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Y4 Special senses > Dermatology > Flashcards

Dermatology Flashcards

1
Q

Presenting complaint dermatology history

A

How long has it been there for
Any recent changes in creams, medication

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2
Q

History of presenting compliant- dermatology history

A
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3
Q

What are four different management options for a superficial BCC?

A
  1. Curettage (scraping) and cautery (sealing with heat)
  2. Cryotherapy
  3. Surgical excision
  4. 5-FU and Imiquimod
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4
Q

What non-cutaneous manifestations can occur in psoriasis

A

Nail psoriasis
- Pitting
- Ridging
- Oncholysis

Associated with inflammatory arthritis
Cardiovascular disease
IBD
Uveitis
Coeliac disease

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5
Q

Where does chronic plaque psoriasis commonly occur?

A

Plaques usually on the knees, elbows, trunk, scalp and behind ears

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6
Q

Where does guttate psoriasis commonly occur?

A

Small plaques of psoriasis scattered over the body

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7
Q

What is the general management of Psoriasis

A

General measures: Emollients, aqueous cream

1st line: Topical therapies, corticosteroids and vitamin D analogues
2nd line: Phototherapy
3rd line: Systemic therapy (methotrexate, cyclosporin, acitretin and biologics)

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8
Q

Risks of Isotretinoin

A

Teratogenic
Raises cholesterol
Can cause mood changes, risk of depression and suicidal ideation

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9
Q

Second line management of eczema

A

UV phototherapy, oral corticosteroids and ither immunosuppressants

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10
Q

Causes of nail dystrophy

A
  • Trauma
  • Psoriasis
  • Congenital abnormalities
  • Lichen planus
  • Benign tumours
  • rarely cancer
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11
Q

Causes of nail dystrophy

A
  • Trauma
  • Psoriasis
  • Congenital abnormalities
  • Lichen planus
  • Benign tumours
  • rarely cancer
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12
Q

How to manage a melanoma

A

Excise with 2mm margin. Dependent on depth of melanoma will require wide local excision maybe a sentinel lymph node biopsy.

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13
Q

What is molluscum contagiosum

A

Shiny smooth umbilicated papules
Few centrally eroded with crust
Self-limiting viral infection.

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14
Q

Where should you look on examination of a patient with scabies

A

Look at anterior wrist/inter-digital spaces
Look for linear burrows, papules, excoriations

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15
Q

How do you manage scabies

A

Permethrin 5% cream
Apply once weekly for two doses
Apply over the whole body
Wash-off after 8-12 hours

Contacts should be treated at the same time whether they are itchy or not

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16
Q

What is the difference between bullous pemphigoid and pemphigus vulgaris?

A

Pemphigus is characterized by shallow ulcers or fragile blisters that break open quickly.
Pemphigoid presents with tense blisters that don’t open easily

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17
Q

Difference between fitzpatrick 1 and 2

A

1 burns but doesn’t tan, 2 burns then tans

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18
Q

Examination between SCC and Actinic keratosis

A

Try and feel the lump under an SCC

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19
Q

Characteristics of SCC

A
  • Sun exposed sites
  • Fast growing
  • Painful
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20
Q

Management of SCC with no palpable lymph nodes

A

WLE biopsy

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21
Q

If a patient can’t have surgery for an SCC, how do you proceed with management?

A

Radiotherapy

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22
Q

When would you do cautery and curettage?

A

Superficial BCC
Actinic keratosis

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23
Q

Characteristics of BCC

A
  • Not painful
  • Slow growing over a couple of years
  • Telangiectasia
  • Pearly border
  • Rolled edge appearance
  • Nodular
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24
Q

Management of BCC

A

Routine referral- very rarely metastasize
Excision
Curettage and cautery
5-FU

Once it is excised- nothing else we need to do

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25
Q

How long would you be on tetracyclines for with acne?

A

3 months

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26
Q

When would you refer for Roaccutane?

A
  • If it is having a significant impact on her life
  • Scarring
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27
Q

Most common side effects of Roaccutane (isotretinoin)

A
  • Teratogenic can cause birth defects if pregnant
  • Pregnancy prevention programme (pregnancy tests every month and should be on contraception
  • Mood changes- association, screen to make sure they are not having symptoms of depression/mental health disorders. But acne does cause low mood!
  • Reduced libido
  • Severe skin drying
  • Warn about sun exposure
  • Muscle aches, fatigue, headaches
  • LFTs and cholesterol levels
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28
Q

Would hydrocortisone be enough for an eczema flare?

