembolism psychological distress
What are 4 nail changes seen in psoriasis? what percentage of patients are affected?
Psoriatic nail changes affect both fingers and toes and do not reflect the severity of psoriasis but there is an association with psoriatic arthropathy - around 80-90% of patients with psoriatic arthropathy have nail changes.
Nail changes that may be seen in psoriasis
pitting onycholysis (separation of the nail from the nail bed) subungual hyperkeratosis loss of the nail
What are 4 exacerbating features of psoriasis?
The following factors may exacerbate psoriasis:
trauma alcohol drugs: beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab withdrawal of systemic steroids
Streptococcal infection may trigger guttate psoriasis.
Describe 1st line, 2nd line and 3rd line treatment for psoriasis
NICE recommend a step-wise approach for chronic plaque psoriasis
regular emollients may help to reduce scale loss and reduce pruritus
first-line: NICE recommend:
a potent corticosteroid applied once daily plus vitamin D analogue applied once daily
should be applied separately, one in the morning and the other in the evening)
for up to 4 weeks as initial treatment
second-line: if no improvement after 8 weeks then offer:
a vitamin D analogue twice daily
third-line: if no improvement after 8-12 weeks then offer either:
a potent corticosteroid applied twice daily for up to 4 weeks, or
a coal tar preparation applied once or twice daily
short-acting dithranol can also be used
Secondary care treatment for psoriasis: Phototherapy
-What is the treatment of choice?
-How often should this be given?
-what are 2 adverse effects?
Phototherapy
narrowband ultraviolet B light is now the treatment of choice. If possible this should be given 3 times a week photochemotherapy is also used - psoralen + ultraviolet A light (PUVA) adverse effects: skin ageing, squamous cell cancer (not melanoma)
Secondary care treatment for psoriasis: Systemic therapy
-What is used first line?
-What are 4 other options?
Systemic therapy
oral methotrexate is used first-line. It is particularly useful if there is associated joint disease ciclosporin systemic retinoids biological agents: infliximab, etanercept and adalimumab ustekinumab (IL-12 and IL-23 blocker) is showing promise in early trials
Describe the management of scalp psoriasis
Outline
NICE recommend the use of potent topical corticosteroids used once daily for 4 weeks if no improvement after 4 weeks then either use a different formulation of the potent corticosteroid (for example, a shampoo or mousse) and/or a topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid
Describe the management of face, flexural and genital psoriasis
Outline
NICE recommend offering a mild or moderate potency corticosteroid applied once or twice daily for a maximum of 2 weeks
Topical steroids in psoriasis
-what is the maximum steroids should be used on the scalp/face/flexures per month
-when may systemic side-effects be seen with topical steroid use?
-How long should you break between topical steroids?
-what is the max potent steroids should be used at a time? what about very potent steroid?
Using topical steroids in psoriasis
as we know topical corticosteroid therapy may lead to skin atrophy, striae and rebound symptoms
the scalp, face and flexures are particularly prone to steroid atrophy so topical steroids should not be used for more than 1-2 weeks/month
systemic side-effects may be seen when potent corticosteroids are used on large areas e.g. > 10% of the body surface area
NICE recommend that we aim for a 4-week break before starting another course of topical corticosteroids
they also recommend using potent corticosteroids for no longer than 8 weeks at a time and very potent corticosteroids for no longer than 4 weeks at a time
Vit D analogues in psoriasis
-How do these work?
-can they be used long term? do they smell/stain?
-How do they improve plaques?
-When should these be avoided?
-what is the max. weekly amount?
Vitamin D analogues
examples of vitamin D analogues include calcipotriol (Dovonex), calcitriol and tacalcitol they work by ↓ cell division and differentiation → ↓ epidermal proliferation adverse effects are uncommon unlike corticosteroids they may be used long-term unlike coal tar and dithranol they do not smell or stain they tend to reduce the scale and thickness of plaques but not the erythema they should be avoided in pregnancy the maximum weekly amount for adults is 100g
Dithranol in psoriasis
-How does this work?
-How is this applied?
-what are 2 adverse effects?
Dithranol
inhibits DNA synthesis wash off after 30 mins adverse effects include burning, staining
What is the mechanism of action of coal tar?
Coal tar
mechanism of action not fully understood - probably inhibit DNA synthesis
what is used for non-biological systemic therapy in psoriasis?
