Dermatology Flashcards
History derm 1
Duration:
Onset - sudden versus gradual.
Previous episodes - eg, photodermatoses tend to recur every spring with the onset of good weather.
Change - fluctuation versus persistence. Consider variation in severity - eg, occupational contact allergic dermatitis may improve when on holiday.
Location - Eczema tends to be on flexural surfaces whilst psoriasis tends to be on extensor parts. Lesions may have a specific distribution - around the genitals, in sweaty regions or in sun-exposed areas. Establish whether the lesion has spread.
Provoking or relieving factors
Associated symptoms:
Itch - Psoriasis is said to be non-itchy but there may be pruritus in the genital area.
Tenderness
Bleeding or discharge - bleeding may indicate malignancy and discharge may occur with an infected lesion.
Systemic symptoms - such as pyrexia, malaise, joint pain and swelling or weight loss.
Response to treatment
Derm exam
A general look - Note whether the patient looks ill.
Inspect:
Leison position (Eg symmetrical - psoriasis)
Establish whether there are areas of friction or pressure, wheather sweaty regions, whether exposed regions are involved, whether sexual contact is a factor (consider genital lesions but also the lower abdomen and upper thighs).
Palpate - Tenderness, Warmth, Thickness, Consistency (hard, soft, firm, fluctuant).
Note whether firm pressure leads to blanching.
Note whether it is friable and whether it bleeds easily.
If appropriate, see if there is any evidence of infestation - eg, scabies’ burrows.
Describe - SCAM:
Site - site + distribution (generalised, flexural/extensor, photosensitive) or size and shape
Colour + configuration- discrete, confluent, linear, target. Erythematous, purpuric, hyper/hypopigmented
A - associated changes eg surface features - scale, crust, excoriation, ulceration
M- morphology
ABCD for pigmented:
Asymmetry
Border
Colour
Diameter
Systematic check:
Look at the nails.
Note whether mucous membranes are involved. Examine the genitals where appropriate.
Note regional lymph nodes. This may be relevant for infectious or malignant lesions.
Malignant lesion
Major features of the lesions (score two points each):
Change in size.
Irregular shape.
Irregular colour.
Minor features of the lesions (score one point each):
Largest diameter 7 mm or more.
Inflammation.
Oozing.
Change in sensation.
Suspicion is greater for lesions scoring three points or more but, if there are strong concerns, any one feature is sufficient to prompt urgent referral, as should:
Any new solitary nodule or plaque, regardless of colour where a benign diagnosis (eg, a dermatofibroma) cannot be made with confidence.
A new pigmented line in a nail.
Lesions growing under a nail.
Pigmented lesions on mucosal surfaces.
Investigations
Swabs - can be taken for bacteriology and virology.
Skin scrapings - for microscopy - to diagnose fungal infections and ectoparasitic infections such as scabies.
Nail clippings
Hair root samples can be useful in suspected tinea capitis.
Wood’s light - This is an ultraviolet light used in a darkened room. When shone on some fungal infections, the light causes fluorescence.
Most tinea capitis infections are caused by Trichophyton species that do not fluoresce.
Skin biopsy - aid diagnosis and further management.
Shave and punch biopsy techniques can be used.
Punch biopsies remove a core of skin from the epidermis to subcutaneous fat. Ideally the biopsy should include normal skin, part of the lesion and the transition zone.
Excisional biopsies aim to remove the entire lesion - provide treatment as well as diagnosis.
Biopsy can also be used for immunofluorescence and culture (eg, mycobacterium, leishmaniasis).
Patch and skin prick tests - investigation of contact allergic dermatitis and other allergies.
Fitzpratick skin types
Type 1 - White - always burns
2 - White - usually burns
3 - white - sometimes burns, average tan
4 - moderate brown - rarely burns, tans with ease
5 - dark brown - rarely burns, tans easily
6 - black - does not burn, tans easily
History of derm 2
Past medical history: eg, diabetes may suggest necrobiosis lipoidica.
Family history: eg eczema and psoriasis. Alternatively, concurrent and recent affliction of other members of family suggests a contagious or environmental aetiology. Familial atypical mole and melanoma (FAMM) syndrome should be considered where several family members have multiple melanocytic lesions, some atypical, with at least one case of melanoma in the family.
Occupation, hobbies and pastimes: where there may be exposure to chemicals or a very hot environment.
Travel: exotic locations = risk of rarer tropical diseases. Consider exposure to sunlight or sunbeds and history of sunburn - increase the risk of skin malignancies.
Drugs
Smoking and alcohol: alcohol use has an association with psoriasis. Smoking increases the risk of some malignancies and has a close association with palmoplantar pustular psoriasis.
Allergies.
Impact of skin complain on life - eg people with severe or disfiguring skin disease may suffer from anxiety, depression and social isolation. Psychological problems may also cause skin disease - eg, dermatitis artefacta.
ICE
What symptoms can a patient get from disorders of the skin?
What key aspects in the history must NOT be overlooked when assessing a patient with a skin presentation?
