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Dermatology Flashcards

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USMLE® Step 1 flashcards
1
Q

What is the epidemiology of malignant melanoma?

A

F>M 1.5L1. In the UK, 10,000 and 2,000 deaths per year. Up 80% in 20 years, and 75% of skin cancer deaths

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2
Q

What are the features of malignant melanoma?

A
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3
Q

What are the risk factors for malignant melanoma?

A
  • Sunlight - esp intense exposure in early years
  • Fair skinned (low fitzpatrick skin type)
  • Lots of common moles
  • Positive family history
  • Old age
  • Immunosuppression
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4
Q

How do you classify malignant melanoma?

A
  • Superficial spreading (80%)
    • Irregular borders, colour variation
    • Commonest in Caucasians
    • Grow slowly, metastasise late, better prognosis
  • Lentigo maligna melanoma
    • Often elderly
    • Face or scalp, longstanding lentigo maligna
  • Acral lengtiginous
    • Asians/blacks
    • Palms, soles, subungual (with Hutchinson’s sign)
  • Nodular melanoma
    • All sites; pigmented nodule
    • Younger age, new lesion
    • Invade deeply and metastasise early = poor prognosis
  • Amelanotic
    • Atypical appearance - delayed diagnosis
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5
Q

What determines the prognosis in malignant melanoma?

A

Breslow thickness: the thickness of the tumours to the deepest point of dermal invasion.

  • <1mm = 95-100% 5 year survival
  • >4mm = 50% 5 years
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6
Q

How do you stage malignant melanoma?

A

Clark’s Staging - stratifies depth by 5 anatomical levels, 1 being the epidermis and 5 being the subcutaneous fat

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7
Q

Where does malignant melanoma metastasise to?

A

Liver, eye

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8
Q

What is the management for malignant melanoma?

A
  • Excision with a 2mm margin depending on breslow depth
  • ± lymphadenectomy
  • ± adjuvant chemo (may use isolated limb perfusion
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9
Q

What are some poor prognostic indicators in malignant melanoma?

A
  • Male sex (more tumours on trunk compared to females)
  • Higher mitotic rate
  • Satellite lesions (lymphatic spread)
  • Ulceration
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10
Q

What are the features of a squamous cell carcinoma?

A

Ulcerated lesion with hard, raised, everted edges on sun exposed areas

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11
Q

What are the causes of SCC?

A
  • Sun exposure - scalp, face, ears, lower leg
  • May arise in chronic ulcers: Marjolin’s ulcer
  • Xeroderma pigmentosa
  • Radiation scarring
  • Smoking
  • Arsenic
  • HPV
  • Organic hydrocarbons
  • Immunosuppression
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12
Q

How does SCC evolve?

A

Solar/actinic keratosis -> Bowen’s -> SCC

Lymph node spread is rare

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13
Q

How do you treat SCC?

A

Excision and radiotherapy to affected nodes

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14
Q

What is a keratoacanthoma?

A

Rapidly growing low-grade SCC that appears in sun exposed areas arising from hair follicles and can have surgical Rx. Dome shaped with a keratin plug.

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15
Q

What are the features of actinic keratoses?

A

Irregular, crusty, warty lesions that are premalignant (~1% transformation/year)

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16
Q

How do you treat actinic keratoses?

A
  • Cautery
  • Cryo
  • 5-FU
  • Imiquimod
  • Photodynamic phototherapy
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17
Q

What is Bowen’s disease?

A

Red/brown scaly plaques. SCC in situ needing treatment similar to actinic keratosis (removal chemically/cryo etc)

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18
Q

What are the features of basal cell carcinoma?

A
  • Commonest cancer
  • Pearly nodule with rolled telangiectactic edge
  • May ulcerate
  • Typically on face in sun exposed area (above line from tragus -> angle of mouth)
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19
Q

How do BCCs behave?

A

Low grade malignancy that rarely metastasises but can be locally invasive.

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20
Q

What are the types of BCC?

A
  • Nodular/cystic
  • Morphoeic
  • Pigmented
  • Superficial
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21
Q

How do you treat BCCs?

A
  • Excision
    • Mohs: complete circumferential margin assessment using frozen section histology
  • Cryo/radio
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22
Q

What are the risk factors for BCC?

A
  • Sun
  • Radiation treatment
  • Chronic scarring
  • Ingestion of arsenic
  • Basal naevus syndrome (Gorlin syndrome)
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23
Q

What is psoriasis?

