Dermatology Flashcards
1
Q
What is important to elicit in a history in Dermatology?
A
PC:
Nature, site, duration
Evolution/progression
Associated sx, Aggrivating/relieving factors
Contact (change in detergents, clothes, soap etc..)
Events - Stress, illness, travel, sunburn, tanning
Past med/fam hx: Skin disease, atopy (asthma, allergic rhinitis, eczema)
Social: QoL, occupation, hobbies, sport!
2
Q
Give 3 diseases most associated with atopy
A
Asthma, eczema, allergic rhinitis
3
Q
When performing an examination, how would you describe a dermatology finding?
A
SSCAAMM
Size + Shape
Colour
Associated secondary changes + Area (distribution)
Morphology + Margin
4
Q
What is variegation
A
Multicolour or varied colours
5
Q
What diameter of skin lesion would concern you? (in terms of cancer)
A
> 6mm
6
Q
You see a pigmented lesion, how would you describe it?
A
ABCDE
Asymmetry
Border (irregular)
Colour variegation (2 or more colours)
Diameter (>6mm)
Evolving: Change in size, colour, bleeding
7
Q
Define a lesion
Define a Rash
A
Lesion = area of altered skin
Rash = Eruption of lesions (AKA multiple)
8
Q
Define Erythema
Define Purpura
A
Erythema = redness that blanches on pressure
Purpura = Red/purple that does NOT blanch on pressure
9
Q
What are the 2 types of Purpura?
A
Petechiae: Small pinpoint macules (1-3mm)
Ecchymosis: Large bruise-like patches (>1cm)
10
Q
Define Macule
Define Patch
A
Macule = Flat area of altered colour <10mm (e.g. Freckles)
Patch = Large flat area of altered colour >10mm (e.g. Naevus Flammeus or port-wine stain)
11
Q
Define Papule
Define Nodule
A
Papule: Solid, raised lesion <5mm e.g. Xanthelasma
Nodule: Solid, raised lesion >5mm
12
Q
Define Vesicle
Define Pustule
Define Bulla
A
Vesicle: Raised, clear fluid lesion <5mm
Pustule: Pus-containing lesion <5mm
Bulla: Raised clear fluid lesion >5mm
13
Q
Define Plaque
Give an example
A
Palpable raised scaly lesions
e.g. Psoriasis
14
Q
What lesion is Acne. Define it
A
Comedone which is a plug of sebaceous follicle-containing altered sebum, bacteria, cellular debris
15
Q
What are the 2 main layers of the skin
A
Epidermis
Dermis
16
Q
What is a naevus?
Is it typically benign or malignant?
What are the different types of naevi?
A
Naevus = mole = localised malformation of tissue structures
Typically benign
1) Congenital Naevus (birthmark)
2) Intradermal Naevus (birthmark)
3) Junctional Naevus (in junction between epidermis and dermis)
4) Compound Naevus (Group of naevus cells found in each epidermis and dermis)
5) Halo naevus (Mole surrounded by a ring)
6) Atypical naevus (Benign dysplastic mole)
17
Q
Benign skin lesions are common and well-defined. They are typically asymptomatic.
Are they pigmented?
What are Red flags?
A
They may be pigmented
18
Q
What type of naevus is most associated with a malignancy? What type of malignancy?
A
Atypical naevus -> Melanoma
19
Q
What type of Naevus is this?
A
Congenital Naevus (birthmark)
20
Q
What type of Naevus is this?
A
Intradermal Naevus (birthmark). elevated, dome shape
21
Q
What type of Naevus is this?
A
Junctional Naevus (in junction between epidermis and dermis)
22
Q
What type of Naevus is this?
A
Compound Naevus (Group of naevus cells found in each epidermis and dermis)
23
Q
What type of Naevus is this?
A
Halo naevus (Mole surrounded by a ring)
24
Q
What type of Naevus is this?
A
Atypical naevus (Benign dysplastic mole). Risk of Melanoma
25
What is shown in this photo?
Where is it typically found?
What population is more likely to have this?
If you were to examine it, would be hard and firm or soft and mobile?
How would you manage a patient with this?
