Dermatology Flashcards

Question

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?

Answer 1

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

Answer 2

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

Answer 3

Dithranol inhibits DNA synthesis wash off after 30 mins adverse effects include burning, staining

Answer 4

Coal tar mechanism of action not fully understood - probably inhibit DNA synthesis

Answer 5

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

Answer 6

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.

Answer 7

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

Answer 8

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

Answer 9

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

Answer 10

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

Answer 11

This sequence of events can ultimately cause scarring ice-pick scars hypertrophic scars

Answer 12

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

Answer 13

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

Answer 14

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

Answer 15

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

Answer 16

-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

Answer 17

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

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

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

Answer 22

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

Answer 23

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.

Answer 24

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

Answer 25

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

Answer 26

Associated conditions include HIV Parkinson's disease

Answer 27

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

Answer 28

Pathogenesis: Chronic inflammatory occlusion of folliculopilosebaceous units that obstructs the apocrine glands and prevents keratinocytes from properly shedding from the follicular epithelium.

Answer 29

Risk factors: Family history Smoking Obesity, diabetes, polycystic ovarian syndrome Mechanical stretching of skin

Answer 30

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.

Answer 31

clinically

Answer 32

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.

Answer 33

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

Answer 34

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

Answer 35

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

Answer 36

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

Answer 37

Tinea pedis (athlete's foot) characterised by itchy, peeling skin between the toes common in adolescence

Answer 38

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

Answer 39

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

Answer 40

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

Answer 41

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

Answer 42

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

Answer 43

Predisposing factors -occurs in healthy individuals -immunosuppression -malnutrition -Cushing's

Answer 44

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

Answer 45

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.

Answer 46

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

Answer 47

Management self-limiting - usually disappears after 6-12 weeks

Answer 48

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).

Answer 49

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

Answer 50

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

Answer 51

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

Answer 52

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

Answer 53

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.

Answer 54

Risk factors increasing age HIV: strong risk factor, 15 times more common other immunosuppressive conditions (e.g. steroids, chemotherapy)

Answer 55

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

Answer 56

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

Answer 57

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

Answer 58

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

Answer 59

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)

Answer 60

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

Answer 61

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

Answer 62

Scabies is caused by the mite Sarcoptes scabiei and is spread by prolonged skin contact. It typically affects children and young adults. The scabies mite burrows into the skin, laying its eggs in the stratum corneum. The intense pruritus associated with scabies is due to a delayed-type IV hypersensitivity reaction to mites/eggs which occurs about 30 days after the initial infection.

Answer 63

Features -widespread pruritus -linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist in infants, the face and scalp may also be affected -secondary features are seen due to scratching: excoriation, infection

Answer 64

Management -permethrin 5% is first-line -malathion 0.5% is second-line give appropriate guidance on use (see below) pruritus persists for up to 4-6 weeks post eradication The BNF advises to apply the insecticide to all areas, including the face and scalp, contrary to the manufacturer's recommendation. Patients should be given the following instructions: -apply the insecticide cream or liquid to cool, dry skin -pay close attention to areas between fingers and toes, under nails, armpit area, creases of the skin such as at the wrist and elbow -allow to dry and leave on the skin for 8-12 hours for permethrin, or for 24 hours for malathion, before washing off -reapply if insecticide is removed during the treatment period, e.g. If wash hands, change nappy, etc repeat treatment 7 days later

Answer 65

Patient guidance on treatment (from Clinical Knowledge Summaries) -avoid close physical contact with others until treatment is complete -all household and close physical contacts should be treated at the same time, even if asymptomatic -launder, iron or tumble dry clothing, bedding, towels, etc., on the first day of treatment to kill off mites.

Answer 66

Crusted scabies is seen in patients with suppressed immunity, especially HIV. The crusted skin will be teeming with hundreds of thousands of organisms. Ivermectin is the treatment of choice and isolation is essential

Answer 67

Molluscum contagiosum is a common skin infection caused by molluscum contagiosum virus (MCV), a member of the Poxviridae family. Transmission occurs directly by close personal contact, or indirectly via fomites (contaminated surfaces) such as shared towels and flannels. The majority of cases occur in children (often in children with atopic eczema), with the maximum incidence in preschool children aged 1-4 years. Typically, molluscum contagiosum presents with characteristic pinkish or pearly white papules with a central umbilication, which are up to 5 mm in diameter. Lesions appear in clusters in areas anywhere on the body (except the palms of the hands and the soles of the feet). In children, lesions are commonly seen on the trunk and in flexures, but anogenital lesions may also occur. In adults, sexual contact may lead to lesions developing on the genitalia, pubis, thighs, and lower abdomen. Rarely, lesions can occur on the oral mucosa and on the eyelids

