Dermatology

Question 1

What are effective treatments for head lice?

Answer 1

Permethrin, malathion,and phenothorin (insecticides). Rub into head and allow to dry naturally, leave overnight and then wash off. Repeat again and then wash off 7 days later to catch live eggs that were missed by the initial Rx.Wet combing (cheap, no exposure to chemicals) - should be used at least three times a week until no eggs found, but extend this is eggs found.Non-insectacide based shampoos are also available. Including dimerticone or isopropyl myristat (apply for ten mins twice, seven days apart).Skin irritation and exacerbation of asthma are not uncommon.Treat only if you find live lice - but not that combing through for lice is more effective than finding live in other ways.Tea tree oil has only anecdotal evidence

Question 2

What is the treatment for public lice?

Answer 2

Expererts recommend aqueous malathion 0.5% or permethrin 5% dermal cream. However, very little evidence base for any treatment.

Question 3

How do you apply public lice treatment?

Answer 3

DO NOT FOLLOW INSTRUCTIONS ON PACKET!! apply to the entire body, not jus the hairy bits, and allow to dry naturally. APPLY TO THE HAIR AND NECK AND FACE, EVEN THUOGH THE PACKET SAYS NOT TO. Wash off after 8-10 hours; if any area is washed off before this, reapply. The repeat in seven days.

Question 4

How would you define tinea barbae? what is the differential?

Answer 4

Fungal infection of the beard area leading to pustules and inflammatoation.Differentials - effects of shaving, folliculitis, staph arueus infection, impetigo.

Question 5

Treatment for tinea barbae?

Answer 5

Terbinifine 250mg daily for 4 weeks.Itroconzaole daily for 2 weeks.

Question 6

What is tine incognito?

Answer 6

Spreading erythema that has lost its raised palpable edge and looks more indistinct.

Question 7

How is tinea incognito treated?

Answer 7

Stop topical steroids, and treat with topical terbinifine once a week for six weeks.

Question 8

What is the treatment for scabies?

Answer 8

5% perpmethrin applied over whole body including head neck and face (contrary to what it says on the packet), wash off after 8-12/12, repeat after 7 days.Malathion is also another treatment.

Question 9

What is onychomycosis?

Answer 9

It is a fungal a nail infection - note that many nails look like they are fungal infected, but they are not fungal infected –> hence the role for sending cutting to the labs for confirmation.]Evidence is very poor for the treatment of this.Ketoconazole should NOT be used due to fears over hepatotoxicity.Nail lacquers - evidence is poor, but they are applied daily for ages (like 9 monte) and they are not as affective as organ agent.

Question 10

What is one way of treating viral warts?

Answer 10

Duct tape, salicylic acid, and cryotherapy are effective effective.Duct tape is cheap, easy, and does not involve chemicals - also low cost and patient can do easily at home - sou could be tried first.

Question 11

What is imiquimod?

Answer 11

It is an immune response modulation - induces interferon alpha and other cytokines, It is increasingly popular as a treatment for early skin malignancies. (Only licensed for use for BCC’s.

Question 12

What is hyperhydrosis?

Answer 12

This is a condition described as focal sweating in excess of what is required for thermoregulation?

Question 13

How is hyperhydrrosis managed?

Answer 13

First step is to assess and invest age and advice on lifestyle. E.g., weak loose firing clothes made from natural fibres, use an antiperspirant deodorant. Avoid spicy food and alcohol. After this, try topical aluminium chloride, refer to deem if still problematic.

Question 14

what are the two types of allopecia, and which is most common?

Answer 14

-Alopecia areata: autoimmune, non-scarring disorder of hair growth often with a genetic link. Includes alopecia totarlis (full head hair loss, rare) and allopicia universalis (loos of all body hair, very rare); more often just a circular bald patch.-Androgenic allopecia - treated with topical minoxidil (5% in men, 2% in women, 2% hair loss)

Question 15

What are the grades of actinic keratosis?How is it prevented?

Answer 15

1- Slightly palpable, slightly colour change; may just feel crusty.2- Moderately thickened, visible to the naked eye3-Very thick and hyperkaratotic Prevented by reducing sun exposure and wearing sun cream

Question 16

What famous people suffer from rosacea? (Might help to mention them to patients if they are sad they have big red noses).