Pruritis
PMH or FMH of skin cancer
What are the key components of the skin? Consider examples of skin conditions which affect particular
components of the skin. b) What are the main physiological functions of the skin?
Weighted 7-point checklist
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for melanoma if they have a suspicious pigmented skin lesion with a weighted 7-point checklist score of 3 or more.
Major features of the lesions (scoring 2 points each):
Change in size.
Irregular shape.
Irregular colour.
Minor features of the lesions (scoring 1 point each):
Largest diameter 7 mm or more.
Inflammation.
Oozing.
Change in sensation.
SCC
Over production of squamous cells on top layer of skin.
Raised lesion and ulcerated. Crusty top. Nodular base. Bleeding may occur.
higher-risk sun-exposed areas. Most SCCs appear on the skin of the head and neck.
Site: tumour location in order of increasing metastatic potential:
SCC arising at sun-exposed sites excluding the lip and ear.
In non-sun-exposed sites (eg, the perineum, sacrum, sole of foot).
Diameter: tumours greater than 2 cm in diameter are twice as likely to recur locally and three times as likely to metastasise.
Depth: tumours greater than 4 mm in depth are more likely to recur and metastasise compared with thinner tumours.
Histological differentiation: poorly differentiated tumours have a poorer prognosis, with more than double the local recurrence rate and triple the metastatic rate of better-differentiated SCC.
Tumours with perineural involvement are more likely to recur and to metastasise.
Host immunosuppression: tumours arising in patients who are immunosuppressed have a poorer prognosis.
Previous treatment
In-situ - destructive eg flourouracil
Invasive - Excisional surgery
Metastatic - Excision, radio, chemo
Patients who have had a single completely excised BCC or low-risk cSCC can be discharged after a single post-operative visit. (G)
• Patients with an excised high-risk cSCC should be reviewed three to six monthly for two years, with further annual review depending upon clinical risk.
Emollient
Use spatula to take out of tub
High oil content
Topical steroids
Wash hands
Avoid with emollients
Skin thinning- low if used correctly
d) How does a patient with urticaria commonly present?
e) What key aspects in the history must NOT be overlooked when assessing a patient with urticaria?
g) What is the management of urticaria?
Urticaria is a superficial swelling of the skin that results in a red, raised, itchy rash.
Acute — symptoms for less than 6 weeks.
Chronic — symptoms persist for 6 weeks+ include:
Chronic spontaneous urticaria - no identifiable external cause but may be aggravated by heat, stress, drugs, and infections.
Autoimmune urticaria — characterized by presence of IgG autoantibodies to the high-affinity receptor for IgE.
Chronic inducible urticaria (CINDU) — occurs in response to a physical stimulus.
Management:
UAS7 score - severity of itching and no of weals in a week - more than 28=severe.
Investigations to identify triggers.
Manage underlying cause.
Acute - self-limiting.
If requiring treatment:
non-sedating antihistamine to be taken daily for up to 6 weeks.
For severe symptoms, short course of oral corticosteroid also.
Consideration to prescribe antihistamine treatment daily for 3–6 months.
If response to treatment is inadequate consider inc the dose, alternative, calamine lotion to relieve itch, sedating anti-h for itching at night.
Referral to a dermatologist or immunologist.
e) What key aspects in the history must NOT be overlooked when assessing a patient with urticaria?
f) What is the correct terminology to describe a typical urticarial rash?
Urticarial vasculitis — lesions remain for longer than 24 hours and are painful, non-blanching, and palpable (leaving petechial haemorrhage, purpura, or bruising). Systemic symptoms, such as fever, malaise, and arthralgia.
Significant social or psychological problems.
Wheals
Atopic eczema
chronic, itchy, inflammatory skin condition
Usually before 5 years of age
It is typically an episodic disease of flares and remissions
Genetic predisposition, environmental factors (such as exposure to pets, house-dust mites, and pollen), and immune system dysfunction play a role.
diagnosis - clinical
Management:
A stepped approach:
Emollients (flammable) - first-line- during both acute flares and remissions - 4-6 times a day
Topical steroids for red, inflamed skin. Mild - hydrocortisone. Moderate - univate. Severe - dermavate. Moderate + severe avoid near mouth, eyes, genitals.
If there is severe itch, or urticaria - a one-month trial of a non-sedating antihistamine.
If itching is severe and affecting sleep - a short course of a sedating antihistamine should be considered.
If there is severe, extensive eczema, a short course of oral corticosteroids should be considered.
If eczema is weeping, crusted, or pustules with fever - secondary bacterial infection - antibiotic treatment.
If fungal - clotrimazole, dakticourt
Combination - hydrocortisone + oxytetracycline + ant-fungal
Immediate hospital admission should be arranged if eczema herpeticum (characterized by rapidly worsening, painful eczema; clustered blisters; and punched out erosions) is suspected.
Referral to a dermatologist if:
Eczema is not controlled, recurrent secondary infection, high risk of complications, food allergy trigger is suspected.
Referral to a clinical psychologist - quality of life and psychological well-being have not improved
Cutting nails, Cold compress, bandages
Safety - avoid scratching, infection
