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Phase 4 Derm, Sexual Health, Breast, Renal, Urology, ENT > Dermatology > Flashcards

Dermatology Flashcards

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Dermatology Board Prep flashcards
1
Q

What is acanthosis nigricans?

A

Symmetrical, brown, velvety plaques that are often found on the neck, axilla and groin

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2
Q

What are the causes of acanthosis nigricans?

A

T2DM
GI Cancer
Obesity
PCOS
Acromegaly
Cushing’s disease
Hypothyroidism
Prader-Willi syndrome
Drugs: COCP, Nicotinic Acid

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3
Q

What is the pathophysiology of acanthosis nigricans?

A

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

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4
Q

What is Acne Vulgaris and what are the common subtypes?

A

Chronic inflammation of the pilosebaceous unit with or without localised infection

Comedones: Dilated sebaceous follicle (whitehead/blackhead)

Papules/Pustules: Inflammatory lesions form when the follicle bursts releasing irritants

Nodules/cysts: Excessive inflammatory response

Scarring: Ice pick scars/ hypertrophic scars

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5
Q

What are the classifications of Acne Vulgaris?

A

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

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6
Q

What is the treatment for mild-moderate Acne Vulgaris?

A

First Line: 12-week course of topical combination therapy

Topical adapalene with topical benzoyl peroxide

Topical tretinoin with topical clindamycin

Topical benzoyl peroxide with topical clindamycin

Topical benzoyl peroxide may be used as monotherapy if contraindicated or if the person doesn’t want a topical retinoid or antibiotic.

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7
Q

What is the treatment for moderate-severe Acne Vulgaris?

A

First Line: 12-week course of

Topical adapalene with topical benzoyl peroxide

Topical tretinoin with topical clindamycin

Topical adapalene with topical benzoyl peroxide + oral lymecycline or oral doxycycline

Topical azelaic acid + either oral lymecycline or oral doxycycline

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8
Q

When should Acne Vulgaris be referred to a dermatologist?

A

Acne conglobate: a rare and severe form of acne found in men with extensive inflammatory papules, suppurative nodules (that may coalesce to form sinuses), and cysts on the trunk.
Patients with nodulocystic acne

Referral should be considered in the following scenarios:

Mild-moderate acne has not responded to two completed courses of treatment
moderate-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

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9
Q

Why are retinoids/ benzyl peroxide co-prescribed with oral antibiotics?

A

Reduces the risk of antibiotic resistance

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10
Q

What complications can occur from long-term antibiotic usage? How would you treat it?

A

Gram-negative folliculitis. Treated by high dose oral trimethoprim

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11
Q

What should be avoided in pregnancy for Acne? what can be used?

A

Avoid Tetracyclines and avoid oral isotretinoin (Teratogenic). Use erythromycin

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12
Q

What can be used as an alternative to oral antibiotics for Acne in women?

A

First Line: COCP, used in combination with topical agents

Second Line: Dianette (co-cyprindiol), has VTE risk so only given for 3 months.

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13
Q

What is only given under specialist supervision for Acne Vulgaris?

A

Oral isotretinoin. Contraindicated in pregnancy

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14
Q

What are Actinic keratoses?

A

Actinic, or solar, keratoses (AK) is a common premalignant skin lesion that develops due to chronic sun exposure.

Small, crusty, scaly lesions. May be pink, red, brown, or the same as the skin.

Sun-exposed areas e.g. temples of head
multiple lesions may be present

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15
Q

What is the management of Actinic keratoses?

A

Sun avoidance, sun cream

Fluorouracil cream: 2- 3 weeks. 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

Cryotherapy

Curettage and cautery

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16
Q

What is alopecia areata?

A

An 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.

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17
Q

What is the management plan for alopecia areata?

A

Hair will regrow in 50% of patients by 1 year and in 80-90% eventually.

Other treatment options include:
Topical or intralesional corticosteroids
Topical minoxidil
Phototherapy
Dithranol
Contact immunotherapy
Wigs

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18
Q

What is Tinea Pedis? What is it caused by?

A

Athletes Foot. Caused by Trichophyton Fungi

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19
Q

How does Tinea Pedis present?

A

Scaling, flaking, and itching between the toes

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20
Q

What is the treatment for Tinea Pedis?

A

Topical imidazole, undecenoate, or terbinafine

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21
Q

What is Basal Cell Carcinoma?

A

1 of the 3 types of skin cancer. Lesions are also known as rodent ulcers and are characterised by slow growth and local invasion. Metastases are extremely rare.

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22
Q

What are the features of Basal Cell Carcinoma?

A

Nodular BCC occurs on sun-exposed sites.

Initially a pearly, flesh-coloured papule with telangiectasia
may later ulcerate leaving a central ‘crater’.

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23
Q

What are management options for Basal Cell Carcinoma?

A

Surgical removal
Curettage
Cryotherapy
Topical imiquimod/ fluorouracil
Radiotherapy

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24
Q

What is ur’s Disease?

A

Precancerous dermatosis 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.