Methotrexate and ciclosporin are the main agents which are used. Methotrexate is generally used first-line unless any of the following apply, resulting in ciclosporin being a better choice:
need rapid or short-term disease control (for example a psoriasis flare) or
have palmoplantar pustulosis or
are considering conception (both men and women) and systemic therapy cannot be avoided
what four agents are used for biological systemic therapy? what is a requirement for patients to go onto these?
The main agents used are adalimumab (subcutaneous injection), etanercept (subcutaneous injection), infliximab (intravenous infusion) and ustekinumab (subcutaneous injection). As for non-biological systemic therapy NICE stipulate criteria regarding their use. A failed trial of methotrexate, ciclosporin and PUVA is a requirement.
what 8 things are patients with psoriasis at an increased risk of?
Patients with psoriasis are at an increased risk of:
cardiovascular disease
hypertension
venous thromboembolism
depression
ulcerative colitis and Crohn’s disease
non-melanoma skin cancer
other cancers including liver, lung and upper gastrointestinal tract cancers
What is acne vulgaris? What percentage of teenagers are affected?
Acne vulgaris is a common skin disorder which usually occurs in adolescence. It typically affects the face, neck and upper trunk and is characterised by the obstruction of the pilosebaceous follicle with keratin plugs which results in comedones, inflammation and pustules.
Epidemiology
affects around 80-90% of teenagers, 60% of whom seek medical advice
acne may also persist beyond adolescence, with 10-15% of females and 5% of males over 25 years old being affected
What are 3 factors contributing to the pathophysiology of acne vulgaris?
Pathophysiology is multifactorial
follicular epidermal hyperproliferation resulting in the formation of a keratin plug. This in turn causes obstruction of the pilosebaceous follicle. Activity of sebaceous glands may be controlled by androgen, although levels are often normal in patients with acne
colonisation by the anaerobic bacterium Propionibacterium acnes
inflammation
What 6 lesions are seen in acne vulgaris?
Acne is a disease of the pilosebaceous unit. Several different types of acne lesions are usually seen in each patient
Comedones are due to a dilated sebaceous follicle
if the top is closed a whitehead is seen
if the top opens a blackhead forms
Inflammatory lesions form when the follicle bursts releasing irritants
papules
pustules
An excessive inflammatory response may result in:
nodules
cysts
What 2 scar types are seen in acne vulgaris?
This sequence of events can ultimately cause scarring
ice-pick scars
hypertrophic scars
What lesions are seen in drug-induced acne?
What is acne fulminans?
In contrast, drug-induced acne is often monomorphic (e.g. pustules are characteristically seen in steroid use)
Acne fulminans is very severe acne associated with systemic upset (e.g. fever). Hospital admission is often required and the condition usually responds to oral steroids
How is acne classified?
Acne may be classified into mild, moderate or severe:
mild: open and closed comedones with or without sparse inflammatory lesions
moderate acne: widespread non-inflammatory lesions and numerous papules and pustules
severe acne: extensive inflammatory lesions, which may include nodules, pitting, and scarring
What are 3 treatment options for mild-moderate acne? what can be used if patients want to avoid using topical retinoid or an antibiotic?
For people with mild to moderate acne: CKS
-a 12-week course of topical combination therapy should be tried first-line:
-a fixed combination of topical adapalene with topical benzoyl peroxide
-a fixed combination of topical tretinoin with topical clindamycin
-a fixed combination of topical benzoyl peroxide with topical clindamycin
-topical benzoyl peroxide may be used as monotherapy if these options are contraindicated or the person wishes to avoid using a topical retinoid or an antibiotic
What are 4 treatment options for moderate to severe acne?
a 12-week course of one of the following options:
-a fixed combination of topical adapalene with topical benzoyl peroxide
-a fixed combination of topical tretinoin with topical clindamycin
-a fixed combination of topical adapalene with topical benzoyl peroxide + either oral lymecycline or oral doxycycline
-a topical azelaic acid + either oral lymecycline or oral doxycy
Who should tetracyclines be avoided in? What antibiotic may be used in pregnancy?
How long can you use treatment options that include an antibiotic?
What should be co-prescribed with a topical retinoid or benzoyl peroxide?
What should not be used in combination?
what may occur as a complication of long-term abx use?