Answer 16

Bill Clinton
Cameron Diaz
Renee Zellweger

Question 17

Any other treatments for rosacea patients?

Answer 17

Camouflage make up can help reduce patient’s embarrassment.
The charity “changing faces” provides this free via GP referral.
Rosacea can trigger depression and social isolation. Think about this, and consider if counselling or an SSRI is appropriate.

Question 18

When should patient’s with rosacea be followed up? What then?

Answer 18

Follow up at 3-6 months.
If no improvement –> refer to specialist.
If improvement, but there is psychological distress –> consider ref feral to a specialist.
If patients are responding well to Rx, continue therapy for 3-6/12, then either step down the dose or consider a drug holiday.

Question 19

What is the prevalence of psoriasis in Western Europe? When are most patient’s diagnosed?

Answer 19

Prevalence of 1.5%.

Most patients are diagnosed before 30, but there is a second spike around 50-60.

Question 20

Is there a genetic component to psoriasis?

Answer 20

At the moment this seems to be the case, with the CARD14 gene being implicated in both plaque and pustular forms.

Question 21

With what condition is psoriasis linked?

Answer 21

There seems to be a link between psoriasis and CVD. Q-risk should be carried out at initial diagnosis and every 5 years.
There is also a link with VTE and with other autoimmune diseases, like Crohn’s.

Question 22

On a histological level, what is psoriasis characterised by? (4 things)

Answer 22

1) Epidermal hyperplasia.
2) Dilated prominent blood vessels within the dermis.
3) An inflammatory infiltrate consisting of leukocytes and other cells.
4) There is an increased turnover of keratocytes with immature cells appearing on the upper layers - this led to the belief that psoriasis was primarily a disorder of keratinocyte hyperplasia.

Question 23

What is the current belief surrounding the aetiology of psoriasis?

Answer 23

An immune process mediated by CD4 and CD8 cells as well as dendritic cells is thought to be at work, accounting for much of the inflammatory infiltrate seen in affected tissue. The response of patients to agents such as methotrexate and ciclosporin supports this view.

Question 24

What are the 6 sub-types of psoriasis?

Answer 24

1) Plaque.
2) Guttate.
3) Palmoplantar pustulosis.
4) Generalised pustular psoriasis.
5) Erythrodermic psoriasis.
6) Psoriatic arthropathy.

Question 25

What is psoriasis vulgarise also known as? How common is it? What are the appearances of the psoriasis here? Where is typically affected?

Answer 25

AKA plaque psoriasis!
Accounts for 90% of people with psoriasis.
The plaques are well demarcated with a silvery scale, and often red (or salmon-pink) in appearance, Common sites are the extensor surfaces of the elbows and knees, as well as the lower back. Scalp, flexures, and palms are also frequently involved.
Nails show pitting and sometimes nail separation. Patients with nail changes are more likely to have joint disease.

Question 26

What does guttate mean? What does guttate psoriasis tend to follow? Where is affected?

Answer 26

Means tear shaped. Appears 1-2 weeks after a strep throat infection. Antibiotics used to treat the strep throat often stop the guttate psoriasis. If they do not, topical therapy or phototherapy can be tried. Affected individuals are at greater risk of developing other forms of psoriasis later in life.

Question 27

How will patients with palmoplantar pustulosis psoriasis present?

Answer 27

It’s relatively rare.
Affects hands and soles of feet.
Crops of spots filled with creamy or yellow coloured pus appear - but these are sterile. The hands and feet can become very sore.
Of note, 80% of people who develop PPP are smokers.
It is treated with coal tar or topical steroids, but can be very stubborn. If resistant to Rx, may need referral for psoralen and UVA (PUVA).

Question 28

How should generalised pustular psoriasis be treated? What are the differentials?

Answer 28

Immediate admission. There is often a rapid onset widespread rash affecting any area of the body, consisting of small pustules on a red base, and accompanied by a fever. Admission is required for fluid balance monitoring and possibly other Rx.
The differentials include drug reactions and skin infections.

Question 29

How should erythrodermic psoriasis be managed?

Answer 29

Admission. Need to control fluid balance and hyper/hypothermia.

Question 30

What can be said about psoriatic arthropathy? What percentage of psoriasis patients have it? What are the different presentations (name 4)?

