Dermatology Flashcards
1
Q
Rosacea features?
A
- Nose, cheeks, forehead
- Flushing, telangiectasia
- Develops into persistent erythema with papules and pustules
- Rhinophyma (enlarged bulbous nose with thickened skin)
- Ocular involvement = blepahritis
- Sunlight may exacerbate features
2
Q
Rosacea Rx?
A
- Topical metronidazole for mild symptoms
- Topical brimonidine gel with predominant flushing but limited telangiectasia
- Oral oxytetracycline for more severe disease
- Sunscreen, camouflage cream, laser therapy if prominent telangiectasia
- Rhinopyma –> referred to dermatology
3
Q
Bullous pemphigoid definition?
A
An autoimmune condition causing sub-epidermal blistering of the skin
4
Q
Bullous pemphigoid pathophysiology?
A
Development of antibodies against hemidesmosomal proteins in the basement membrane, specifically BP180 (type XVII collagen) and BP230.
5
Q
Bullous pemphigoid features?
A
- Itchy, tense blisters around flexures
- Blisters heal without scarring
- No mucosal involvement
6
Q
Bullous pemphigoid biopsy?
A
Immunofluorescence shows IgG and C3 at dermo-epidermal junction
7
Q
Bullous pemphigoid Rx?
A
- Referral to dermatology for biopsy and confirmation of Dc
- Oral corticosteroids
- Topical corticosteroids, immunosuppressants and Abx are also used
8
Q
Seborrhoeic keratosis features?
A
- Large variation in colour from flesh to light-brown to black
- Have a stuck-on appearance
- Keratotic plugs may be seen on the surface
9
Q
Seborrhoeic keratosis Rx?
A
- Reassurance
- Removal = curettage, cryosurgery, shave biopsy
10
Q
Shingles definition?
A
Acute, unilateral, painful blistering rash caused by reactivation of the varicella-zoster virus (VZV). Following primary infection with VZV (chickenpox), the virus lies dormant in the dorsal root or cranial nerve ganglia
11
Q
Shingles RFs?
A
- Age
- HIV: x15
- Immunsuppression
12
Q
Most commonly affected shingle dermatomes?
A
T1-L2
13
Q
Shingles features?
A
- Prodromal period = burning pain over dermatome for 2-3 days, may interfere with sleep, 20% will experience fever/headache/lethargy
- Rash = erythematous and macular, becomes vesicular, well demarcated by dermatome and doesnt cross midline, bleeding into adjacent areas may be seen
14
Q
Shingles Dx?
A
Clinical
15
Q
Shingles Rx?
A
- Potentially infectious = avoid pregnant and immunosuppressed, infectious until vesicles crusted over, 5-7 days following onset, covering lesions reduces risk
- Analgesia = Paracetamol and NSAIDs, neuropathic agents, oral corticosteroids may be considered in the first 2 weeks in immunocompetent adults with localized shingles if the pain is severe and not responding to the above treatments
- Antivirals = within 72h, unless unless the patient is < 50 years and has a ‘mild’ truncal rash associated with mild pain and no underlying risk factors. Reduced incidence of post-herpetic neuralgia. Aciclovir/famciclovir/valaciclovir
16
Q
Shingles complications?
A
- Post-herpetic neuralgia = most common, 5-30%, usually resolves within 6 months
- Herpes zoster ophthalmicus
- Herpes zoster oticus (Ramsay-Hunt syndrome)
17
Q
Eczema herpeticum mushkies?
A
Severe primary infection of the skin by HSV 1/2. On examination, monomorphic punched-out erosions (circular, depressed, ulcerated lesions) usually 1–3 mm in diameter are typically seen. Rx = IV aciclovir as is potentially life threatening
18
Q
Toxic epidermal necrolysis (TEN) definition?
A
A potentially life-threatening skin disorder that is most commonly seen secondary to a drug reaction. In this condition, the skin develops a scalded appearance over an extensive area. Some authors consider TEN to be the severe end of a spectrum of skin disorders which includes erythema multiforme and Stevens-Johnson syndrome
19
Q
TEN features?
A
- Systemically unwell e.g. pyrexia, tachycardia
- Positive Nikolsky’s sign = epidermis separates with mild lateral pressure
20
Q
Drugs known to induce TEN?
A
- Phenytoin, Penicillins
- Sulphonamides
- Allopurinol
- Carbamazepine
- NSAIDs
21
Q
TEN Rx?
A
- Stop precipitating factor
- Supportive care = ITU
- IVIG 1st line
- Others = immunosuppressive agents (ciclosporin and cyclophosphamide), plasmapharesis
22
Q
Chondrodermatitis nodularis helicis definition?
A
A common and benign condition characterised by the development of a painful nodule on the ear. It is thought to be caused by factors such as persistent pressure on the ear (e.g. secondary to sleep, headsets), trauma or cold. CNH is more common in men and with increasing age.
23
Q
Chondrodermatitis nodularis helicis Rx?
A
- Reducing pressure on ears = foam protectors
- Cryotherapy, steroid injection, collagen injection
- Surgery possible but high recurrence rate
24
Q
Lichen planus features?
A
- Itchy, papular rash on palms, soles, genitalia and flexor surfaces of arms
- Rash often polygonal, white lines on surface (Wickham’s striae)
- Koebner phenomenon
- Oral involvement on 50%
- Nails = thinning of nail plate, longitudinal ridging
25
Lichenoid drug eruption causes?
1. Gold
2. Quinine
3. Thiazides
26
Lichen planus Rx?
1. Potent topical steroids
2. Benzydamine mouthwash or spray for oral
3. If extensive may require oral steroids or immunosuppression
27
Chronic plaque psoriasis Rx?
Regular emollients
1. 1st line = Potent corticosteroid OD + Vitamin D analogue OD, apply separately one in AM and one in PM, for up to 4 weeks as initial treatment
2. 2nd line = If no improvement after 8 weeks, Vitamin D analogue BD
3. 3rd line = If no improvement after 8-12 weeks, Potent corticosteroid BD up to 4 weeks or coal tar OD/BD
4. Short acting dithranol can also be used
28
Psoriasis secondary care management?
1. Phototherapy
2. Systemic therapy
29
Psoriasis phototherapy mushkies?