-tetracyclines should be avoided in pregnant or breastfeeding women and in children younger than 12 years of age. Erythromycin may be used in pregnancy
-minocycline is now considered less appropriate due to the possibility of irreversible pigmentation
-only continue a treatment option that includes an antibiotic (topical or oral) for more than 6 months in exceptional circumstances
-a topical retinoid (if not contraindicated) or benzoyl peroxide should always be co-prescribed with oral antibiotics to reduce the risk of antibiotic resistance developing. Topical and oral antibiotics should not be used in combination or as monotherapy.
-Gram-negative folliculitis may occur as a complication of long-term antibiotic use - high-dose oral trimethoprim is effective if this occurs
What are an alternative to oral abx in women with mod-severe acne?
combined oral contraceptives (COCP) are an alternative to oral antibiotics in women
as with antibiotics, they should be used in combination with topical agents
Dianette (co-cyprindiol) is sometimes used as it has anti-androgen properties. However, it has an increased risk of venous thromboembolism compared to other COCPs, therefore it should generally be used second-line, only be given for 3 months and women should be appropriately counselled about the risks
NICE referral criteria for acne
-Who should be referred?
-Who should referral be considered for?
NICE referral criteria CKS
the following patients should be referred to a dermatologist:
-patients with acne conglobate acne: a rare and severe form of acne found mostly in men that presents with extensive inflammatory papules, suppurative nodules (that may coalesce to form sinuses) and cysts on the trunk.
-patients with nodulo-cystic acne
referral should be considered in the following scenarios:
-mild to moderate acne has not responded to two completed courses of treatment
-moderate to severe acne has not responded to previous treatment that includes an oral antibiotic
-acne with scarring
-acne with persistent pigmentary changes
-acne is causing or contributing to persistent psychological distress or a mental health disorder
Give 8 adverse effects of retinoids
Isotretinoin is an oral retinoid used in the treatment of severe acne. Two-thirds of patients have a long-term remission or cure following a course of oral isotretinoin.
Adverse effects
-teratogenicity
females should ideally be using two forms of contraception (e.g. Combined oral contraceptive pill and condoms)
-dry skin, eyes and lips/mouth
the most common side-effect of isotretinoin
-low mood
whilst this is a controversial topic, depression and other psychiatric problems are listed in the BNF
-raised triglycerides
-hair thinning
-nose bleeds (caused by dryness of the nasal mucosa)
-intracranial hypertension: isotretinoin treatment should not be combined with tetracyclines for this reason
-photosensitivity
What is rosacea?
-Give 7 clinical features of rosacea?
Rosacea (sometimes referred to as acne rosacea) is a chronic skin disease of unknown aetiology.
Features
-typically affects nose, cheeks and forehead
-flushing is often first symptom
-telangiectasia are common
-later develops into persistent erythema with papules and pustules
-rhinophyma
-ocular involvement: blepharitis
-sunlight may exacerbate symptoms
Management of rosacea
-what is the management for predominant erythema/flushing in rosacea?
-what is the management of predominant erythema/flushing
-What is the management of mild-moderate papules and/or pustules in rosacea?
-What is the management of moderate-severe papules and/or pustules in rosacea?
Management
-simple measures
-recommend daily application of a high-factor sunscreen
camouflage creams may help conceal redness
predominant erythema/flushing CKS
-topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia
-brimonidine is a topical alpha-adrenergic agonist
this can be used on an ‘as required basis’ to temporarily reduce redness
-it typically reduces redness within 30 minutes, reaching peak action at 3-6 hours, after which the redness returns to the baseline
mild-to-moderate papules and/or pustules CKS
-topical ivermectin is first-line
alternatives include: topical metronidazole or topical azelaic acid
moderate-to-severe papules and/or pustules CKS
-combination of topical ivermectin + oral doxycycline
When should referral be considered for rosacea?
Referral should be considered if CKS
symptoms have not improved with optimal management in primary care
laser therapy may be appropriate for patients with prominent telangiectasia
patients with a rhinophyma
What is seborrheic dermatitis? what is this thought to be caused by?
Seborrhoeic dermatitis in adults is a chronic dermatitis thought to be caused by an inflammatory reaction related to a proliferation of a normal skin inhabitant, a fungus called Malassezia furfur (formerly known as Pityrosporum ovale). It is common, affecting around 2% of the general population.
