Dermatology Flashcards
usually starts with a single ‘herald patch’, followed by a ‘Christmas-tree’ distribution of smaller patches along skin cleavage lines, predominantly on the trunk.
Pityriasis rosea
late pregnancy
benign
erythematous papules, vesicles or plaques. The rash often starts on the abdomen, particularly within stretch marks (striae), and can spread to the thighs and buttocks but rarely involves the face or mucous membranes
Polymorphic eruption of pregnancy
is a rare autoimmune blistering disorder associated with pregnancy. It usually begins in the second or third trimester or immediately postpartum. Lesions often start around the umbilicus before spreading to other parts of the body but unlike PEP, pemphigoid gestationis frequently involves the palms, soles and mucous membranes.
Pemphigoid gestationis
poxvirus
multiple dome-shaped papules with central umbilication
small, multiple lesions
umbilicated
6-12 months
Molluscum contagiosum
purple, polygonal, pruritic papules and plaques, often with a white lacy pattern (Wickham’s striae) visible on their surface. The lesions are typically larger than 1-2mm and lack umbilication. They commonly affect the flexor surfaces of wrists, legs, and oral mucosa.
lichen planus
congenital haemangioma occurring in around one in 20 babies. They tend to grown rapidly over the first few months of life then spontaneously regress over the course of a few years.
strawberry naevus
when is strawberry naevus a problem?
if over the spine (or impairing vision/ hearing)
The rolled, pearly edges with telangiectasia on the inferior border of the lesion
BCC
hand eczema, precipitated by humidity (e.g. sweating) and high temperatures
Pompholyx eczema (dyshidrotic eczema)
how to manage sebaceous cyst?
Excision of the cyst wall needs to be complete to prevent recurrence.
stress ulcer that can occur after severe burns
Curling’s ulcer
areas of bluish discolouration over the lower back and buttock which often disappear by 1 year of age.
mongolian blue spots
raised brown/black nodules which can be hairy and up to 20cm in diameter. There is a risk of developing melanomas from these and so they should be closely monitored.
melanocytic naevi
white patches in the oral cavity that cannot be rubbed off and are not attributed to any other identifiable cause. It is important to exclude other conditions such as lichen planus and squamous cell carcinoma through biopsy,
leukoplakia
well-demarcated areas of depigmentation due to destruction of melanocytes.
vitiligo
management scabies
permethrin 5% is first-line
malathion 0.5% is second-line
apply the insecticide cream or liquid to cool, dry skin
pay close attention to areas between fingers and toes, under nails, armpit area, creases of the skin such as at the wrist and elbow
allow to dry and leave on the skin for 8-12 hours for permethrin, or for 24 hours for malathion, before washing off
reapply if insecticide is removed during the treatment period, e.g. If wash hands, change nappy, etc
repeat treatment 7 days later
itching can persist for up to 6 weeks after successful treatment due to a delayed hypersensitivity reaction to the mites, even if all the mites have been killed. Retreatment should only be considered if new burrows or rashes appear, or if living mites are found upon examination.
Causes of scarring alopecia
include trauma/burns, radiotherapy, lichen planus, discoid lupus, tinea capitis
non scaring alopecia causes
male-pattern baldness
drugs: cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, colchicine
nutritional: iron and zinc deficiency
autoimmune: alopecia areata
telogen effluvium: hair loss following stressful period e.g. surgery
trichotillomania
molloscum contagious - do they need to go off school?
Time off school is not necessary but, as the condition is infectious, it is advised to avoid sharing baths, towels, or clothing with others to prevent transmission.
flexural psoriasis treatment
only mild/moderate steroid NOT fit D
Remember that the treatment of flexural psoriasis differs from extensor psoriasis. The skin of flexure areas of the body is much thinner and more sensitive to steroids compared to the extensor surfaces. Flexural surfaces that tend to be affected are the groin, genital region, axillae, inframammary folds, abdominal folds, sacral and gluteal cleft.