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25
Q

What are the features of Bowen’s Disease?

A

Red, scaly patches, slow growing, 10-15mm
Sun-exposed areas such as the head (e.g. temples) and neck, lower limbs

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26
Q

What is the management of Bowen’s Disease?

A

Topical 5-fluorouracil, BD, 4 weeks

Often results in significant inflammation/erythema so topical steroids are often given to control this

Cryotherapy

Excision

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27
Q

What is Bullous pemphigoid?

A

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

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28
Q

What are the features of Bullous pemphigoid?

A

Itchy, tense blisters typically around flexures (usually heal without scarring)
No mucosal involvement (i.e. the mouth is spared)

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29
Q

What is the management of Bullous pemphigoid?

A

immunofluorescence shows IgG and C3 at the dermo-epidermal junction

Referral to a dermatologist for skin biopsy (immunofluorescence shows IgG and C3 at the dermo-epidermal junction

Oral corticosteroids,

Topical corticosteroids, immunosuppressants and antibiotics are also used

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30
Q

What is Cherry haemangioma? What are the features of it?

A

Benign skin lesions which contain an abnormal proliferation of capillaries.

Erythematous, papular lesions, 1-3mm in size
Non-blanching
Not found on the mucous membranes

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31
Q

What is the treatment for Cherry haemangioma?

A

Benign, No treatment required.

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32
Q

What is chronic plaque psoriasis? What are the features of it?

A

Most common form of psoriasis

Erythematous plaques covered with a silvery-white scale

Extensor surfaces such as the elbows and knees.

Also common on the scalp, trunk, buttocks and periumbilical area

Clear delineation between normal and affected skin
plaques (1-10cm)

If the scale is removed, a red membrane with pinpoint bleeding points may be seen (Auspitz’s sign)

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33
Q

What are the two types of contact dermatitis?

A

Irritant contact dermatitis (common)

Allergic contact dermatitis (uncommon)

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34
Q

What are the features of Irritant contact dermatitis?

A

Erythema is typical, crusting and vesicles are rare

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35
Q

What are the features of allergic contact dermatitis? What is the treatment?

A

Type IV hypersensitivity reaction.

Often seen on the head following hair dyes. Cement causes it on the hands.

Acute weeping eczema affecting the margins of the hairline.

Topical treatment with a potent steroid is indicated.

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36
Q

What is Dermatitis herpetiformis?

A

Autoimmune blistering skin disorder associated with coeliac disease. It is caused by the deposition of IgA in the dermis.

More than 90% of patients exhibit small bowel biopsy findings consistent with some degree of gluten-sensitive enteropathy.

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37
Q

What are the features of Dermatitis herpetiformis?

A

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

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38
Q

How do you diagnose and treat Dermatitis herpetiformis?

A

Skin biopsy: direct immunofluorescence shows deposition of IgA in a granular pattern in the upper dermis

Gluten-free diet
Dapsone (antibiotic)

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39
Q

What is a Dermatofibroma?

A

Benign fibrous skin lesions are caused by the abnormal growth of dermal dendritic histiocyte cells, often following a precipitating injury. Common areas include the arms and legs.

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40
Q

What are the features of a Dermatofibroma?

A

Solitary firm papule or nodule, typically on a limb (5-10mm)

Overlying skin dimples on pinching the lesion

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41
Q

What is the treatment of a Dermatofibroma?

A

Benign, No treatment required.

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42
Q

What is Eczema Herpeticum?

A

Severe primary infection of the skin by HSV1/2

It is more commonly seen in children with atopic eczema and often presents as a rapidly progressing painful rash.

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43
Q

What are the features of Eczema Herpeticum?

A

Monomorphic punched-out erosions (circular, depressed, ulcerated lesions) (1-3mm)

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44
Q

What is the treatment for Eczema Herpeticum?

A

As it is potentially life-threatening children should be admitted for IV aciclovir.

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45
Q

What are the different treatment options for Eczema?

A

Topical Steroids

Mild: Hydrocortisone 0.5-2.5%

Moderate:
Betamethasone valerate 0.025% (Betnovate RD)
Clobetasone butyrate 0.05% (Eumovate)

Potent:
Fluticasone propionate 0.05% (Cutivate)
Betamethasone valerate 0.1% (Betnovate)

Very Potent:
Clobetasol propionate 0.05% (Dermovate)

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46
Q

What is the fingertip rule for eczema and what are the values for each area?

A

Fingertip rule
1 finger-tip unit (FTU) = 0.5 g, sufficient to treat a skin area about twice that of the flat of an adult hand

Hand and fingers (front and back): 1.0 FTU
A foot (all over): 2.0 FTU
Front of chest and abdomen: 7.0 FTU
Back and buttocks: 7.0 FTU
Face and neck: 2.5 FTU
An entire arm and hand: 4.0 FTU
An entire leg and foot: 8.0 FTU

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47
Q

What is Erysipelas and what is the treatment?

