Dermatology 2 Flashcards

1
Q

What is your spot diagnosis?

A

Lichen planus

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2
Q

How does lichen planus present?

A

itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms

rash often polygonal in shape, with a ‘white-lines’ pattern on the surface (Wickham’s striae)

Koebner phenomenon may be seen

oral involvement in around 50% of patients: typically a white-lace pattern on the buccal mucosa

nails: thinning of nail plate, longitudinal ridging

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3
Q

How may lichen planus be managed?

A

potent topical steroids are the mainstay of treatment

benzydamine mouthwash or spray is recommended for oral lichen planus

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4
Q

What is your spot diagnosis?

A

Lichen sclerosus

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5
Q

What is lichen sclerosus? How may it present?

A

an inflammatory condition that usually affects the genitalia and is more common in elderly females

Features
white patches that may scar
itch is prominent
may result in pain during intercourse or urination

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6
Q

How should lichen sclerosus be managed?

A

Management
topical steroids and emollients

Follow-up: increased risk of vulval cancer

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7
Q

A lipoma is a common, benign tumour of adipocytes that is generally found in subcutaneous tissue.

What are its key features?
How should it be managed?

A

smooth, mobile, painless lump

may be observed
if diagnosis uncertain, or compressing on surrounding structures then may be removed

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8
Q

Malignant transformation of lipoma to liposarcoma is very rare.

What might be the signs that this was happening?

A

Size >5cm
Increasing size
Pain
Deep anatomical location

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9
Q

What is your spot diagnosis?

A

Livedo Reticularis

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10
Q

What is Livedo Reticularis?
What may cause this?

A

a purplish, non-blanching, reticulated rash caused by obstruction of the capillaries resulting in swollen venules

Causes:
idiopathic (most common)
SLE
antiphospholipid syndrome
Ehlers-Danlos Syndrome

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11
Q

What is your spot diagnosis?

A

Malignant melanoma

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12
Q

What are the main risk factors for developing melanoma?

A

Increasing age
Family history
High UV exposure- living close to the equator, outdoor occupation, use of sunbeds
Fitzpatrick Scale 1-2 skin type
High number of moles
Giant congenital melanocytic naevus
IBD

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13
Q

What are the 4 main subtypes of malignant melanoma?

A

In order of most to least common:
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous

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14
Q

Which is the most aggressive form of melanoma?

A

Nodular melanoma

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15
Q

Where does superficial spreading melanoma typically affect?
How does it present?

A

Arms, legs, back and chest
found in young people

presents as a growing mole

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16
Q

Where does nodular melanoma typically affect?
How does it present?

A

Sun exposed skin, middle-aged people

Red or black lump or lump which bleeds or oozes

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17
Q

What are the major and minor criteria for referral for suspected malignant melanoma?

A

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

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

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18
Q

What is the single most important factor in determining prognosis of patients with malignant melanoma?

A

The invasion depth of a tumour (Breslow depth)

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19
Q

How may suspected malignant melanoma be investigated?

A

2ww referral
dermoscopy to visualise
excision biopsy
can do genetic testing
vitamin D levels measured in all patients

staging:
sentinel lymph node biopsy
staging CT
PET-CT

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20
Q

Outline melanoma stages 1-4

A
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21
Q

How should stage 0-2 melanoma be managed?

A

Surgical excision with margin of at least
0.5cm in stage 0 melanoma
1cm in stage I melanoma
2cm in stage II melanoma

Consider sentinel lymph node biopsy for staging if Breslow thickness >0.8mm or <0.8mm with ulceration

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22
Q

How should stage 3 melanoma be managed?

A

Consider completion lymphadenectomy if SLN +ve

Other options include lymph node dissection

Adjuvant targeted therapy (if BRAF mutation present) or immunotherapy can now be offered for patients with fully resected or unresectable stage III melanoma

Offer CT staging

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23
Q

How should patients with melanoma be followed up?

A

Patient education for all
Self-examination, sun protection, avoiding vitamin D depletion

Discharge if stage 0

Follow-up for up to 5 years (every 3 months initially), depending on stage

Personalised follow-up for Stage IV

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24
Q

What are milia?