chronic plaque psoriasis management
a 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
2nd line= just vit D
scalp psoriasis management
just potent steroid NOT vit D
What is the defining feature of erythema multiforme major
associated with mucosal involvement
Blisters/bullae - what two skin disease? (2)
NO MUCOSAL INVOLVEMENT = bullous pemphigoid
MUCOSAL INVOLVEMENT =pemphigus vulgaris
(Vulgaris =mucus)
Skin disorders and malignancy:
acanthosis nigricans
gastric cancer
Skin disorders and malignancy:
acquired ichthyosis
lymphoma
Skin disorders and malignancy:
acquired hypertrichosis lanuginosa
gastrointestinal and lung cancer
Skin disorders and malignancy:
dermatomyositits
ovarian and lung
Skin disorders and malignancy:
erythroderma
lymphoma
Skin disorders and malignancy:
migratory thrombophlebitis
pancreatic
Skin disorders and malignancy:
pyoderma gangrenosum
myeloproliferative disorders
Skin disorders and malignancy:
sweet syndrome
haematologyical
Skin disorders and malignancy:
tylosis
oesophageal
Guttate psoriasis
2-4 weeks pre streptococcal infection
Guttate psoriasi vs pitiriasiis rosea
Guttate:
tear drops
PR:
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
non sedating antihistamine
cetirizine AND Loratadine
Fitzpatrickk
I: Never tans, always burns (often red hair, freckles, and blue eyes)
II: Usually tans, always burns
III: Always tans, sometimes burns (usually dark hair and brown eyes)
IV: Always tans, rarely burns (olive skin)
V: Sunburn and tanning after extreme UV exposure (brown skin, e.g. Indian)
VI: Black skin (e.g. Afro-Caribbean), never tans, never burns
Diabetes, waxy yellow shin lesions
necrobiosis lipoidica diabeticorum
The characteristic clinical presentation includes shiny plaques on the anterior aspect of the lower legs that are yellowish-brown with telangiectasias and atrophic skin. The plaques may be asymptomatic or painful and usually start as small papules that slowly enlarge.
qsymmetrical, erythematous, tender, nodules which heal without scarring
most common causes are streptococcal infections, sarcoidosis, inflammatory bowel disease and drugs (penicillins, sulphonamides, oral contraceptive pill)
erythema nodosum
Shin skin problems:
symmetrical, erythematous lesions seen in Graves’ disease
shiny, orange peel skin
Pretibial myxoedema
Shin problems:
initially small red papule
later deep, red, necrotic ulcers with a violaceous border
idiopathic in 50%, may also be seen in inflammatory bowel disease, connective tissue disorders and myeloproliferative disorders
Pyoderma gangrenosum
Shin problems:
shiny, painless areas of yellow/red skin typically on the shin of diabetics
often associated with telangiectasia
Necrobiosis lipoidica diabeticorum
Impetigo management
management
1st= hydrogen peroxide 1% cream
2nd= topic fuscidic acid
benign, painful nodule on the ear
Chondrodermatitis nodularis helicis
Pityriasis rosea - what is the cause ? (1)
self limiting
herpes hominis virus 7 (HHV-7)
herald patch
hyperhidrosis
topical aluminium chloride preparations are first-line. Main side effect is skin irritation
iontophoresis: particularly useful for patients with palmar, plantar and axillary hyperhidrosis
botulinum toxin: currently licensed for axillary symptoms
surgery: e.g. Endoscopic transthoracic sympathectomy. Patients should be made aware of the risk of compensatory sweating
Causes of puritis:
History of alcohol excess
Stigmata of chronic liver disease: spider naevi, bruising, palmar erythema, gynaecomastia etc
Evidence of decompensation: ascites, jaundice, encephalopathy
liver disease
Causes of puritis:
Pallor
Other signs: koilonychia, atrophic glossitis, post-cricoid webs, angular stomatitis
iron deficiency anaemia
Causes of puritis:
Pruritus particularly after warm bath
‘Ruddy complexion’
Gout
Peptic ulcer disease
Polycythaemia
Causes of puritis:
Lethargy & pallor
Oedema & weight gain
Hypertension
Chronic kidney disease
Causes of puritis:
Night sweats
Lymphadenopathy
Splenomegaly, hepatomegaly
Fatigue
Lymphoma
first line plaque psoriasis
POTENT steroids + vit D (BETAMETHASON not hydrocortisone)
Ankylosing spondylitis is associated HLA B27, a risk factor for which skin disease?
psoriasis
Lichen Planus vs lichen schlerosus
planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham’s striae over surface. Oral involvement common
sclerosus: itchy white spots typically seen on the vulva of elderly women
A 45-year-old woman presents with itchy, violaceous papules on the flexor aspects of her wrists. She is normally fit and well and has not had a similar rash previously. What is it?
lichen plants
Management lichen plants
potent topical steroids are the mainstay of treatment
benzydamine mouthwash or spray is recommended for oral lichen planus
extensive lichen planus may require oral steroids or immunosuppression
reatment of choice in capillary haemangiomas requiring intervention
AKA strawberry naevus
propanalol
Topical beta-blockers such as timolol are also sometimes used.