Answer 30

Up to 7% of psoriasis sufferers have psoriatic arthropathies. Sometimes the joint problem is the first presentation of the illness. There are several different presentations:

1) Arthritis mutilans - thankfully rare - there is erosive finger joint destruction.
2) Asymmetrical oligoarthritis affects mostly hands and feet.
3) Symmetrical polyarthritis can resemble RA.
4) DIP joint arthritis.

Question 31

If someone with psoriasis has arthritis, will they have raised rheumatoid factor?

Answer 31

No, because it is a seronegative arthritis. CRP and ESR can both be raised though.

Question 32

What blood tests might be useful in someone with psoriasis who develops arthritis? (4)

Answer 32

RF
Autoimmune profile
CRP and ESR
Serum urate

Question 33

What are the differentials for arthropathy associated with psoriasis, which should hence be ruled out? (3)

Answer 33

SLE
Gout
Polymyalgia rhumatica

Question 34

Should patients with psoriasis be screened for anything else? How?

Answer 34

Depression. NICE recommend asking:
-During the last month have you been bothered by feeling down, depressed, or hopeless?
-During the last month have you often been bothered by little interest or pleasure in doing things?
If either answer is +ive, then do a PHQ9

Question 35

Topicall therapy is often used as first line in which forms of psoriasis? What topical therapies?

Answer 35

Plaque psoriasis, guttate psoriasis, and palmoplantar pustulosis. The Rx used depends on the site of the lesion.
Emollients - help with dryness and scale, but are unlikely to lead to resolution by themselves.
Trunks and limbs - these should be treated with a once-daily regime of a potent corticosteroid (e.g., clobetesol propionate) in combination with a vitamin D analogue (e.g., calcipotriol or calcitrol). This should be continued for 4 weeks. If no change, the vitamin component should be changed to BD. If a further 8 weeks shows no improvement, then the steroid can be upped to BD also; alternatively, a coal tar preparation can be added.

Question 36

What is an example of a combined steroid and vitamin D preparation that can be used once a day?

Answer 36

Dovobet.

Question 37

When treating psoriatic lesions on the face, what changes should be made to how other sites would be treated?

Answer 37

The face, flexures, and genitals are obviously more delicate. They should be treated with only two weeks (i.e. not 4 weeks) of moderate (e.g., clobetasone butyrate) or weak (e.g., hydrocortisone) steroids, with onward referral if the results are poor. So NOT potent topical steroids such as clobetasol propionate.

Question 38

How should scalp psoriasis be treated?

Answer 38

Potent topical corticosteroids should be tried initially. If no response after 4 weeks, a change of formulation could be considered (e.g., to a shampoo). An agent can also be used to break up any scale, e.g., salicylic acid preparations. If after a further four weeks there is no response, then add vitamin D/vitamin D analogues. These agents should be tried for 8 weeks. If response is poor, there are further options - coal tar, a change to a very potent corticosteroid, or dithranol.
Dithranol used to be widely used, but has fallen out of favour in recent years.
Onward referral to dermatology is the next option.

Question 39

When should a patient with psoriasis be referred to a dermatologist? (9!)

Answer 39

1) If there is suspected generalised pustular psoriasis or erythroderma, urgent same day specialist assessment should be sought.
2) If the patient is a child or young person, refer at presentation.
3) If the diagnosis is uncertain, refer.
4) If there is severe or extensive psoriasis (>10% body surface area affected)
5) If the psoriasis cannot be controlled by topical therapy.
6) If the patient has acute guttate psoriasis and needs phototherapy.
7) If there is nail bed disease with major functional or cosmetic impact.
8) If the psoriasis is having a major effect on the patient’s social, psychological, or physical health.
9) If there is any suspicion of psoriatic arthritis, the person should be referred to a rheumatologist for specialist assessment and to plan ongoing care.

Question 40

When is systemic treatment for psoriasis indicated? (Carried out in secondary care, 4).
How do these systemic agents act and what do they require?

Answer 40

1) Not responding to topical therapy.
2) Extensive disease affecting >10% of the body surface.
3) Significant psychological or social impact.
4) Poor response to UV light therapy.
Systemic agents are initiated in secondary care, act on the immune system, and require close monitoring (often might involve the GP in this role!)

