Dermatology Flashcards
Name some skin disorders a/w Diabetes
- Necrobiosis lipoidica
- Infection: Candida, Staphylococcal
- Granuloma annulare
- Neuropathic ulcer
- Vitiligo
- Lipoatrophy
What is Necrobiosis lipoidica ??
- typically seen on SHINS
- Shiny, PAINLESS, area of yellow/red/brown skin
- a/w TELANGIECTASIA
What is Granuloma annulare ??
- Papular lesions
- slightly Hyperpigmented + centrally depressed
Site: Dorsal Hands & feet, Extensors of Arms & legs
Causes of Acanthosis Nigricans ??
Symmetrical, brown, velvety plaque on Neck, Axilla, Groin
- GI Cancer
- Obesity
- PCOS
- Acromegaly, Cushing’s disease
- Hypothyroid
- T2DM
- Prader-Willi
- Nicotinic acid
- COCPs
- Familial
What is the pathophysiology of Acanthosis N ??
Insulin resistance==> HYPERINSULINAEMIA==> interaction with IGF receptor-I ==> KERATINOCYTES & Dermal FIBROBLASTS proliferation
Name the skin conditions a/w Pregnancy
- Atopic eruption of pregnancy (MC)
- Polymorphic eruptions
- Pemphigoid gestationis
Features of Atopic eruptions of Pregnancy ??
- MC skin disorder seen
- Eczematous + Itchy + Red rash
- No specific treatment
Features of Polymorphic eruptions of Pregnancy ??
- Pruritic condition a/w LAST Trimester
- 1st appears in Abd. STRIAE
- Rx.(based on severity)- Emollients, mild potency topical steroids, Oral steroids
Features of Pemphigoid gestationis ??
- Pruritic blistering lesions
- starts at Peri-Umbilical region ==> later spreading to trunk, back, buttocks & arms
- 2nd or 3rd trimester
- RARELY seen in 1st pregnancy
- Rx.- Oral Corticosteroids
What are the skin disorders a/w TB ??
- LUPUS VULGARIS (50% cases)
- Erythema nodosum
- Scarring alopecia
- Scrofuloderma
- Verrucosa cutis
- Gumma
What is Lupus Vulgaris ??
MC form of Cutaneous TB seen in Indian subcontinent
- Site: Face, common around Nose & Mouth
- Initial- Erythematous flat plaque
- Later- Elevated & ulcerates
What is Scrofuloderma ??
Breakdown of skin overlying a TB focus
What skin condition is a/w the following
- Oesophageal Ca
- Gastric Ca
- Pancreatic Ca
- GI & Lung Ca
- Tylosis
- Acanthosis nigricans
- Migratory thrombophlebitis
- Acquired hypertrichosis lanuginosa
What skin condition is a/w the following
- Lymphoma
- Myeloproliferative disorder
- Glucogonoma
- Acquired ichthyosis, Erythroderma
- Pyoderma gangrenosum (Bullous & Non-bullous form)
- Necrolytic Migratory erythema
What skin condition is a/w the following
- Lung Ca
- Ovarian & Lung ca
- GI & Lung Ca
- Erythema gyratum repens
- DERMATOMYOSITIS
- Acquired hypertrichosis lanuginosa
Which skin conditions are a/w Haematological malignancy eg.- Myelodysplasia- tender, purple plaques ??
Sweet’s syndrome (Acute febrile Neutrophillic dermatosis)
- sudden onset well defined tender plaques or nodules
- Fever
- Arthralgia
- Ocular inflammation
- Systemic symptoms
Lesions reveal Neutrophilic Infiltrates
RF for SCC of skin ??
- Excessive Sunight
- Psoralen UVA therapy
- Immune suppression (Post-Renal transplant, HIV)
- Smoking
- Actinic keratosis, Bowen’s disease
- MARJOLIN’s ulcer (long standing leg ulcer)
Which genetic condition is a/w SCC of skin ??
Xeroderma pigmentosum
Oculocutaneous albinism
Rx. of SCC of skin ??
Surgical excision
- Tumour < 20mm, excise with 4mm margin
- Tumour > 20mm, excise with 6mm margin
Mohs Micrographic Sx.
- used in High risk pts.
- Cosmetically important sites
Prognosis of SCC of skin ??
Good prognosis
- Well differentiated, < 20mm diameter, < 2mm deep, Not a/w any disease
Poor prognosis
- Poorly diferentiated, > 20mm diameter, > 4mm deep, Immunosuppression for any reason
Which is the MC type of skin cancer in the western world ??
BCC aka Rodent ulcers
- Slow growing with local invasion
- Metastases is extremely rare
Features of BCC ??
MC type is NODULAR type
- Site- Head & Neck
- Sun exposed areas
- Initial: Pearly lesion
- Later: Ulcerate leaving a central ‘Crater’
ROUTINE Referral made
Rx. of BCC of skin ??
- Surgical removal
- Curettage
- Cryotherapy
- Topical cream: IMIQUIMOD, FLUROURACIL
- Radiotherapy
What are the types of Malignant Melanoma ??