Eczema herpeticum is a primary infection of the skin caused by …
herpes simplex virus (HSV)
eczema herpeticum treatment
IV acyclovir
dermatofibroma: where usually found? (1)
can be started by (2)
lower limbs
trauma or insect bites
Renal transplant patients are at risk of what cancer
squamous cell due to immunosuppression
Polymorphic eruption of pregnancy vs phemigoid gestationis
phemhigoid gestations= BLISTERING
Acne vulgaris in pregnancy treatment
erythromycin
(if topical acne treatments not effective)
most common type of melanoma with typical features of changing mole (85% of cases)
Superficial spreading melanoma
keratocanthoma management
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.
Topical adapalene is a type of
retinoid
shinglets treatment
oral antivirals
(can be any of aciclovir, famciclovir, or valaciclovir are recommended)
Seborrhoeic dermatitis associated with which diseases
HIV and parkinsons
Seborrhoeic dermatitis main features
- eczematous lesions on scalp, periorbital, auricular and nasolabial folds
- otitis externa
- blepharitis
Dermatophyte nail infections (onychomycosis)
oral terbinafine
A 65-year-old lady presents to the GP as she has noticed some small spots on her shoulder. She describes small lesions with a number of tiny blood vessels radiating from the middle. On examination you can press down on them, causing them to go white and then refill from the centre.
what is this?
spider nevi
Spider naevi vs talengiectasia
PRESS ON THEM
Spider naevi fill from the centre, telangiectasia from the edge
purplish, lace-patterned discolouration of the skin
Livedo reticularis
how is alopecia areata caused?
autoimmune (related to all the other autoimmune disorders)
spider naevi causes
liver disease
pregnancy
combined oral contraceptive pill
what is purpura?
bleeding into the skin from small blood vessels that produces a non-blanching rash
purpura in kids
meningococcal septicaemia or acute lymphoblastic leukaemia.
Telogen effluvium
loss and thinning of hair in response to severe stress
Trichotillomania
a disorder where people pull their own hair out, would give asymmetrical, uneven hair loss, and might be preceded by other psychiatric complaints.
acne rosacea
- chronic inflammatory skin condition primarily affecting the central face
- characterised by transient or persistent erythema, telangiectasia, papules and pustules but not comedones
- typically affects nose, cheeks and forehead
flushing is often first symptom
telangiectasia are common
later develops into persistent erythema with papules and pustules
rhinophyma
ocular involvement: blepharitis
sunlight may exacerbate symptoms
Curling’s ulcer
a gastric ulcer caused by necrosis of the gastric mucosa, usually due to hypovolaemia. They carry a high rate of bleeding and mortality.
(caused by stress and burns)
Which one of the following complications is most associated with psoralen + ultraviolet A light (PUVA) therapy?
squamous cell cancer
actinic keratoses vs seborrhoeic keratosis
ACTINIC: premalignant skin lesions caused by chronic exposure to ultraviolet (UV) radiation, typically seen in fair-skinned individuals and those with a history of outdoor work such as builders. The appearance of these lesions as erythematous, rough patches is consistent with actinic keratoses. In some cases, they can progress to squamous cell carcinoma if left untreated.
SEBORRHOEIC: Seborrhoeic keratoses are benign epidermal growths that appear as waxy, brownish-black ‘stuck-on’ plaques. They commonly occur on the trunk and face but have a different appearance than the erythematous, rough lesions described in this case.
keloid scar treatment
- intra-lesional steroids e.g. triamcinolone
- excision is sometimes required but careful consideration needs to given to the potential to create further keloid scarring
symmetrical vesicular rash as shown below and also some early lesions on the back of his arms.
Coeliac (Dermatitis herpetiformis)
pityriasis vesicolor management
topical antifungal. NICE advises ketoconazole shampoo as this is more cost effective for large areas
if failure to respond to topical treatment then consider alternative diagnoses (e.g. send scrapings to confirm the diagnosis) + oral itraconazole
psoriasis nail features (4)
oncholysis (separation of the nail from the nail bed)
pitting
sublingual hyperkeratosis
loss of nail
Seborrhoeic dermatitis first line (dandruff)
topical ketoconazole (for head and arms/ trunk too)
isotretinoin most common SE
dry skin
what type of reaction can scabies cause
delayed type IV hypersensitivity reaction
when to consider retreating for scabies
e itching can persist for up to 6 weeks after successful treatment due to a delayed hypersensitivity reaction to the mites, even if all the mites have been killed. Retreatment should only be considered if new burrows or rashes appear, or if living mites are found upon examination.