A

localised skin infection caused by Streptococcus pyogenes. (More superficial, limited version of cellulitis)

Flucloxacillin

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48
Q

What is Erythema ab igne? What are the features of it?

A

Erythema ab igne is a skin disorder caused by overexposure to infrared radiation. If the cause is not treated then patients may go on to develop squamous cell skin cancer

Reticulated, erythematous patches with hyperpigmentation and telangiectasia.

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49
Q

What is onchomycosis?

A

Fungal nail infection that involves any part of the nail, or the entire nail unit. Toenails are significantly more likely to become infected than fingernails

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50
Q

What organisms cause onychomycosis?

A

Dermatophyte: Trichophyton rubrum

Yeasts: Candida

Non-dermatophyte moulds

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51
Q

What is the treatment for onychomycosis?

A

Dermatophyte or Candida infection confirmed

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

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.

More extensive involvement due to a Candida infection: oral itraconazole is recommended first-line; ‘pulsed’ weekly therapy is recommended

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52
Q

What is hereditary haemorrhagic telangiectasia (HHT)?

A

Osler-Weber-Rendu syndrome, hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant condition characterised by multiple telangiectasia over the skin and mucous membrane

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53
Q

What are the 4 main diagnostic criteria of hereditary haemorrhagic telangiectasia (HHT)?

A

Epistaxis

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

2 = possible diagnosis of HHT
3 = definite diagnosis of HHT

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54
Q

What is Hidradenitis suppurativa (HS)?

A

Chronic, painful, inflammatory skin disorder. Development of inflammatory nodules, pustules, sinus tracts, and scars in intertriginous areas.

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

Axilla is the most common site

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55
Q

What is the management for Hidradenitis suppurtiva?

A

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.

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56
Q

What is the difference between Hirsutism and hypertrichosis?

A

Hirsutism = androgen-dependent hair growth

Hypertrichosis = androgen-independent hair growth

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57
Q

What are causes of hirsutism?

A

PCOS
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

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58
Q

What scoring system is used to assess hirsutism?

A

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

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59
Q

What is the management of hirsutism?

A

Weight Loss
Waxing/bleaching - not available on the NHS
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 VTE

Facial hirsutism: topical eflornithine - contraindicated in pregnancy and breast-feeding

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60
Q

What are the causes of hypertrichosis?

A

Drugs: minoxidil, ciclosporin, diazoxide

Congenital hypertrichosis lanuginosa, congenital hypertrichosis terminalis

Porphyria cutanea tarda

Anorexia nervosa

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61
Q

What is hyperhidrosis and what is the management?

A

Hyperhidrosis describes the excessive production of sweat.

First Line: Topical aluminium chloride (can cause skin irritation)

Iontophoresis: particularly useful for patients with palmar, plantar and axillary hyperhidrosis

Botulinum toxin: currently licensed for axillary symptoms

Surgery: Endoscopic transthoracic sympathectomy. Patients should be made aware of the risk of compensatory sweating

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62
Q

What is Tinea Capitis?

A

Fungal infection of the scalp (scalp ringworm)

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63
Q

What is Tinea Corporis

A

Fungal infection of the trunk, legs and arms (Ringworm)

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64
Q

What are the features, diagnosis and management of Tinea Capitis?

A

A raised, pustular, spongy/boggy mass called a kerion may form

Scalp scrapings

Oral antifungals:

Terbinafine for Trichophyton

Griseofulvin for Microsporum infections.

Topical ketoconazole shampoo for first 2 weeks = reduced transmission

65
Q

What are the features, diagnosis and management of Tinea Corporis?

A

Trichophyton verrucosum (e.g. From contact with cattle)

Well-defined annular, erythematous lesions with pustules and papules

Oral Flucanozole

66
Q

What is Urticaria? What is the most common cause?

A

A local or generalised superficial swelling of the skin.

Most commonly caused by allergic reaction

67
Q

What are the features and management of Urticaria?

A

Pale, pink raised skin. Variously described as ‘hives’, ‘wheals’, ‘nettle rash’
pruritic

First Line: Non-sedating antihistamines (e.g. loratadine or cetirizine). Should be continued for up to 6 weeks following an episode of acute urticaria

Sedating antihistamine (e.g. chlorphenamine) can be used at night

Prednisolone is used for severe or resistant episodes

68
Q

What is squamous cell carcinoma of the skin? What are some risk factors?

A

Squamous cell carcinoma is a common variant of skin cancer. Metastases are rare but may occur in 2-5% of patients.

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

69
Q

What are the features and management of squamous cell carcinoma of the skin?

A

Sun-exposed sites of the body

Rapidly expanding painless, ulcerate nodules
May have a cauliflower-like appearance
there may be areas of bleeding

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 cosmetically important sites.

70
Q

What is the prognosis for squamous cell carcinoma of the skin?

A

Good Prognosis

Well-differentiated tumours
<20mm diameter
<2mm deep
No associated diseases

Poor Prognosis

Poorly differentiated tumours
>20mm in diameter
>4mm deep
Immunosuppression

71
Q

What is scabies?