- Superficial spreading (70% cases)
- Nodular (2nd MC, MOST AGGRESSIVE)
- Lentigo Maligna (Less common)
- Acral Lentiginous (Rare)
Describe Superficial spreading Malignant melanoma
- Young people
- Site: Arm, Leg, back & chest
- Appearance: Growing mole + Dx. criteria
Describe Nodular Melanoma
- Most aggressive form
- Middle aged people
- Sun exposed areas
- Appearance: Red/ Black lump (or) lump which bleeds/ oozes
Describe Lentigo maligna
Is a type of Melanoma in situ
- Older people
- Chronic sun exposed areas
- Progresses slowly, at some stage stage becomes invasive causing Lentigo maligna melanoma
- Appearance: Growing mole + Dx. criteria
Describe Acral lentiginous
- African Americans or Asians
- Nails, Palm or Soles
- Appearance: Subungual pigmentation (HUTCHINGSON’s Sign) (or) on Palms or Feet
Name some rare forms of Malignant Melanoma
- Desmoplastic M
- Amelanotic M
- Melanoma arising from other parts of body eg. Ocular M
What are the Dx. Criteria of Malignant Melanoma ??
Major Criteria
- Change in Size
- Change in Shape
- Change in Colour
Minor Criteria
- Diameter >= 7mm
- Inflammation
- Oozing or Bleeding
- Altered Sensation
Rx. of Malignant Melanoma ??
- Suspicious lesion: Excision Biopsy
- Lesion should be removed en mass
How is the Margins of excision related to Breslow thickness ??
Lesions 0-1mm thick = 1cm
Lesions 1-2mm thick = 1-2cm (depending on the site & pathological features
Lesions 2-4mm thick = 2-3cm (depending on site & pathological features)
Lesions > 4mm thick = 3 cm
What is the single most imp. factor that determines the prognosis in Malignant Melanoma ??
Breslow DEPTH (invasion depth of tumour)
< 0.75mm = 95-100% (5 year survival)
0.76- 1.5mm = 80-96%
1.51- 4mm = 60- 75%
> 4mm = 50%
What is Mycosis Fungoides ??
aka Alibert-Bazin synd. or Granuloma Fungoides
- Rare form of Blood Cancer (T-Cell Lymphoma) causing Skin lesions
- Itchy, flat, scaly, pink or red patch
- Plaque that can be red, scaly & itchy
What is Sezary syndrome ??
type of T-Cell Cutaneous Lymphoma
- Pruritis
- Erythroderma of Palms, Soles & Face
- Lymphadenopathy
- Hepato-splenomegaly
- Atypical T-cells
What is Systemic Mastocytosis ??
Neoplastic proliferation of Mast cells
- Urticaria pigmentosa- produces a wheal on rubbing (Darier’s sign)
- Flushing
- Abdominal pain
- Monocytosis on Blood film
How do we Dx. Systemic Mastocytosis ??
Raised S. Tryptase levels
Monocytosis
Urinary histamine
What is Keratoacanthoma ??
BENIGN epithelial tumour
MC with advancing age & rare among young people
Features of Keratoacanthoma ??
Looks like volcano or crater
- Initial: smooth dome-shaped papule
- Rapidly growing to become Crater centrally filled keratin
Spontaneous regression within 3 months is common
- they should be urgently excised (to exclude SCC)
What is Actinic Keratosis ??
Solar keratoses is a common PRE-MALIGNANT lesion
- Chr. Sun exposure
- Sun exposed areas (eg. Temple region)
- Small, crusty or scaly lesions
- Pink/Red/Brown/same colour as skin
- Multiple lesions may be present
Rx. of Solar or Actinic Keratosis ??
- Flurouracil cream [(2-3 wks course), use Hydrocortisone cream if skin becomes red & inflamed]
- Mild AKs: Topical Diclofenac
- Topical Imiquimod
- Cryotherapy
- Curettage & Cautery
- Sun avoidance, Sun-screen
What causes Impetigo ??
Bacterial skin infection (very contageous)
Staph. aureus or Strept. pyogenes
- ‘Golden crusted skin around mouth’
Rx. of Impetigo ??
Pts. who are NOT systemically unwell or at high risk of complication
- H2O2 (1% )cream
Topical Abx. cream
- Fusidic acid
- Mupirocin (IF resistant to Fusidic acid) & also in MRSA
Extensive disease
- Oral FLUCLOXACILLIN
- Oral Erythromycin (if penicillin allergic)
What is the School exclusion criteria for Impetigo ??
Until lesions are Crusted & healed (or)
48hrs after starting Abx. Rx.
Molluscum contagiosum causitive organism ??
MC virus (POX-VIRIDAE family)
- Direct transmission: Personal contact
- Indirect transmission: via FOMITES (contaminated surfaces)
RF for Molluscum C ??
- Childern
- Kids with ATOPIC Dermatitis
- Max. incidence: Preschool [1-4 yrs]
What are the presentations of Molluscum C infection ??
Pinkish/ Pearly white papule with central umbilication; upto 5mm in diameter
Site
- Children: Trunk & Flexures; but anogenital lesions may occur
- Adults: Sexual contact- genitalia, pubis, thighs & lower abdomen; rarely Oral mucosa & on Eyelids
Rx. of Molluscum C ??
Self limiting (spontaneous resolution in 18 months)
But things like the following can be done
- After bath: Squeezing (with fingernails) or Piercing (Orange stick)
- Cryotherapy (older kids & adults)
If a/w Eczema/ Inflammation
- Mild topical Steroids (HC 1%)
If infected (eg.-oedema, crusting)
- Topical Fusidic acid 2%
When is referral considered in Molluscum C cases ??
- HIV (+) with extensive lesions = HIV specialist
- Eye-lid margins/ Ocular lesions = Ophthalmologist
- Adults + Ano-genital lesions = GUM clinic (for STI screening)
What is Erythema ab igne ??
Skin disorder caused by over exposure to INFRARED Radiations
- Reticulated, Erythematous patches with Hyperpigmentation & Telengiectasia
- “Elderly women who sits next to the open fire”
- Risk of SCC development
What is Erythrasma ??