1. Narrowband UVB 3x week preferred
2. Photochemotherapy (PUVA)
30
Phototherapy s/e?
Skin ageing, SCC (not melanoma)
31
Psoriasis systemic therapies?
1. Oral MTX 1st line
2. Ciclosporin
3. Systemic retinoids
4. Biological = Infliximab, Etanercept, Adalimumab
5. Ustekinumab (IL12 & IL23) showing promise
32
Scalp psoriasis Rx?
1. Potent topical corticosteroid OD 4 weeks
2. If no improvement after 4 weeks --> use different formulation of the potent corticosteroid (for example, a shampoo or mousse) and/or a topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid
33
Face, flexural and genital psoriasis Rx?
Mild/moderate potency corticosteroid OD/BD for maximum 2 weeks
34
Topical steroids psoriasis mushkies?
1. S/e = skin atrophy, striae, rebound symptoms
2. Don't treat scalp, face and flexures for more than 1-2 weeks per month
3. Systemic s/e seen when used >10% BSA
4. 4 week break before starting another course of topical corticosteroids
5. Potent corticosteroids for no longer than 8 weeks at a time, very potent corticosteroids for no longer than 4 weeks at a time
35
Psoriasis Vitamin D analogue mushkies?
1. Calcipotriol (Dovonex), calcitriol, tacalcitol
2. Reduce cell division and differentiation, reducing epidermal proliferation
3. Adverse effects are uncommon
4. Can be used long term, do not smell or stain
5. Avoid in pregnancy
6. Maximum weekly amount for adults is 100g
7. Tend to reduce the scale and thickness of plaques but not the erythema
36
Dithranol mushkies?
Inhibits DNA synthesis, wash off after 30 mins, s/e = burning, staining
37
Coal Tar MOA?
Probably inhibits DNA synthesis
38
Venous ulceration typically seen where?
Above medial malleolus
39
Venous ulceration Ix?
ABPI (Normal 0.9-1.2). Values below 0.9 indicate arterial disease. Interestingly, values above 1.3 may also indicate arterial disease, in the form of false-negative results secondary to arterial calcification (e.g. In diabetics)
40
Venous ulceration Rx?
1. 4 layer compression banding (only treatment shown to be of real benefit)
2. Oral pentoxifylline (peripheral vasodilator), improves healing rate
3. Flavinoids
4. Little evidence for hydrocolloid dressings, topical growth factors, ultrasound therapy and intermittent pneumatic compression
41
Dermatitis herpetiformis definition?
Autoimmune blistering skin disorder associated with coeliac disease
42
Dermatitis herpetiformis pathophysiology?
Deposition of IgA in the dermis
43
Dermatitis herpetiformis features?
Itchy, vesicular skin lesions on the extensor surfaces (e.g. elbows, knees, buttocks)
44
Dermatitis herpetiformis Dx?
Skin biopsy = direct immunofluorescence shows deposition of IgA in a granular pattern in the upper dermis
45
Dermatitis herpetiformis Rx?
1. Gluten-free diet
2. Dapsone
46
2 main types of contact dermatitis?
1. Irritant
2. Allergic
47
Irritant contact dermatitis mushkies?
Common non-allergic reaction due to weak acids or alkalis (e.g. detergents). Often seen on the hands. Erythema is typical, crusting and vesicles are rare
48
Allergic contact dermatitis mushkies?
Type IV hypersensitivity reaction. Uncommon - often seen on the head following hair dyes. Presents as an acute weeping eczema which predominately affects the margins of the hairline rather than the hairy scalp itself. Topical treatment with a potent steroid is indicated
49
Frequent cause of contact dermatitis?
Cement. The alkaline nature of cement may cause an irritant contact dermatitis whilst the dichromates in cement also can cause an allergic contact dermatitis.
50
Sparing of nasolabial folds?
SLE
51
Milia?
Small, benign, keratin-filled cysts that typically appear around the face. They may appear at any age but are more common in newborns.
52
Strawberry naevus AKA?
Capillary haemangioma
53
Strawberry naevus/capillay haemangioma features?
1. Not present at birth but may grow rapidly in 1st month of life
2. Erythematous, raised, multilobed tumours
3. Typically they increase in size until around 6-9 months before regressing over the next few years (around 95% resolve before 10 years of age).
4. Common sites include the face, scalp and back. Rarely they may be present in the upper respiratory tract leading to potential airway obstruction
5. Capillary haemangiomas are present in around 10% of white infants. Female infants, premature infants and those of mothers who have undergone chorionic villous sampling are more likely to be affected
54
Capillary haemangioma potential complications?
1. Mechanical = obstructing visual fields or airway
2. Bleeding
3. Ulceration
4. Thrombocytopenia
55
Capillary haemangioma Rx?
If treatment is required (e.g. Visual field obstruction) then propranolol is increasingly replacing systemic steroids as the treatment of choice. Topical beta-blockers such as timolol are also sometimes used.
56
What is a cavernous haemangioma?
Deep capillary haemangioma
57
Acute onset tear-drop scaly papules on trunk and lumbs?
Guttate psoriasis
58
Guttate psoriasis features?
1. More common in children and adolescents
2. May be precipitated by streptococcal infection 2-4 weeks prior to lesions appearing
3. Tear drop papules on the trunk and limbs, pink/scaly patches or plaques of psoriasis
4. Tends to be acute onset over days
59
Guttate psoriasis Rx?
1. Usually resolve spontaneously within 2-3 months
2. No evidence for Abx
3. Topical agents as per psoriasis
4. UVB phototherapy
5. Tonsillectomy may be necessary with recurrent episodes
60
Guttate psoriasis needs to be differentiated from?
Pityriasis rosea
61
Pityriasis rosea mushkies?
1. Many patients report recent respiratory tract infections but this is not common in questions
2. Herald patch followed 1-2 weeks later by multiple erythematous, slightly raised oval lesions with a fine scale confined to the outer aspects of the lesions.May follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer. This may produce a 'fir-tree' appearance
3. Self-limiting, resolves after around 6 weeks
62
Vitiligo definition?
Autoimmune condition which results in the loss of melanocytes and consequent depigmentation of the skin
63
Vitiligo epidemiology?