Answer 68

Self-care advice: -Reassure people that molluscum contagiosum is a self-limiting condition. -Spontaneous resolution usually occurs within 18 months -Explain that lesions are contagious, and it is sensible to avoid sharing towels, clothing, and baths with uninfected people (e.g. siblings) -Encourage people not to scratch the lesions. If it is problematic, consider treatment to alleviate the itch -Exclusion from school, gym, or swimming is not necessary

Answer 69

Treatment is not usually recommended. If lesions are troublesome or considered unsightly, use simple trauma or cryotherapy, depending on the parents' wishes and the child's age: Squeezing (with fingernails) or piercing (orange stick) lesions may be tried, following a bath. Treatment should be limited to a few lesions at one time Cryotherapy may be used in older children or adults, if the healthcare professional is experienced in the procedure Eczema or inflammation can develop around lesions prior to resolution. Treatment may be required if: Itching is problematic; prescribe an emollient and a mild topical corticosteroid (e.g. hydrocortisone 1%) The skin looks infected (e.g. oedema, crusting); prescribe a topical antibiotic (e.g. fusidic acid 2%)

Answer 70

Referral may be necessary in some circumstances: -For people who are HIV-positive with extensive lesions urgent referral to a HIV specialist -For people with eyelid-margin or ocular lesions and associated red eye urgent referral to an ophthalmologist -Adults with anogenital lesions should be referred to genito-urinary medicine, for screening for other sexually transmitted infections

Answer 71

Describes symmetrical, brown, velvety plaques that are often found on the neck, axilla and groin.

Answer 72

Causes -type 2 diabetes mellitus -gastrointestinal cancer -obesity -polycystic ovarian syndrome -acromegaly -Cushing's disease -hypothyroidism -familial -Prader-Willi syndrome drugs -combined oral contraceptive pill -nicotinic acid

Answer 73

Pathophysiology insulin resistance → hyperinsulinemia → stimulation of keratinocytes and dermal fibroblast proliferation via interaction with insulin-like growth factor receptor-1 (IGFR1)

Answer 74

S. Aureus or S. pyogenes The incubation period is between 4 to 10 days. Features 'golden', crusted skin lesions typically found around the mouth very contagious

Answer 75

Limited, localised disease NICE Clinical Knowledge Summaries now recommend -hydrogen peroxide 1% cream for 'people who are not systemically unwell or at a high risk of complications' the change was announced in 2020 by NICE and Public Health England and seems aimed at cutting antibiotic resistance the evidence base shows it is just as effective at treating non‑bullous impetigo as a topical antibiotic topical antibiotic creams: topical fusidic acid topical mupirocin should be used if fusidic acid resistance is suspected MRSA is not susceptible to either fusidic acid or retapamulin. Topical mupirocin should, therefore, be used in this situation Extensive disease oral flucloxacillin oral erythromycin if penicillin-allergic

Answer 76

School exclusion children should be excluded from school until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment

Answer 77

Lichen sclerosus was previously termed lichen sclerosus et atrophicus. It is an inflammatory condition that usually affects the genitalia and is more common in elderly females. Lichen sclerosus leads to atrophy of the epidermis with white plaques forming

Answer 78

Features white patches that may scar itch is prominent may result in pain during intercourse or urination

Answer 79

The diagnosis is usually made on clinical grounds but a biopsy may be performed if atypical features are present* Management topical steroids and emollients

Answer 80

Follow-up: increased risk of vulval cancer A confirmatory biopsy, although ideal, is not always practical, particularly in children. It is not always essential when the clinical features are typical. However, histological examination is advisable if there are atypical features or diagnostic uncertainty and is mandatory if there is any suspicion of neoplastic change. Patients under routine follow-up will need a biopsy if: (i) there is a suspicion of neoplastic change, i.e. a persistent area of hyperkeratosis, erosion or erythema, or new warty or papular lesions; (ii) the disease fails to respond to adequate treatment; (iii) there is extragenital LS, with features suggesting an overlap with morphoea; (iv) there are pigmented areas, in order to exclude an abnormal melanocytic proliferation; and (v) second-line therapy is to be used.