CORYNEBACTERIUM Minutissimum overgrowth
- Asymptomatic, flat, slightly scaly, pink/brown rash at GROIN or AXILLAE
Dx. & Rx. of Erythrasma
- Wood’s light examination reveals Coral-Red fluorescence
- Mild: Topical Miconazole or Antibacterials
- Extensive: Oral ERYTHROMYCIN
What is Tinea infection & its types ??
Dermatophyte fungal infections
3 main types
- T corporis: Trunk, Leg, Arm
- T capitis: Scalp
- T pedis: Feet (Athlete’s foot)
- T cruris
Hallmark features of T capitis (Scalp Ringworm) ??
- MCC: Trichophyton tonsurans in UK % USA
- Also caused by Microsporum canis (cats & dogs)
Dx- Fluorescence under Wood’s Lamp - M canis: GREEN
- T tonsurans: do not fluoresce
Ix. & Rx. of T capitis ??
- Scalp scrapings
- Oral Antifungals
— T tonsurans: TERBINAFINE
— M canis: GRISEOFULVIN
Topical KETOCONAZOLE shampoo for 2 wks. to reduce transmission
Hallmark of T corporis
Trichophyton rubrum & T verrucosum (eg. from contact with Cattles)
- Well defined annular, erythematous lesions with pustules & papules
Rx.- Oral FLUCONAZOLE
Hallmark of T pedis ??
Athlete’s foot
- Itchy, peeling skin b/w toes
- common in Adolescence
What is Pityriasis Versicolor ??
aka Tinea versicolor, is a Superficial Fungal infection
- MALASSEZIA Furfur
Features of Pityriasis versicolor ??
- MC site: TRUNK
- Hypopigmented, pink/brown (hence Versicolor); more noticeable under Sun-tan
- Scales is common, Mild Pruritis
RF: Immunosuppression, Malnutrition, Cushing’s
Rx. of Pityriasis Versicolor ??
- Topical Anti-fungals
- Ketoconazole shampoo
If Rx. failure
- Send scrapings to confirm Dx.
- Oral ITRACONAZOLE
What is Pityriasis Rosea ??
Acute, self-limiting rash (after 6-12 wks) seen in Young adults
- HERPES HOMINIS Virus 7 (HHV-7) may play a role.
Features of Pityriasis Rosea ??
- No prodrome; but minority of pts. give a H/o recent viral infection
- HERALD Patch (on Trunk)
- followed by Erythematous, oval, scaly patches
The longitudinal diameters of the oval lesions run parallel to Line of langer ==> ‘Fir tree’ appearance
What is Onycholysis & mention a few causes ??
Separation of nail plate from nail bed
- Idiopathic
- Trauma (eg. over manicuring)
- Infection (usually FUNGAL)
- Psoriasis, Dermatitis
- PVD (eg.- Raynaud’s)
- Hyper/Hypo-thyroidism
What is Onychomycosis & mention the causes ??
Fungal infection of nails
- Dermatophytes: T rubrum (90% cases)
- Yeasts: Candida
- Non-Dermatophyte moulds
Mention some hallmarks of Onychomycosis
RF: DM & Increasing age
C/F- Thick, Rough, Opaque nails & Unsightly nails
Ix.- Nail clippings, Scrapings from nails
Rx. of Onychomycosis ??
Asymptomatic + Pt. not bothered by looks : NO need of Rx.
Dermatophyte infection:
- 1st line: Oral TERBINAFINE
- 2nd line: Oral Itraconazole
- Finger nail : 6wks to 3 months Rx
- Toenail : 3 to 6 months
Candida infection:
- Mild: Topical Antifungals (AMOROLFINE)
- Severe: Oral ITRACONAZOLE (12wks)
- Finger nail : 6 months Rx.
- Toe nails : 9 to 12 months Rx.
Is scabies an infection or a reaction ??
Delayed Type 4 HS reaction to mites/ eggs which occur 30 days after initial manifestation
Features of Scabies
Sarcoptes scabiei
- Mites burrow into skin & lay eggs in Stratum CORNEUM
- Widespread pruritis
- Linear burrow on sides of finger, webspaces & wrist flexors
Infants: Face & Scalp can be affected
Rx. of Scabies ??
1st line: Permethrin 5%
2nd line: Malathion 0.5%
Allow the cream to dry & leave on the skin for : Permethrin- 8 to 12 hrs & Malathion- 24 hrs before washing off
REPEAT Rx. after 7 days
- Pruritis persists for upto 4-6 wks post eradication
- Blanket therapy
What is Crusted Scabies ??
- aka Norwegian scabies
- Common in Immunosuppressed specially in HIV pts.
- Rx.- IVERMECTIN + Isolation
HLA a/w Psoriasis ??
Chr. skin disorder a/w increased risk of Arthritis & CVS disease
B13, B17 & Cw6
Strong concordance (70%) in identical twins
What is the Pathogenesis of Psoriasis ??
Immunological & Environmental
- Abnormal T-cell activity==+==> KERATINOCYTE proliferation (mediated by Th-cells producing IL-17, designated Th-17)
Worsened by - Skin trauma & Stress
Triggered by - Strept. infection
Improved by - Sunlight
- Munro microabscess (Collection of neutrophils) found on skin biopsy
In Psoriasis, how much time does it take for Keratinocytes to transform to Anucleate Corneocytes ??
