Dermatology 2 Flashcards
What is your spot diagnosis?
Lichen planus
How does lichen planus present?
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
How may lichen planus be managed?
potent topical steroids are the mainstay of treatment
benzydamine mouthwash or spray is recommended for oral lichen planus
What is your spot diagnosis?
Lichen sclerosus
What is lichen sclerosus? How may it present?
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
How should lichen sclerosus be managed?
Management
topical steroids and emollients
Follow-up: increased risk of vulval cancer
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?
smooth, mobile, painless lump
may be observed
if diagnosis uncertain, or compressing on surrounding structures then may be removed
Malignant transformation of lipoma to liposarcoma is very rare.
What might be the signs that this was happening?
Size >5cm
Increasing size
Pain
Deep anatomical location
What is your spot diagnosis?
Livedo Reticularis
What is Livedo Reticularis?
What may cause this?
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
What is your spot diagnosis?
Malignant melanoma
What are the main risk factors for developing melanoma?
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
What are the 4 main subtypes of malignant melanoma?
In order of most to least common:
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Which is the most aggressive form of melanoma?
Nodular melanoma
Where does superficial spreading melanoma typically affect?
How does it present?
Arms, legs, back and chest
found in young people
presents as a growing mole
Where does nodular melanoma typically affect?
How does it present?
Sun exposed skin, middle-aged people
Red or black lump or lump which bleeds or oozes
What are the major and minor criteria for referral for suspected malignant melanoma?
The main diagnostic features (major criteria):
Change in size, shape or colour
Secondary features (minor criteria)
Diameter >= 7mm
Inflammation
Oozing or bleeding
Altered sensation
What is the single most important factor in determining prognosis of patients with malignant melanoma?
The invasion depth of a tumour (Breslow depth)
How may suspected malignant melanoma be investigated?
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
Outline melanoma stages 1-4
How should stage 0-2 melanoma be managed?
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
How should stage 3 melanoma be managed?
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
How should patients with melanoma be followed up?
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
What are milia?
small, benign, keratin-filled cysts that typically appear around the face
more common in newborns
What is your spot diagnosis?
Molloscum contagiosum
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
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
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
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
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
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
How can you remember the main difference between pemphigus and pemphigoid?
PemphiguS = Superficial (easily ruptures)
PemphioD = Deep (therefore tense)
What is your spot diagnosis?
pemphigus vulgaris
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
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
What is your spot diagnosis?
Pityriasis rosea
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
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
How can pityriasis rosea be managed?
self-limiting - usually disappears after 6-12 weeks
What is your spot diagnosis?
Pityriasis versicolor, also called tinea versicolor
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
What factors predispose to developing Pityriasis versicolor?
occurs in healthy individuals
immunosuppression
malnutrition
Cushing’s
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
What is your spot diagnosis?
Polymorphic eruption of pregnancy
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
What is your spot diagnosis?
Pompholyx (dyshidrotic eczema)
a type of eczema which affects both the hands and the feet
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
What is your spot diagnosis?
Port wine stain birthmark
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
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
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
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
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
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
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
What may exacerbate psoriasis?
trauma
alcohol
drugs- lithium, beta blockers
withdrawal of systemic steroids
Streptococcal infection may trigger guttate psoriasis
Which drugs can exacerbate psoriasis?
BLANQ = white in french; white plaques of psoriasis
Beta blockers
Lithium
Alcohol
NSAIDs
Quines e.g. chloroquine
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
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
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
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
What is your spot diagnosis?
purpura
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
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)
What is your spot diagnosis?
Pyoderma gangrenosum
uncommon cause of very painful skin ulceration
What may cause pyoderma gangrenosum?
idiopathic in 50%
inflammatory bowel disease in 10-15%
primary biliary cirrhosis
RA, SLE
haematological
granulomatosis with polyangiitis
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)
What is your spot diagnosis?
Pyogenic granuloma - relatively common benign skin lesion
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
What is your spot diagnosis?
Rosacea
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
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
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
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
What is your spot diagnosis?
Seborrhoeic dermatitis
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
What conditions are associated with seborrheic dermatitis?
HIV
Parkinson’s disease
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
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
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
What is your spot diagnosis?
shingles
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)
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
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
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
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
What skin conditions specifically affect women during pregnancy?
Atopic eruption of pregnancy
Polymorphic eruption of pregnancy
Pemphigoid gestationis
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
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
How may SLE manifest in the skin?
SLE makes you BALD
photosensitive ‘Butterfly’ rash
Alopecia
Livedo reticularis: net-like rash
Discoid lupus
What is your spot diagnosis?
butterfly rash - SLE
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
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
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
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
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
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
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
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
What is your spot diagnosis?
Urticaria - a local or generalised superficial swelling of the skin
The most common cause of urticaria is allergy
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
Give 2 large vessel vasculidities
temporal arteritis
Takayasu’s arteritis
Give 2 medium vessel vasculidities
polyarteritis nodosa
Kawasaki disease
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
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
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
What is your spot diagnosis?
Vitiligo: an autoimmune condition which results in the loss of melanocytes and consequent depigmentation of the skin
What conditions are associated with Vitiligo?
type 1 diabetes mellitus
Addison’s disease
autoimmune thyroid disorders
pernicious anaemia
alopecia areata
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)
How can Vitiligo be managed?
sunblock for affected areas of skin
camouflage make-up
topical corticosteroids may reverse the changes if applied early