Answer 81

Lichen planus is a skin disorder of unknown aetiology, most probably being immune-mediated. Features -itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms -rash often polygonal in shape, with a 'white-lines' pattern on the surface (Wickham's striae) -Koebner phenomenon may be seen (new skin lesions appearing at the site of trauma) -oral involvement in around 50% of patients: typically a white-lace pattern on the buccal mucosa -nails: thinning of nail plate, longitudinal ridging

Answer 82

Lichenoid drug eruptions - causes: gold quinine thiazides

Answer 83

Management -potent topical steroids are the mainstay of treatment -benzydamine mouthwash or spray is recommended for oral lichen planus -extensive lichen planus may require oral steroids or immunosuppression

Answer 84

Lichen sclerosus affecting penis May be itchy, associated with white plaques and can cause significant scarring

Answer 85

The Koebner phenomenon describes skin lesions that appear at the site of injury. It is seen in: psoriasis vitiligo warts lichen planus lichen sclerosus molluscum contagiosum

Answer 86

Zoon's balanitis (also known as plasma cell balanitis) is a chronic condition affecting the head of the penis. It is typically seen in middle-aged/elderly men who are uncircumcised. Features erythematous, well-demarcated shiny patches which affect the head of the penis

Answer 87

Investigation whilst Zoon's balanitis is benign, biopsy may be indicated to exclude alternative diagnoses Management circumcision is generally curative carbon dioxide laser therapy and topical corticosteroids may also have a role

Answer 88

There are two main types of contact dermatitis -irritant contact dermatitis: common - non-allergic reaction due to weak acids or alkalis (e.g. detergents). Often seen on the hands. Erythema is typical, crusting and vesicles are rare -allergic contact dermatitis: type IV hypersensitivity reaction. Uncommon - often seen on the head following hair dyes. Presents as an acute weeping eczema which predominately affects the margins of the hairline rather than the hairy scalp itself. Topical treatment with a potent steroid is indicated

Answer 89

Cement is a frequent cause of contact dermatitis. The alkaline nature of cement may cause an irritant contact dermatitis whilst the dichromates in cement also can cause an allergic contact dermatitis

Answer 90

Nickel is a common cause allergic contact dermatitis and is an example of a type IV hypersensitivity reaction. It is often caused by jewellery such as watches It is diagnosed by a skin patch test

Answer 91

Periorificial dermatitis is a condition typically seen in women aged 20-45 years old. Topical corticosteroids, and to a lesser extent, inhaled corticosteroids are often implicated in the development of the condition.

Answer 92

Features -clustered erythematous papules, papulovesicles and papulopustules -most commonly in the perioral region but also the perinasal and periocular region -skin immediately adjacent to the vermilion border of the lip is typically spared

Answer 93

Management -steroids may worsen symptoms -should be treated with topical or oral antibiotics

Answer 94

Alopecia may be divided into scarring (destruction of hair follicle) and non-scarring (preservation of hair follicle)

Answer 95

Scarring alopecia -trauma, burns -radiotherapy -lichen planus -discoid lupus -tinea capitis* *scarring may develop in untreated tinea capitis if a kerion develops

Answer 96

Non-scarring alopecia -male-pattern baldness -drugs: cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, colchicine -nutritional: iron and zinc deficiency -autoimmune: alopecia areata -telogen effluvium (hair loss following stressful period e.g. surgery) -trichotillomania

Answer 97

Alopecia areata is a presumed autoimmune condition causing localised, well demarcated patches of hair loss. At the edge of the hair loss, there may be small, broken 'exclamation mark' hairs

Answer 98

Hair will regrow in 50% of patients by 1 year, and in 80-90% eventually. Careful explanation is therefore sufficient in many patients. Other treatment options include: -topical or intralesional corticosteroids -topical minoxidil -phototherapy -dithranol -contact immunotherapy -wigs

Answer 99

Causes of skin bullae -congenital: epidermolysis bullosa -autoimmune: bullous pemphigoid, pemphigus -insect bite -trauma/friction -drugs: barbiturates, furosemide

Answer 100

Bullous pemphigoid is an autoimmune condition causing sub-epidermal blistering of the skin. This is secondary to the development of antibodies against hemidesmosomal proteins BP180 and BP230.

Answer 101

Bullous pemphigoid is more common in elderly patients. Features include -itchy, tense blisters typically around flexures -the blisters usually heal without scarring -there is stereotypically no mucosal involvement (i.e. the mouth is spared) -in reality around 10-50% of patients have a degree of mucosal involvement. It would, however, be unusual for an exam question to mention mucosal involvement as it is seen as a classic differentiating feature between pemphigoid and pemphigus.

Answer 102

Skin biopsy immunofluorescence shows IgG and C3 at the dermoepidermal junction

Answer 103

Management referral to a dermatologist for biopsy and confirmation of diagnosis oral corticosteroids are the mainstay of treatment topical corticosteroids, immunosuppressants and antibiotics are also used

Answer 104

Pemphigus vulgaris is an autoimmune disease caused by antibodies directed against desmoglein 3, a cadherin-type epithelial cell adhesion molecule. It is more common in the Ashkenazi Jewish population.