A

May not be strong enough

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29
Q

How to remember increasing strengths of steroids

A

Hydrocortisone
- Hydro is for mostly water, very weak steroid

Eumovate
- E is for eyes and ears- safe to put on the face

Betnovate
- B is for body, suitable for body eruptions torso and limbs

Dermovate
- Dermatology referral, very strong topical steroid

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30
Q

Potential complications with eczema

A
  • Infection
  • Eczema herpeticum (secondary infection with HSV virus)- aciclovir
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31
Q

Where do

A
  • Younger patients
  • Trunk and extremities
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32
Q

What is sclerosing BCC?

A

Morphaeform (sclerosing/infiltraing BCC)
Waxy scar like plaques with poorly defined borders
Usually found in the mid-face
Can sub-clinically spread
Poorest prognosis

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33
Q

Differential diagnoses for nodular BCC

A

Amelanotic melanoma
Fibrous papule

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34
Q

Differential diagnoses for superficial BCC

A

Inflammatory skin disease (psoriasis, lichenoid keratosis, actinic keratosis, bowen’s disease)

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35
Q

Differential diagnoses for Morphaeform

A
  • Scar
  • Localised scleroderma
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36
Q

What is a dermatoscope useful for with BCC?

A

Telangiectasia or micro-ulcerations which may not be visible to the naked eye

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37
Q

Histological features of all BCC

A
  • Basophilic aggregations of basaloid keratinocytes with large niclei and scant cytoplasm
  • Clefts of tumour tissue
  • Apoptotic cells
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38
Q

Treatment for low risk BCC

A

Complete surgical excision (4mm margin)

Curretage and cautery, 5-FU and photodynamic therapy, cro

Imiquimod

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39
Q

Treatment for high risk BCC

A

Mohs (also if the lesion that needs preservation
Simple recectino (6mm margin) with adjuvant radiotherapy

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40
Q

Complications

A
  • Recurrence
  • Increased risk of skin cancer
  • Disfiguration if not treated
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41
Q

What is the aetiology of actinic keratosis?

A

Sun exposure leading to DNA damage with keratinocytes
Small chance it will develop into SCC

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42
Q

How to describe actinic keratosis

A

Thickened papules and plauques
White or yellow; scaly, warty
Skin is red or pigmented

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43
Q

Differentials for AK

A
  • Seborrheic keratosis- well demarcated, waxy, pigmented plaques with a stuck on appearance
  • Cutaneous horns
  • Psoriasis- well defined erythematous plaques with silvery scales
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44
Q

Management for AK

A

Cryotherapy
5-FU
Imiquimod
Patient education on sun protective measures to prevent further AK formation

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45
Q

What is the most common type of skin cancer in the UK?

A

BCC

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46
Q

What is the second most common type of skin cancer in the UK?

A

SCC

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47
Q

How SCC happens

A

p53 tumour suppressor e
squamous keratinocytes mutated

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48
Q

Risk factors for SCC

A
  • Genetic syndromes (Xeroderma pigmentosum)
  • Old age
  • Male sex
  • Pre-disposing lesions- AK, bowen’s disease
  • Marlin ulcer (SCC develops in a site of chronically inflamed ulcers)
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49
Q

PMH for dermatology

A

Bowen’s disease, actinic keratosis, solid organ transplant recipient

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50
Q

Bowen’s disease

A

Cancerous cells are confined to the epidermis

SCC in situ

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51
Q

Investigations for SCC

A

Incisional/punch small 4mm part of the lesion)

Used if the lesion is large, in an inaccessible area, present in a cosmetically sensitive area

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52
Q

What makes an SCC high risk?

A
  • Immunosuppressed
  • Poor differentiation
  • High tumour budding
  • > 2mm deep or >20mm wide
  • Face, ear, genitals, hand, feet
  • Recurrence
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53
Q

SCC management

A

1st line- cryotherapy, 5-FU
Cryotherapy is a form of non-surgical destruction, liquid nitrogen to freeze the skin lesion

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54
Q

What is Mohs?