1% of the population and symptoms typically develop by the age of 20-30 years.
64
Vitiligo features?
1. Well demarcated patches of depigmented skin
2. Peripheries tend to be most affected
3. Koebner phenomenon
65
Vitiligo associated conditions?
1. T1DM
2. Addison's
3. Thyroid
4. Pernicious anaemia
5. Alopecia areata
66
Vitiligo Rx?
1. Sunblock
2. Camouflage make-up
3. Topical corticosteroids may reverse the changes if applied early
4. May also be a role for topical tacrolimus and phototherapy, although caution needs to be exercised with light-skinned patients
67
Purpura definition?
Bleeding into the skin from small blood vessels that produces a non-blanching rash. Smaller petechiae (1-2 mm in diameter) may also be seen. It is typically caused by low platelets but may also be seen with bleeding disorders, such as von Willebrand disease.
68
Purpura definition?
Bleeding into the skin from small blood vessels that produces a non-blanching rash. Smaller petechiae (1-2 mm in diameter) may also be seen. It is typically caused by low platelets but may also be seen with bleeding disorders, such as von Willebrand disease.
69
Purpura definition?
Bleeding into the skin from small blood vessels that produces a non-blanching rash. Smaller petechiae (1-2 mm in diameter) may also be seen. It is typically caused by low platelets but may also be seen with bleeding disorders, such as von Willebrand disease.
70
Molluscum contagiosum transmission?
Closer personal contact, fomites
71
Molluscum contagiosum epidemiology?
Maximum incidence 1-4 y/o
72
Molluscum contagiosum features?
1. Pinkish/pearly white papules with central umbilication, up to 5mm in diameter
2. Do not occur on palms or soles
73
Molluscum contagiosum self care advice?
1. Self limiting, within 18m
2. Avoid sharing towels etc., do not scratch lesions
3. No exclusion from school/gym/swimming necessary
74
Molluscum contagiosum Rx?
1. Not usually recommended, if lesions troublesome use simple trauma or cryotherapy
2. Squeezing with fingernails or piercing with orange stick following a batch
3. Cryotherapy in older children or adults
4. Eczema can develop around lesion --> 1% hydrocortisone if itching problematic, fusidic acid 2% if skin looks infected
75
Molluscum contagiosum and HIV +ve?
Urgent referral to HIV specialist
76
Molluscum contagiosum on eyelid margin/ocular lesions/red eye Rx?
Urgent referral to ophthalmologist
77
Anogenital Molluscum contagiosum in adults Rx?
Refer to GUM for screening for other STIs
78
Allergic contact dermatitis Ix?
Patch testing
79
Seborrheoic dermatitis definition?
A chronic dermatitis thought to be caused by an inflammatory reaction related to a proliferation of a normal skin inhabitant, a fungus called Malassezia furfur (formerly known as Pityrosporum ovale). It is common, affecting around 2% of the general population.
80
Seborrhoeic dermatitis in adults features?
1. Eczematous lesions on sebum-rich areas: scalp, periorbital, auricular and nasolabial folds
2. Otitis externa and blepharitis may develop
81
Seborrhoeic dermatitis associated conditions?
1. HIV
2. Parkinsons
82
Seborrhoeic dermatitis scalp disease Rx?
1. OTC containing zinc pyrithione (H&S) and tar (Neutrogena T/gel) 1st line
2. Ketoconazole 2nd line
3. Selenium sulphide and topical corticosteroid may also be useful
83
Seborrhoeic dermatitis face and body Rx?
1. Topical antifungals = ketoconazole
2. Topical steroids = short periods
3. Difficult to treat = recurrences are common
84
Scabies cause?
Sarcoptes scabiei
85
Scabies pathophysiology?
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.
86
Scabies features?
1. Widespread pruritis
2. Linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist
3. In infants, the face and scalp may also be affected
4. Secondary features are seen due to scratching: excoriation, infection
87
Scabies Rx?
1. Permethrin 1st line
2. Malathion 0.5% 2nd line
3. All household/close physical contacts should be treated at the same time, even if asymptomatic
4. Launder, iron or tumble dry clothing, bedding, towels, etc., on the first day of treatment to kill off mites.
88
How long can pruritis persist after scabies Rx?
Up to 4-6 weeks post eradication
89
Permethrin application isntructions?
1. Apply to cool, dry skin
2. Pay close attention to areas between fingers and toes, under nails, armpit area, creases of the skin such as at the wrist and elbow
3. Allow to dry and leave on the skin for 8-12 hours for permethrin, or for 24 hours for malathion, before washing off
4. Reapply if insecticide is removed during the treatment period, e.g. If wash hands, change nappy, etc
5. Repeat treatment 7 days later
90
Crusted (Norwegian) Scabies?
1. Seen in patients with suppressed immunity, especially HIV
2. Will have hundreds of thousands of organisms
3. Ivermectin is the Rx of choice and isolation is essential
91
Hirsutism definition?
Androgen-dependent hair growth in women
92
Hypertrichosis definition?
Androgen-independent hair growth
93
Causes of hirsutism?
1. PCOS, Cushings, CAH, Androgen therapy
2. Obesity, adrenal tumour, androgen secreting ovarian tumour
3. Drugs = phenytoin, corticosteroids
94
Assessment of hirsutism?
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
95
Hirsutism Rx?
1. Weight loss if overweight
2. Waxing/bleaching not available on NHS
3. COCP e.g. co-cyprindiol (Dianette) or ethinylestradiol and drospirenone (Yasmin)
4. Facial hirsutism = topical eflornithine - contraindicated in pregnancy and breast-feeding
96
Causes of hypertrichosis?
1. Drugs = minoxidil, ciclosporin, diazoxide
2. Congenital hypertrichosis lanuginosa, congenital hypertrichosis terminalis
3. Porphyria Cutanea Tarda
4. Anorexia Nervosa
97
Acne vulgaris pathophysiology?
Obstruction of the pilosebaceous follicles with keratin plugs which results in comedones, inflammation and pustules
98
Acne classification?