Answer 105

Features -mucosal ulceration is common and often the presenting symptom. Oral involvement is seen in 50-70% of patients -skin blistering - flaccid, easily ruptured vesicles and bullae. Lesions are typically painful but not itchy. These may develop months after the initial mucosal symptoms. Nikolsky's describes the spread of bullae following application of horizontal, tangential pressure to the skin -acantholysis on biopsy

Answer 106

Management steroids are first-line immunosuppressants

Answer 107

Dermatitis herpetiformis is an autoimmune blistering skin disorder associated with coeliac disease. It is caused by deposition of IgA in the dermis. More than 90% of patients exhibit small bowel biopsy findings consistent with some degree of gluten-sensitive enteropathy.

Answer 108

Features itchy, vesicular skin lesions on the extensor surfaces (e.g. elbows, knees, buttocks)

Answer 109

Diagnosis skin biopsy: direct immunofluorescence shows deposition of IgA in a granular pattern in the upper dermis Management gluten-free diet dapsone

Answer 110

Actinic, or solar, keratoses (AK) is a common premalignant skin lesion that develops as a consequence of chronic sun exposure Features small, crusty or scaly, lesions may be pink, red, brown or the same colour as the skin typically on sun-exposed areas e.g. temples of head multiple lesions may be present

Answer 111

Management options include -prevention of further risk: e.g. sun avoidance, sun cream -fluorouracil cream: typically a 2 to 3 week course. The skin will become red and inflamed - sometimes topical hydrocortisone is given following fluorouracil to help settle the inflammation -topical diclofenac: may be used for mild AKs. Moderate efficacy but much fewer side-effects -topical imiquimod: trials have shown good efficacy -cryotherapy -curettage and cautery

Answer 112

There are four main subtypes of melanoma. Nodular melanoma is the most aggressive whilst the other forms spread more slowly. Superficial spreading Nodular Lentigo maligna Acral lentiginous

Answer 113

70% of cases Arms, legs, back and chest, young people A growing moles with diagnostic features

Answer 114

Second commonest Sun exposed skin, middle-aged people Red or black lump or lump which bleeds or oozes

Answer 115

Less common Chronically sun-exposed skin, older people A growing mole with diagnostic features listed above Lentigo maligna is a type of melanoma in-situ. It typically progresses slowly but may at some stage become invasive causing lentigo maligna melanoma.

Answer 116

Rare form Nails, palms or soles, People with darker skin pigmentation Subungual pigmentation (Hutchinson's sign) or on palms or feet

Answer 117

The main diagnostic features (major criteria): Change in size Change in shape Change in colour

Answer 118

Secondary features (minor criteria) Diameter >= 7mm Inflammation Oozing or bleeding Altered sensation

Answer 119

Suspicious lesions should undergo excision biopsy. The lesion should be removed in completely as incision biopsy can make subsequent histopathological assessment difficult. Once the diagnosis is confirmed the pathology report should be reviewed to determine whether further re-excision of margins is required.

Answer 120

Margins of excision-Related to Breslow thickness Lesions 0-1mm thick 1cm Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features) Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features) Lesions >4 mm thick 3cm

Answer 121

The invasion depth of a tumour (Breslow depth) is the single most important factor in determining prognosis of patients with malignant melanoma Breslow Thickness Approximate 5 year survival < 0.75 mm 95-100% 0.76 - 1.50 mm 80-96% 1.51 - 4 mm 60-75% > 4 mm 50%

Answer 122

Bowen's disease is a type of precancerous dermatosis that is a precursor to squamous cell carcinoma. It is more common in elderly patients. There is around a 5-10% chance of developing invasive skin cancer if left untreated.

Answer 123

Features red, scaly patches often 10-15 mm in size slow-growing often occur on sun-exposed areas such as the head (e.g. temples) and neck, lower limbs

Answer 124

Management options: -may sometimes be diagnosed and managed in primary care if clear diagnosis or repeat episode topical 5-fluorouracil typically used twice daily for 4 weeks often results in significant inflammation/erythema. Topical steroids are often given to control this cryotherapy excision

Answer 125

Squamous cell carcinoma is a common variant of skin cancer. Metastases are rare but may occur in 2-5% of patients. Risk factors include: -excessive exposure to sunlight / psoralen UVA therapy -actinic keratoses and Bowen's disease -immunosuppression e.g. following renal transplant, HIV -smoking -long-standing leg ulcers (Marjolin's ulcer) -genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism

Answer 126

Features -typically on sun-exposed sites such as the head and neck or dorsum of the hands and arms -rapidly expanding painless, ulcerate nodules -may have a cauliflower-like appearance -there may be areas of bleeding

Answer 127

Surgical excision with 4mm margins if lesion <20mm in diameter. If tumour >20mm then margins should be 6mm. Mohs micrographic surgery may be used in high-risk patients and in cosmetically important sites.