A
  • Ensuring all cancerous cells are removed
  • Maximising the amount of healthy tissue that is preserved
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55
Q

What percentage of melanomas come from normal moles?

A

1/3 develop from pre-existing melanocytic naevi

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56
Q

Subtypes of malignant melanoma

A
  1. Superficial spreading melanoma (most common type, perhaps the most forgiving)
  2. Nodular (most aggressive type, often ulcerate/bleed)
  3. Lentigo maligna melanoma- change in a sun spot in elderly people
  4. Acral lengitinous melanoma (palms of hands, soles of feet and under nails)
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57
Q

Risk factors for malignant melanoma

A
  • Genetic syndromes (xeroderma pigmentosum)
  • BRAF mutations
  • Immunosuppression
  • Red/light coloured hair
  • High freckle density
  • light eye colour
  • numerous moles
  • Old age
  • Family history of melanoma
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58
Q

Differentials for malignant melanoma

A
  • Pigmented BCC
  • Benign naevus
    -SK
  • Dysplastic nevus
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59
Q

Malignant melanoma investigations

A

Visual inspection and using a dermatoscope

Suspicious lesions are excised with a lateral margin of 2-3mm and sent for histology

Diagnosis is made following a full thickness excisional skin biopsy

60
Q

Advanced malignant melanoma medical management

A

Targeted- dabrafenib BRAF 600

Immunotherapy- nivolumab, ipilmumab

61
Q

What is 5 year survival for stage 1A vs 4 melanoma

A

1A- 95%

4- 7-19%

62
Q

What is the most significant risk factor for melanoma?

A

Having a family history of melanoma (over lots of sunburn)

63
Q

Most appropriate management of SCC

A

Immediate excision biopsy
SCC have the potential to metastasise

64
Q

Most appropriate management in BCC near the left eye?

A

Mohs micrographic surgery
For high-risk facial BCCs, especially those near the eye

Preserve as much healthy tissue as possible

More cosmetic

65
Q

What factor most strongly predicts a poor prognosis for a patient with melanoma?

A

Breslow thickness

Deeper lesions are associated with a higher risk of depth of invasion and metastasis into the skin

66
Q

Most appropriate management in Bowen’s?

A

Topical 5-FU
First line for Bowen’s disease

67
Q

Why is skin cancer on the rise?

A

People are living longer

4-5 decades on- catching up with people who didn’t use suncream in the 50s/60s

Cumulative sun exposure

68
Q

Margin of excision for melanoma

A

2mm

69
Q

BCC timeline of spread

A

6 months to 1 year

70
Q

SCC timeline of spread

A

2-3 months

71
Q

BCC under dermatoscope

A

Tree branching telangiectasia normally on the borders

72
Q

Margins of excision for the three different types of skin cancer

A

Melanoma- 2mm margin

SCC- 6mm margin

BCC- 4mm margin

73
Q

How would you manage varicose eczema?

A
  • Doppler ultrasound to rule out arterial disease
  • Compression
  • Steroids
  • Emollient
74
Q

Different types of eczema

A
  • Atopic dermatitis
  • Contact dermatitis (allergic and irritant)
  • Seborrheic dermatitis
  • Varicose dermatitis
  • Dyshidrotic eczema
  • Nummular eczema
  • Keratosis pilaris
75
Q

How to rule out other diagnoses in rosacea

A
  • Started a new medication? photosensitive
  • Lupus- joint pain
  • Atopic eczema (not itchy or flaky)
76
Q

How to manage rosacea

A

Initially for mild- topical metronidazole, topical Ivermectin
Avoid sun exposure- sunblock, soap substitutes (Dermol 500- antiseptic but moisturizing)

77
Q

Pityriasis rosea typical presentation and differential

A

Herald patch
2 weeks later- christmas tree distrubution, multiple erythematous patches with scale

Secondary syphyllis

78
Q

Tinea capitis (scalp ringworm) how to manage

A

More common in children of afro-carribean descent with curly hair

Management (based on NICE guidelines): oral antifungals: terbinafine for Trichophyton tonsurans infections and griseofulvin for Microsporum infections. Topical ketoconazole shampoo should be given for the first two weeks to reduce transmission

79
Q

How to tell the difference between tinea capitis and discoid eczema?