A

Caused by mites (Sarcoptes scabiei) and spread by prolonged skin contact.

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.

72
Q

What are the features of scabies?

A

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

73
Q

What is the management of scabies?

A

Permethrin 5% is first-line

Malathion 0.5% is second-line

Patient guidance

Pruritus persists for up to 4-6 weeks post eradication
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

74
Q

What are pressure ulcers? What can predispose you to them?

A

Ulcers that typically develop over bony prominences such as the sacrum or heel.

Malnourishment
Incontinence: urinary and faecal
Lack of mobility
Pain (leads to a reduction in mobility)

75
Q

What score is used for pressure ulcers? What does it consist of?

A

Waterlow score
BMI body, nutritional status, skin type, mobility and continence

76
Q

What are the grades of the pressure ulcers?

A

Grade 1: Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin.

Grade 2: Partial thickness skin loss involving epidermis or dermis, or both. The
ulcer is superficial and presents clinically as an abrasion or blister

Grade 3: Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
Grade 4 Extensive destruction, tissue necrosis, or damage to muscle, bone or
supporting structures with or without full-thickness skin loss

77
Q

What is the diagnosis and management of head lice?

A

Diagnosis
Fine-toothed combing of wet or dry hair

Management
Treatment is only indicated if live lice are found
Malathion, wet combing, dimeticone, isopropyl myristate and Cyclomethicone
Household contacts of patients with head lice do not need to be treated unless they are also affected
School exclusion is not advised for children with head lice

78
Q

What is impetigo? How is it spread?

A

Impetigo is a superficial bacterial skin infection usually caused by either Staphylococcus aureus or Streptococcus pyogenes

Direct contact with discharges from the scabs of an infected person. Infection is spread mainly by the hands

Indirect spread via toys, clothing, equipment and the environment may occur.

79
Q

What are the features of Impetigo?

A

‘golden’, crusted skin lesions typically found around the mouth
very contagious

80
Q

What is the management of Impetigo?

A

Limited, localised disease

Hydrogen peroxide 1% cream

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

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

81
Q

What are the common causes of pruritis?

A

Liver disease:

History of alcohol excess
Stigmata of chronic liver disease: spider naevi, bruising, palmar erythema, gynecomastia etc
Evidence of decompensation: ascites, jaundice, encephalopathy

Iron deficiency anaemia
Pallor
Other signs: koilonychia, atrophic glossitis, post-cricoid webs, angular stomatitis

Polycythaemia
Pruritus particularly after a warm bath, ‘Ruddy complexion’, Gout, Peptic ulcer disease

Chronic kidney disease
Lethargy & pallor, Oedema & weight gain, Hypertension

Lymphoma
Night sweats, Lymphadenopathy, Splenomegaly, hepatomegaly, Fatigue

82
Q

What is erythema multiforme?

A

Hypersensitivity reactions triggered by infections

83
Q

What are the features of erythema multiforme?

A

Target lesions are 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

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

84
Q

What are the causes of erythema multiforme?

A

Viruses: herpes simplex virus (the most common cause)

Idiopathic

Bacteria: Mycoplasma, Streptococcus

Drugs: penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill, nevirapine

Connective tissue disease e.g. Systemic lupus erythematosus

Sarcoidosis

Malignancy

85
Q

What is erythema nodosum? What are some features?

A

Inflammation of subcutaneous fat
typically causes tender, erythematous, nodular lesions

Usually occurs over shins, but may also appear elsewhere (e.g. forearms, thighs)

Usually resolves within 6 weeks
lesions heal without scarring

86
Q

What are some causes of erythema nodosum?

A

Infection
Streptococci
Tuberculosis
Brucellosis

Systemic disease
Sarcoidosis
Inflammatory bowel disease
Behcet’s

Malignancy/lymphoma

Drugs
Penicillins
Sulphonamides
COCP

Pregnancy

87
Q

What is guttate psoriasis? What are some features?

A

Guttate psoriasis may be precipitated by a streptococcal infection 2-4 weeks before the lesions appear.

Features

Teardrop papules on the trunk and limb
Pink, scaly patches or plaques of psoriasis
Acute onset over days

88
Q

What is the management for guttate psoriasis?

A

Resolve spontaneously within 2-3 months

Topical agents as per psoriasis

UVB phototherapy

Tonsillectomy may be necessary with recurrent episodes

89
Q

What is pityriasis rosea? What are some features?

A

Acute, self-limiting rash which tends to affect young adults. Herpes hominis virus 7 (HHV-7) may play a role.

Features
Usually no prodrome,
Some might have a history of a recent viral infection
Herald patch (usually on the trunk)
followed by erythematous, oval, scaly patches (fir tree appearance)

90
Q

What is the management for pityriasis rosea?

A

Self-limiting usually disappears between 6-12 weeks

91
Q

What is the management for animal bites?

A

cleanse wound. Puncture wounds should not be sutured closed unless cosmesis is at risk

Co-amoxiclav

If penicillin-allergic then doxycycline + metronidazole is recommended

92
Q

What is the management for human bites?