1. Mild = open and closed comedones with or without sparse inflammatory lesions
2. Moderate = widespread non-inflammatory lesions and numerous papules and pustules
3. Severe = extensive inflammatory lesions, which may include nodules, pitting, and scarring
99
Acne Rx?
1. Single topical therapy = topical retinoids, benzoyl peroxide
2. Topical combination therapy
3. Oral Abx
4. COCP
5. Oral isotretinoin
100
Acne oral Abx mushkies?
1. Tetracycline = lymecycline, doxycycline, oxytetracycline
2. Avoid tetracyclines in pregnant/breastfeeding/children<12y/o
3. Use erythromycin in pregnancy
4. Single oral abx should be used for maximum of 3m
5. Topical retinoid (if not contraindicated) or benzoyl peroxide should always be co-prescribed with oral antibiotics to reduce the risk of antibiotic resistance developing
6. Gram-negative folliculitis may occur as a complication of long-term antibiotic use - high-dose oral trimethoprim is effective if this occurs
101
Topical and oral Abx in combination?
No
102
Gram -ve folliculitis Rx?
High dose oral trimethoprim
103
Acne COCP Rx mushkies?
1. Use in combination with topical agents
2. Dianette (co-cyprindiol) is sometimes used as it has anti-androgen properties. However, it has an increased risk of venous thromboembolism compared to other COCPs, therefore it should generally be used second-line, only be given for 3 months and women should be appropriately counselled about the risks
104
Any role for dietary modification in pts with acne?
No
105
Erythema nodosum mushkies?
1. Inflammation of subcutaneous fat
2. Tender, erythematous, nodular lesions
3. Occur over shins, may also occur elsewhere e.g. forearms, thighs
4. Usually resolves within 6 weeks
5. Lesions heal without scarrgin
106
Erythema nodosum causes?
1. Infection = Strep, TB, Brucella
2. Inflammation = Sarcoid, IBD, Behcets
3. Malignancy/lymphoma
4. Drugs = penicillins, sulphonamides, COCP
5. Pregnancy
107
Acanthosis nigricans definition?
Symmetrical, brown, velvety plaques that are often found on the neck, axilla and groin.
108
Acanthosis nigricans causes?
1. T2DM, Obesity, PCOS, Acromegaly, Cushings, Hypothyroidism
2. GI Cancer
3. Familial
4. Prader-Willi syndrome
5. Drugs = COCP, Nicotinic acid
109
Acanthosis nigricans pathophysiology?
Insulin resistance → hyperinsulinemia → stimulation of keratinocytes and dermal fibroblast proliferation via interaction with insulin-like growth factor receptor-1 (IGFR1)
110
Erythema multiforme mushkies?
A hypersensitivity reaction that is most commonly triggered by infections. It may be divided into minor and major forms.
Previously it was thought that Stevens-Johnson syndrome (SJS) was a severe form of erythema multiforme. They are now however considered as separate entities.
111
Erythema multiforme features?
1. Target lesions initially seen on back of hands/feet before spreading to the torso
2. Upper limbs are more commonly affected than the lower limbs
3. Pruritis occasionally seen and is usually mild
112
Erythema multiforme causes?
1. Viral = HSV (most common), Orf
2. Bacteria = Mycoplasma, Streptococcus
3. CTD = SLE
4. Sarcoidosis
5. Malignancy
6. Idiopathic
7. Drugs = Penicillins, sulphonamides, carbamazepine, allopurinol, NSAIDs, COCP, Nevirapine
113
Most common cause of erythema multiforme?
HSV
114
Erythema multiforme major?
Mucosal involvement
115
Alopecia classification?
1. Scarring = destruction of hair follicle
2. Non-scarring = preservation of hair follicle
116
Scarring alopecia causes?
1. Trauma, burns
2. Radiotherapy
3. Lichen planus
4. Discoid lupus
5. Tinea capitis
117
Non-scarring alopecia causes?
1. Male-pattern baldness
2. Iron and zinc deficiency
3. AI = alopecia areata
4. Telogen effluvium = hair loss following stressful period
5. Trichotillomania
6. Drugs = cytoxic drugs, carbimazole, heparin, COCP, colchicine
118
When can scarring develop in untreated tinea capitis?
If a kerion develops
119
Lichen sclerosus definition?
An inflammatory condition that usually affects the genitalia and is more common in elderly females. Lichen sclerosus leads to atrophy of the epidermis with white plaques forming
120
Lichen sclerosus features?
1. White patches that may scar
2. Itch is prominent
3. May result in pain during intercourse or urination
121
Lichen sclerosus Dx?
Clinical, but biopsy may be performed if atypical features present
122
Lichen sclerosus Rx?
Topical steroids and emollients
123
Why does lichen sclerosus require f/up?
Increased risk of vulval cancer
124
Fitzpatrick skin types?
1. Never tans, always burns (often red hair, freckles, and blue eyes)
2. Usually tans, always burns
3. Always tans, sometimes burns (usually dark hair and brown eyes)
4. Always tans, rarely burns (olive skin)
5. Sunburn and tanning after extreme UV exposure (brown skin, e.g. Indian)
6. Black skin (e.g. Afro-Caribbean), never tans, never burns
125
Psoriasis exacerbating features?
1. Trauma
2. Alcohol
3. Withdrawal of systemic steroids
4. Drugs
126
Drugs that exacerbate psoriasis?
1. BB
2. Lithium
3. Antimalarials = chloroquine and HCQ
4. NSAID
5. ACEi
6. Infliximab
127
Why is minocycline avoided in acne now?
Increased risk of drug-induced lupus and hyperpigmentation
128
Granuloma annulare association?
Diabetes
129
Granuloma nnulare mushkies?
1. Papular lesions that are often slightly hyperpigmented and depressed centrally
2. Typically occur on the dorsal surfaces of the hands and feet, and on the extensor aspects of the arms and legs
130
Leukoplakia mushkies?
1. Premalignant condition which presents as white, hard spots on the mucous membranes of the mouth. It is more common in smokers.
2. Diagnosis of exclusion. Candidiasis and lichen planus should be considered, especially if the lesions can be 'rubbed off'
3. Biopsies are usually performed to exclude alternative diagnoses such as squamous cell carcinoma and regular follow-up is required to exclude malignant transformation to squamous cell carcinoma, which occurs in around 1% of patients.