A

Clearance of the centre- ringworm/fungal

Discoid eczema- scaling on the whole lesion

80
Q

How to treat infected eczema herpeticum in children

A

IV anti-virals
IV flucloxacillin

On examination, monomorphic punched-out erosions (circular, depressed, ulcerated lesions) usually 1-3 mm in diameter are typically seen.

81
Q

Trigger for guttate psoriasis

A

Streptococcal infection

82
Q

Difference between erysipelas and cellulitis

A

Erysipelas has a well-defined border and cellulitis does not

83
Q

What is a furuncle

A

Abscess of the hair follicle
Carbuncle= when furuncles join up

84
Q

What is necrotising fascitis?

A

Strep pyogenes
Gets to the fascial layers- necrosis of the fascia
Surgical emergency- surgical debridement is the mainstay of treatment

85
Q

Staphylococcal scalded skin syndrome

A

Release of exotoxins from toxigenic strains of staphylococcus
Presents in children under the age of 5
Renal clearance is not good enough to clear the toxins

86
Q

Most common dermatophytes

A

Trichophyton, microsporum and epidermophyton
Dermatophytes need keratin for growth

87
Q

Types of tinea infections

A

Corporis- body
Capitits- head
Unguium- nail

May need systemic/longer acting treatment for nails and hair as harder to treat

88
Q

Topical (first lines)

A
  • Miconazole
  • Ketoconazole
89
Q

Systemic treatments for tinea infections that are persistent

A
  • Itraconazole
  • Fluconazole
  • Terbinafine
90
Q

Other types of candida species apart from candida albicans

A
  • C. Glabrata
  • C. parapsilosis
  • C. tropicalis
91
Q

Risk factors for candida infections

A
  • Recent antibiotic use
  • Diabetes
  • Immunosupression
92
Q

Usual topical treatment for scabies

A

5% permethrin cream

93
Q

How a biofilm forms

A
  1. Attachment of bacteria to surface
  2. Formulation of monolayer and production of matrix
  3. Micro-colony formation, multi-layer
  4. Mature biofilm, characteristic mushroom formed of polysaccharide- behave as if they are one organism
  5. Detachment of planktonic bacteria at the surface. All bacteria closest to prosthetic device, is metabolically inactive (hence antibiotics won’t work) you have to remove the device.
94
Q

What bacteria causes acne?

A

Cultibacterium acnes

95
Q

Main difference between SJS and TEN

A

SJS <10%

TEN >30%

96
Q

Most common drugs that cause SJS

A
  • Penicillins
  • Sulphonamides
  • Lamotrigine
  • Allopurinol
  • Oral contraceptive pills
  • NSAIDs
97
Q

Pathophysiology of SJS and TEN

A

Detachment of epidermis from papillary dermis due to keratinocyte apoptosis

Cytotoxic CD8 T cells are strongly linked

98
Q

Signs and symptoms of SJS/TEN

A

Around 3 weeks after initiating medication
Starts off with fever, malaise, headaches and keratoconjunctivitis
Rash starts off on the face/upper torso

99
Q

Buzz words for rash in SJS/TEN

A

Maculopapular rash with target lesions
Can develop into vesicles/bullae
Nikolsky sign is positive
Mucosal involvement and can even involve the resp and GI tract

100
Q

Differentials for SJS and TEN

A

SJS or early TEN
Erythema multiforme

Late TEN
Toxic shock syndrome
Staphylococcal scalded skin syndrome (spares mucous membranes)

101
Q

How to manage SJS/TEN

A
  • Remove precipitating cause
  • IV fluids and wound care
  • Sometimes cyclosporine and plasmaphereses are considered
102
Q

What kind of a reaction is erythema multiforme

A

Type 4 hypersensitivity reaction

103
Q

Common causes of erythema multiforme

A
  • Herpes simples
  • Mycoplasma
  • SLE
  • Sarcoidosis
104
Q

What is erythema multiforme major

A

Preceding mycoplasma/herpes simplex
Two mucosal sites are involved (ocular/oral/genital)

105
Q

What is erythroderma

A

Generalised erythema and oedema involving 90% of the body

Erythroderma is a term used when more than 95% of the skin is involved in a rash of any kind.