Question 41

What are the big boy options in secondary care for psoriasis treatment? (4)

Answer 41

1) UV therapy
2) Methotrexate
3) Cyclosporin
4) Biological agents (e.g., TNF-alpha)

Question 42

How is ciclosporin used for psoriasis treatment? What side effects? How long used for?

Answer 42

Only under specialist initiation. It is useful for when rapid control of symptoms is needed.
Side effects include nephrotoxicity and hypertension.
It tends to be used for short bursts, maybe a few months, before switching to another agent.

Question 43

Methotrexate is one of the big guns sometimes used in psoriasis - how often would it be given? Should it be initiated in primary care?
What bloods need to be monitored and why?

Answer 43

It should never be initiated in primary care, but it can be monitored in primary care - regular blood tests, looking at FBC and LFT’s.
It carries the risk of hepatic fibrosis and cirrhosis. Also the risk of immune suppression.

Question 44

What types of psoriasis might PUVA be used for? What specific predisposition within a patient would preclude the use of PUVA?

Answer 44

Guttate or plaque psoriasis, or sometimes palmoplantar pustulosis.
A strong predisposition to skin cancer is a contraindication.

Question 45

What is a myxoid cyst?

Answer 45

A mucus or myxoid cyst arises from degeneration in the connective tissue on top of the last segment of the finger.
The cyst has a smooth, shiny surface, and often causes a groove in the nail a few mm in width, which extends the length of the nail. Cyst size may vary, and jelly-like substances may be expressed from it.
They are benign ganglion cysts of the digits, and are usually asymptomatic, unless knocked (when they might be very painful).
They are often associated with OA of the DIP joint, i.e., near to the nail.

Question 46

How do you treat a myxoid cyst? (AKA mucus cysts, benign ganglion cysts of the digits.

Answer 46

Most require no Ix or Rx.
An XR will demonstrate underlying OA of the DIP joint.
However, there are treatments that can be performed if the patient wishes/is adamant: puncture, aspiration, drainage; unroofing with electrodessection; injection therapy with steroids or sclerosing alcohol; curettage and compression, multiple needling and drainage; simple surgical excision.
However, recurrence rates are high.

Question 47

Rosacea exacerbation can be triggered by what? (8!)

Answer 47

1) Alcohol
2) Sunlight, cold or harsh wind.
3) Stress.
4) Perfumed or scented creams, some moisturisers.
5) Drugs (calcium channel blockers, opioids, nitrates,, topical steroids).
6) Strenuous exercise.
7) Hot and/or spicy food or drink.
8) Hot or humid weather.

Question 48

People of what skin type typically suffer with rosacea?

Answer 48

Caucasians with blue eyes and Celtic origin.

Question 49

What areas does rosacea affect?

Answer 49

Facial skin can be involved entirely!
The soft tissues of the nose may swell - this is called rhinophyma.
The eyes can also be affected, causing the sensation of a foreign body.

Question 50

Is rosacea more common in men or women?

Answer 50

It is more common in women, but rhinophyma (swelling of the soft tissues f the nose) is more common in men.

Question 51

What is the cause of rosacea?

Answer 51

No one knows!

Question 52

What age group usually suffers from the manifestation of rosacea?

Answer 52

30-40yr olds.

Question 53

What are the features of rosacea? (6)

Answer 53

1) Facial flushing.
2) Erythema.
3) Pustules.
4) Papules.
5) Telangectasia.
6)Swelling of the soft tissues of the nose (rhinophyma)
Note that these symptoms do not necessarily all occur - there can be any combination of them!

Question 54

What are some differentials for rosacea, and what might mark them out?

Answer 54

1) Acne vulgaris - patients have comedomes, and the condition improves with sunlight, unlike rosacea (where sunlight makes it worse).
2) Perioral dermatitis - in this case there are pustules around the mouth and chin, with premenstrual exacerbation.
3) Lupus erythematous - patients have erythema, light sensitivity, scarring, but NO pustules.
4) Seborrhoeic dermatitis - scalp dandruff and facial eczema with no pustules.

Question 55

What are the diagnostic histopathological features of rosacea?

Answer 55

There are none!

Question 56

Name the different clinical subtypes of rosacea?

Answer 56

1) Erythmatelangiectatic.
2) Papulopustular.
3) Phymatous.
4) Ocular.