131
Onychomycosis definition?
Fungal infection of the nails
132
Onychomycosis causes?
1. Dermatophytes - mainly Trichophyton rubrum, accounts for 90% of cases
2. Yeasts e.g. Candida
3. Non-dermatophyte moulds
133
Fungal nail infection RFs?
DM and age
134
Fungal nail infection features?
1. Unsightly nails
2. Thickened, rough, opaque nails
135
Fungal nail infection Ddx?
1. Psoriasis
2. Repeated trauma
3. Lichen planus
4. Yellow nail syndrome
136
Fungal nail infection Ix?
1. Nail clippings
2. Nail scrapings
3. False-negative for cultures are around 30%, so repeat samples may need to be sent if the clinical suspicion is high
137
Fungal nail infection Rx?
1. No Rx needed if asymptomatic and pt not bothered by appearance
2. Dx should be confirmed by microbiology before starting treatment
3. Rx depends on organism
138
Dermatophyte nail infection Rx?
1. Oral terbinafine is currently recommended first-line with oral itraconazole as an alternative
2. 6 weeks - 3 months therapy is needed for fingernail infections whilst toenails should be treated for 3 - 6 months
3. Treatment is successful in around 50-80% of people
139
Candida nail infection Rx?
1. Mild disease should be treated with topical antifungals (e.g. Amorolfine) whilst more severe infections should be treated with oral itraconazole for a period of 12 weeks
2. if topical topical treatment is given treatment should be continued for 6 months for fingernails and 9-12 months for toenails
140
PUVA complication?
SCC
141
Seborrheoic dermatitis complications?
Otitis externa and blepharitis
142
Tinea definition?
Dermatophyte fungal infection
143
3 main Tinea infections?
1. Tinea capitis = scalp
2. Tinea corporis = trunk, legs or arms
3. Tinea pedis = feet
144
Tinea capitis (scalp ringworm) mushkies?
1. A cause of scarring alopecia mainly seen in children
2. If untreated, a raised, pustular, spongy/boggy mass called a kerion may form
3. Most common cause is Trichophyton tonsurans in the UK and the USA
4. May also be caused by Microsporum canis acquired from cats or dogs
5. Diagnosis: lesions due to Microsporum canis green fluorescence under Wood's lamp*. However the most useful investigation is scalp scrapings
145
Tinea capitis Rx?
1. Oral terbinafine for Trichophyton tonsurans
2. Oral griseofulvin for Microsporum
3. Topical ketoconazole shampoo should be given for the first two weeks to reduce transmission
146
Tinea corporis (ringworm) mushkies?
1. Causes include Trichophyton rubrum and Trichophyton verrucosum (e.g. From contact with cattle)
2. Well-defined annular, erythematous lesions with pustules and papules
3. Rx = oral fluconazole
147
Tinea pedis AKA?
Athlete's foot
148
Pregnancy sin disorders?
1. Atopic eruption of pregnancy
2. Polymoprhic eruption of pregnancy
3. Pemphigoid gestationis
149
Atopic eruption of pregnancy mushkies?
1. Commonest in pregnancy
2. Eczematous, itchy rash
3. No specific Rx needed
150
Polymorphic eruption of pregnancy mushkies?
1. Last trimester
2. Lesions appear first in abdominal striae
3. Rx depends on severity = emollients, mild potency topical steroids, oral steroids
151
Pemphigoid gestationis mushkies?
1. Pruritic blistering lesions
2. Often in peri-umbilical region, later spread to trunk, back, buttocks and arms
3. Usually presents in 2nd or 3rd trimester and is rarely seen in the first pregnancy
4. Oral corticosteroids are usually required
152
Keloid scars most common where?
Sternum
153
Keloid scar definition?
Tumour-like lesions that arise from the connective tissue of a scar and extend beyond the dimensions of the original wound
154
Keloid scar predisposing factors?
1. Ethnicity = dark skin
2. Young adults, rarely in elderly
3. Common sites = sternum, shoulder, neck, face, extensor surface of limbs, trunk
155
Keloid scars less likely if made where?
Along relaxed skin tension lines
156
Keloid scar Rx?
1. Early keloids may be treated with intra-lesional steroids e.g. triamcinolone
2. Excision is sometimes required but careful consideration needs to given to the potential to create further keloid scarring
157
Angular cheilosis in anorexia cause?
Zinc deficiency (also Vitamin B2 riboflavin deficiency)
158
Zinc deficiency features?
1. Acrodermatitis = red, crusted lesions = acral distribution, peri-orificial, peri-anal
2. Alopecia
3. Short stature
4. Hypogonadism
5. Hepatosplenomegaly
6. Geophagia (ingesting clay/soil)
7. Cognitive impairment
159
Acrodermatitis enteropathica?
A recessively inherited partial defect in intestinal zinc absorption
160
What % of pts with psoriatic arthropathy have nail changes?
80-90%
161
Does psoriatic nail changes affect the severity of psoriasis?
No
162
Psoriasis nail changes?
1. Pitting
2. Onycholysis (separation of the nail from the nail bed)
3. Subungual hyperkeratosis
4. Loss of the nail
163
Most important factor in determining malignant melanoma prognosis?
Breslow thickness
164
Breslow thickness and survival rates?
1. <0.75 mm = 95-100%
2. 0.76 - 1.5 mm = 80-96%
3. 1.51 - 4mm = 60-75%
4. >4mm = 50%
165
Volcano?
Keratoacanthoma
166
Keratoacanthoma definition?
A benign epithelial tumour. They are more common with advancing age and rare in young people.
167
Keratoacanthoma features?
1. Said to look like a volcano or crater
2. Initially a smooth dome-shaped crater
3. Rapidly grows to become a crater centrally-filled with keratin
168
Keratoacanthoma Prognosis and Rx?
Spontaneous regression of keratoacanthoma within 3 months is common, often resulting in a scar. Such lesions should however be urgently excised as it is difficult clinically to exclude squamous cell carcinoma. Removal also may prevent scarring.
169
Spider naevi definition?
Describe a central red papule with surrounding capillaries. The lesions blanch upon pressure. Spider naevi are almost always found on the upper part of the body.