A

An immune-mediated, chronic, multisystem inflammatory disease

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24
Q

What is the epidemiology of psoriasis?

A
  • 2% of caucasians
  • Peaks in 20s and 50s
  • F=M
  • 30% have a family history
  • Genetic predisposition
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25
Q

What is the pathology in psoriasis?

A
  • TIV hypersensitivity
  • Epidermal proliferation
  • T cell driven inflammatory infiltration
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26
Q

What histological features are seen in psoriasis?

A
  • Acanthosis: thickening of the epidermis
  • Parakeratosis: nuclei in the stratum corneum
  • Munro’s microabscesses: neutrophils
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27
Q

What are the triggers for psoriasis?

A
  • Stress
  • Infections (especially streps)
  • Skin trauma: Köbner phenomenon
  • Drugs: beta blockers, lithium, anti malarials, EtOH
  • Smoking
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28
Q

What are the skin changes of psoriasis?

A
  • Symmetrical well defined red plaques with a silvery scale
  • Extensors: elbows, knees
  • Flexures (no scales): axillae, groins, submammary
  • Scalp, behind ears, navel, sacrum
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29
Q

What are the nail changes of psoriasis?

A
  • Seen in 50%
  • Pitting
  • Onycholysis
  • Sunungual hyperkeratosis
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30
Q

What are the features of psoriatic arthritis?

A
  • 10-40% get seronegative arthritis
  • Mono/oligo arthritis - DIPs commonly involved
  • Rheumatoid-like
  • Asymmetrical polyarthritis
  • Psoriatic spondylitis
  • Arthritis mutilans
  • May lead to dactylitis
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31
Q

What are the common variants of psoriasis?

A
  • Guttate
    • Acute, drop like salmon pink papules with a fine scale, mainly on the trunk
    • Occurs in children associated with strep infection
  • Pustular
    • Sterile pustules
    • May be localised to palms and soles
    • Can progress to erythroderma
  • Erythroderma and generalised pustular
    • Generalised exfoliative dermatitis
    • Severe systemic upset: fever, raised WCC, dehydration
    • May be triggered by rapid steroid withdrawal
    • Strongly associated with smoking and middle aged women
  • Flexural
    • Axillae, submammary, natal cleft
    • Lesions smooth, red, glazed
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32
Q

Which other conditions is psoriasis associated with?

A
  • Major cardiac adverse events (MACE)
  • Arthropathy
  • Gout
  • Malabsorption
  • Lymphoma
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33
Q

What are the conservative management options ofr psoriasis?

A
  • Avoid triggers
  • Soap substitutes - aqueous cream, dermol cream, epaderm ointment
  • Emollients - epaderm, dermol, diprobase
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34
Q

What are the topical treatment options for psoriasis beyond emollients?

A
  • Vitamin D3 analogue: e.g. calcipotriol
  • Steroids e.g. betamethasone
    • Dovobet = calcipotriol + betamethasone
  • Tar: mainly for inpatient use
  • Dithranol
  • Retinoids: e.g. tazarotene
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35
Q

What are the non-topical treatment options for psoriasis?

A
  • UV phototherapy (local immunosuppression)
    • Narrow band UVB
    • Psoralen + UVA: PUVA
      • Psoralen is a photosensitising agent and can be topical or oral
    • PUVA is more effective but increases skin cancer risk
  • Non biologicals
    • Methotrexate
    • Ciclosporin
    • Acetretin (oral retinoid/vit A analogue)
      • Side effects: high lipids, high glucose
  • Biologicals
    • Infliximab
    • Etanercept
    • Adalimumab
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36
Q

What are the causes of the Köbner phenomenon?

A
  • Psoriasis
  • Lichen planus
  • Vitiligo
  • Viral warts
  • Molluscum contagiosum
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37
Q

How does exzema present?

A
  • Extremely itchy
  • Poorly demarcated rash
    • Acute: oozing papules and vesicles
    • Subacute: red and scaly
  • Chronic eczema -> lichenification
    • Skin thickening with exaggeration of skin markings
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38
Q

What pathology is seen in eczema?

A

Epidermal spongiosus

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39
Q

What causes atopic eczema?

A
  • TH2 driven inflammation with increased IgE production
  • Family history of atopy common
  • Allergens: house dust mite, animal dander
  • Diet: dairy products
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40
Q

Who gets atopic eczema?

A
  • Affects 2% infants
  • Most group out of it by 13 years
  • Associated with asthma and hay fever
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41
Q

How does atopic eczema present?