Bullous pemphigoid management
autoimmune blistering disease that primarily affects the elderly. It is characterised by tense blisters on normal or erythematous skin, often with a urticarial pre-stage and it can be life-threatening if left untreated. The diagnosis of bullous pemphigoid requires histopathological examination and direct immunofluorescence testing, which are not available in primary care. Therefore, patients suspected of having bullous pemphigoid should be referred to secondary care (dermatology) promptly for further evaluation and management.§
irritant vs allergic contact dermatitis
ALLERGIC = after sensitisation to a specific allergen over time (type IV hypersensitivity reaction). more intense pruritus and may show vesiculation.
IRRITANT= more acute
most common sites are head/neck, upper trunk and hands. Lesions in the oral mucosa are common in pregnancy
initially small red/brown spot
rapidly progress within days to weeks forming raised, red/brown lesions which are often spherical in shape
the lesions may bleed profusely or ulcerate
pyogenic granuloma
pyogenic granuloma management
lesions associated with pregnancy often resolve spontaneously post-partum
other lesions usually persist. Removal methods include curettage and cauterisation, cryotherapy, excision
Molluscum contagiosum - what virus?
POXvirus (self-limiting)
Referral may be necessary in some circumstances:
For people who are HIV-positive with extensive lesions urgent referral to a HIV specialist
For people with eyelid-margin or ocular lesions and associated red eye urgent referral to an ophthalmologist
Adults with anogenital lesions should be referred to genito-urinary medicine, for screening for other sexually transmitted infections
Rosacea first line management if papule and/or pustules
Topical ivermectin
what formula used for burns
Parkland
a rash consisting of numerous small patches of psoriasis that develop acutely over several days 1-2 weeks after a streptococcal infection
guttate psoriasis
management alopecia areata
steroids + REFER
when does Pompholyx eczema get worse
high temperature and humidity (e.g. summer)
Abx used in acne rosacea?
topical metronidazole
NOT steroids as they can make it worse
benign, painful nodule on the ear, more common in men than women
Chondrodermatitis nodularis helicis
yellow shin
associated with telangiectasis
Necrobiosis lipoidica diabeticorum
severe systemic reaction affecting the skin and mucosa, almost always caused by a drug reaction. The characteristic rash is typically maculopapular with target lesions.
Stevens-Johnson syndrome
a hypersensitivity reaction that is most commonly triggered by infections. It may be divided into minor and major forms.
Features
target lesions
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
erythema multiforme
MUCOSAL INVOLVEMENT= erythema multiform major
chronic plaque psoriasis first line management
POTENT steroid
topical betamethason + topilla caldipotriol
Bullous pemphigoid VS pemphigus vulgaris
VULGARIS = MUCOSAL involvement
Blisters/bullae
no mucosal involvement: bullous pemphigoid
mucosal involvement: pemphigus vulgaris
white patches have been present for the past few months and are asymptomatic. He is a smoker who is known to have type 2 diabetes mellitus.
oral leukoplakia
asymptomatic and prolonged nature
–> BIOPSY to confirm diagnosis (and exclude squamous cell carcinoma/ lichen planus)
DIAGNOSIS OF EXCLUSION
CANNOT BE RUBBED OFF (if it can consider candidiasis or lichen planus)
oral leukoplakia management
monitor as 10-20%–> squamous cell carcinoma
STOP SMOKING
DIABETES + SHIN RASH
well-demarcated erythematous plaques on the shins which are often surrounded by telangiectasia and may have a yellowish hue due to lipid deposition
Necrobiosis lipoidica
Wickham striae on the oral mucosa
lichen planus
Seborrhoeic dermatitis - first-line treatment
topical ketoconazole
SEVERE rosacea management
topical ivermectin + oral doxycycline is first-line for patients with severe papules and/or pustules
lichen planus vs psoriasis
distribution: psoriasis EXTENSOR, planus FLEXURAL (we.g. wrists, legs, trunk, oral mucosa)
lesions; psoriasis SILVERY, planus WHITE LINES (WICKHAM STRAE)
nail changes: in both, but planus is thining
Cetirizine - sedating or not?
NON SEDATING (or loratadine)
Chlorphenamine - sedating or not?