170
How to differentiate spider naevi from telangiectasia?
Spider naevi fill from the centre, telangiectasia from the edge
171
What % of people will have one or more spider naevi?
10-15%, and they are more common in childhood
172
SPider naevi association?
1. Liver disease
2. Pregnancy
3. COCP
173
Chronic plaque is what % of psoriasis?
80%
174
Lichen planus Ps?
Planus:
1. Purple
2. Polygonal
3. Pruritic
4. Papular
175
Hyperhidrosis Rx?
1. 1st line = topical aluminium chloride preparations, main s/e = skin irritation
2. Iontophoresis = particularly useful for patients with palmar, plantar and axillary hyperhidrosis
3. Botulinum toxin = axillary symptoms
4. Surgery = Endoscopic transthoracic sympathectomy. Patients should be made aware of the risk of compensatory sweating
176
Rodent ulcer?
BCC
177
BSS and metastases?
Rare
178
Most common type of cancer in western world?
BCC
179
BCC features?
1. Sun-exposed sites
2. Pearly, flesh coloured papule with telangiectasia
3. May ulcerate, leaving a central crater
180
BCC referral?
If suspected, routine referral should be made
181
BCC Rx?
1. Surgical removal
2. Curettage
3. Cryotherapy
4. Topical cream = Imiquimod, Fluorouracil
5. Radiotherapy
182
Pyoderma gangrenosum pathophysiology?
Classified as a neutrophilic dermatosis. Neutrophilic dermatoses are skin conditions characterised by dense infiltration of neutrophils in the affected tissue and this is often seen on biopsy
183
Pyoderma gangrenosum causes?
1. Idipathic in 50%
2. IBD
3. Rheum = RhA, SLE
4. Haem = myeloproliferative disorders, lymphoma, myeloid leukaemias, monoclonal gammopathy (IgA)
5. GPA
6. PBC
184
Pyoderma gangrenosum features?
1. Location = typically lower limb, often at the site of a minor injury
2. Usually starts suddenly, small pustule, red bump or blood-blister
3. Skin breaks down, resulting in an ulcer. Edge of ulcer often purple, violaceous and undermined. Ulcer itself may be deep and necrotic
4. May be accompanied by fever and myalgia
185
Pyoderma gangrenosum Dx?
1. Often made by the characteristic appearance, associations with other diseases, the presence of pathergy, histology results and when other diseases have been ruled out
2. Histology is not specific and can vary depending on the time and site of the specimen but may be helpful in ruling out other causes of an ulcer
186
Pyoderma gangrenosum Rx?
1. Oral steroids 1st line (potential for rapid progression is high)
2. Ciclosporin and infliximab in difficult cases
3. Surgery should be postponed until the disease process is controlled on immunosuppression to risk worsening of the disease (pathergy)
187
Shin lesion DDx?
1. Erythema nodosum
2. Pretibial myxoedema
3. Pyoderma gangrenosum
4. Necrobiosis lipoidica diabeticorum
188
Pretibial myxoedema mushkies?
1. Symmetrical, erythematous lesions seen in Graves' disease
2. Shiny, orange peel skin
189
Necrobiosis lipoidica diabeticorum mushkies?
1. Shiny, painless areas of yellow/red skin typically on the shin of diabetics
2. Often associated with telangiectasia
190
Topical steroid classification?
1. Mild
2. Moderate
3. Potent
4. Very potent
191
Mild topical steroid?
Hydrocortisone 0.5-2.5%
192
Moderate topical steroid?
1. Betamethasone valerate 0.025% (Betnovate RD)
2. Clobetasone butyrate 0.05% (Eumovate)
193
Potent topical steroid?
1. Fluticasone propionate 0.05% (Cutivate)
2. Betamethasone valerate 0.1% (Betnovate)
194
Very potent topical steroid?
Clobetasol propionate 0.05% (Dermovate)
195
Finger tip 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
196
Grave's disease, orange peel shin lesions?
Pretibial myxoedema
197
HHT definition?
An autosomal dominant condition characterised by multiple telangiectasia over the skin and mucous membranes. Twenty percent of cases occur spontaneously without prior family history.
198
HHT Diagnostic criteria?
2 = possible Dx, 3 = definite diagnosis
1. Epistaxis
2. Telangiectasias
3. Visceral lesions
4. FHx
199
HHT visceral lesions?
1. GI
2. Lung AVM
3. Hepatic AVM
4. Cerebral AVM
5. Spinal AVM
200
Dermatofibroma AKA?
Histiocytoma
201
Dermatofibroma definition?
Common benign fibrous skin lesions. They are caused by the abnormal growth of dermal dendritic histiocyte cells, often following a precipitating injury. Common areas include the arms and legs.
202
Dermatofibroma features?
1. Solitary firm papule or nodule, typically on a limb
2. Typically 5-10mm in size
3. Overlying skin dimples on pinching lesions
203
Dimple sign?
Dermatofibroma
204
Impetigo definition?
Impetigo is a superficial bacterial skin infection usually caused by either Staphylcoccus aureus or Streptococcus pyogenes. It can be a primary infection or a complication of an existing skin condition such as eczema, scabies or insect bites. Impetigo is common in children, particularly during warm weather.
The infection can develop anywhere on the body but lesions tend to occur on the face, flexures and limbs not covered by clothing.
205
Impetigo spread?
Spread is by direct contact with discharges from the scabs of an infected person. The bacteria invade the skin through minor abrasions and then spread to other sites by scratching. Infection is spread mainly by the hands, but indirect spread via toys, clothing, equipment and the environment may occur. The incubation period is between 4 to 10 days.
206
Impetigo features?
1. 'Golden' crusted skin lesions typically found around the mouth
2. Very contagious
207
Impetigo Rx?
1. Hydrogen peroxide 1% cream for 'people who are not systemically unwell or at a high risk of complications'
2. Topical Abx cream = Fusidic Acid, Mupirocin if fusidic acid resistance suspected
208
Impetigo extensie disease Rx?
1. Oral flucloxacillin
2. Oral erythromycin if pen-allergic
209
Impetigo school exclusion?
Children should be excluded from school until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment
210
Ruddy complexion?
Polycythaemia
211
Polycythaemia features?