A
  • Face: especially around eyes, cheeks
  • Flexures: knees, elbows
  • May become secondarily infected
    • Staph -> fluclox
    • HSV -> aciclovir
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42
Q

What investigations can you consider in atopic eczema?

A
  • IgE (raised)
  • RAST testing: identify specific antigen
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43
Q

What are some common causes of irritant contact dermatitis?

A

Detergents, soaps, oils, solvents, venous stasis

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44
Q

What are some causes of allergic contact dermatitis?

A
  • Type IV hypersensitivity reaction
  • Common allergens:
    • Nickel
    • Chromates (leather)
    • Lanolin: creams, cosmetics
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45
Q

What test should you do to determine the cause of allergic contact dermatitis?

A

Patch testing

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46
Q

How does adult seborrhoeic dermatitis present?

A
  • Red, scaly rash
  • Location: scalp (dandruff), eyebrows, cheeks, nasolabial folds
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47
Q

What is the cause of adult seborrhoeic dermatitis?

A

Overgrowth of skin yeasts (e.g. malassezia), pitysporum ovale

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48
Q

How do you treat adult seborrhoeic dermatitis?

A

Mild topical steroids/antifungals. Daktacort: miconazole + hydrocortisone

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49
Q

How do you manage atopic eczema?

A
  • Avoid triggers e.g. soap
  • Soap substitute: aqueous cream, dermol cream, epaderm ointment
  • Emollients: epaderm, dermol, diprobase, oilatum (bath oil)
  • Topical therapy:
    • Steroids:
      • 1% hydrocortisone on face, groin
      • Eumovate: can use briefly (<1/week) on face
      • Betnovate
      • Dermovate: very strong, brief use on thick skin (palms, soles)
    • 2nd line therapies:
      • Topical tacrolimus
      • Phototherapy
      • Ciclosporin or azathioprine
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50
Q

What are the causes of pruritus?

A
  • Generalised
    • Chronic renal failure
    • Cholestasis
    • Haematological
      • Polycythaemia
      • Hodgkin’s
      • Leukaemia
      • Iron deficiency
    • Endocrine
      • DM
      • Hyper/hypothyroidism
      • Pregnancy
    • Malignancy
    • Senility
    • Morphine
  • Itchy dermatological diseases
    • Eczema
    • Urticaria
    • Scabies
    • Dermatitis herpetiformis
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51
Q

What causes tinea?

A

Superficial mycosis caused by dermatophytes:

  • Microsporum
  • Epidermophyton
  • Trichophyton
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52
Q

How does tinea present?

A
  • Round scaly lesion
  • Itchy
  • Central clearing
  • Scalp, body, foot, groin, nails
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53
Q

How do you treat tinea?

A
  • Skin: terbinafine or topical ketoconazole/miconazole
  • Scalp: griseofulvin or terbinafine
  • Nails: terbinafine
54
Q

What are the risk factors for candida?

A

Immunosuppression, antibiotics, steroid inhalers

55
Q

How does candida present?

A
  • Pink + white patches
  • Moist
  • Satellite lesions
  • Mouth, vagina, skin folds, toe web
56
Q

How do you treat candida?

A

Mouth: nystatin

Vagina: clotrimazole cream and pessary

57
Q

What causes pityriasis versicolor?

A

Malassezia furfur

58
Q

How does pityriasis versicolor present?

A
  • Common in hot and humid environments
  • Circular hypo/hyper pigmented patches
  • Fine white scale
  • Itchy
  • Back of neck and trunk
59
Q

What investigation diagnoses pityriasis versicolor?

A

Spaghetti and meatballs appearance with a KOH stain

60
Q

How do you treat pityriasis versicolor?

A

Selenium sulphate or ketoconazole shampoos

61
Q

What is impetigo?

A

Contagious superficial skin rash caused by staph aureus

62
Q

How does impetigo present?

A
  • Peak at 2-5 years
  • Honey coloured crusts on erythematous base
  • Common on face
63
Q

How do you treat impetigo?

A
  • Mild: topical antibiotics (fusidic acid, mupirocin)
  • More severe: fluclox PO
64
Q

What is erysipelas?

A
  • Sharply defined superficial infection by strep pyogenes
  • Often affects the face
  • High fever and raised WCC
65
Q

How do you treat erysipelas?

A

Benpen IV or pen V and fluclox PO

66
Q

What are the common causes of cellulitis?

