Dermatology Flashcards
1st line treatment acne
Benzoyl peroxide 5%
Adapalene 0.1%
Epiduo- adapalene+ benzoyl peroxide 5%
Duac- clindamycin + benzoyl peroxide
Moderate acne treatment
1st- Duac or clindamycin+benzoyl peroxide
2nd- tretinoin 0.025% + clindamycin 1%
Or Dalacin T (clindamycin monotherapy) and Zineryt (erythromycin and zinc complex
Stop at 6 months
+ COCP?
3rd line moderate acne
Continue with topical benzoyl peroxide, azelaic acid, or retinoid preparation.
Doxycycline 100 mg OD or lymecycline 408 mg OD
Reserve erythromycin for patients aged 12 years or younger, pregnant women, and patients unresponsive or unable to tolerate tetracyclines.
Take abx 2 to 3 months then assess
Criteria for referral to dermatology for acne
Severe cystic acne with scarring
Extreme psychological response to acne
Prolonged acne beyond the age of 25 years
No response or relapse on treatment with oral antibiotics
For consideration of isotretinoin
Red flag in eczema
Eczema herpeticum
Sudden and rapid deterioration in eczema.
Painful punched-out erosions and blisters usually prominent on the head and neck.
The patient may be unwell with flu-like symptoms, fever, and lymphadenopathy.
Risk of encephalitis/keratitis of cornea
Venous eczema features
Itchy red, blistered and crusted plaques on lower legs
Orange-brown macular pigmentation due to haemosiderin
Atrophie blanche (white irregular scars surrounded by red spots)
‘Champagne bottle’ lipodermatosclerosis
Treatment seborrhoeic dermatitis
Non soap cleaner for face BD
Keratolytics for scale (salicylic acid/urea)
Ketoconazole shampoo
Mild topic steroids for flares
Coal tar for scalp
Phototherapy/tacrolimus/oral itraconazole if severe
Steroid cream potency
Mild- hydrocortisone
Mod- eumovate
Potent- betnovate
Very potent- dermovate
Risk factors for poor outcome in fungal nail infections
Diabetes mellitus
Immunosuppression
Previous history of fungal nail infection
More than 50% nail plate involvement
Chronic paronychia
When would you treat fungal nail infections?
fungal nail is severe, painful, or debilitating, or
patient has peripheral vascular disease, diabetes, or is immunocompromised.
Treatments of fungal nail infections and likelihood of cure
25% fail cure with any treatment.
OTC amorolfine 5% nail lacquer.-
Treat up to 2 affected nails, cure rate 50%.
Requires good mobility and time to file, cleanse, and apply.
Oral terbinafine:
Fingernail– 250 mg OD 6 -12 weeks.
Toenail – 250 mg OD for 3- 6 months.
cure rate of 70%, monitor LFT before treatment then periodically after 6 weeks
Features suggestive of melanoma
7‑point weighted checklist for pigmented skin lesions. Suspect melanoma if 3 or more (66% of melanoma cases).
Major features (worth 2 points each):
Change in size
Irregular shape
Irregular colour
Minor features (worth 1 point each):
Largest diameter is 7 mm or more
Inflammation
Oozing
Change in sensation or itching
elevated, firm, and growing over a period of 4 to 6 weeks are suspicious for melanoma, even if non‑pigmented.
What is acral lentiginous melanoma?
Characterised by site of origin – palm, sole, fingers, toes, or beneath the nail (subungual).
Not related to sun exposure – cause is unknown.
May present as an enlarging patch of discoloured skin, often thought initially to be a stain.
Over 30% of cases are hypomelanotic, and may mimic plantar warts or tinea infection
Causes of itch without rash
Iron deficiency
Liver disease
Primary biliary cirrhosis
Malignancy, e.g. Hodgkin’s disease, leukaemia
Polycythaemia
Renal failure
Thyroid dysfunction
Dry skin, particularly in older people
Urticaria
Drugs
Pregnancy
Regional neuropathy
Delusion of parasitosis/amphetamine use
Drug causes of itch
ACE inhibitors
Aspirin
Antibiotics
Antimalarials
Diuretics
Lamotrigine
Opiates
Statins
Investigations of itch without primary rash
FBC, U+E, LFTs, blood glucose, ESR/CRP, immunoglobulins.