Question 57

What is the clinical pattern of erythmatelangiectatic rosacea

Answer 57

Facial erythema, with flushing, often with little provocation. They also often have skin sensitivity and have telangectasia. With this subtype, patients can also have ocular rosacea and rhinophyma.

Question 58

What is the clinical manifestation of the pustularpapular rosacea subtype?

Answer 58

Persistent facial erythema with erythmatous papules and small pustules similar to acne vulgaris. The lesions are typically monomorphic and occur on the cheek. Again, this subtype can involve the eyes and nose.

Question 59

What is the presentation of phymatous rosacea?

Answer 59

In the phymatous subtype, there is thickening of the skin of the nose, ears, forehead, chin, and eyelids. There may be nodules. When it affects the nose, it is known as rhinopyma or “whisky nose”. It may occur alone, or in combination with erythmatelangectatic or papulopustular subtypes.

Question 60

What are the clinical features of the ocular subtype of rosacea? How common is it?

Answer 60

This affects up to 50% of rosacea patients. They have gritty eye symptoms. There is erythema and telangectasia of the eyelid margin. Patients may get recurrent chalazia or hordeola, which can be painful. Conjunctivitis and keratitis occurs more frequently.

Question 61

How does keratitis present? What form of skin condition may this be present in?

Answer 61

Keratitis presents with a red, painful eye with blurred vision. It can occur in ocular rosacea.

Question 62

What is steroid rosacea?

Answer 62

Caused by the side effects of prolonged steroid use –> telangectasia with papules and pustules.
The steroids should of course be stopped!!

Question 63

How might there be social or psychological aspects to rosacea?

Answer 63

Social phobias, anxiety, and depression can develop. It is often worth screening for these conditions, or asking about them directly.

Question 64

What non-medical management strategies are there for rosacea?

Answer 64

1) There is no cure to this chronic condition, and patients should be told this.
2) Avoidance of triggers can be helpful e.g., using sunblock, avoiding spicy food.
3) Ensure no medications are being taken which might make the condition worse, especially topical steroids.

Question 65

What topical treatments can be offered for rosacea? What form of the disease are they most useful for?

Answer 65

Topical treatments are most effective for patients with papules and pustules; they are less effective for people with erythema and telangectasia.
Topical metronidazole 0.75% cream or gel can be applied once or twice a day for 8-12 weeks. (NOTE: should not be used in pregnancy.
Adalaide acid can also be used and it has the advantage of being usable in pregnancy, but can lead to skin dryness and increased sensitivity.
Less commonly, topical erythromycin and clarithromycin can be used; they have the same anti-inflammatory and anti-bacterial action as topical metronidazole, but can be used in pregnancy.

Question 66

What are the oral Rx for rosacea?
What warning should be given?
How long a course?
What about for a pregnant women?

Answer 66

A course of tetracycline, oxytetracycline, or doxycycline. They are thought to work by anti-inflammatory rather than anti-bacterial action.
Doxycycline can cause photosensitivity - warn patients of this!
Tetracyclines can deposit in growing teeth and bones - hence do not give to children, pregnant or breastfeeding women. An alternative might be erythromycin.
A long course is required - around 3 to 6 months.

Question 67

How much will antibiotics improve the symptoms of rosacea?

Answer 67

Will significantly improve symptoms in 1/3 of patients. A second course will significantly improve another third. The remainder will need a longer course, though it is UNLICENSED.
Clonidine is NOT recommended.

Question 68

How should ocular rosacea be treated? (2)

Answer 68

1) Advice on eyelid hygiene.
2) Hot compress and eyelid massage.
3) Involve an ophthalmologist early if there is diagnostic doubt or suspected keratitis.

Question 69

How can patients with the rhniophyma form of rosacea be treated? (6)

Answer 69

1) Advice about keeping the nose very clean.
2) Antibiotics being used at first sign of an infection.
3) Although topical steroids SHOULD NOT be used in general in rosacea, in rhynophyma they may sometimes be used cautiously to prevent scar formation.
4) Severe cases may require skin grafting or surgical intervention (rare)
5) There is generally a good response to electrosurgery.
6) Other options include cryotherapy and argon/carbon dioxide lasers. (They work by destroying the excess sebaceous soft tissue).