Give 2 clinical features of seborrheic dermatitis in adults
Features
eczematous lesions on the sebum-rich areas: scalp (may cause dandruff), periorbital, auricular and nasolabial folds
otitis externa and blepharitis may develop
§1qw6789op[]’]poq
What is hidredenitis suppurativa?
Is it more common in men vs women? at what age are patients affected?qL;/.Q
Hidradenitis suppurativa (HS) is a chronic, painful, inflammatory skin disorder. It is characterized by the development of inflammatory nodules, pustules, sinus tracts, and scars in intertriginous areas. It should be suspected in pubertal or post-pubertal patients who have a diagnosis of recurrent furuncles or boils, especially in intertriginous areas.
Epidemiology:
Women are more likely to develop HS than men.
It most commonly affects adults under 40
What are 2 assoc. conditions with seborrheic dermatitis
Associated conditions include
HIV
Parkinson’s disease
What is the management of seborrhoeic dermatitis affecting scalp? what is the management affecting face/body?
Scalp disease management
the first-line treatment is ketoconazole 2% shampoo
over the counter preparations containing zinc pyrithione (‘Head & Shoulders’) and tar (‘Neutrogena T/Gel’) may be used if ketoconazole is not appropriate or acceptable to the person
selenium sulphide and topical corticosteroid may also be useful
Face and body management
topical antifungals: e.g. ketoconazole
topical steroids: best used for short periods
difficult to treat - recurrences are common
What is the pathogenesis of hidredenitis suppurativa?
Pathogenesis:
Chronic inflammatory occlusion of folliculopilosebaceous units that obstructs the apocrine glands and prevents keratinocytes from properly shedding from the follicular epithelium.
what are 4 risk factors for hidredenitis suppurativa?
Risk factors:
Family history
Smoking
Obesity, diabetes, polycystic ovarian syndrome
Mechanical stretching of skin
What are 5 clinical features of hidredanitis suppurativa?
Clinical features:
-Initial manifestation involves recurrent, painful, and inflamed nodules.
-HS occurs most commonly on intertriginous skin. However, non-intertriginous skin involvement also can occur. The axilla is the most common site
-Other areas include inguinal, inner thighs, perineal and perianal, inframammary skin.
-The nodules may rupture, discharging purulent, malodorous material.
-Coalescence of nodules can result in plaques, sinus tracts and ‘rope-like’ scarring.
How is a diagnosis of hidredanitis supparativa made?
clinically
Give 6 management points for hidredenitis suppurativa?
Management:
-Encourage good hygiene and loose-fitting clothing
-Smoking cessation
-Weight loss in obese
-Acute flares can be treated with steroids (intra-lesional or oral) or flucloxacillin. Surgical incision and drainage may be needed in some cases.
-Long-term disease can be treated with topical (clindamycin) or oral (lymecycline or clindamycin and rifampicin) antibiotics.
-Lumps that persist despite prolonged medical treatment are excised surgically.
Give 5 complications of hidradenitis suppurativa?
Complications:
-Sinus tracts, fistulas
-Comedones
-Scarring - severe scarring can lead to dense, rope-like bands in the skin with strictures and
lymphedema
-Contractures
-Lymphatic obstruction
What is tinea?
Tinea is a term given to dermatophyte fungal infections. Three main types of infection are described depending on what part of the body is infected
tinea capitis - scalp
tinea corporis - trunk, legs or arms
tinea pedis - feet
what is tinea capitis? who is this mainly seen in? what can happen if left untreated? what is the most common cause?
What is the diagnosis?
What is the management?
Tinea capitis (scalp ringworm)
-a cause of scarring alopecia mainly seen in children
-if untreated a raised, pustular, spongy/boggy mass called a kerion may form
-most common cause is Trichophyton tonsurans in the UK and the USA
may also be caused by Microsporum canis acquired from cats or dogs
-diagnosis: lesions due to Microsporum canis green fluorescence under Wood’s lamp*. However the most useful investigation is scalp scrapings
management (based on CKS guidelines): oral antifungals: terbinafine for Trichophyton tonsurans infections and griseofulvin for Microsporum infections. Topical ketoconazole shampoo should be given for the first two weeks to reduce transmission
Tinea corporis
-What are the most common causes?
-What does this look like?
-How is this treated?