Causes:
Atopic dermatitis
Psoriasis (especially after withdrawal of systemic steroids)
Less frequently: contact dermatitis, seborrheic dermatitis and staphylococcal scalded skin syndrome

106
Q

What is necrotizing fasciitis

A

Deep soft tissue compartments
Dermis, subcutaneous tissue, fascia and muscle

106
Q

What is eczema herpeticum

A

Severe primary infection with HSV 1/2 but also varicella zoster

On examination, monomorphic punched-out erosions (circular, depressed, ulcerated lesions) usually 1-3 mm in diameter are typically seen.

Systemic= fever, lethargy and irritability

106
Q

Management of eczema herpeticum

A
  • Viral swabs
  • Treatment is started anyway with IV aciclovir (more severe)
107
Q

What are the different organisms of type one and type 2 necrotizing fascitis

A

It can be classified according to the causative organism:
type 1 is caused by mixed anaerobes and aerobes (often occurs post-surgery in diabetics). This is the most common type

type 2 is caused by Streptococcus pyogenes

108
Q

Symptoms and examination findings of nec fasc

A

Pain disproportionate to clinical findings
Local pain
Erythema, blistering and bullae
Skin discolouration
Poorly defined margins
Crepitations on palpation

109
Q

Diagnosis and investigations of necrotizing fascitis

A
  • FBC, LFT, U&E, G&S
  • Blood cultures
  • Wound swabs
  • Bedside POCUS
  • CT
  • Imaging should not delay emergency surgical management
110
Q

Management of necrotizing fascitis

A
  • A-E approach
  • Broad spectrum antibiotics in keeping with local guidelines
  • Surgical debridement
111
Q

What is the difference between acute and chronic urticaria

A

Acute is sudden onset lasting less than 6 weeks
Chronic= longer than 6 weeks

112
Q

What is the pathophysiology of urticaria?

A

Mast cells are activated by autoantibodies and cytokines, releasing histamine

Histamine causes increased permeability of local capillaries and small venules

113
Q

What is the difference between provocation and patch testing?

A

Provocataion- for type 1

Patch testing= type 4 hypersensitivity reactions

114
Q

What is morbilliform drug eruption?

A

Delayed type 4 reaction
Generalized maculopapular rash which can become confluent if drug isn’t discontinued.

115
Q

How to manage morbilliform drug eruptions?

A

Withdraw the drug
Emollients
Topical steroids
Anti-histamines

116
Q

What is DRESS?

A

Drug reaction with eosinophila and systemic symptoms
Delayed type 4 hypersensitivity
Systemic symptoms like fever, cardiac/lung involvement
Facial oedema is characteristic
Lip erosions and target lesions

117
Q

What is acute generalized exanthematous pustulosis

A

Within 24 hours
Eruption of pustules- itchy and painful
Febrile patient

118
Q

What is staphylococcus scalded skin syndrome?

A

Caused by a type of staph.aureus that produces epidermolytic toxins

Condition affects children younger than 5 (can be seen in immunocompromised patients)

119
Q

Staphylococcal scalded skin syndrome

A
  • Skin looks thin and wrinkles
  • Bullae start to form
  • Bullae burst leaving sore erythematous skin
  • Nikolsky’s sign is positive
120
Q

Treatment of staphylococcal scalded skin syndrome

A
  • IV fluid and electrolyte
  • Pain management
  • Wound care
  • Admission and treatment with IV flucloxacillin
121
Q

Treatment of erythema multiforme

A

Most common

122
Q

What is Baboon syndrome/SDRIFE?

A

Symmetrical drug-related intertriginos and flexural erythema is a type of drug reaction.

Common culprits are antibiotics (beta-lactams), chemotherapy agents and antipsychotics.

123
Q

Why is steven’s-johnson syndrome initially dismissed?

A

Can be dismissed as the flu initially as it presents with fever, sore throat, fatigue and conjunctivitis before the rash appears.

124
Q

Describe the rash seen in SJS

A

Rash starts as erythematous macules or papules that may develop into target lesions.
Dusky or purpuric centre.
Lesions can progress into bullae.

125
Q

What risk assessment tool is used in SJS?

A

SCORTEN

126
Q

Briefly outline the management of melanoma

A

2mm excision with an elipse shape
Depending on the breslow depth (looking at breslow density in the future) will determine the WLE margin.