Answer 128

Well differentiated tumours <20mm diameter <2mm deep No assoc. diseases

Answer 129

Poorly differentiated tumours >20mm diameter >4mm deep Immunosupression

Answer 130

Keratoacanthoma is a benign epithelial tumour. They are more common with advancing age and rare in young people. Features - said to look like a volcano or crater initially a smooth dome-shaped papule rapidly grows to become a crater centrally-filled with keratin Spontaneous regression of keratoacanthoma within 3 months is common, often resulting in a scar. Such lesions should however be urgently excised as it is difficult clinically to exclude squamous cell carcinoma. Removal also may prevent scarring.

Answer 131

Leukoplakia is a premalignant condition which presents as white, hard spots on the mucous membranes of the mouth. It is more common in smokers. Leukoplakia is said to be a diagnosis of exclusion. Candidiasis and lichen planus should be considered, especially if the lesions can be 'rubbed off' Biopsies are usually performed to exclude alternative diagnoses such as squamous cell carcinoma and regular follow-up is required to exclude malignant transformation to squamous cell carcinoma, which occurs in around 1% of patients.

Answer 132

Basal cell carcinoma (BCC) is one of the three main types of skin cancer. Lesions are also known as rodent ulcers and are characterised by slow-growth and local invasion. Metastases are extremely rare. BCC is the most common type of cancer in the Western world.

Answer 133

Features -many types of BCC are described. -The most common type is nodular BCC, which is described here -sun-exposed sites, especially the head and neck account for the majority of lesions -initially a pearly, flesh-coloured papule with telangiectasia may later ulcerate leaving a central 'crater'

Answer 134

Referral generally, if a BCC is suspected, a routine referral should be made Management options: surgical removal curettage cryotherapy topical cream: imiquimod, fluorouracil radiotherapy

Answer 135

Mycosis fungoides is a rare form of T-cell lymphoma that affects the skin. Features itchy, red patches which are lesions tend to be of different colours in contrast to eczema/psoriasis where there is greater homogenicity

Answer 136

Cherry haemangiomas (Campbell de Morgan spots) are benign skin lesions which contain an abnormal proliferation of capillaries. They are more common with advancing age and affect men and women equally.

Answer 137

Features -erythematous, papular lesions -typically 1-3 mm in size -non-blanching -not found on the mucous membranes As they are benign no treatment is usually required.

Answer 138

Chondrodermatitis nodularis helicis (CNH) is a common and benign condition characterised by the development of a painful nodule on the ear. It is thought to be caused by factors such as persistent pressure on the ear (e.g. secondary to sleep, headsets), trauma or cold. CNH is more common in men and with increasing age.

Answer 139

Management reducing pressure on the ear: foam 'ear protectors' may be used during sleep other treatment options include cryotherapy, steroid injection, collagen injection surgical treatment may be used but there is a high recurrence rate

Answer 140

Dermatitis artefacta is a rare psycho-dermatological condition characterised by self-inflicted skin lesions. Patients typically deny that these are self-induced. Epidemiology: It typically affects adolescence but may present at any age it is 4-20 times more common in females Risk factors: dermatitis artefacta is strongly associated with personality disorder, dissociative disorders and eating disorders the prevalence of dermatitis artefacta is up to 33% in patients with bulimia or anorexia

Answer 141

Clinical features: -patients typically present with linear/geometric lesions that are well-demarcated from normal skin. The appearance of lesions depends on the mechanism of injuries which may be either (scratching with fingernails or other objects, burning skin with cigarettes) or chemical (deodorant spray) -skin lesions are typically described to appear suddenly e.g. overnight. They usually appear whole and complete and do not evolve over time. There may be multiple lesions at various stages of healing -commonly affected areas are the face (especially cheeks) and the dorsum of the hands -despite the severity of skin lesions, patients may be nonchalant, displaying 'la belle indifference' (also known as Mona Lisa smile) -In the history, there may be recent life events or triggers such as a marital dispute or recent bereavement

Answer 142

Diagnostic approach: -this condition is diagnosed clinically based on history and after exclusion of other dermatological conditions -biopsy of skin lesions is not routine but may be helpful to exclude other conditions. -Histopathological analysis of self-inflicted lesions is non-specific psychiatric assessment may be necessary

Answer 143

Differential diagnosis: -other dermatological conditions e.g. cutaneous T-cell lymphoma, pyoderma gangrenosum, basal cell carcinoma, lichen planus, psoriasis -other factitious disorders e.g. Munchausen syndrome (self-inflicting is not limited to the skin), malingering (self-inflicting for secondary gain e.g. to avoid work or to gain compensation)

Answer 144

Dermatofibromas (also known as histiocytomas) are common benign fibrous skin lesions. They are caused by the abnormal growth of dermal dendritic histiocyte cells, often following a precipitating injury. Common areas include the arms and legs. Features solitary firm papule or nodule, typically on a limb typically around 5-10mm in size overlying skin dimples on pinching the lesion

Answer 145

Erythema ab igne is a skin disorder caused by over exposure to infrared radiation. Characteristic features include reticulated, erythematous patches with hyperpigmentation and telangiectasia. A typical history would be an elderly women who always sits next to an open fire. If the cause is not treated then patients may go on to develop squamous cell skin cancer.