Iron studies, TSH, LDH
consider chest X-ray.
pregnancy test
Treatment of itch
Moisturiser
Menthol ointment
Steroid cream
Antihistamines
Avoid hot showers, keep nails short
What is guttate psoriasis? Any tests?
Young adults 2 to 3 weeks after tonsillitis or viral infection, rapid onset
Widespread, small, thin, teardrop lesions on the trunk.
Lasts 2 to 3 months.
UVB therapy, emollients
Ix for streptococcal throat infection to guide abx:
Throat swab microscopy, culture, and sensitivity
Anti-DNase B
Anti Streptococcal O Titre (ASOT)
Risk factors for psoriasis
metabolic syndrome.
cardiovascular disease.
inflammatory bowel disease (especially Crohn’s disease).
coeliac disease.
depression.
alcoholism.
Management psoriasis
Sun exposure
Tar shampoo, Polytar, Alphosyl 2 in 1.
Smoking cessation
Limiting alcohol
weight loss and exercise can improve psoriasis + metabolic syndrome.
Emollients
Steroid cream + calcipotriol
Exorex coal tar 5%
Management scalp psoriasis and face psoriasis
Cocois ointment or Sebco ointment for 1 hour (or overnight if tolerated) and wash out with Polytar, Alphosyl 2 in 1. Use daily until skin is clear, then twice a week for maintenance.
If inadequate response after 2 weeks, change to betamethasone scalp application.
Face psoriasis in conjunction with seborrhoeic dermatitis Daktacort cream OD 7 to 10 days.
Basal cell carcinoma (BCC) Characteristics
non‑healing sore with visible blood vessels.
slowly growing plaque or nodule.
skin‑coloured, pink, or pigmented.
varies in size from a few millimetres to several centimetres in diameter.
spontaneous bleeding or ulceration.
hyperkeratosis, which may indicate an SCC.
If you stretch the skin, pearly edge
Features SCC
Classic – tenderness, thickening, and induration of lesion, often with hyperkeratosis
Keratoacanthoma – rapidly growing lesions, often with a smooth outer dome and central keratin core
Treatment warts
No treatment.
Keep covered continuously with an occlusive dressing, e.g. duct tape or strapping tape.
Salicylic acid treatment has similar effectiveness to cryotherapy for verruca, but is less painful.
Cryotherapy, if offered in GP
When to suspect underlying cause of hair loss
Absent or reduced eyebrows or eyelashes — may suggest a frontal fibrosing alopecia or alopecia areata.
Inflammation, papules or pustules, scaling, or scarring of the scalp — may suggest scarring alopecia.
Systemic disease, such as a recent severe infection, iron deficiency, or hypothyroidism.
Exposure to (or a change of) medication.
Change in dietary habits or rapid weight loss
Causes of scarring alopecia
Tinea capitis —itchy, scaly scalp with patchy, irregular hair loss. Lymphadenopathy (post-auricular and cervical) if inflammatory tinea capitis, and in more severe cases, erythema, pustules, permanent alopecia, and scarring of hair follicles
Discoid lupus erythematosus — persistent scaly, disc-like plaques on the scalp, face, and ears that may cause violaceous or pink erythema, scarring, and hair loss.
Dermatomyositis —rare acquired inflammatory myopathy that is accompanied by an itchy reddish or bluish-purple patches, mostly on sun-exposed areas of the body.
Treatment of male pattern hair loss
Minoxidil 5% scalp foam (Regaine for Men Extra Strength Scalp Foam 5%) can be prescribed or purchased OTC.
Finasteride 1 mg tablets (Propecia) private prescription.