1. Pruritis after warm bath
2. ruddy complexion
3 Gout
4. Peptic ulcer disease
212
Pityriasis versicolor definition?
Superficial cutaneous fungal infection caused by Malassezia furfur (formerly termed Pityrosporum ovale)
213
Pityriasis versicolor features?
1. Most commonly affects trunk, patches may be hypopigmented/pink/brown. Msay be more noticeable following a suntan
2. Scale is common
3. Mild pruritis
214
Predisposing factors?
1. Occurs in healthy individuals
2. immunosuppression
3. Malnutrition
4. Cushing's
215
Pityriasis versicolor Rx?
1. Ketoconazole shampoo
2. If failure to respond consider other diagnosis e.g. send scrapings + oral itraconazole
216
Nickel dermatitis Ix?
Skin patch tst
217
Exclamation mark?
Alopecia areata
218
Alopecia areata definition?
A presumed 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
219
Alopecia areata prognosis?
Hair will regrow in 50% of patients by 1 year, and in 80-90% eventually. Careful explanation is therefore sufficient in many patients.
220
Alopecia areata Rx?
1. Topical/intralesional corticosteroids
2. Topical minoxidil
3. Phototherapy
4. Dithranol
5. Contact immunotherapy
6. Wigs
221
Mycosis fungoides definition?
Rare form of T-cell lymphoma that affects the skin
222
Mycosis fungoides features?
1. Itchy, red patches
2. Lesions tend to be of different colours in contrast to eczema/psoriasis where there is greater homogenicity
223
Mycosis fungoides can present like?
Eczema or psoriasis
224
Mycosis fungoides on biopsy?
Pautrier microabscesses
225
Pyogenic granuloma definition?
A relatively common benign skin lesion. The name is confusing as they are neither true granulomas nor pyogenic in nature. There are multiple alternative names but perhaps 'eruptive haemangioma' is the most useful.
226
Pyogenic granuloma causes?
1. Trauma
2. Pregnancy
3. More common in women and young adults
227
Pyogenic granuloma features?
1. Most common sites are head/neck, upper trunk and hands. Lesions in the oral mucosa are common in pregnancy
2. Initially small red/brown spot, rapidly progress within days to weeks forming raised, red/brown lesions which are often spherical in shape
3. Lesions may bleed profusely or ulcerate
228
Pyogenic granuloma Rx?
1. Lesions associated with pregnancy often resolve spontaneously post-partum
2. Other lesions usually persist - removal methods include curettage and cauterisation, cryotherapy, excision
229
Ataxia telangiectasia AKA?
Louis-Bar syndrome
230
Actinic keratosis definition?
A common premalignant skin lesion that develops as a consequence of chronic sun exposure
231
Actinic keratosis features?
1. Small, crusty or scaly lesions
2. May be pink, red, brown or the same colour as the skin
3. Typically on sun exposed areas
4. Multiple lesions may be present
232
Actinic keratoses Rx?
1. Prevention of further risk e.g. sun avoidance, sun cream
2. Fluorouracil cream = typically a 2 to 3 week course. The skin will become red and inflamed - sometimes topical hydrocortisone is given following fluorouracil to help settle the inflammation
3. Topical diclofenac = may be used for mild AKs. Moderate efficacy but much fewer side-effects
4. Topical imiquimod
5. Cryotherapy, curettage and cautery
233
Mucosal blisters?
Pemphigus vulgaris
234
Pemphigus vulgaris definition?
An autoimmune disease caused by antibodies directed against desmoglein 3, a cadherin-type epithelial cell adhesion molecule. It is more common in the Ashkenazi Jewish population.
235
Pemphigus vulgaris features?
1. Mucosal ulceration is common and often the presenting symptom. Oral involvement is seen in 50-70% of patients
2. Skin blistering - flaccid, easily ruptured vesicles and bullae. Lesions are typically painful but not itchy. These may develop months after the initial mucosal symptoms. Nikolsky's describes the spread of bullae following application of horizontal, tangential pressure to the skin
3. Acantholysis on biopsy
236
Pemphigus vulgaris Rx?
1. Steroids 1st line
2. Immunosuppressants
237
Is MRSA susceptible to fusidic acid?
No, topical mupirocin should be used instead
238
Sedating antihistamine?
Chlorphenamine
239
Non-sedating antihistamine?
Loratadine, cetirizine
240
What % of pts have a long term remission or cure following oral isotretinoin?
2/3
241
Retinoids s/e?
1. Teratogenicity = 2 forms of contraception
2. Dry skin, eyes and lips/mouth = most common
3. Low mood
4. Raised trigylcerides, hair thinning, nose bleeds
5. Intracranial hypertension
6. Photosesitivity
242
Is pruritis a feature of rosacea?
No
243
DM skin disorders?
1. Necrobiosis lipoidica
2. Infection = candida, staph
3. Neuropathic ulcers
4. Vilitigo
5. Lipoatrophy
6. Granuloma annulare
244
Psoriasis pathophysiology?
1. Multifactorial and not yet fully understood
2. Genetic = associated HLA-B13, -B17, and -Cw6. Strong concordance (70%) in identical twins
3. Immunological = abnormal T cell activity stimulates keratinocyte proliferation
4. Environmental = recognised that psoriasis may be worsened (e.g. Skin trauma, stress), triggered (e.g. Streptococcal infection) or improved (e.g. Sunlight) by environmental factors
245
Subtypes of psoriasis?
1. Plaque = most common sub-type resulting in the typical well-demarcated red, scaly patches affecting the extensor surfaces, sacrum and scalp
2. Flexural = skin is smooth
3. Guttate = transient psoriatic rash frequently triggered by a streptococcal infection
4. Pustular = commonly on palms and soles
246
Psoriasis other features?
Nail signs and arthritis
247
Psoriasis complications?
1. Psoriatic arthropathy (around 19%)
2. Psychological distress
3. Increased incidence of CVD, VTE, metabolic syndrome
248
SCC risk factors?
1. Sunlight/PUVA
2. Actinic keratoses and Bowne's disease
3. Immunosuppression
4. Smoking
5. Long standing ulcer e.g. MArjolin's
6. Genetic = xeroderma pigmentosum, oculocutaneous albinism
249
SCC features?