A

small, benign, keratin-filled cysts that typically appear around the face
more common in newborns

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25
What is your spot diagnosis?
Molloscum contagiosum
26
What is Molloscum contagiosum? How is it transmitted? Who is it more common in?
skin infection caused by molluscum contagiosum virus, a member of the Poxviridae family transmission is by close personal contact, or shared towels and flannels often in children with atopic eczema, with the maximum incidence in preschool children aged 1-4
27
What self care advice can you give to patients with molloscum?
Reassure people that molluscum contagiosum is self-limiting and spontaneous resolution usually occurs within 18 months Explain that lesions are contagious, and it is sensible to avoid sharing towels, clothing, and baths with uninfected people (e.g. siblings) Encourage people not to scratch the lesions Exclusion from school, gym, or swimming is not necessary
28
What treatment is given for molloscum contagiosum?
supportive care treatment is not usually indicated 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
29
What is your spot diagnosis?
Mycosis fungoides rare form of T-cell lymphoma that affects the skin lesions tend to be different colours in contrast to eczema/psoriasis where there is greater homogenicity
30
Nickel dermatitis is caused by what type of hypersensitivity reaction? How can it be diagnosed?
type IV hypersensitivity reaction often caused by jewellery such as watches It is diagnosed by a skin patch test
31
Pellagra is a caused by nicotinic acid (niacin) deficiency. What features does it present with?
dermatitis (brown scaly rash on sun-exposed sites - termed Casal's necklace if around neck) diarrhoea dementia, depression death if not treated
32
How can you remember the main difference between pemphigus and pemphigoid?
PemphiguS = Superficial (easily ruptures) PemphioD = Deep (therefore tense)
33
What is your spot diagnosis?
pemphigus vulgaris
34
What is Pemphigus vulgaris? How can it be managed?
autoimmune skin condition mucosal ulceration is usually the presenting sx Management: steroids are first-line immunosuppressants
35
Periorificial dermatitis is a condition typically seen in women aged 20-45 years old. How should it be managed?
steroids may worsen symptoms should be treated with topical or oral antibiotics
36
What is your spot diagnosis?
Pityriasis rosea
37
What is pityriasis rosea?
acute, self-limiting rash which tends to affect young adults thought that herpes hominis virus 7 (HHV-7) may play a role
38
What features does pityriasis rosea present with?
in the majority of patients there is no prodrome, but a minority may give a history of a recent viral infection herald patch (usually on trunk), followed by erythematous, scaly, oval patches patches follow a characteristic distribution with the longitudinal diameters of lesions running parallel to the line of Langer. This may produce a 'fir-tree' appearance
39
How can pityriasis rosea be managed?
self-limiting - usually disappears after 6-12 weeks
40
What is your spot diagnosis?
Pityriasis versicolor, also called tinea versicolor
41
What is Pityriasis versicolor?
superficial cutaneous fungal infection caused by Malassezia furfur hypopigmented, pink or brown patches, largely affecting the trunk scale is common mild pruritus
42
What factors predispose to developing Pityriasis versicolor?
occurs in healthy individuals immunosuppression malnutrition Cushing's
43
How can Pityriasis versicolor be managed?
ketoconazole shampoo (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
44
What is your spot diagnosis?
Polymorphic eruption of pregnancy
45
How does Polymorphic eruption of pregnancy present? How should it be managed?
pruritic condition associated with the last trimester lesions often first appear in abdominal striae the periumbilical area is often spared management depends on severity: emollients, mild topical steroids and oral steroids may be used
46
What is your spot diagnosis?
Pompholyx (dyshidrotic eczema) a type of eczema which affects both the hands and the feet
47
Pompholyx eczema (pictured below) may be precipitated by humidity (e.g. sweating) and high temperatures. How can it be managed?
cool compresses emollients topical steroids
48
What is your spot diagnosis?
Port wine stain birthmark
49
What are port wine stains? How may port wine stain birthmarks be managed?
vascular birthmarks that tend to be unilateral 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 tx = cosmetic camouflage or laser therapy
50
What is your spot diagnosis?