Tinea corporis (ringworm)
causes include Trichophyton rubrum and Trichophyton verrucosum (e.g. From contact with cattle)
well-defined annular, erythematous lesions with pustules and papules
may be treated with oral fluconazole
Tinea pedis
-What is this?
-Who is this common in?
Tinea pedis (athlete’s foot)
characterised by itchy, peeling skin between the toes
common in adolescence
Give 3 causative organisms for fungal nail infections
Fungal nail infection (onychomycosis) may involve any part of the nail, or the entire nail unit. Toenails are significantly more likely to become infected than fingernails
Causative organisms
-dermatophytes
account for around 90% of cases
mainly Trichophyton rubrum
-yeasts
account for around 5-10% of cases
e.g. Candida
-non-dermatophyte moulds
what are 4 risk factors for fungal nail infections? what are the features?
Risk factors
-increasing age
-diabetes mellitus
-psoriasis
-repeated nail trauma
Features
-‘unsightly’ nails are a common reason for presentation
-thickened, rough, opaque nails are the most common finding
What is the investigation for fungal nail infection
Investigation: nail clippings +/- scrapings of the affected nail
-microscopy and culture
-should be done for all patients if antifungal treatment is being considered
-the false-negative rate for cultures are around 30%, so repeat samples may need to be sent if the clinical suspicion is high
What is the management of a fungal nail infection
Management
do not need to be treated if it is asymptomatic and the patient is not bothered by the appearance
if dermatophyte or Candida
infection is confirmed
-if limited involvement (≤50% nail affected, ≤ 2 nails affected, more superficial white onychomycosis): topical treatment with amorolfine 5% nail lacquer; 6 months for fingernails and 9 - 12 months for toenails
-if more extensive involvement due to a dermatophyte infection: oral terbinafine is currently recommended first-line; 6 weeks - 3 months therapy is needed for fingernail infections whilst toenails should be treated for 3 - 6 months
-if more extensive involvement due to a Candida infection: oral itraconazole is recommended first-line; ‘pulsed’ weekly therapy is recommended
Pityriasis versicolor
-What is this caused by?
-what are 4 clinical features?
Pityriasis versicolor, also called tinea versicolor, is a superficial cutaneous fungal infection caused by Malassezia furfur (formerly termed Pityrosporum ovale)
Features
most commonly affects trunk
patches may be hypopigmented, pink or brown (hence versicolor). May be more noticeable following a suntan
scale is common
mild pruritus
What are 4 predisposing factors of pityriasis versicolor?
Predisposing factors
-occurs in healthy individuals
-immunosuppression
-malnutrition
-Cushing’s
What is the management of pityriasis versicolor?
Management
-topical antifungal. NICE Clinical Knowledge Summaries advise ketoconazole shampoo as this is more cost effective for large areas
-if failure to respond to topical treatment then consider alternative diagnoses (e.g. send scrapings to confirm the diagnosis) + oral itraconazole
What is pityriasis rosea?
Pityriasis rosea describes an acute, self-limiting rash which tends to affect young adults. The aetiology is not fully understood but is thought that herpes hominis virus 7 (HHV-7) may play a role.
Give 3 clinical features of pityriasis rosea?
Features
-in the majority of patients there is no prodrome, but a minority may give a history of a recent viral infection
-herald patch (usually on trunk)
-followed by erythematous, oval, scaly patches which follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer. This may produce a ‘fir-tree’ appearance
what is the management of pityriasis rosea?
Management
self-limiting - usually disappears after 6-12 weeks
what virus causes chickenpox?
Varicella-zoster is the herpes virus that causes chickenpox. Shingles is an acute, unilateral, painful blistering rash caused by reactivation of the varicella-zoster virus (VZV).
Chickenpox
-How can this be spread?
-Describe the infectivity of chicken pox
-what is the incubation period of chickenpox?
Chickenpox is highly infectious
spread via the respiratory route
can be caught from someone with shingles
infectivity = 4 days before rash, until 5 days after the rash first appeared*
incubation period = 10-21 days
Give 3 clinical features of chickenpox?
Clinical features (tend to be more severe in older children/adults)
fever initially
itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular
systemic upset is usually mild
What is the management of chickenpox? describe school exclusion for chickenpox?
Management is supportive
-keep cool, trim nails
-calamine lotion
-school exclusion: NICE Clinical Knowledge Summaries state the following: Advise that the most infectious period is 1–2 days before the rash appears, but infectivity continues until all the lesions are dry and have crusted over (usually about 5 days after the onset of the rash).