3 days
[Normally it takes 28 to 30 days]
- Epidermal cells fail to secrete adequate amount of LIPIDS => Scaling (due to loss of S Corneum integrity)
Name the subtypes of Psoriasis
Plaque psoriasis (MC subtype)
Flexural P (skin is smooth in this type)
Guttate P
Pustular P (common on PALMS & SOLES)
Describe Plaque Psoriasis
MC subtype of P
- Typical well-demarcated red, scaly patches
- Extensor surface, Sacrum, Scalp
Describe Guttate Psoriasis
Transient psoriatic rash commonly triggered by STREPTOCOCCAL infection (Sore throat 2-4 wks prior).
- Multiple, red, TEAR-drop lesions on the body
- MC in Children & Adolescents
What are the exacerbating factors for Psoriasis ??
Trauma
Alcohol
Drugs
- ACEi & Beta-blockers
- Lithium
- Antimalarials (CQ & HCQ)
- NSAIDs
- Infliximab
- Systemic Steroid withdrawal
Rx. of Chr. Plaque Psoriasis
- 1st line (tried for 4 wks) : Potent CS (od) + Vit.D analogue (od) [applied at separate times- one in morning & one at evening]
- 2nd line (tried if no improvements after 8 wks) : Vit. D analogue (bd)
- 3rd line (if no improvement after 8 to 12 wks) : Potent CS (bd) for 4 wks (OR) Coal tar preparations (od or bd)
Short acting DITHRANOL can also be used
Rx. for Scalp psoriasis ??
Potent Topical CS (od) for 4 wks.
If no improvement after 4 wks, then either use
- Different formulation of the potent CS (eg. shampoo or mousse) &/or
- Topical agent to remove adherent scalp (eg. salicylates/emmolients/oils) before applying potent CS
Rx. for Face, Flexure & Genital Psoriasis ??
Mild to Moderate potency CS applied (od) or (bd) for <= 2 wks
Which phototherapy is used in Psoriasis ??
ToC- Narrow band UV-B light for <= 3 wks
Photochemotherapy can also be used- PUVA (psoralen + UV-A)
What is the S/E of Phototherapy used in Psoriasis ??
Skin aging
SCC (not Melanoma)
Drug of choice for Psoriasis with Joint disease ??
Oral MTX
Why should topical steroids not used for long time in Psoriasis ??
- Steroid skin atrophy (very common in Scalp, Face & Flexures)
- Stria
- Rebound symptoms
Give some eg. of Vit D analogues
- Calcipotriol (Dovonex)
- Calcitriol & Tacalcitol
NOTE: They reduce scales & thickness of plaque but NOT Erythema.
Which elective procedure is done in pts. with Recurrent Guttate Psoriasis ??
TONSILLECTOMY
What is Erythema nodosum ??
Inflammation of Subcutaneous fat (Panniculitis)
- Tender + Erythematous + Raised red/ violet Nodular
- Site: SHINS (also Forearms, thighs)
Resolves within 6 wks.
Heals without Scarring
NSAIDs can reduce the symptoms
Which infections cause Erythema nodosum??
BTS
- Brucellosis, TB, Streptococci
[Also seen in Sarcoidosis, IBD, Behcet’s]
-Pregnancy
- COCPs (use Non-Oestrogen based Contraceptions)
What is Erythema Multiforme ??
HS reaction triggered by Infection
- Divided into Minor & Major forms
- Major form is a/w Mucosal involvement
Features of Erythema Multiforme ??
- Target lesions
- Initially: Hands/ Feets before spreading to Torso
- ULs»_space;> LLs
- Pruritis is mild
MCC is HSV infection
What is Orf ??
Skin disease of sheep & goats
PARAPOX Virus
Can cause Erythema Multiforme
What is Erythroderma ??
Term used when > 95% of skin is involved in a RASH of ANY kind
Sometimes called ‘Red man Synd.’
Causes
- Idiopathic
- Psoriasis, Eczema
- Drugs: Gold
- Lymphomas, Leukaemias
Rx for Erythroderma Psoriasis ??
1st line: Ciclosporin
Infliximab (if 1st line is CI or ineffective)
What is Lichen Planus ??
Skin disorder of unknown etiology, most probably is Immune mediated
- Itchy, papular rash
- Site: Palm & Soles, Genitalia & Arm flexors
- Wickham’s striae: Polygonal rash + ‘white lines’ pattern on surface
- Koebner phenomenon can be seen
Features of Lichen Planus ??
- Wickham’s Striae: Polygonal rash + ‘White lines’ pattern on surface
- Koebner’s phenomenon (new skin lesion appearing on site of trauma)
- Oral involvement (50% cases):White-lace pattern on buccal mucosa
- Nails: Thinning, Longitudinal ridges
Causes & Rx. of Lichen Planus ??
Lichenoid drug eruptions- causes:
- Gold, Quinine, Thiazides
Rx.
- Potent Topical Steroids
- Benzydamine mouth wash/spray
- Severe: Oral steroids or Immunosuppression
What is Pemphigus vulgaris ??
Autoimmune disease caused by antibodies directed against
- Desmoglein-3 (Cadherin-type epithelial cell adhesion molecule)
MC in Ashkenazi Jewish pepole
Features of Pemphigus Vulgaris ??
Mucosal ulceration (MC); Oral involvement in 50-70% pts.
Skin blistering
- Flaccid, easily ruptured vesicles & bullae
- PAINFUL but NOT Itchy
Nikolsky’s sign: Spread of bullae following application of horizontal, tangential pressure to the skin
ACANTHOLYSIS on biopsy
Rx. for Pemphigus Vulgaris ??