A

Common organisms include:

Streptococci spp.
Staphylococcus aureus
Eikenella
Fusobacterium
Prevotella

Co-amoxiclav

The risk of viral infections such as HIV and hepatitis C should also be considered.

93
Q

What is the management for bed bugs?

A

Topical hydrocortisone is suitable for controlling itch

Definitive Management is a pest management company and fumigation of the house.

Bed bug numbers may be controlled by hot-washing bed linen and using mattress covers.

94
Q

What is Lyme Disease?

A

Caused by the spirochaete Borrelia burgdorferi and is spread by ticks.

95
Q

What are the early features of Lyme Disease (< 30 days)?

A

Erythema migrans
- Bulls-eye rash, 1-4 weeks after bite, 5cm

Headache

Lethargy

Fever

Arthralgia

96
Q

What are the late features of Lyme Disease (> 30 days)?

A

Cardiovascular
- Heart block
- Peri/myocarditis

Neurological
- Facial nerve palsy
- Radicular pain
- Meningitis

97
Q

What is the investigation for Lyme Disease?

A

Diagnosed clinically if erythema migrans is present

(ELISA) antibodies to Borrelia burgdorferi are the first-line test

If negative and Lyme disease is still suspected in people tested within 4 weeks from symptom onset, repeat the ELISA in 4-6 weeks.

If more than 12 weeks of symptoms immunoblot test for Lyme disease should be done

98
Q

What is the management for Lyme Disease?

A

Remove Tick

Doxycycline for early disease. Amoxicillin is an alternative if doxycycline is contraindicated (e.g. pregnancy)

Erythema migrans should be commenced on antibiotics without the need for further tests

Ceftriaxone if disseminated disease

Side Effect: Jarisch-Herxheimer reaction is sometimes seen after initiating therapy: fever, rash, tachycardia after the first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)

99
Q

How do you measure the extent of the burns?

A

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

100
Q

What is the immediate first aid management for burns?

A

ABC

Burns caused by heat: remove the person from the source. Within 20 minutes of the injury rinse the burn with cool (not iced) water for between 10 and 30 minutes. Cover the burn using cling film, layered, rather than wrapped around a limb

Superficial epidermal: symptomatic relief - analgesia, emollients etc
superficial dermal: cleanse wound, leave blister intact, non-adherent dressing, avoid topical creams, review in 24 hours

Electrical burns: switch off the power supply, and remove the person from the source

Chemical burns: brush any powder off then rinse with water. Attempts to neutralise the chemical are not recommended

101
Q

What is the assessment for the depth of burns?

A

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 patches of non-blanching erythema. Reduced sensation, painful to deep pressure

Full thickness (Third degree)
White (‘waxy’)/brown (‘leathery’)/black, no blisters, no pain

102
Q

When do you refer burns to secondary care?

A

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

103
Q

What is the management of severe burns?

A

The initial aim is to stop the burning process and resuscitate the patient.

Airway Assessment
- Smoke inhalation can cause airway oedema
- Early intubation should be considered e.g. if deep burns to the face or neck, blisters or oedema of the oropharynx, stridor etc

IV fluids (children 10% Surface Area, 15% Adult Surface Area)
- Parkland formula: volume of fluid = total body surface area of the burn % x weight (Kg) x4. Half of the fluid is administered in the first 8 hours.

A urinary catheter should be inserted.

Analgesia should be given.

Complex burns, burns involving the hand perineum and face and burns >10% in adults and >5% in children should be transferred to a burns unit.

Circumferential burns affecting a limb or severe torso burns impeding respiration may require escharotomy to divide the burnt tissue.

Complex burns may require excision and skin grafting. Excision and primary closure are not generally practised as there is a high risk of infection.

104
Q

What is lichen planus and what are the features?

A

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 with a ‘white-lines’ pattern on the surface (Wickham’s striae)
- Koebner phenomenon (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 the nail plate, longitudinal ridging

105
Q

What can cause Lichenoid drug eruptions?

A

Gold
Quinine
Thiazides

106
Q

What is the management of Lichen Planus?

A

Potent topical steroids are the mainstay of treatment

Benzydamine mouthwash or spray for oral lichen planus

Extensive lichen planus: oral steroids or immunosuppression

107
Q

What is Rosacea and what are some features of it?

A

Chronic skin disease of unknown aetiology.

Features
- Nose, cheeks and forehead
- Flushing
- Telangiectasia
- Develops into persistent erythema with papules and pustules
- -Rhinophyma
- Ocular involvement: blepharitis
sunlight may exacerbate symptoms

108
Q

What is the management of Rosacea?

A

Daily application of high SPF

Predominant flushing but limited telangiectasia
- Topical brimonidine gel (alpha adrenergic agonist)

Mild-to-moderate papules and/or pustules
- Topical ivermectin is first-line
- Topical metronidazole or topical azelaic acid

Moderate-to-severe papules and/or pustules
- Combination of topical ivermectin + oral doxycycline

Laser therapy for patients with prominent telangiectasia
patients with a rhinophyma

109
Q

What is Seborrhoeic dermatitis?

