Dermatology Flashcards
What is the Glasgow 7 point scale as it pertains to when to refer moles urgently?
Minor features are worth 1 point, major features are worth 2 points.
3 points or more merits an urgent referral to dermatology.
Major features:
* Change in size
* Irregular colour
* Irregular shape
Minor features:
* Diameter > 7mm
* Oozing
* Inflammation
* Change in sensation
How does hereditary haemorrhagic telangiectasia / Osler-Rendu/Weber present?
Spontaneous recurrent nose bleeds
Often a family history
Telangiectasia may appear on skin, lips, mucus membranes often first appearing in early adulthood
May present with iron deficiency anaemia due to bleeds from gastrointestinal telangiectasia
What is the typical presentation of pityriasis alba?
Areas of pale / hypopigmented skin in children / young people.
May have several plaques / patches crop up, no specific tx needed, self-resolve over several weeks - months
Typically on face
Association with dry skin / eczema
What is the typical presentation of spitz naevus?
Spitz navus - is a mole / naevus that normally appears in childhood / adolescence.
They appear and then grow in size very rapidly until plateauing at around 6 months.
They are BENIGN but require urgent referral to derm < 2 wks as they closely mimic melanoma.
What is the typical presentation of acanthosis nigricans?
Velvety, brown plaques in the skin creases (axilla, neck and groin)
Related to conditions that cause insulin resistance / hyperinsulinaemia (PCOS, Type II diabetes, obesity, Cushing’s, GI malignancy)
Rosaecea management as per NICE CKS
General advice:
- Avoid direct sunlight / wear high factor SPF everyday
- Keep a diary to identify and avoid triggers - hot/cold weather, spicy foods, smoking, alcohol, emotional stress
- Use of a gentle, soap-free cleanser and non-oily emollient
Medical Tx:
- If erythema predominant symptoms
-> 1st line - topical bromonidine 0.5% gel for PRN use (alpha adrenergic agonist) -> works to reduce redness in about 30 mins, then lasts ~ 3-6 hours and then wears off
- If papules/pustules predominant symptom
-> 1st line - topical ivermectin OD for 2-3 month trial (not licensed in pregnancy/BF - consider topical metronidazole or azeleic acid instead)
-> If severe papules or phymatous disease (thickening, bumpiness of the skin, typically around the nose (rhinophyma) but can be elsewhere on the face), can add in oral Doxycycline MR 40mg OD for 2-3 month trial (DO NOT GIVE DOXY in pregnancy, risk of skeletal malformation in 1st trimester and fetal teeth discolouration in later trimesters -> can give Erythromycin instead) in addition to topical ivermectin - If oculuar involvement
- Lid hygiene
- Artificial tears / lid lubricant
Optimum management of venous ulcers?
1st line - Compression bandaging (typically 4 layers) - most evidence-based intervention
Oral Pentoxifylline (a vasodilator, used in peripheral vascular disease) can also help with wound healing in venous ulcers
Some evidence that a diet high in flavinoids can help.
What is the typical presentation of pityriasis rosea and what causes it?
Pityriasis rosea is caused by REACTIVATION of a virus (normal human herpes virus 6 or 7, also associated with Covid and flu) - occasionally can be caused by a drug reaction
It presents with scaly, red patches in a christmas tree distribution (limited to trunk and proximal limbs, lesions along the lines of cleavage)
75% of cases will have a Herald patch (quite a large 2-5cm red patch with central clearing and scaling around the edge)
Main age of onset is age 10-35
SELF-LIMITING - in most people most lesions will be gone by ~ 2 months Normally assymptomatic but occasionally can be itchy which you can treat with topical emollients, moderate steroid or oral antihistamines
Refer to derm if persisting past 3 months or severe and impacting QOL
What is the typical presentation of pityriasis versicolor and what causes it?
Superficial fungal infection caused when Malassezia yeast (a commensal fungal on the skin) activates into it’s pathological / hyphae form.
Either hypo or hyperpigmented well-demarcated plaques with overlying scale.
Normally presents on the trunk and/or extremities - often during hot, humid periods and mainly in teens/early twenties when sebum production is highest
Mx:
1st line - topical agents - topical ketoconazole (leave on for ~ 10 mins then wash off, repeat daily for ~ 7 days) or topical imidazole (e.g Miconazole) OD-BD for a few weeks
2nd line or if widespread - PO Itraconazole 200mg OD for 7 days
Reoccurence is common! ~ 80% reoccur within 2 years. Only counts as recurrent if fine scale is present (pigmentation changes may be present for months before natural skin pigmentation returns)
If recurs can suggest prophylaxis with ketoconazole use every 2 weeks for 6 months
What does pityriasis mean in latin ?