1st line: STEROIDS
2nd line: Immunosuppressants
What is Bullous Pemphigoid ??
Autoimmune condition causing Sub-epithelial blistering of skin secondary to development of antibody against
- Hemi-Desmosomal proteins BP180 & BP230
MC in Elderly
Features of Bullous Pemphigoid ??
- ITCHY, tense blisters typically at Flexures
- Blisters heal without Scarring
- NO Mucosal involvement (Mouth spared) BUT in reality, 10 to 50% have mucosal involvement
- Exam purpose: mucosa not involved
Ix. & Rx. of Bullous Pemphigoid ??
Dermatologist referral for biopsy & Dx. confirmation
- Skin biopsy: Immunofluorescence shows IgG & C3 at Dermo-epidermal junc.
Rx.
- Oral Corticosteroids (mainstay)
- Topical CS, Immunosuppressants & Abx. are also used
Differentiate b/w
- Pemphigus Vulgaris
- Bullous Pemphigoid
BOTH are autoimmune diseases
- Antibodies (IgG) against Desmoglein 3; Mucosa inolved; PAINFUL but NOT Itchy; Ashkenazi Jewish
- Antibodies against Hemi-desmosamal proteins BP180, BP230; Mucosa NOT involved; ITCHY; Elderly
What is Pemphigus & Pemphigoid ??
- a/w Penicillamine & Captopril; tends to present as ulcers with fragile small blisters that quickly breakdown. Mouth & Genitals can be affected
- Large flaccid blisters; DPP4 inhibitors is a/w Pemphigoid
What is Stevens-Johnson Synd. ??
Severe systemic reaction affecting skin & mucosa ie. almost always due to DRUG Reaction
- Common in CHINESE/ Thai descents due to the presence of HLA-B1502
- Increased risk in European, a/w HLA-A3101
Features of SJS ??
- Maculopapular; typical ‘Target lesions’
- May develop into vesicle/bullae
- Mucosa involved
- Fever, Artharlgia
Drugs causing SJS ??
‘NO SLAP’
- NSAIDs. - OCPs
- Sulfonamides
- Lamotrigine, Carbamazepine, Phenytoin
- Allopurinol. - Penicillins
- INDAPAMIDE (it has Sulfonamide moiety)
Rx.
- Admit & Supportive care
What is Toxic Epidermal Necrolysis ??
Life threatening skin disorder MC seen secondary to DRUG Reaction
- Skin develops a SCALDED appearance over an extensive area
- TEN is the extreme end of a spectrum of skin disorder which includes E multiforme & SJS
Causes & Features of TEN ??
Causes
- NSAIDs. - Sulfonamides
- Carbamazepine, Phenytoin
- Allopurinols. - Penicillins
C/F
- Pyrexia, Tachycardia
- Nikolsky’s sign (+)ve
Rx. of TEN ??
- STOP ppt. factors
- 1st line: IVIGs
- Immunosuppressive agents (Ciclosporin, Cyclophosphamide)
- Plasmapheresis
Supportive care
-ICU - Correct volume loss & electrolyte derangement
Rx. of Hyperhidrosis ??
- 1st line: Topical AlCl prep. (main s/e is skin irritation)
- Iontophoresis (particularly useful in Palmer, Plantar & Axillary symptoms)
- Botox for axillary symptoms
- Endoscopic Transthoracic Sympathectomy (risk of compensatory sweating)
What is Pompholyx ??
Dyshidrotic Eczema
Type of eczema that affects
- Hands: Cheiropompholyx
- Feet: Pedopompholyx
Ppt. by HUMIDITY (Sweating) & High Temp.
Hallmarks of Pompholyx ??
‘Pt. has been on summer holidays in hot area where he was sweating a lot’
- Small blisters on Palms & Soles
- Pruritic; often intensely Itchy & Burning
- Once blisters burst, skin may become dry & crack
Rx. of Pompholyx or Dyshidrotic Eczema ??
Cool compresses
Emollients
Topical Steroids
What is Seborrhoeic Dermatitis ??
Chr. dermatitis due to proliferation of normal skin commensal MALASSEZIA Furfur (formerly-Pityrosporum Ovale)
Features of Seborrhoeic Dermatitis ??
Eczematous lesions on sebum rich areas
- Scalp (may cause dandruff)
- Periorbital, Auricular & NL folds
- O Externa & Blepharitis may occur
a/w HIV & Parkinson’s disease
Rx of Seborrhoeic Dermatitis ??
Scalp disease
- 1st line: Zn Pyrithione (Head & Shoulders) & Tar (Neutrogena T/Gel)
- 2nd line: Ketoconazole
- Selenium sulphide & Topical CS
Face & Body disease
- Topical Antifungals: Ketoconazole
- Topical Steroids: for Short period
- RECURRENCE is common
What is Nickel dermatitis ??
Type 4 HS reaction
- Caused by jewelry (eg.- Watches)
Dx.- SKIN PATCH test
What are the 2 main types of Contact Dermatitis ??
Irritant CD (Common)
- Non allergic
- Due to Weak acids & alkalis (eg. detergents)
- Common in Hands
- ERYTHEMA is typical
Allergic CD
- Type 4 HS reaction
- Uncommon- seen on head after hair dye
- Acute weeping eczema, predominantly affects Hairline MARGINS rather than Scalp itself
What kind of dermatitis is seen with Cement exposure ??
BOTH types
- Its Alkaline nature: Irritant CD
- Dichromates in cement: Allergic CD
What is Eczema Herpeticum ??