Skin tag
Typically on neck, groin, and skin folds => High BMI patients
Soft and mobile
Management is not necessary as it is harmless. If patient wants it removed, excision, cryothermy, or diathermy may be used
26
Describe the image on the left
What is this?
Where is it found most commonly?
How would you manage this patient?
non-erythematous, raised, round lesion with central punctuation. It has a regular border with overlying telangiectasia.
Most commonly found on neck, face, and trunk
Management is not necessary but if the patient wants it removed, then excision.
27
What is shown in these images?
How would you describe these lesions?
Does this have malignant potential?
What is the management of this?
This is Seborrheic Keratosis
Darkly pigmented papules/plaques with an irregular, scaly, elevated appearance
No malignant potential
Management not necessary but if needed, surgical excision or cryotherapy
28
What is cryotherapy
Any tx that involves the use of freezing temperature to destroy tissue
29
What is shown in this image?
Describe what you see
If you were to examine this patient. Would this be soft or hard consistency?
How would you manage this patient?
Lipoma
Large, dome-shaped subcutaneous lesion with regular border. It has a soft/medium consistency as it is fat
Management is not necessary but if the patient wants it removed, then excision.
30
What is a lipoma?
Lipomas are benign, slow growing subcutaneous adipose tissue/cells
31
What is the most common malignancy in dermatology?
SCC
32
What pre-malignant skin lesions are we concerned about in dermatology?
Which one is associated with sun-induced immunosuppression?
Actinic Keratosis
Bowen's disease (SCC in-situ) - Sun-induced immunosuppresion
33
Describe what you see in these images
What is the most likely diagnosis?
Where are these lesions typically found?
How would you manage this patient?
Actinic Keratosis: Small erythematous, scaly lesions and rough patches. There are yellow adherent crusts on them as well
These are typically found on sun-exposed skin
Management:
Topical 5FU OD 4/52
3% Diclofenac gel BD 2/52
Cryotherapy
Curettage and Cautery
34
What is 5FU?
5-fluorouracil is a cytotoxic chemotherapy medication
35
What is diclofenac?
NSAID
36
What is curettage?
Procedure in which surgeon scrapes off a skin lesion using a sharp blade called a curette
37
What is Cautery?
Procedure that is used to stop bleeding and seal wounds
38
Describe what you see in these images
What is the most likely diagnosis?
Give 1 other feature of this disease not found in the pictures
How would you manage this?
Bowen's disease/SCC in-situ: Large, erythematous, scaly, papules that are typically scattered
May also have ulcerations and bleeding
Management
1) Topical 5FU
2) Cryotherapy
3) Superficial skin surgery
4) Photodynamic therapy
39
Differentiate between actinic keratosis and Bowen's disease
Actinic keratosis is typically small in size (0.5-2cm) whereas Bowen's enlarges slowly up to 3cm in size
Bowen's lesions are also more erythematous and scalier than Actinic karatosis
40
What are the 3 most common types of skin cancer
Malignant melanoma (1%)
SCC - Squamous cell carcinoma
BCC - Basal Cell Carcinoma
41
Malignant Melanomas only represent 1% of skin cancers but 80% of skin cancer deaths. How would you describe a lesion suspected on being a melanoma?
What sign is associated with Malignant melanomas? Define it
Give 5 RFs for Malignant melanoma
How would you manage malignant melanoma?
ABCDE
Asymmetry
Border (irregular)
Colour variegation (2 or more colours)
Diameter (>6mm)
Evolving: Change in size, colour, bleeding
Ugly Duckling sign: Elevated abnormal lesion, raised compared to surrounding lesion
RFs:
1) UV exposure
2) Skin Type I
3) Increased age
4) Male
5) Immunosuppression
6) Hx of frequent or severe sunburn in childhood
7) Hx of skin cancer
8) Genetic predisposition
Management:
Surgical excision +/- Radiotherapy +/- Chemotherapy if metastasis
42
What is Skin Type I?
It is the type of skin that always burns and never tans
43
What is shown in these images?
Describe the lesion (ideal)
These pictures are showing squamous cell carcinomas
Hyperkeratotic irregular nodule with central ulceration and scaly appearance
44
UV exposure is one of the main causes of cancer. How does that vary between skin cancers found in the young and older population?