Psoriasis - chronic autoimmune skin condition dry, scaly, faintly erythematous skin lesions that appear in raised and rough plaques, commonly over the extensor surfaces of the elbows and knees and on the scalp
51
What are the 4 main subtypes of psoriasis?
plaque psoriasis: most common sub-type resulting in the typical well-demarcated red, scaly patches affecting the extensor surfaces flexural psoriasis: in contrast to plaque psoriasis the skin is smooth guttate psoriasis: transient psoriatic rash frequently triggered by a streptococcal infection, red teardrop lesions appear on the body pustular psoriasis: commonly occurs on the palms and soles
52
What signs can you look for on examination of a patient with psoriasis?
Auspitz sign refers to small points of bleeding when plaques are scraped off Koebner phenomenon refers to the development of psoriatic lesions to areas of skin affected by trauma Residual pigmentation of the skin after the lesions resolve
53
What nail changes may be seen in psoriasis?
pitting onycholysis (separation of the nail from the nail bed) subungual hyperkeratosis loss of the nail around 80-90% of patients with psoriatic arthropathy have nail changes
54
What are the potential complications of psoriasis?
psoriatic arthropathy (around 10%) increased incidence of metabolic syndrome increased incidence of cardiovascular disease increased incidence of VTE psychological distress
55
What is the incidence of psoriatic arthropathy?
occurs in 10 – 20% of patients with psoriasis usually occurs within 10 years of developing the skin changes typically affects people in middle age
56
What may exacerbate psoriasis?
trauma alcohol drugs- lithium, beta blockers withdrawal of systemic steroids Streptococcal infection may trigger guttate psoriasis
57
Which drugs can exacerbate psoriasis?
BLANQ = white in french; white plaques of psoriasis Beta blockers Lithium Alcohol NSAIDs Quines e.g. chloroquine
58
What is the first line mx of patients with chronic plaque psoriasis?
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
59
What is the second line and third line mx of patients with chronic plaque psoriasis?
second line: if no improvement with first line tx after 8 weeks then offer a vitamin D analogue twice daily third line options: coal tar preparation short-acting dithranol
60
What are the management options for psoriasis in secondary care?
phototherapy: narrowband ultraviolet B light 3 times a week OR psoralen + ultraviolet A light (PUVA) risk of SCC systemic therapy: oral methotrexate ciclosporin
61
What vitamin D analogues can be used to treat psoriasis? How do they work? What are the advantages and disadvantages of their use?
calcipotriol (Dovonex), calcitriol and tacalcitol they work by ↓ cell division and differentiation → ↓ epidermal proliferation adverse effects are uncommon unlike steroids they may be used long-term unlike coal tar and dithranol they do not smell or stain they should be avoided in pregnancy
62
What is your spot diagnosis?
purpura
63
What are purpura?
bleeding into the skin from small blood vessels that produces a non-blanching rash typically caused by low platelets but may also be seen with bleeding disorders, such as von Willebrand disease
64
What may cause purpura in adults?
Immune thrombocytopenic purpura Senile purpura Bone marrow failure (secondary to leukaemias, myelodysplasia or bone metastases) Drugs (quinine, antiepileptics, antithrombotics) Nutritional deficiencies (vitamins B12, C and folate)
65
What is your spot diagnosis?
Pyoderma gangrenosum uncommon cause of very painful skin ulceration
66
What may cause pyoderma gangrenosum?
idiopathic in 50% inflammatory bowel disease in 10-15% primary biliary cirrhosis RA, SLE haematological granulomatosis with polyangiitis
67
How can pyoderma gangrenosum be investigated and managed?
diagnosis often made by the characteristic appearance histology may be helpful in ruling out other causes of an ulcer Management: oral steroids as first-line treatment surgery should be postponed until the disease process is controlled on immunosuppression to risk worsening of the disease (pathergy)
68
What is your spot diagnosis?
Pyogenic granuloma - relatively common benign skin lesion
69
What may cause a pyogenic granuloma to develop? How may this be managed?
Causes: trauma pregnancy more common in women and young adults Management: lesions associated with pregnancy often resolve spontaneously post-partum other lesions usually persist - curettage and cauterisation, cryotherapy, excision
70
What is your spot diagnosis?
Rosacea
71
What are the key presenting features of rosacea?