Severe primary infection of skin by Herpes Simplex V 1 or 2
- MC in Children with atopic eczema
- Rapid progressing Painful Rash
- Monomorphic, punched out erosions (circular, depressed, ulcerated lesions)
- 1 to 3 mm in diameter
Rx. of Eczema Herpaticum ??
Life threatening in Children
- Admit + IV Aciclovir
What is Dermatitis Herpetiformis ??
Autoimmune Blistering skin disorder a/w Coeliac disease
- Caused by IgA Deposition in Dermis (dermal papillae).
Itchy vesicular skin lesions on extensor surfaces (elbows, knees, buttocks)
Ix. & Rx. of Dermatitis Herpetiformis ??
Skin biopsy:
- Direct Immunofluorescence shows “Granular pattern IgA deposition in Upper DERMIS”
Rx.
- Gluten free diet
- DAPSONE
What is Acne Rosacea ??
Rosacea is a chronic skin condition of unknown aetiology
- Site: Nose, Cheeks & Forehead
- 1st sign: Flushing => later persistent Erythema with papules & pustules
- Rhinophyma
- Blepharitis
- Sunlight can exacerbate symptoms
- Telangiectasia are common
Rx. of Acne Rosacea ??
- Mild (limited no. of papules, pustules, NO plaques) : Topical Metronidazole & Azelaic acid
- Flushing predominant + limited Telangiectasia: Topical Brimonidine gel
- More severe: Systemic Abx. Oxytetracycline
- Prominent Telangiectasia: Laser
- High factor Sun-screen
- Rhinophyma: Dermatology referral
What is Acne Vulgaris ??
Common skin disorder- Adolescence
- Site: face, Neck, Upper trunk
Follicular epidermal hyper-proliferation=> Keratin plug formed => obstructs Pilosebaceous follicle ==> causes Comedones, Inflam. & Pustules
PROPIONOBACTERIUM Acne colonization
Rx. of Acne Vulgaris ??
- Single topical therapy (Retinoids, Benzoyl peroxide)
- TOPICAL combination therapy (Abx., Benzoyl peroxide, Retinoids)
- Oral Abx. (Single oral Abx. for 3 m)
- COCPs are an alternative to Oral Abx. in women
- Oral Isotretinoin (Specialist supervision) [Topical & oral forms are CI in Pregnancy]
What are the Oral Abx. used in Acne Vulgaris ??
TTCs: Lymecycline, OxyTTC, Doxy.
- Avoided in: Pregnant/ Breastfeeding < 12yrs old
ERYTHROMYCIN is used in Pregnancy
Topical Retinoids/ Benzoyl peroxide is always co-prescribed with Oral Abx.
[Topical + Oral] Abx. - NOT used
Gram (-) Folliculitis can occur with long term Abx. use => High dose Oral TRIMETHOPRIM
How is COCPs used as a Rx. in Acne Vulgaris ??
used in combination with Topical agents
- 2nd line: CO-CYPRINDIOL (Dianette) is used as it has Anti-androgen property (But increased risk of VTE compared to other COCPs) & is only given for 3 months.
What is Pellagra ??
Skin condition due to Nicotinic acid (Niacin, Vit B3) deficiency
Causes
- Isoniazid {Tryptophan ==(-)==> Niacin}
- Alcoholics
Features of Pellagra ??
4 D’s
- Dermatitis: Brown scaly rash on SUN-exposed sites- Casal’s necklace if around neck
- Diarrhoea
- Dementia, Depression
- Death (if not treated)
What is Porphyria Cutanea Tarda (PCT) ??
It is the most common HEPATIC Porphyria
- Inherited defect in Uroporphyrinogen decarboxylase (or)
- Hepatic damage eg.- Alcohol, HCV, Oestrogen
Features of Porphyria Cutanea Tarda ??
- PHOTOSENSITIVE Rash with Blistering
- Skin fragility on Face & Dorsal Hands (MC feature)
- Hypertrichosis
- Hyperpigmentation
Ix. for Porphyria Cutanea Tarda ??
Urine: elevated Uroporphyrinogen
Wood’s Lamp: Pink fluorescence of urine
Guide therapy: S. Iron Ferritin levels
Rx. of Porphyria Cutanea Tarda ??
- Chloroquine
- Venesection (preferred if iron ferritin >= 600 ng/ml)
How does Zinc deficiency manifest ??
Acrodermatitis Enteropathica
- A R inherited defect of intestinal Zn absorption
Features of Acrodermatitis Enteropathica ??
Acrodermatitis: Red, crusted lesions
- Acral distribution
- Peri-orificial
- Peri-anal
Short stature, Hypogonadism
Alopecia
Hepatosplenomegaly
GEOPHAGIA (Clay/Soil ingestion)
Cognitive impairment
What is Pyogenic granuloma ??
aka Eruptive Haemangioma
- BENIGN skin condition
- Its a misnomer (they are neither true granuloma nor pyogenic)
- MC in Women & Young adults
Features of Eruptive Haemangioma aka Pyogenic granuloma ??
Linked to Trauma & Pregnancy
- Site: Head/Neck, Upper trunk & Hands
- Oral mucosa lesions (common in Pregnancy)
Initially- Small red/brown spot
Rapidly progresses in days to weeks forming Raised, red/brown lesion, spherical in shape
Can bleed profusely/ ulcerate
Rx. of Eruptive Haemangioma aka Pyogenic Granulona ??
- Lesions a/w pregnancy: often Resolve Spontaneously
- Other lesions usually persists
- Excision, Curettage & Cauterisation, Cryotherapy
Difference b/w Hirsutism & Hypertrichosis ??