SEDATING
if the scale is removed, a red membrane with pinpoint bleeding points may be seen
psoriasis (Auspitz sign)
Face, flexural and genital psoriasis management
mild/ moderate potency corticosteroids 1-2 x per day, max 2 weeks
NOT vit D
(scalp also just steroids for 4 weeks no vit D )
UV light therapy - increased risk of what cancer
squamous cell carcinoma
severe acne treatment
oral antibiotic and topical benzoyl peroxide TOGETHER
and –> REFER
(if mild/moderate then topical of both okay)
commonly caused by anti-epileptics such as carbamazepine and is characterised by a rash affecting <10% of body surface area and mucosal involvement.
the rash is typically maculopapular with target lesions being characteristic
may develop into vesicles or bullae
Nikolsky sign is positive in erythematous areas - blisters and erosions appear when the skin is rubbed gently
mucosal involvement
systemic symptoms: fever, arthralgia
Stevens-Johnson syndrome
Difference between SJS and Toxic epidermal necrolysis and erythema multiforme major
SJS= <10% body
TEN= Toxic epidermal necrolysis also involves mucous membranes but the rash is more extensive affecting at least 30% of body surface area. It is also triggered by drugs.
erythema multiform major= acral distribution and lesions are often raised
SJS causes
penicillin
sulphonamides
lamotrigine, carbamazepine, phenytoin
allopurinol
NSAIDs
oral contraceptive pill
normal ABPI
0.9-1.2
what is clobetasone butyrate
STEROID (e..g used in lichen planus)
gold standard for TB diagnosis
Sputum culture
longstanding Hx bleeding e.g. nose bleeds or rectal bleeding, red spots, FHx
hereditary haemorrhage telangiectasia
scarring alopecia
trauma, burns
radiotherapy
lichen planus
discoid lupus
tinea capitis*
non-scaring alopecia
male-pattern baldness
drugs: cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, colchicine
nutritional: iron and zinc deficiency
autoimmune: alopecia areata
telogen effluvium
hair loss following stressful period e.g. surgery
trichotillomania
eye complications in rosacea
blepharitis and conjunctivitis
target lesions
erythema multiforme
what is a sebaceous cyst? how to treat
basically a spot with a puncture
(non cancer lump with skin/hair contained)
SURGERY to completely remove and prevent reoccurrence
Children with new-onset purpura
immediate referral to paeds
–> ALL and meningococcal disease
Whilst petechiae can be seen in a viral illness or with increased superior vena cava pressure (e.g. following a cough) purpura are never a normal finding in children. She needs to be immediately admitted to exclude a serious underlying condition.
PURPURA= BAD
PETECHIAE= possibly OK
when to do urgent referral for BCC (2WW)
if in eyes/ nasal Ala
systemic itch
CKD
liver disease
iron def
polycythaemia
lymphoma
Migratory thrombophlebitis - cancer?
pancreatic
Dermatomyositis - cancer?
ovarian and lung
Sweet’s syndrome
Haematological malignancy e.g. Myelodysplasia - tender, purple plaques
carbamazepine and skin
causes erythema multiform
guttate psoriasis treatment
reassurance and topical treament if symptomatic
2 main Abx used in acne (2)
what to do if fails to work? (1)
doxycycline and lymecycline
if not worked –> ORAL RETINOIDS (vitamin A) (REFER)
a topical retinoid (if not contraindicated) or benzoyl peroxide should always be co-prescribed with oral antibiotics to reduce the risk of antibiotic resistance developing. Topical and oral antibiotics should not be used in combination
Acne: when to refer
when to consider referring
- patients with acne conglobate acne: a rare and severe form of acne found mostly in men that presents with extensive inflammatory papules, suppurative nodules (that may coalesce to form sinuses) and cysts on the trunk.
- patients with nodulo-cystic acne
referral should be considered in the following scenarios:
- mild to moderate acne has not responded to two completed courses of treatment
- moderate to 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
Pityriasis rosea often follows
a VIRAL infection
(Streptococcal throat infection tends to trigger guttate psoriasis)
treatment actinic keratoses
topical fluorouracil
keratocanthoma management
2WW
(they normally spontaneously regress)
Features - said to look like a volcano or crater
initially a smooth dome-shaped papule
rapidly grows to become a crater centrally-filled with keratin
lichen sclerosus management
no skin biopsy needed - diagnosis on clinical exam
increased risk of vulval cancer
may scan
itch prominent
Superficial spreading melanoma
Most common type of melanoma that has the typical diagnostic features of a changing mole
Eczema herpeticum - 2 possible causes (2)
is a primary infection of the skin caused by herpes simplex virus (HSV) and uncommonly coxsackievirus
monomorphic punched-out erosions (circular, depressed, ulcerated lesions) usually 1-3 mm in diameter
Eczema herpeticum
vitiligo and trauma
precipitates skin lesions (KOEBNER PHENOMENON)
drugs than worsen psoriasis
beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab
AND ALCOHOL AND TRAUMA
How to identiy any steroids
remember -ONE likely a steroid
e.g. triamcinolone
how common is oral involvement in lichen planus
COMMON