typically affects nose, cheeks and forehead flushing is often first, telangiectasia are common later develops into persistent erythema with papules and pustules rhinophyma ocular involvement: blepharitis sunlight may exacerbate symptoms
72
How can rosacea be managed?
recommend daily application of a high-factor sunscreen, camouflage creams predominant erythema/flushing topical brimonidine gel mild-to-moderate papules and/or pustules topical ivermectin moderate-to-severe papules and/or pustules CKS combination of topical ivermectin + oral doxycycline
73
How does brimonidine work for treatment of rosacea?
brimonidine is a topical alpha-adrenergic agonist this can be used on an 'as required basis' to temporarily reduce redness it typically reduces redness within 30 minutes, reaching peak action at 3-6 hours, after which the redness returns to the baseline
74
When should referral be considered for patients with rosacea?
symptoms have not improved with optimal management in primary care laser therapy may be appropriate for patients with prominent telangiectasia patients with a rhinophyma
75
What is your spot diagnosis?
Seborrhoeic dermatitis
76
What is Seborrhoeic dermatitis? What are its key presenting features?
a chronic dermatitis thought to be caused by an inflammatory reaction to a fungus called Malassezia furfur eczematous lesions on the sebum-rich areas: scalp (may cause dandruff), periorbital, auricular and nasolabial folds otitis externa and blepharitis may develop
77
What conditions are associated with seborrheic dermatitis?
HIV Parkinson's disease
78
How can seborrheic dermatitis be managed?
scalp disease: the first-line treatment is ketoconazole 2% shampoo face and body: topical antifungals: e.g. ketoconazole topical steroids: best used for short periods difficult to treat - recurrences are common
79
What is your spot diagnosis? What are the key features of these lesions?
Seborrhoeic keratoses benign epidermal skin lesions seen in older people large variation in colour from flesh to light-brown to black have a 'stuck-on' appearance keratotic plugs may be seen on the surface
80
What would be your key ddx for lesions on the shins?
erythema nodosum - seen in sarcoidosis and IBD pretibial myxoedema - seen in Graves disease pyoderma gangrenosum - seen in IBD necrobiosis lipoidica diabeticorum
81
What is your spot diagnosis?
shingles
82
Shingles (herpes zoster infection) is an acute, unilateral, painful blistering rash caused by reactivation of the varicella-zoster virus (VZV). What are the risk factors for developing it?
increasing age HIV: strong risk factor, 15 times more common other immunosuppressive conditions (e.g. steroids, chemotherapy)
83
How does shingles present?
The most commonly affected dermatomes are T1-L2 prodromal period: burning pain over the affected dermatome for 2-3 days rash: initially erythematous, macular rash over the affected dermatome quickly becomes vesicular
84
How may shingles be managed?
patients should be advised that they are infectious until the vesicles have crusted over, usually 5-7 days following onset covering lesions reduces the risk avoid pregnant women and the immunosuppressed analgesia: paracetamol and NSAIDs are first-line if not responding then use of neuropathic agents (e.g. amitriptyline) can be considered antivirals within 72 hours for the majority of patients: reduced incidence of post-herpetic neuralgia, particularly in older people
85
What are the potential complications of shingles?
post-herpetic neuralgia: most common complication more common in older patients usually resolves with 6 months but may last longer herpes zoster ophthalmicus (shingles affecting affecting the ocular division of the trigeminal nerve) herpes zoster oticus (Ramsay Hunt syndrome): may result in ear lesions and facial paralysis
86
What is your spot diagnosis? What are the key features?
Kaposi Sarcoma Tumour of vascular and lymphatic endothelium, presents as purple cutaneous nodules Associated with immunosupression and HIV Classical form affects elderly males and is slow growing
87
What skin conditions specifically affect women during pregnancy?
Atopic eruption of pregnancy Polymorphic eruption of pregnancy Pemphigoid gestationis
88
What is atopic eruption of pregnancy?
is the commonest skin disorder found in pregnancy it typically presents as an eczematous, itchy red rash. no specific treatment is needed
89
What is your spot diagnosis? How does it typically present? How should it be managed?
Pemphigoid gestationis pruritic blistering lesions often develop in peri-umbilical region, later spreading to the trunk, back, buttocks and arms usually presents 2nd or 3rd trimester and is rarely seen in the first pregnancy oral corticosteroids are usually required