A

Chronic dermatitis caused by an inflammatory reaction related to the proliferation of a normal skin inhabitant, a fungus called Malassezia furfur.

110
Q

What are the features and associated conditions with Seborrhoeic dermatitis?

A

Features
- Eczematous lesions on the sebum-rich areas: scalp (may cause dandruff), periorbital, auricular and nasolabial folds
- Otitis externa and blepharitis may develop

Associated conditions:
HIV
Parkinson’s disease

111
Q

What is the scalp disease management for Seborrhoeic dermatitis?

A

Ketoconazole 2% shampoo

OTC preparations containing zinc pyrithione (‘Head & Shoulders’) and tar (‘Neutrogena T/Gel’)

Selenium sulphide and topical corticosteroid

112
Q

What is the Face and body management for Seborrhoeic dermatitis?

A

Topical Ketoconazole

Topical steroids: best used for short periods

113
Q

What is Cradle cap?

A

Seborrhoeic dermatitis in children.
Affects the scalp (‘Cradle cap’), nappy area, face and limb flexures.

Erythematous rash with coarse yellow scales.

114
Q

What is the management of Cradle cap?

A

Reassurance: usually resolves within a few weeks

Topical emollient onto the scalp to loosen scales, brush gently with a soft brush and wash off with shampoo.

If severe/persistent a topical imidazole cream may be tried

115
Q

What are the causes of Pruritus?

A

Liver disease
Iron deficiency anamiea
Polycythaemia
CKD
Lymphoma
Hyper/Hypothyroidism
Diabetes
Pregnancy
‘senile’ pruritus
Urticaria
Skin disorders: eczema, scabies, psoriasis, pityriasis rosea

116
Q

What are keloid scars?

A

Tumour-like lesions that arise from the connective tissue of a scar and extend beyond the dimensions of the original wound

117
Q

What are the predisposing factors for keloid scars?

A

Dark skin

Young adults, rare in the elderly

Common sites (in order of decreasing frequency): sternum, shoulder, neck, face, extensor surface of limbs, trunk

118
Q

What is the treatment for keloid scars?

A

Early keloids may be treated with intra-lesional steroids e.g. triamcinolone

Excision is sometimes required

119
Q

What is a lipoma and what are its features?

A

Benign tumour of adipocytes.
- Malignant transformation to liposarcoma is very rare

Features

  • Smooth, mobile, painless
120
Q

What is the management of lipoma?

A

Observe

121
Q

What are the features suggestive of liposarcoma?

A

Size >5cm

Increasing size

Pain

Deep anatomical location

122
Q

What are Venous leg ulcers and what are their features?

A

Venous leg ulcers

Most due to venous hypertension, secondary to chronic venous insufficiency

Features
- Oedema, brown pigmentation, lipodermatosclerosis, eczema
- Above the ankle, painless

Deep venous insufficiency is related to previous DVT and superficial venous insufficiency is associated with varicose veins

Doppler ultrasound looks for the presence of reflux and duplex ultrasound looks at the anatomy/ flow of the vein

123
Q

What is the management of venous leg ulcers?

A

4-layer compression banding after exclusion of arterial disease or surgery

Skin grafting if it fails to heal after 12 weeks or >10cm2

124
Q

What is Marjoilin’s Ulcer?

A

Squamous cell carcinoma

Occurring at sites of chronic inflammation e.g; burns, osteomyelitis after 10-20 years

Mainly occur on the lower limb

125
Q

What are arterial ulcers?

A

Chronic wounds are caused by insufficient blood supply to the affected area, typically resulting from peripheral arterial disease (PAD).

Atherosclerosis

Risk factors are same as CVD

Other contributing factors include thrombosis, embolism, and trauma

126
Q

What are the clinical features of arterial ulcers?

A

Lower extremities, particularly over bony prominences (lateral malleolus, toes, and anterior tibial)

Appearance
- Small, round, and have well-defined edges. The ulcer base may appear pale, dry, or necrotic.

Pain:
- Very painful, particularly at night or when the leg is elevated.

Surrounding Skin
- Shiny, thin, and hairless.

Pulses
- Peripheral pulses (dorsalis pedis and posterior tibial) are often diminished or absent.

Temperature
- Cool to the touch.

127
Q

How do you diagnose arterial ulcers?

A

Physical examination of the ulcer and assessment of peripheral pulses.

Ankle-Brachial Pressure Index (ABPI):
- ABPI measures blood pressure in the ankle: blood pressure in the arm (Ratio)
An ABPI of less than 0.9 is indicative of PAD.

Doppler Ultrasound:
- Assess blood flow in the arteries and to detect areas of stenosis or occlusion.

Magnetic Resonance Angiography (MRA) or Computed Tomography Angiography (CTA)

Lipid profile, Blood glucose levels

128
Q

What is the management of arterial ulcers?