1. Sun exposed sites
2. Rapidly expanding painless, ulcerating nodules
3. Cauliflower-like appearance
4. Areas of bleeding
250
SCC Rx?
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 in cosmetically important sites.
251
SCC poor prognosis?
1. Poorly differentiated
2. >20mm deep
3. >4mm deep
4. Immunsupression
252
CC good prognosis?
1. Well differentiated
2. <20mm deep
3. <2mm deep
4. No associated diseases
253
Basal cell carcinoma in high risk area e.g. eyelid, nasal ala Rx?
Refer urgently 2ww
254
Stevens-Johnson syndrome definition?
A severe systemic reaction affecting the skin and mucosa that is almost always caused by a drug reaction.
Previously it was thought that Stevens-Johnson syndrome (SJS) was a severe form of erythema multiforme. They are now however considered as separate entities.
255
SJS causes?
1. Penicillin
2. Sulphonamides
3. Lamotrigine, carbamazepine, phenytoin
4. Allopurinol
5. NSAIDs
6. COCP
256
SJS features?
1. Maculopapular rash with target lesions being characteristic = vesicles or bullae, Nikolsky sign positive in erythematous areas
2. Mucosal involvement
3. Systemic symptoms = fever, arthralgia
257
SJS Rx?
Hospital admission for supportive treatment
258
Anti-epileptic and rash?
SJS
259
SJS Body % affected?
<10%
260
TEN Body % affected?
>30%
261
Erythroderma % affected?
>90%
262
Skin disorders affecting soles of the feet?
1. Verrucas
2. Tinea pedis
3. Corn and calluses
4. Keratoderma
5. Pitted keratolysis
6. Palmoplantar pustulosis
7. Juvenile plantar dermatosis
263
Verrucas mushkies?
1. Secondary to HPV
2. Firm, hyperkeratotic lesions
3. Pinpoint petechiae centrally within the lesions
4. May coalesce with surrounding warts to form mosaic warts
264
Corn?
A corn is small areas of very thick skin secondary to a reactive hyperkeratosis
265
Callus?
A callus is larger, broader and has a less well defined edge than a corn
266
Keratoderma mushkies?
1. Acquired or congenital
2. Describes a thickening of the skin of the palms and soles
3. Acquired causes include reactive arthritis (keratoderma blennorrhagica)
267
Pitted keratolysis?
1. Affects people who sweat excessively
2. Patients may complain of damp and excessively smelly feet
3. Usually caused by Corynebacterium
4. Heel and forefoot may become white with clusters of punched-out pits
268
Palmoplantar pustulosis?
1. Crops of sterile pustules affecting the palms and soles
2. The skin is thickened, red. Scaly and may crack
3. More common in smokers
269
Juvenile plantar dermatosis?
1. Affects children. More common in atopic patients with a history of eczema
2. Soles become shiny and hard. Cracks may develop causing pain
3. Worse during the summer
270
Acanthosis nigricans associated malignancy?
Gastric cancer
271
Acquired ichthyosis associated malignancy?
Lymphoma
272
Acquired hypertrichosis lanuginosa associated malignancy?
GI and lung
273
Dermatomyositis associated malignancy?
Ovarian and lung
274
Erythema gyratum repens associated malignancy?
Lung
275
Erythroderma associated malignancy?
Lymphoma
276
Migratory thrombophlebitis associated malignancy?
Pancreatic
277
Necrolytic migratory erythema associated malignancy?
Glucagonoma
278
Pyoderma gangrenosum associated malignancy?
Myeloproliferative disorders
279
Sweet's syndrome associated malignancy?
Haem
280
Tylosis associated malignancy?
Oesophageal cancer
281
Port wine stain mushkies?
Vascular birthmarks that tend to be unilateral. They are deep red or purple in colour. Unlike other vascular birthmarks such as salmon patches and strawberry haemangiomas, they do not spontaneously resolve, and in fact often darken and become raised over time. Treatment is with cosmetic camouflage or laser therapy (multiple sessions are required)
282
Sebaceous cyst definition?
Sebaceous cysts is a general term which encompasses both epidermoid and pilar cysts. It is a bit of a misnomer and probably best avoided where possible.
Epidermoid cysts are due to a proliferation of epidermal cells within the dermis. Pilar cysts (also known as trichilemmal cysts or wen) derive from the outer root sheath of the hair follicle.
283
Sebaceous cyst typcally contain a?
Punctum
284
How to prevent sebaceous cyst recurrence?
Surgical excision of the whole structure
285
Pompholyx definition?
Pompholyx is a type of eczema which affects both the hands (cheiropompholyx) and the feet (pedopompholyx). It is also known as dyshidrotic eczema.
Pompholyx eczema may be precipitated by humidity (e.g. sweating) and high temperatures.
286
Pompholyx features?
1. Small blisters on the palms and soles
2. Pruritic = often intensely itchy, sometimes burning sensation
3. Once blisters burst skin may become dry and crack
287
Pompholyx Rx?
1. Cool compresses
2. Emollients
3. Topical steroids
288
Pompholyx eczema precipitants?
Humidity and high temperatures
289
Cutaneous manifestation of sarcoidosis?
Lupus pernio
290
Livedo reticularis definition?
A purplish, non-blanching, reticulated rash caused by obstruction of the capillaries resulting in swollen venules
291
Livedo reticularis causes?
1. Idiopathic (most common)
2. PAN
3. SLE, APS
4. Cryoglobulinaemia
5. Ehlers-Danlos syndrome, homocystinuria
292
Urticaria definition?
A local or generalised superficial swelling of the skin. The most common cause of urticaria is allergy although non-allergic causes are seen.
293
Urticaria features?
1. Pale, pink raised skin --> AKA hives, wheals, nettle rash
2. Pruritic
294
Urticaria Rx?
1. Non-sedating antihistamines 1st line
2. Prednisolone used for severe or resistant episodes
295
Curling's ulcer?
Stress ulcer than can occur after severe burns
296
Superficial burn healing?
Keratinocytes migrate to form a new layer over the burn site
297
Full thickness burn healing?
Dermal scarring. Usually need keratinocytes from skin grafts to provide optimal coverage.