90
How may SLE manifest in the skin?
SLE makes you BALD photosensitive 'Butterfly' rash Alopecia Livedo reticularis: net-like rash Discoid lupus
91
What is your spot diagnosis?
butterfly rash - SLE
92
What are spider naevi? How may they be differentiated from telangiectasia? What conditions may they be associated with?
a central red papule with surrounding capillaries, blanches under pressure, usually found on the upper body can be differentiated from telangiectasia by pressing on them and watching them fill - spider naevi fill from the centre, telangiectasia from the edge Associations: liver disease pregnancy combined oral contraceptive pill
93
Strawberry naevi (capillary haemangioma) are usually not present at birth but may develop rapidly in the first month of life. How do they present?
erythematous, raised and multilobed tumours common sites include the face, scalp and back increase in size until around 6-9 months before regressing over the next few years
94
What are the potential complications of strawberry naevi? How may they be treated?
mechanical e.g. Obstructing visual fields or airway bleeding ulceration thrombocytopaenia If treatment is required (e.g. Visual field obstruction): propranolol
95
What is your spot diagnosis? What is this caused by? How may it be investigated and managed?
Tinea capitis (scalp ringworm) most common cause is Trichophyton tonsurans in the UK Diagnosis: scalp scrapings Management: oral antifungals: terbinafine Topical ketoconazole shampoo should be given for the first two weeks to reduce transmission
96
What is your spot diagnosis? What is this caused by? How may it be managed?
Tinea corporis (ringworm) causes include Trichophyton rubrum and Trichophyton verrucosum (e.g. From contact with cattle) well-defined annular, erythematous lesions with pustules and papules may be treated with oral fluconazole
97
What is your spot diagnosis?
Toxic epidermal necrolysis (TEN) a potentially life-threatening skin disorder that is most commonly seen secondary to a drug reaction
98
How may TEN present? What drugs are known to induce it?
systemically unwell e.g. pyrexia, tachycardic positive Nikolsky's sign: the epidermis separates with mild lateral pressure Causes: phenytoin penicillins allopurinol NSAIDs
99
How can TEN be managed?
stop precipitating factor supportive care: often in an intensive care unit volume loss and electrolyte derangement are potential complications intravenous immunoglobulin
100
What is your spot diagnosis?
Urticaria - a local or generalised superficial swelling of the skin The most common cause of urticaria is allergy
101
How may urticaria present? How may it be managed?
pale pink raised skin : 'hives', 'wheals', 'nettle rash' pruritic non-sedating antihistamines (e.g. loratadine or cetirizine) are first-line (for up to 6 weeks) a sedating antihistamine (e.g. chlorphenamine) may be considered for night-time use prednisolone is used for severe or resistant episodes
102
Give 2 large vessel vasculidities
temporal arteritis Takayasu's arteritis
103
Give 2 medium vessel vasculidities
polyarteritis nodosa Kawasaki disease
104
List some small vessel vasculidities
ANCA-associated vasculitides: granulomatosis with polyangiitis (Wegener's granulomatosis) eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) microscopic polyangiitis immune complex small-vessel vasculitis: HSP Goodpasture's syndrome
105
Where do venous ulcers typically present? How should they be investigated?
typically seen above the medial malleolus Investigations: Ankle-brachial pressure index (ABPI) is important in non-healing ulcers to assess for poor arterial flow which could impair healing Values below 0.9 indicate arterial disease
106
How should venous ulcers be managed?
compression bandaging, usually four layer (only treatment shown to be of real benefit) oral pentoxifylline, a peripheral vasodilator, improves healing rate
107
What is your spot diagnosis?
Vitiligo: an autoimmune condition which results in the loss of melanocytes and consequent depigmentation of the skin
108
What conditions are associated with Vitiligo?
type 1 diabetes mellitus Addison's disease autoimmune thyroid disorders pernicious anaemia alopecia areata
109
What key features does vitiligo present with?
well-demarcated patches of depigmented skin the peripheries tend to be most affected trauma may precipitate new lesions (Koebner phenomenon)
110
How can Vitiligo be managed?
sunblock for affected areas of skin camouflage make-up topical corticosteroids may reverse the changes if applied early