A

Risk factor modification:
- Lifestyle changes, including smoking cessation, dietary modifications, and regular exercise.
- Control of comorbid conditions such as diabetes, hypertension, and hyperlipidemia.

Revascularisation:
- Angioplasty, stenting, or bypass surgery

Pharmacotherapy
- Antiplatelet agents (e.g., aspirin, clopidogrel) and statins

Wound care
- Debridement: Removal of necrotic tissue to promote healing.
- Dressings: Hydrocolloid, alginate, or foam dressings.
- Infection control: Topical or systemic antibiotics

Monitoring for complications, including:
osteomyelitis

129
Q

What are neuropathic Ulcers?

A

Neuropathic ulcers
Commonly over the plantar surface of the metatarsal head and the plantar surface of the hallux

The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients

Due to pressure

Management includes cushioned shoes to reduce callous formation

130
Q

What is Pyoderma gangrenosum?

A

Erythematous nodules or pustules which ulcerate

Associated with inflammatory bowel disease/RA

Can occur at stoma sites

131
Q

What is the management of venous ulceration?

A

Compression bandaging,4 layer

Oral pentoxifylline, a peripheral vasodilator, improves the healing rate

132
Q

What is atrophic vaginitis?

A

Vaginal dryness, dyspareunia and occasional spotting.
The vagina may appear pale and dry

Post menopasual women

133
Q

What is the treatment for atrophic vaginitis?

A

Vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.

134
Q

What is Pruritus vulvae?

A

Vaginal itching

Usually has an underlying cause
- Latex condoms, lubricants
- Atopic dermatitis
- Seborrhoeic dermatitis
- Lichen planus
- Lichen sclerosis
- Psoriasis: seen in around a third of patients with psoriasis

135
Q

What is the management for Pruritus vulvae?

A

Take showers rather than baths

Clean the vulval area with an emollient such as Epaderm or Diprobase (OD)

Treat underlying causes

136
Q

What are some common nail signs?

A

Nail pitting
- Psoriasis
- Alopecia areata

Blue nails
- Wilson’s disease

Leuconychia
- Hypoalbuminaemia
- Fungal disease, lymphoma

Half and half
- distal portion brown and proximal portion pale
- chronic renal failure

Nail patella syndrome

Yellow nail syndrome
- associated with congenital lymphoedema, pleural effusions, bronchiectasis and chronic sinus infections

137
Q

What are psoriatic nail changes?

A

Affects both fingers and toes and does not reflect the severity of psoriasis but there is an association with psoriatic arthropathy - around 80-90% of patients with psoriatic arthropathy have nail changes.

Nail changes that may be seen in
- psoriasis
- pitting
- onycholysis (separation of the nail from the nail bed)
- subungual hyperkeratosis
- loss of the nail

138
Q

How does eczema present in children?

A

Itchy, erythematous rash
repeated scratching may exacerbate affected areas

In infants, the face and trunk are often affected

In younger children, eczema occurs on the extensor surfaces

In older children, a more typical distribution is seen, with flexor surfaces affected and the creases of the face and neck

139
Q

What is the management of eczema in children?

A

Avoid irritants
Simple emollients
- Large quantities should be prescribed (e.g. 250g / week), roughly in a ratio of with topical steroids of 10:1

If a topical steroid is also being used the emollient should be applied first followed by waiting at least 30 minutes before applying the topical steroid
creams soak into the skin faster than ointments

Wet wrapping
- Large amounts of emollient (and sometimes topical steroids) applied under wet bandages

In severe cases, oral ciclosporin

140
Q

What is cellulitis and what are some of its features?

A

Cellulitis is a bacterial infection that affects the dermis and the deeper subcutaneous tissues.
Most commonly caused by infection with Streptococcus pyogenes or less commonly Staphylococcus aureus.

Features
- Shins
- Unilateral
- Erythema
- Well-defined margins
- Blisters and bullae may be seen with more severe disease
- Swelling
- Systemic upset
- Fever
- Malaise
- Nausea

141
Q

What classification is used for cellulitis?

A

Eron Classification system

1
There are no signs of systemic toxicity and no uncontrolled co-morbidities

2
Either systemically unwell or systemically well but with a co-morbidity (for example PAD, chronic venous insufficiency, or morbid obesity) which may complicate or delay the resolution of infection

3
Significant systemic upset such as acute confusion, tachycardia, tachypnoea, hypotension, or unstable co-morbidities that may interfere with a response to treatment or a limb-threatening infection due to vascular compromise

4
The person has sepsis syndrome or a severe life-threatening infection such as necrotizing fasciitis.

142
Q

When should you be admitted for IV antibiotics for cellulitis?

A

Has Eron Class 3 or 4cellulitis.
Has severe or rapidly deteriorating cellulitis (for example extensive areas of skin).
Is very young (under 1 year of age) or frail.
Is immunocompromized.
Has significant lymphoedema.
Has facial cellulitis (unless very mild) or periorbital cellulitis.