Young = Intermittent high intensity UV exposure
Older = Cumulative UV exposure
45
SCC are hyperkeratotic irregular lesions that are associated with a chronic wound/scar. It is the 2nd most common skin cancer and 5% metastasise. How would you manage SCC?
Surgical excision +/- radiotherapy
46
What is shown in this image?
Describe the lesion (ideal)
Basal cell carcinoma
Nodular with pearly edges, telangiectasia, central ulceration
47
There are several types of BCC, nodular being the most common and characterised by pearly edges, telangiectasia, and central ulceration. BCC rarely metastasises but may still happen. How would you manage a patient with BCC?
Cryotherapy
Topical Imiquimod or 5FU
Surgical excision +/- radiotherapy
48
Dermatitis is inflammation of the skin. What are it's lesions characterised by?
What is it associated with (3)?
How is it classified?
Itchy, dry papules on an erythematous base
A/w Asthma, allergic rhinitis, and atopy
Classified as either Endogenous (Atopic dermatitis, Venous eczema) or Exogenous (Contact dermatitis)
49
What is shown in this image? Define the diagnosis
Dermatitis on the flexor aspect => characteristic of Atopic dermatitis. It is a chronic inflammatory condition (Atopic) characterised by Itchy, dry papules on an erythematous base (dermatitis)
50
Where does the rash of atopic dermatitis typically occur?
How would you manage Atopic dermatitis?
Infants typically on face and extensor surfaces
Children and adults -> Flexor aspect
Management:
1) Emollients
2) Topical Steroids for flareups
3) Tacrolimus
4) Phototherapy by dermatology (for non-responsive cases)
51
What is Tacrolimus?
What is the benefit of using this in the treatment of atopic dermatitis
It is a topical immunomodulator to reduce the inflammation or immune response. It is an alternative that does not include steroids as to not subject the patient to long-term steroid use
52
What is shown in this image?
Atopic dermatitis (yes again)
53
What is shown in this image?
What is the pathophysiology behind this?
Thick, hyperpigmented, scaly skin => Venous eczema
Increased hydrostatic pressure and capillary damage leading to increased permeability and red cell extravasation. These deposits of haem cause the eczematous lesions
54
Venous eczema is represented by thick, hyperpigmented, scaly skin due to increased hydrostatic pressure and capillary damage leading to increased permeability and red cell extravasation. These deposits of haem cause the eczematous lesions.
Where are these lesions typically found?
How would you manage a patient presenting with venous eczema
Typically proximal to the media malleolus (shin)
Management:
1) Leg elevation
2) Support stocking
3) Weight reduction
4) Emollients
5) Topical steroids for exacerbations/flareups
55
When prescribing support stockings what should be done prior?
Must ensure that the ankle brachial index >0.8
56
When prescribing topical steroids what are your options? State them in increasing order of strength
Each step is 5x stronger than the previous
1) Hydrocortisone
2) Clobetasone
3) Betamethasone
4) Clobetasol
57
What would you prescribe first line for a rash causing an itch?
Calamine lotion
Not an emollient as it does not have moisturising properties but it is soothing
58
Describe the lesion in the first image.
What is your most likely diagnosis? Give 2 differentials.
What type of dermatitis is this?
If this were to occur acutely? What would be the cause?
White yellowish scaly patches/plaques on an erythematous base
Most likely = seborrheic dermatitis
Others include psoriasis and atopic dermatitis
This could either acutely occur in response to Malassezia yeast classifying it as exogenous or it can be endogenous where it is a chronic condition
59
Where does seborrheic dermatitis typically occur?
What is this condition called in paediatrics?
How would you manage this condition?
Hairy regions especially in the scalp, eyebrows and face
Cradle cap (baby shampoo)
Management: Ketonazole shampoo +/- cream +/- topical steroids
60
What are the 2 types of dermatitis? Associate each to the images shown.
First picture: Irritant dermatitis showing lip licking
Second picture: Allergic dermatitis to the material in contact with the skin
61
Contact dermatitis typically occurs as a result of an irritant or an allergen.
How does Irritant dermatitis occur?
How is it managed?
How does allergic dermatitis occur?