Ix for hyperhydrosis secondary causes
FBC, CRP, U+E, LFT, HbA1c, TFT
?HIV/tuberculosis
?Blood film for malaria
24-hour urine catecholamines, metanephrines (phaeochromocytoma) and 5-hydroxyindoleacetic acid (carcinoid tumours).
Chest X-ray
2ndary causes hyperhidrosis
Anxiety
Pregnancy or menopause.
Infections — TB, brucellosis, HIV, and malaria.
Malignancy — Hodgkin’s disease, myeloproliferative disorders.
Endocrine — hyperthyroidism, diabetic hypoglycaemia, diabetes insipidus, phaeochromocytoma, acromegaly, carcinoid syndrome, hyperpituitarism, obesity, and gout.
Neurological — PD, epilepsy, hypothalamic lesions.
Drugs -SNRIs, SSRIs, TCAs,, pilocarpine; propranolol, ciprofloxacin, aciclovir, esomeprazole, and opioids.
Drug or alcohol misuse or withdrawal
Management hyperhidrosis
20% aluminium chloride hexahydrate OTC
Apply at night to dry skin, wash off in morning.
Apply every 1–2 days as tolerated then PRN which may be up to every 6 weeks
Specialist treatments of glycopyrrolate, oxybutinin, glycopyrronium, propanthaline bromide, iontophoresis, botox
Treatment alopecia
If non scarring + no hair regrowth trial potent topical corticosteroid betamethasone valerate 0.1% for 3 months
Specialist treatment: steroids, topical immunotherapy, topical minoxidil, PUVA, immunosupressants
Hypopigmentation/depigmentation causes
-Vitiligo
-Hypopigmentation following eczema, psoriasis, lichen planus, scleroderma or systemic sclerosis, SLE, and syphilis.
-Lichen sclerosis -itchy, white atrophic plaques in the perineum
-Progressive macular hypomelanosis- ill-defined macules on trunk, often confluent in and around the midline
-Pityriasis versicolor- superficial yeast infection, small (less than 1 cm in diameter), round, pale hypopigmented, fine, dry scale.
-Tuberculoid leprosy
Progressive macular hypomelanosis treatment
Narrowband UVB phototherapy
Oral tetracyclines
Topical anti-acne preparations eg, clindamycin and benzoyl peroxide
Treatment pityriasis versicolour
Ketoconazole 2% shampoo OD for up to 5 days
Perioral dermatitis
An acneiform eruption, surrounding skin scaly and flaky
Burning sensation, itch
Stop steroid cream + washes
4-8 weeks Metronidazole 0.75–1%
Erythromycin 1% gel
Treatment rosacea
Sunscreen
Tinted cosmetics
Brimonidine 0.5% gel for flushing OD PRN
Topical ivermectin for moderate papules/pustules OD 8–12 weeks, or metronidazole 0.75% gel BD or azelaic acid 15% BD
If severe, topical ivermectin, + PO doxycycline MR 40 mg 8–12 weeks
Bullous pemphigoid
Autoimmune subepidermal blistering disease, usually age>80
severe itch and (usually) large, tense bullae (fluid-filled blisters), which rupture forming crusted erosions
Ultrapotent steroid cream if < 10% of body surface
Moderate potency topical steroids and emollients
Prednisone 0.5 mg/kg/day
Doxycycline 200 mg/day if mild
Pemphigus vulgaris
Rare autoimmune painful blisters and erosions on the skin and mucous membranes, most commonly inside the mouth, thin-walled flaccid blisters
PO prednisolone/IV methylpred
Hidradenitis suppuritiva
Persistent or recurrent boil-like nodules and abscesses, axillae groin under breasts
benzoyl peroxide wash/hibiscrub
Topical clindamycin phosphate 1% with benzoyl peroxide
Topical antibiotics: fusidic acid, metronidazole.
PO doxycyline/erythromycin
What to do if aktinic keratosis
Teledermatology for opinion
Efudix (flurouracil) ON 3-4 weeks