2b and above will require SLNB

High grade melanomas have BRAF mutation screening for targeted therapy

Follow up is 1-5 years

127
Q

Where can you not use betnovate?

A

Not on face, neck and genital area.

128
Q

Describe a squamous cell carcinoma lesion

A

An irregular asymmetrical nodular lesion on the forehead with central ulceration, crusting and an indurated border.

129
Q

Apart from the lesion, what do you examine in dermatology?

A
  • Lymphoreticular examination
  • Full skin examination
  • Use a dermatoscope
  • Examine the spleen and the liver
130
Q

Differentials for squamous cell carcinoma

A
  • Actinic keratosis (rough, scaly patch on sun-exposed skin)
  • Basal cell carcinoma (pearly, translucent nodule with telangiectasia)
  • Bowen’s disease (well-demarcated, erythematous, scaly plaque)
  • Keratocanthoma (rapidly growing dome-shaped with central keratin plug, often resembles well-differentiated SCC)
131
Q

What is management of a BCC

A

Excision with a 4mm safety margin as there is a risk of it locally invading.
If surgery is not possible- do an initial punch biopsy to confirm diagnosis and then treat with radiotherapy.
Superficial BCC- cryosurgery, imiquimod, 5FU or photodynamic therapy

Risk of it locally invading

132
Q

Describe a BCC lesion

A

Pearly or translucent flesh-coloured nodule with telangiectasia, often with a rolled border and a central depression or ulceration.

133
Q

What should you explain to a patient about to start them on isotretinoin

A

Evidence of scarring, severe acne, affecting mental health. After the initial tests are done can start the patient on Roaccutane. Will need follow up in one month and then monthly reviews including mental health, blood tests and pregnancy testing.
Side effects- very dry skin, lops, eyes and nasal passages. Very sensitive to the sun so will need suncream!
Less common- changes in night vision, headaches and muscle pain
Informed consent

134
Q

How do you treat eczema

A

Dermol 500 wash, diprobase, cut nails, sedating anti-histamines to help with the itching. Wet wrap therapy for severe flares. Avoidance of triggers if known.
Eumovate or Betnovate for the discoid eczema, hydrocortisone will not be enough to treat them.
Establish a consistent skin care routine
Topical Fucidin cream if areas look infected

Topical steroids can be used in flare ups.
Use lukewarm baths
Try and keep nails trimmed and use anti-histamines to help with itching. (Can come in liquid form, piriton syrup).

135
Q

How do you manage psoriasis

A

Emollients- doublebase
Topical corticosteroids for mild to moderate
Betamethasone for thick plaques
Topical vitamin D analogue (calcitriol)
Narrowband UVB for moderate to severe psoriasis.
Review in a couple of months
Psychosocial support

136
Q

Why do beta-lactam antibiotics not work with acne?

A

Because the bacteria responsible in acne is called Proprionibacterium acnes and it is an anaerobic rod.

137
Q

What is Dapsone?

A

An antibiotic belonging to the group sulfones, used in leprosy, PCP and dermatitis herpetiformis

138
Q

Using dermatology terminology, give four features that support a diagnosis of psoriasis

A
  • Erythema
  • Plaques that are well defined
  • White/silvery/thick scales
  • Extensor surfaces
  • Hyperkeratotic nails, pitting, onchylosis
139
Q

Name two medicated topical treatments for psoriasis

A
  • Topical steroids
  • Vitamin D analogues (calcipotriol)
  • Calcineurin inhibitor (tacrolimus)
  • Coal tar preparations
  • Salicylic acid
140
Q

Name three systemic treatments for psoriasis affecting the skin

A
  • Biologics (adalimumab)
  • Ciclosporin
  • Methotrexate
  • Acitretin
141
Q

What are the two most commonly used scores to assess and monitor response to treatment in psoriasis?

A
  • PASI (psoriasis area and severity index)
  • DLQI score (dermatology life quality index)
142
Q

What systemic treatment can you start on a woman who is trying for a family with psoriasis?

A
  • Biologics like Adalimumab, psoriasis has not responded to systemic therapies including ciclosporin, methotrexate and PUVA (psoralen and long-wave ultraviolet radiation)
143
Q

What extracutaneous conditions are commonly associated with this disease?

A
  • Psoriatic arthritis
  • Cardiovascular disease

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