Answer 146

Erythema multiforme is a hypersensitivity reaction that is most commonly triggered by infections. It may be divided into minor and major forms. Previously it was thought that Stevens-Johnson syndrome (SJS) was a severe form of erythema multiforme. They are now however considered as separate entities. Features target lesions initially seen on the back of the hands / feet before spreading to the torso upper limbs are more commonly affected than the lower limbs pruritus is occasionally seen and is usually mild

Answer 147

-viruses: herpes simplex virus (the most common cause), Orf* -idiopathic -bacteria: Mycoplasma, Streptococcus -drugs: penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill, nevirapine -connective tissue disease e.g. Systemic lupus erythematosus -sarcoidosis -malignancy

Answer 148

The more severe form, erythema multiforme major is associated with mucosal involvement.

Answer 149

Overview -inflammation of subcutaneous fat typically causes tender, erythematous, nodular lesions -usually occurs over shins, may also occur elsewhere (e.g. forearms, thighs) -usually resolves within 6 weeks -lesions heal without scarring

Answer 150

Causes -infection: streptococci/ tuberculosis/ brucellosis -systemic disease: sarcoidosis/ inflammatory bowel disease/ Behcet's -malignancy/lymphoma -drugs: penicillins / sulphonamides / combined oral contraceptive pill -pregnancy

Answer 151

Erythrasma is a generally asymptomatic, flat, slightly scaly, pink or brown rash usually found in the groin or axillae. It is caused by an overgrowth of the diphtheroid Corynebacterium minutissimum Examination with Wood's light reveals a coral-red fluorescence. Topical miconazole or antibacterial are usually effective. Oral erythromycin may be used for more extensive infection

Answer 152

Erythroderma is a term used when more than 95% of the skin is involved in a rash of any kind. Causes of erythroderma eczema psoriasis drugs e.g. gold lymphomas, leukaemias idiopathic

Answer 153

Erythrodermic psoriasis may result from progression of chronic disease to an exfoliative phase with plaques covering most of the body. Associated with mild systemic upset more serious form is an acute deterioration. This may be triggered by a variety of factors such as withdrawal of systemic steroids. Patients need to be admitted to hospital for management

Answer 154

Basics papular lesions that are often slightly hyperpigmented and depressed centrally typically occur on the dorsal surfaces of the hands and feet, and on the extensor aspects of the arms and legs A number of associations have been proposed to conditions such as diabetes mellitus but there is only weak evidence for this

Answer 155

Also known as Osler-Weber-Rendu syndrome, hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant condition characterised by (as the name suggests) multiple telangiectasia over the skin and mucous membranes. Twenty percent of cases occur spontaneously without prior family history.

Answer 156

There are 4 main diagnostic criteria. If the patient has 2 then they are said to have a possible diagnosis of HHT. If they meet 3 or more of the criteria they are said to have a definite diagnosis of HHT: -epistaxis : spontaneous, recurrent nosebleeds -telangiectases: multiple at characteristic sites (lips, oral cavity, fingers, nose) -visceral lesions: for example gastrointestinal telangiectasia (with or without bleeding), pulmonary arteriovenous malformations (AVM), hepatic AVM, cerebral AVM, spinal AVM -family history: a first-degree relative with HHT

Answer 157

Hirsutism is often used to describe androgen-dependent hair growth in women, with hypertrichosis being used for androgen-independent hair growth Polycystic ovarian syndrome is the most common causes of hirsutism. Other causes include: Cushing's syndrome congenital adrenal hyperplasia androgen therapy obesity: thought to be due to insulin resistance adrenal tumour androgen secreting ovarian tumour drugs: phenytoin, corticosteroids

Answer 158

Assessment of hirsutism Ferriman-Gallwey scoring system: 9 body areas are assigned a score of 0 - 4, a score > 15 is considered to indicate moderate or severe hirsutism Management of hirsutism advise weight loss if overweight cosmetic techniques such as waxing/bleaching - not available on the NHS consider using combined oral contraceptive pills such as co-cyprindiol (Dianette) or ethinylestradiol and drospirenone (Yasmin). Co-cyprindiol should not be used long-term due to the increased risk of venous thromboembolism facial hirsutism: topical eflornithine - contraindicated in pregnancy and breast-feeding