Give an example
Irritant dermatitis occurs when chemicals/physical agents damage the skin surface faster than the skin is able to repair itself e.g. Lip lickers in children or in the webs/palms in cleaners
Allergic dermatitis is a Type I hypersensitivity reaction that occurs to materials in contact with the skin such as nickel in earrings or belt buckle
62
What are shown in these images?
What is the image on the right associated with?
Guttate psoriasis, associated with tonsillitis
63
Describe the lesion shown in this image
Psoriasis: Sharply demarcated pruritic, erythematous/salmon-pink plaques with overlying silvery scale
64
Where is psoriasis typically found?
State 5 RFs for psoriasis
how is psoriasis managed
Extensor surfaces (unlike atopic which are typically flexor) => Elbows, knees, nails, and scalp
RFs:
1) Trauma
2) Infection (e.g. tonsillitis for guttate psoriasis)
3) Drugs (beta blockers, antimalarials)
4) Stress
5) Alcohol use
Management:
Mild:
1) vitamin D analogues
2) Corticosteroids
3) Dithranol
Severe: Phototherapy by dermatology
Refractory: Methotrexate or TNF-alpha
65
Dithranol, also called Anthralin is used in the treatment of psoriasis. How does this help in the treatment of psoriasis?
Anthralin inhibits keratinocyte hyperproliferation
66
What is shown in this image?
Acne
67
What is Acne?
Where is it typically found?
Inflammatory disease of the Pilosebaceous Follicle
Found on the face, chest, and back
68
Increased sebum production, abnormal follicle keratinisation, bacterial colonisation, and inflammation.
What bacterium is most associated with acne?
Propionibacterium Acne
69
What is the full treatment ladder for acne
1) Comedones only => Topical retinoid (Adapalene +/- Benzoyl Peroxide
2) + Papules/pustules => Adapalene or Clindamycin (topical) + Benzoyl peroxide
3) Moderate/severe => Oral Lymecycline + Benzoyl peroxide
4) If female -> COCP
5) Dermatology referral for Isotrenoin (Roaccutane)
70
What must be prescribed alongside Isotretinoin?
What are the side effects of this medication?
If female, prescribe COCP as it is teratogenic
Dry skin, reduced mood (increased suicidality)
71
What is Lymecycline?
Tetracycline Antibiotic
72
Acne is classified as mild, moderate or severe. Which is shown in this image?
What are the characteristic features of this severity?
How would you manage this patient?
Mild acne is characterised by
<30 lesions
Mainly Comedones
*they may have a few papules and pustules
1) Comedones only => Topical retinoid (Adapalene +/- Benzoyl Peroxide
2) + Papules/pustules => Adapalene or Clindamycin (topical) + Benzoyl peroxide
73
Define Comedones
Where are they mostly found?
What are the 2 types?
plug of sebaceous follicle-containing altered sebum, bacteria, cellular debris
Mostly found in acne => face, back and chest
Blackheads = open
White heads = closed
74
Acne is classified as mild, moderate or severe. Which is shown in this image?
What are the characteristic features of this severity?
What is your initial management of this patient?
Moderate acne
30-125 lesions that include comedones and several inflammatory papules and pustules
Oral Lymecycline + Benzoyl peroxide
75
Acne is classified as mild, moderate or severe. Which is shown in this image?
What are the characteristic features of this severity?
What is your management of this patient?
Severe
>125 lesions including comedomes, papules, pustules and ! Multiple nodules with scarring
Moderate/severe => Oral Lymecycline + Benzoyl peroxide
If female -> COCP
Dermatology referral for Isotrenoin (Roaccutane)
76
Acne affects 85% of people aged between 16 and 18. A patient comes and asks you the following questions
Is acne infectious?
Can poor hygiene make acne worse? Should I be washing my face more often then?
Why cant I play with the pimples?
Thank you for these medications, how long will they take to work?
No acne is not infectious
It is not associated with poor hygiene. You should not be washing your face more than 2x/day. If you choose to do so, please use a fragrant-free cleanser
Do not play/pop them because that can lead to permanent scarring
It will take 6-8 weeks for any of the treatments to work
77
What are the complications of acne
Post-inflammatory hyperpigmentation
Scarring
Deformity
Psychosocial effects
78
Describe what you see
what is the most likely diagnosis?