Hirsutism: Androgen DEPENDENT hair growth
Hypertrichosis: Androgen INDEPENDENT hair growth
Drug causes of
- Hirsutism ??
- Hypertrichosis ??
- Androgen therapy, Phenytoin, Corticosteroids
- Minoxidil, Ciclosporin, Diazoxide
Choice of COCPs for Hirsutism ??
Co-cyprindiol (Dianette): not used on long term basis due to risk of VTE
Ethinylestradiol
Drospirenone (Yasmin)
Rx. of Facial Hirsutism ??
Topical Eflornithine (CI in pregnancy & Breast-feeding)
How to assess Hirsutism ??
Ferrimen-Gallwey Scoring System
- 9 body areas are assigned a score of 0-4; score > 15 = Moderate or Severe
[Note: MCC is PCOS]
Causes of Hypertrichosis ??
Congenital Hypertrichosis lanuginosa
Porphyria Cutanea Tarda
ANOREXIA NERVOSA
Congenital Hypertrichosis terminalis
Drugs: Minoxidil, Ciclosporin, Diazoxide
What is Livedo Reticularis ??
Caused by obstruction of capillaries resulting in swollen venules
- Purplish, Non-blanching, reticulated rash
- MCC is Idiopathic
Causes pf Livedo Reticularis ??
- Idiopathic (MCC)
- PAN
- SLE
- Cryoglobulinaemia
- APLA synd.
- Ehlers-Danlos Synd.
- Homocystinuria
What is a Keloid & how is it treated ??
Tumour like lesion of scar, which arises from Connective tissue of a scar which extends beyond the original wound dimension
Rx.
- Early keloid: Intra-lesional Steroid injection eg.- Triamcinolone
- Excision
Hallmark features of Keloid scar ??
- More common in Dark skinned
- MC in Young adults, less common in elderly
- Sites: Sternum, Shoulder, Neck, Face, Trunk, Extensors of limbs
They are LESS likely to occur if incision is made along relaxed skin tension lines
- Langer lines: used to determine optimal incision lines (but produces WORSE cosmetic results than when following skin tension lines
What is vitiligo ??
Autoimmune condition which results in loss of Melanocytes ==> Skin depigmentation
- Typically seen in 20 to 30 yrs old
Features of vitiligo ??
- Well demarcated, depigmented
skin patches - PERIPHERIES (most affected)
- Koebner’s phenomenon (+)ve - Trauma may ppt. new lesions
What conditions are a/w Vitiligo & how is it treated ??
Type 1 DM, Addison’s disease
Autoimmune thyroid disease
Pernicious anaemia
Alopecia areata
Rx.
- Topical Steroids (can reverse if used early)
- Topical Tacrolimus & Phototherapy
- Sun-block for affected areas
What is the difference b/w Scarring & Non-scarring Alopecia ??
Scarring: LOSS of hair follicle
Non-scarring: Hair follicle preserved
What are the causes for Scarring alopecia ??
- Trauma & Burns
- Radiotherapy
- LICHEN PLANUS
- DISCOID Lupus (ANA negative)
- Tinea capitis (if KERION develops in untreated cases)
What is Telogen Effluvium ??
Hairloss following stressful period (eg. Surgery)
What is Alopecia Areata ??
Autoimmune condition( increase INF-gamma ==> T-cell infiltration => Follicular epithelium damage) causes - Localised, well demarcated patches of hair loss
- Edge of hair loss: small, broken ‘exclamation mark’ hairs
Rx. of Alopecia Areata ??
Eventually, the hair will grow back in majority pts.
- Topical/Intralesional Corticosteroids
- Topical Minoxidil
- Phototherapy
- Dithranol
- Contact immunotherapy
In which skin lesions can Koebner’s phenomenon can be seen ??
Lichen Planus
Lichen Sclerosis
Molluscum Contagiosum
Psoriasis
Vitiligo
Warts
Name the skin lesions seen on Shin
PEN
Pretibial myxoedema (Grave’s)
- Symmetric, Erythematous;
- Shiny, Orange peel skin
Pyoderma gangrenosum
Erythema nodosum
Necrobiosis Lipoidica Diabeticorum
- Shiny, painless yellow/red skin areas in diabetics
- a/w Telangiectasia
What is Yellow nail synd. ??
Slowing of nail growth leads to the characteristic thickened & discoloured nails
a/w
- Congenital Lymphoedema
- Pleural effusion
- Bronchiectasis
- Chronic sinus infection
What is 1 finger tip unit / Finger tip rule ??
0.5 g - sufficient to treat a skin area about 2x that of the flat of an adult hand
What are the types of Vasculitides??
Large vessel
- Temporal arteritis
- Takayasu
Medium vessel
- Polyarteritis nodosa
- Kawasaki disease
Small vessel
- ANCA associated
- Immune complex associated
What are the types of Small Vessel Vasculitides ??
ANCA associated
- Wegener’s granulomatosis (GPA)
- Churg-Strauss synd. (E-GPA)
- Microscopic Polyangitis
Immune Complex associated
- Henoch-Schonlein purpura
- Goodpasture’s synd.
- Cryoglobulinaemic vasculitis
- Hypocomplementemic Urticarial (anti-C1q vasculitis)
Hallmark features of Venous ulceration ??