Answer 159

Causes of hypertrichosis -drugs: minoxidil, ciclosporin, diazoxide -congenital hypertrichosis lanuginosa, congenital hypertrichosis terminalis -porphyria cutanea tarda -anorexia nervosa

Answer 160

Hyperhidrosis describes the excessive production of sweat. Management options include: -topical aluminium chloride preparations are first-line. Main side effect is skin irritation -iontophoresis: particularly useful for patients with palmar, plantar and axillary hyperhidrosis -botulinum toxin: currently licensed for axillary symptoms -surgery: e.g. Endoscopic transthoracic sympathectomy. Patients should be made aware of the risk of compensatory sweating

Answer 161

Porphyria cutanea tarda is the most common hepatic porphyria. It is due to an inherited defect in uroporphyrinogen decarboxylase or caused by hepatocyte damage e.g. alcohol, hepatitis C, oestrogen.

Answer 162

Features classically presents with photosensitive rash with blistering and skin fragility on the face and dorsal aspect of hands (most common feature) hypertrichosis hyperpigmentation

Answer 163

Investigations urine: elevated uroporphyrinogen and pink fluorescence of urine under Wood's lamp serum iron ferritin level is used to guide therapy

Answer 164

Management chloroquine venesection preferred if iron ferritin is above 600 ng/ml

Answer 165

Juvenile spring eruption is a skin condition which appears following sun exposure. It is a variant of polymorphic light eruption (PLE) and manifests as itchy red bumps which turn into blisters and crusts on the light-exposed parts of the ears. Epidemiology Juvenile spring eruption is less common in females due to increased amounts of hair covering the ears Presentation is usually in boys aged between 5-14 years

Answer 166

Causes Sun-induced allergy rash: More likely to occur in the springtime Some patients may also have PLE elsewhere on the body Increased incidence in cold weather

Answer 167

Signs Itchy red rash consisting of small bumps on the tops of the ears following sun exposure May evolve into painful blisters and crusts Investigations Clinical diagnosis: Usually no clinical tests are required In aggressive cases, lupus should be ruled out by ANA and ENA blood tests

Answer 168

Management General: Provide a patient information leaflet, educate on sun exposure and use of suncream and hats Provide topical treatments such as emollients or calamine lotion Anti-histamines can provide itch relief at night-time For more serious cases, oral steroids such as prednisolone can be used as well as immune-system suppressants

Answer 169

Port wine stains are vascular birthmarks that tend to be unilateral. They are deep red or purple in colour. Unlike other vascular birthmarks such as salmon patches and strawberry haemangiomas, they do not spontaneously resolve, and in fact often darken and become raised over time. Treatment is with cosmetic camouflage or laser therapy (multiple sessions are required).

Answer 170

Salmon patches are a kind of vascular birthmark which can be seen in around half of newborn babies they are also known as stork marks or stork bites. They are pink and blotchy, and commonly found on the forehead, eyelids and nape of the neck. They usually fade over a few months, though marks on the neck may persist.

Answer 171

Strawberry naevi (capillary haemangioma) are usually not present at birth but may develop rapidly in the first month of life. They appear as erythematous, raised and multilobed tumours. Typically they increase in size until around 6-9 months before regressing over the next few years (around 95% resolve before 10 years of age). Common sites include the face, scalp and back. Rarely they may be present in the upper respiratory tract leading to potential airway obstruction

Answer 172

Capillary haemangiomas are present in around 10% of white infants. Female infants, premature infants and those of mothers who have undergone chorionic villous sampling are more likely to be affected Potential complications mechanical e.g. Obstructing visual fields or airway bleeding ulceration thrombocytopaenia

Answer 173

If treatment is required (e.g. Visual field obstruction) then propranolol is increasingly replacing systemic steroids as the treatment of choice. Topical beta-blockers such as timolol are also sometimes used. Cavernous haemangioma is a deep capillary haemangioma

Answer 174

Spider naevi (also called spider angiomas) describe a central red papule with surrounding capillaries. The lesions blanch upon pressure. Spider naevi are almost always found on the upper part of the body. Spider naevi can be differentiated from telangiectasia by pressing on them and watching them fill. Spider naevi fill from the centre, telangiectasia from the edge . Around 10-15% of people will have one or more spider naevi and they are more common in childhood. Other associations liver disease pregnancy combined oral contraceptive pill

Answer 175

Keloid scars are tumour-like lesions that arise from the connective tissue of a scar and extend beyond the dimensions of the original wound Predisposing factors -ethnicity: more common in people with dark skin -occur more commonly in young adults, rare in the elderly -common sites (in order of decreasing frequency): sternum, shoulder, neck, face, extensor surface of limbs, trunk Keloid scars are less likely if incisions are made along relaxed skin tension lines* Treatment -early keloids may be treated with intra-lesional steroids e.g. triamcinolone -excision is sometimes required but careful consideration needs to given to the potential to create further keloid scarring