-immunocompromised patients and newborns with peripartum exposure should receive varicella zoster immunoglobulin (VZIG). If chickenpox develops then IV aciclovir should be considered
Give 5 complications of chickenpox?
A common complication is secondary bacterial infection of the lesions
NSAIDs may increase this risk
whilst this commonly may manifest as a single infected lesion/small area of cellulitis, in a small number of patients invasive group A streptococcal soft tissue infections may occur resulting in necrotizing fasciitis
Rare complications include
pneumonia
encephalitis (cerebellar involvement may be seen)
disseminated haemorrhagic chickenpox
arthritis, nephritis and pancreatitis may very rarely be seen
What is shingles?
Shingles (herpes zoster infection) is an acute, unilateral, painful blistering rash caused by reactivation of the varicella-zoster virus (VZV). Following primary infection with VZV (chickenpox), the virus lies dormant in the dorsal root or cranial nerve ganglia.
what are 3 risk factors for shingles?
Risk factors
increasing age
HIV: strong risk factor, 15 times more common
other immunosuppressive conditions (e.g. steroids, chemotherapy)
What dermatomes are most commonly affected by shingles? describe the prodromal period? describe the rash
The most commonly affected dermatomes are T1-L2.
Features
prodromal period
-burning pain over the affected dermatome for 2-3 days
-pain may be severe and interfere with sleep
-around 20% of patients will experience fever, headache, lethargy
rash
-initially erythematous, macular rash over the affected dermatome
quickly becomes vesicular
-characteristically is well demarcated by the dermatome and does not cross the midline. However, some ‘bleeding’ into adjacent areas may be seen
What is the diagnosis of shingles? what can be used for analgesia? When are antivirals used?
The diagnosis is usually clinical.
Management
-remind patients they are potentially infectious
may need to avoid pregnant women and the immunosuppressed
should be advised that they are infectious until the vesicles have crusted over, usually 5-7 days following onset
covering lesions reduces the risk
Analgesia
paracetamol and NSAIDs are first-line
-if not responding then use of neuropathic agents (e.g. amitriptyline) can be considered
-oral corticosteroids may be considered in the first 2 weeks in immunocompetent adults with localized shingles if the pain is severe and not responding to the above treatments
Antivirals
-NICE Clinical Knowledge Summaries makes recommendations on when to use antivirals
-in practice, they recommend antivirals within 72 hours for the majority of patients, unless the patient is < 50 years and has a ‘mild’ truncal rash associated with mild pain and no underlying risk factors
-one of the benefits of prescribing antivirals is a reduced incidence of post-herpetic neuralgia, particularly in older people
-aciclovir, famciclovir, or valaciclovir are recommended
Give 3 complications of shingles
Complications
-post-herpetic neuralgia
the most common complications
more common in older patients
affects between 5%-30% of patients depending on age
most commonly resolves with 6 months but may last longer
-herpes zoster ophthalmicus (shingles affecting affecting the ocular division of the trigeminal nerve) is associated with a variety of ocular complications
-herpes zoster oticus (Ramsay Hunt syndrome): may result in ear lesions and facial paralysis
What are the 2 types of varicella-zoster vaccine?
There are two types of varicella-zoster vaccine:
-a vaccine that stops you from developing primary varicella infection (chickenpox)
-a vaccine that reduces the incidence of herpes zoster (shingles) caused by reactivation of VZV
Vaccination against primary varicella infection
-what kind of vaccine is this?
-Give 2 example indications?
This is a live attenuated vaccine. Examples include Varilrix and Varivax.
Example indications include:
-healthcare workers who are not already immune to VZV
-contacts of immunocompromised patients (e.g. child whose parent is undergoing chemotherapy)
Shingles vaccine
-who is this offered to?
-what type of vaccine is this and how is it given?
-Give an example
In 2013 the NHS introduced a vaccine to boost the immunity of elderly people against herpes zoster. Some important points about the vaccine:
-offered to all patients aged 70-79 years*
-is live-attenuated and given sub-cutaneously
-examples include Zostavax
What is a contraindication to shingles vaccine? give 2 side effects?
As it is a live-attenuated vaccine the main contraindications are immunosuppression.
Side-effects
injection site reactions
less than 1 in 10,000 individuals will develop chickenpox