Erythema, flushing, telangiectasia, papules, and pustules on the face especially on the cheeks, nose, and perioral area
Rosacea
79
What is seen in this image?
Rhinophyma, a complication of Rosacea
80
What is Rosacea?
It is most common in those aged between 30 and 50. What population group are mostly affected by this?
What are the triggers for rosacea?
Where does rosacea typically appear most?
How is Rosacea treated?
It is a chronic inflammatory facial dermatosis characterised by a relapsing remitting pattern typically on the cheek, nose, forehead, and chin
Those with fair skin => northern european countries (Scandinavian)
Triggers:
1) Sun exposure/heat
2) Stress/exercise
3) Alcohol
Management:
1) Avoid triggers
2) Topical Metronidazole gel or Oral Tetracycline (Lymecycline)
3) Referral to dermatoloy esp if complications (Rhinophyma)
81
What is shown in this image?
What is the causative agent?
Is it contagious?
How is it treated?
Crusted gold lesion => Impetigo
Staph Aureus or Strep Pyogenes
Yes it is contagious
Topical Fusidic Acid
or Oral Flucloxacilin
82
What is shown in this image? What is your main differential?
What additional features would you note on exam?
What are the major risks with this?
How would you treat this patient
Cellulitis characterized by !Ill-defined borders, unilateral swelling, erythema, heat, and tenderness. There may also be pyrexia and features of sepsis
Differential = DVT
Risks: Sepsis, abscess formation, lymphoedema, recurrence
Tx: Raise leg, IV antibiotics, Sepsis workup
83
A 9 year old patient presents to you with this. What is your most likely diagnosis?
What are the characteristic features of this seen along with its progression
how would you manage this patient?
Varicella/chicken pox.
Presents as a group of macules -> papules -> vesicles (this picture) on an erythematous base. These will then dry and crust.
Symptomatic management => paracetamol for fever, bed rest, hydration. ! Calamine lotion for the itch
84
What is shown in this image? (diagnosis and description).
Are these painful?
How does this occur?
How is it managed?
Shingles: Asymmetrical unilateral vesicular lesions on an erythematous base. They are painful
Reactivation of the Varicella Zoster virus
Managed via Acyclovir + Analgesia
85
Shingles is due to the reactivation of VZ virus. Where does this lie dormant?
Remains dormant in the dorsal root ganglion
86
What is shown in this image? (Diagnosis)
What is this diagnosis characterised by?
Is it contagious?
How is it managed if
Localised
Widespread
Tinea corpus
Itchy, circular/annular lesion that moves from area to area and person to person => contagious
Managed via topical antifungal - Clotrimazole or Miconazole
If widespread, oral antifungal (Terbinafine)
87
What is shown in this image?
Tinea Cruris
88
What is shown in this image?
Tinea Pedis
89
a patient presents with this. Give your top 2 differentials
Fungal infection of the nails
Onycholisis in psoriasis (or trauma)
90
What is Onycholisis?
Detachment of the nail from the nailbed
91
How would you manage fungal infection of the toenails?
What is it associated with?
Topical antifungal
Send Nailclippings to lab
Associated with hepatotoxicity => conduct LFTs
92
What is shown in this image? (Diagnosis)
What are other differentials?
How would you treat?
Oral candida
ddx: Leukoplakia, Lichen Planus
Topical antifungals (if it doesnt resolve refer to ENT)
93
What is shown in this image?
Urticaria => anaphylaxis
94
What is shown in this image?
How would you manage?
Angioedema => Anaphylaxis
ABCDE, call for help, IM adrenaline, hydrocortisone, antihistamine (chlorphenamine)
95
A patient presents with this rash.
What type of rash is shown?
What will you do on examination?
This is a petechial/purpuric rash
=> Must check if blanching
I will check for Fever, neck stiffness, photophobia
96
A patient presents with this rash. You perform an examination and note that it is non-blanching. The patient also has a fever. What will you do?
This is indicative of meningitis
Phone ambulance, Establish IV access to give benzylpenicillin/Cefotaxime.