Answer 176

Atopic eruption of pregnancy is the commonest skin disorder found in pregnancy it typically presents as an eczematous, itchy red rash. no specific treatment is needed

Answer 177

Polymorphic eruption of pregnancy pruritic condition associated with last trimester lesions often first appear in abdominal striae management depends on severity: emollients, mild potency topical steroids and oral steroids may be used

Answer 178

Skin manifestations of systemic lupus erythematosus (SLE) photosensitive 'butterfly' rash discoid lupus alopecia livedo reticularis: net-like rash

Answer 179

Venous ulceration is typically seen above the medial malleolus Investigations ankle-brachial pressure index (ABPI) is important in non-healing ulcers to assess for poor arterial flow which could impair healing a 'normal' ABPI may be regarded as between 0.9 - 1.2. Values below 0.9 indicate arterial disease. Interestingly, values above 1.3 may also indicate arterial disease, in the form of false-negative results secondary to arterial calcification (e.g. In diabetics)

Answer 180

Management -compression bandaging, usually four layer (only treatment shown to be of real benefit) -oral pentoxifylline, a peripheral vasodilator, improves healing rate small evidence base supporting -use of flavinoids -little evidence to suggest benefit from hydrocolloid dressings, topical growth factors, ultrasound therapy and intermittent pneumatic compression

Answer 181

Vitiligo is an autoimmune condition which results in the loss of melanocytes and consequent depigmentation of the skin. It is thought to affect around 1% of the population and symptoms typically develop by the age of 20-30 years. Associated conditions type 1 diabetes mellitus Addison's disease autoimmune thyroid disorders pernicious anaemia alopecia areata

Answer 182

Features well-demarcated patches of depigmented skin the peripheries tend to be most affected trauma may precipitate new lesions (Koebner phenomenon) Management sunblock for affected areas of skin camouflage make-up topical corticosteroids may reverse the changes if applied early there may also be a role for topical tacrolimus and phototherapy, although caution needs to be exercised with light-skinned patients

Answer 183

Features acrodermatitis: red, crusted lesions acral distribution peri-orificial perianal alopecia short stature hypogonadism hepatosplenomegaly geophagia (ingesting clay/soil) cognitive impairment Acrodermatitis enteropathica is a recessively inherited partial defect in intestinal zinc absorption.

Answer 184

Assessing the extent of the burn Wallace's Rule of Nines: head + neck = 9%, each arm = 9%, each anterior part of leg = 9%, each posterior part of leg = 9%, anterior chest = 9%, posterior chest = 9%, anterior abdomen = 9%, posterior abdomen = 9% Lund and Browder chart: the most accurate method the palmar surface is roughly equivalent to 1% of total body surface area (TBSA). Not accurate for burns > 15% TBSA

Answer 185

Modern terminology Former terminology Appearance Superficial epidermal First degree Red and painful, dry, no blisters Partial thickness (superficial dermal) Second degree Pale pink, painful, blistered. Slow capillary refill Partial thickness (deep dermal) Second degree Typically white but may have pavtches of non-blanching erythema. Reduced sensation, painful to deep pressure Full thickness Third degree White ('waxy')/brown ('leathery')/black in colour, no blisters, no pain

Answer 186

Referral to secondary care all deep dermal and full-thickness burns. superficial dermal burns of more than 3% TBSA in adults, or more than 2% TBSA in children superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso, or neck any inhalation injury any electrical or chemical burn injury suspicion of non-accidental injury

Answer 187

Management stop precipitating factor supportive care often in an intensive care unit volume loss and electrolyte derangement are potential complications intravenous immunoglobulin has been shown to be effective and is now commonly used first-line other treatment options include: immunosuppressive agents (ciclosporin and cyclophosphamide), plasmapheresis

Answer 188

The Dermatology Life Quality Index (DLQI) is a widely used scoring system which assesses the impact of chronic skin disorders on patients lives. Basics 10 questions each scored out of 3. Maximum score is therefore 30, with a higher score indicating a more significant impact on quality of life usually takes around 1-2 minutes to complete covers 6 areas: Symptoms and feelings, Daily activities, Leisure Questions , Work and School , Personal relationships and Treatment

Answer 189

0-1 no effect at all on patient's life 2-5 small effect on patient's life 6-10 moderate effect on patient's life 11-20 very large effect on patient's life 21-30 extremely large effect on patient's life

Answer 190

Notalgia paraesthetica = chronic itch on medial border of scapula