143
Q

What is the management of cellulitis?

A

Eron Class 1/2

First-line treatment: Oral flucloxacillin
Allergy: oral clarithromycin, erythromycin (in pregnancy) or doxycycline

Eron Class 3/4

Admit
Oral/IV co-amoxiclav,
Oral/IV clindamycin
IV cefuroxime or IV ceftriaxone

144
Q

What are the 4 types of malignant melanoma?

A

Superficial spreading (most frequent)
Nodular (most aggressive)
Lentigo maligna
Acral lentiginous (Rare)

145
Q

What are the different features of the 4 types of malignant melanoma?

A

Superficial spreading ( Arms, legs, back and chest, young people), (Growing moles, change in size, change in shape, change in colour)

Nodular (sun-exposed skin, middle-aged people), (Red or black lump or lump which bleeds or oozes)

Lentigo maligna (Chronically sun-exposed skin, older people), (Growing moles, change in size, change in shape, change in colour)

Acral lentiginous (Nails, palms or soles, People with darker skin pigmentation), (Subungual pigmentation (Hutchinson’s sign) or on palms or feet)

146
Q

What are the diagnostic criteria for malignant melanoma?

A

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

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

147
Q

What is the treatment for malignant melanoma?

A

Excision biopsy.

Histopathological assessment

Specialised treatment:
- Sentinel lymph node mapping, isolated limb perfusion and block dissection of regional lymph node groups

148
Q

What is Breslow depth relating to malignant melanoma?

A

The invasion depth of a tumour (Breslow depth) is the single most important factor in determining the 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%

149
Q

What is psoriasis?

A

Common and chronic skin disorder. Red, scaly patches on the skin.

150
Q

What are the subtypes of psoriasis?

A

Plaque psoriasis:
- well-demarcated red, scaly patches affecting the extensor surfaces, sacrum and scalp

Flexural psoriasis:
- skin is smooth

Guttate psoriasis:
- transient psoriatic rash frequently triggered by a streptococcal infection. Multiple red, teardrop lesions appear on the body

Pustular psoriasis:
- occurs on the palms and soles

151
Q

What are some complications of psoriasis?

A

Psoriatic arthropathy (around 10%)

Increased incidence of metabolic syndrome (UC, Chrons)

Increased incidence of CVD, Hypertension

Increased incidence of VTE

Non-melanoma skin cancer

Other cancers (liver, lung, upper GI)

Psychological distress/ Depression

152
Q

What are some exacerbating factors of psoriasis?

A

Trauma

Alcohol

Drugs: beta-blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab

Withdrawal of systemic steroids

Streptococcal infection may trigger guttate psoriasis.

153
Q

What is the management for psoriasis?

A

Regular emollients to reduce scale loss and reduce pruritus

First-line:
- Potent corticosteroid applied once daily plus vitamin D analogue applied once daily
- Should be applied separately, one in the morning and the other in the evening
for up to 4 weeks as initial treatment

Second-line: If no improvement after 8 weeks then offer:
- Vitamin D analogue twice daily

Third-line: if no improvement after 8-12 weeks then offer either:
- Potent corticosteroid applied twice daily for up to 4 weeks, or
a coal tar preparation applied once or twice daily
- Short-acting dithranol can also be used

154
Q

When do you refer for psoriasis?

A

Diagnostic uncertainty

Severe or extensive, more than 10% of the body surface area is affected

If any type of psoriasis cannot be controlled with topical therapy

If acute guttate psoriasis requires phototherapy

Nail disease has a major functional or cosmetic impact

Any major impact on a person’s physical, psychological or social wellbeing

Children and young people with any type of psoriasis should be referred to a specialist at presentation

Patients with erythoderma or generalised pustular psoriasis should be referred on the same day.

155
Q

What is systemic therapy for psoriasis?

A

Methotrexate

Ciclosporin if:
- Need rapid or short-term disease control (for example a psoriasis flare)
- Palmoplantar pustulosis
- Considering conception (both men and women) and systemic therapy cannot be avoided

Biological
- Adalimumab (SC)
- Etanercept (SC)
- Infliximab (IV)
- Ustekinumab (SC)

156
Q

What is the management for scalp psoriasis?

A

Potent topical corticosteroids used once daily for 4 weeks

If no improvement after 4 weeks
- Different formulations of the potent corticosteroid (shampoo or mousse) - -
- Topical agents to remove adherent scale (agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid

157
Q

What is Candidiasis?

A

Yeast infection is a red, itchy rash that usually appears in moist areas or skin folds

158
Q

What is the management for Candidiasis?

A

For adults:
- topical Clotrimazole, econazole, miconazole, or ketoconazole.

For children:
- Topical clotrimazole, econazole, or miconazole

159
Q

What is the management for cutaneous warts and verrucas?

A

Topical salicylic acid (15–50%) applied daily for up to 12 weeks

Cryotherapy with liquid nitrogen

Phase 4 Derm, Sexual Health, Breast, Renal, Urology, ENT (5 decks)

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