Typically seen above Medial malleoli
- ABPI is important in Non-healing ulcers (it assesses the arterial flow)
- > 1.4 : Calcified/hardened vessel
- 1.0 to 1.4 : Normal
- 0.9 to 1.0 : Acceptable
- 0.8 to 0.9 : Some arterial disease
- 0.5 to 0.8 : Moderate arterial disease
- < 0.5 : Severe arterial disease
Rx. of Venous ulceration ??
Compression bandaging (4 layers) most effective
Oral Pentoxifylline (peripheral vasodilator, improves healing)
- Flavinoids
- Hydrocolloid dressings, topical GF, Ultrasound therapy & Intermittent Pneumatic compression
What is Osler-Rendu-Weber synd. ??
Hereditary Haemorrhagic Telangiectasia
- Autosomal DOMINANT
- 20% occurs spontaneously
Multiple telangiectasia over skin & mucous memb.
Diagnostic criteria of Osler-Rendu-Weber synd. ??
4 main criteria
- Epistaxis
- Telangiectasis
- Visceral lesion (GI telangiectasia, Pulm. AV malformation, Hepatic AVM, Cerebral AVM, Spinal AVM)
- Family Hx. (1st degree relative)
2/4 : Possible HHT
>= 3/4 : Definite HHT
What is Lichen Sclerosus ??
aka L S et atrophicus
- Inflammatory condition that usually affects the genitalia & is more common in Elderly females
- Leads to atrophy of the epidermis with white plaques forming
Features & Rx. of Lichen Sclerosus ??
White patches that may scar
ITCH is prominent
Pain during Intercourse or Urination
Rx.-
- Topical Steroids & Emollients
Dx. of Lichen Sclerosus ??
Clinical basis + Biopsy (if atypical features are present)
- Skin Biopsy NOT necessary if Dx. can be made clinically & typical presentation
- Atypical presentation or Diagnostic uncertainity or Suspicion of Neoplasia (Hyperkeratosis, erosion, erythema or new warty or papular lesion)=> HISTOLOGY & Biopsy
Do BIOPSY if :
- Rx. failure
- Extragenital or overlap with Morphea
- Pigmented areas (to exclude abnormal melanocyte proliferation)
- Second line therapy has to be used
Which cancer is commonly seen in pts. with Lichen Sclerosus ??
Vulval Cancer
What is Pyoderma gangrenosum ??
Rare, non-infectious, Inflammatory disorder which causes painful ulcerations
- It is classified as Neutrophilic dermatosis: a skin condition characterised by dense infiltration of neutrophils in the affected tissue & is often seen on biopsy
Causes of Pyoderma gangrenosum ??
- IDIOPATHIC (50% cases)
- IBD (10 to 15% cases)
- RA & SLE
- Myeloproliferative disorder, Lymphoma, Myeloid leukaemias, Monoclonal gammopathy
- Granulomatosis with P
- Primary Biliary Cirrhosis
Features of Pyoderma gangrenosum ??
Site: Lower limbs (typical)
Soften at the site of a minor injury as this is known as Pathergy (Exageratted skin reaction to minor trauma => Papules, Pustules)
Initial c/f:- Sudden onset + Small Pustule, Red bump or Blood-blister
Later:
- Skin breaks => Ulcer (PAINFUL)
- Edge of ulcer: Purple, voilaceous & UNDERMINED
- Ulcer may become deep & necrotic
- Fever & Myalgia
Dx. & Rx. of Pyoderma Gangrenosum ??
Characteristic appearance, a/w other diseases; presence of Pathergy & Histology
Rx.
- 1st line: Oral Steroids
- Immunosuppressive Rx.- Ciclosporin & Infliximab in severe cases
- ANY Sx. should be postponed until the disease is controlled
What is Dermatitis Artefacta ??
Psycho-dermatological condition characterised by self-inflicted skin lesions. Pts. typically deny that these are self induced
- MC in Adolescents & Females
- a/w Personality disorders, Dissociative & Eating disorders
- 33% of pts. with Bulimia & Anorexia
Features of Dermatitis Artefacta ??
- Linear/ Geometric lesions; well demarcated from normal skin
- Lesion appearance depends on mechanism of injury
- Lesions appear suddenly eg- Overnight
- Appear whole, complete & do not evolve over time
- Multiple lesions at various stages of healing
- Common sites: Face (specially cheeks), Dorsum of hand
- Despite the severity of skin lesions, pt. is nonchalant, ‘la belle difference’ aka Mona lisa smile
- H/o recent life events or triggers- marital dispute or bereavement
Dx. of Dermatitis artefacta ??
Based on history & after exclusion of other skin conditions
Psychiatric assessment- to rule out Munchausen synd., Malingering
Rx. og Dermatitis Artefacta ??
- Good rapport
- Co-managed by Dermatologist, Psychologist & Psychiatrists
- SSRIs & CBT may be helpful
What is Anagen Effluvium ??
Occurs when all hairs enter the ANAGEN phase of growth at the same time. This leads to Rapid hair loss; Seen in
- Cancer CT
- Radiotherapy
- Pemphigus vulgaris
Virus causing Kaposi Sarcoma ??
Human Herpes Virus 8
- Multiple Red-brown Nodular lesions affecting arms, legs & torso
Rx. of skin lesions
- IFN alpha
- Liposomal Anthracyclines
- Paclitaxel
What disease is caused by HHV 6 ??
Exanthem subitum aka Roseola infantum or Sixth disease
[Less commonly caused by HHV-7]
Disease caused by the virus in HIV
- CMV
- EBV
- Infectious Mononucleosis like synd., CMV retinitis
- Reactivation of Lymphoma
Resistant Eczema Rx. ??
Ciclosporin, Azathioprine & Mycophenolate mofetil