Scale! So it refers to rashes that have a scaly component.
What is the typical presentation of lichen planus?
An inflammatory dermatoses
Affects men and women equally, often occurs in middle age (40’s - 50’s)
Exact aetiology unknown, but strong genetic influence, more likely if have other autoimmune diseases, also strong association with HEPATITIS C (those with lichen planus are 5x more likely to have hep c)
The 6 P’s of lichen Planus:
- Pururitic - extremely itchy!
- Purple
- Polygonal
- Planar (ie flat topped lesions)
- Papules (start as papules and then coalesce into plaques) - have Wickam’s striae on top of the plaques / papules - white lace like patterns - Wickams striae can also be seen in the oral mucosa
Most common sites are the wrists and ankles and lumbar region (cutaneous lichen planus)- can also sometimes get oral mucosal involvement - can also affect nails, scalp (where it may causes a scarring alopecia) and genitalia
Tx:
Cutaneous lichen planus
Is actually self-limiting in most cases but can take upto 18 mths for it to resolve - Tx is to increase speed of clearance - potent / very potent topical steroids (ointments if possible dermovate, betnovate etc) for upto ~ 6 weeks under occlusion (e.g put clingfilm over the top) then taper down if successful
Oral lichen planus: (erosive oral lichen planus can be quite chronic) good oral hygiene - avoid smoking, spicy foods, alcohol - topical analgesia e.g difflam spray
Can use dermovate off-licence in the mouth but can’t eat for an hour or so after - can also gargle antiinflammatories e.g Betamethasone soluble tablets
Refer if: scarring alopecia or nail destruction, severe pruritus that can’t be managed,
What is the typical presentation of periorofacial dermatitis and how should it be managed?
Periorofacial dermatitis is a relatively common chronic skin condition, often affecting white females in their 20’s - middle age but can also occur in children.
Exact cause unknown but is essentially an irritation reaction and can be linked to excessive cosmetic use, occlusive moisturisers or sunscreens or topical/nasal/inhaled steroid use. Can flare with oral contraceptive use or during pregnancy.
Can be perioral, perinasal or periocular. Cluster of red papules, pustules, vesicles similar to acne, surrounding skin is often dry
Management:
STOP all topical cosmetics, sunscreens etc
Wash skin with only warm water initially and then can move to a non-soap cleanser once the skin clears
STOP all topical corticosteroids
Can use a mild non-occlusive emollient for the dryness
Rinsing the face after use of inhaled / nasal corticosterids may help
If this doesn’t resolve it, can try topical antibiotic cream e.g Metronidazole 0.75-1% or erythromycin 1% for ~ 4 weeks.
If requires oral therapy, tetracycline is first line for a 4 wk course (erythromycin first line for pregnant women or children < 8 yrs)
What is acne conglobata ?
Severe nodulocystic acne, often occuring in males in their teens upto 20s/30s - multiple large abscesses affecting face, neck and back which can form sinuses and bad scars
REFER immediately to derm if suspect/ Normally requires oral retinoids.
What is acne fulminans ?
Acne conglobata with associated systemic side effects (joint pain -often sacroilliac - fever, malaise), hepatosplenomegaly) - requires urgent dermatology review
What does NICE guidance recommend for treatment of acne in primary care?
General advice: Avoid over-washing, use neutral PH gentle skin wash twice a day max, avoid oil-based comedogenic products
Remember that topical retinoids and tetracycline antibiotics are contraindicated in pregnancy or if planning a pregnancy.
Mild-Moderate Acne - 1st line 12 wk course with either topical adapalene with benzylperoxide OR topical tretinoin with clindamycin OR topical benzylperoxide with clindamycin
Can use benzylperoxide monotherapy if don’t want or can’t use the retinoid.
If doesn’t work or more moderate to severe, can add in oral tetracycline (either Lymecycline 408mg OD or Doxycycline 100mg OD - can try trimethoprim or erythromycin if pregnant or allergic ) OR can try 3rd or 4th gen COCP (Dianette/ Co-cyprindiol can be used in mod-severe acne if other options have failed, should be stopped 3 months after skin clears)
Could also try topical Azelaic Acid 15%/20% BD (an antioxidant and dicarboxylic acid - safe in pregnancy!) in addition to the oral antibiotics.
SHOULD NOT USE TOPICAL AND ORAL ANTIBIOTICS AT THE SAME TIME