A

Beta haemolytic strep and staph aureus

67
Q

How does cellulitis present?

A
  • Deeper and less well defined than erysipelas
  • Pain, swelling, erythema and warmth
  • Systemic upset
  • ± lymphadenopathy
68
Q

How do you treat cellulitis?

A
  • Empiric: fluclox IV
  • Confirmed strep: benpen or pen V
  • Pen allergic: clindamycin
69
Q

What causes warts?

A

HPV infection

70
Q

How do you treat warts?

A
  • Expectant
  • Destructive
    • Topical salicylic acid
    • Cryotherapy
    • Podphyllin
    • Imiquimod
71
Q

What are the features of molluscum contagiosum?

A
  • Pox virus
  • Pink papules with umbilicated central punctum
  • Resolve spontaneously
72
Q

What are the features of herpes zoster/shingles?

A
  • Recurrent VZV infection
  • Dermatomal distribution of cropping vesicles and crust
    • 50% thoracic
    • 20% ophthalmic
      • Cornea affected in 50% -> keratitis, iritis
  • May lead to post herpetic neuralgia
73
Q

How do you treat shingles?

A

Aciclovir or famciclovir PO if severe

74
Q

What are the features of herpes simplex skin infection?

A
  • Gingivostomatitis or recurrent genital or oral infections
  • Triggered by infection (e.g. CAP), sunlight and immunosuppression
  • May complicate eczema: eczema herpeticum
  • Grouped painful vesicles on an erythematous base
75
Q

How do you treat herpes simplex skin infection?

A

Acyclovir or famciclovir indicated if immunosuppressed or recurrent genital herpes

76
Q

What causes pityriasis rosea and how does it present?

A

HHV-6/7; herald patch precedes rash, mainly on the trunk

77
Q

How does lichen planus present?

A
  • Skin presentation:
    • Flexors: wrists, forearms, ankles, legs
    • Display Köbner phenomenon
    • Purple
    • Pruritic
    • Polygonal
    • Planar
    • Papules
    • Wickham’s striae (lacy white marks)
  • Lesions elsewhere
    • Scalp: scarring alopecia
    • Nails: longitudinal ridges
    • Mouth: lacy white plaques on inner cheeks
    • Genitals
78
Q

How do you treat lichen planus?

A

Mild: topical steroids

Severe: systemic steroids

79
Q

What is bullous pemphigoid?

A

An autoimmune blistering disease due to auto-antibodies against hemidesmosomes

80
Q

How does bullous pemphigoid present?

A
  • Mainly affects the elderly
  • Tense bullae on an erythematous base
  • Can by itchy
  • Limbs, trunk, flexures, rarely mouth
81
Q

What does a biopsy show in bullous pemphigoid?

A

Linear IgG along the basement membrane and subepidermal bullae

82
Q

How do you treat bullous pemphigoid?

A

Clobetasol (dermavate)

83
Q

What is pemphigus vulgaris and what causes it?

A
  • Autoimmune blistering disease due to auto-antibodies against desmosomes
  • May be precipitated by drugs:
    • NSAIDs
    • ACEi
    • L dopa
84
Q

How does pemphigus vulgaris present?

A
  • Younger patients
  • Large flaccid bullae which rupture easily
  • Nikolsky’s sign positive
  • Mucosa is often affected first - skin lesiosn sometimes months later
85
Q

What is the pathology in pemphigus vulgaris?

A

Intraepidermal bullae

86
Q

How do you treat pemphigus vulgaris?

A
  • Prednisolone
  • Rituximab
  • IVIg
87
Q

What is the pathophysiology of acne vulgaris?

A
  • Increased sebum production: androgens and CRH
  • Propionibacterium acnes - skin commensal that flourishes in the anaerobic environment of the blocked follicle
    • -> inflammation
88
Q

How does acne vulgaris present?

A
  • Inflammation of pilosebaceous follicles
  • Comedones (white- or black-heads), papules, pustules, nodules, cysts
  • Face, neck, upper chest and back
89
Q

How do you treat acne vulgaris?

A
  • Mild: topical therapy
    • Benzoyl peroxide (keratolytic)
    • Erythromycin, clindamycin (not comedolytic)
    • Tretinoin/isotretinoin (comedolytic and anti inflammatory)
  • Moderate: topical benzoyl peroxide + oral antibiotics (doxy or erythro)
  • Severe:
    • Isotretinoin (vitamin A analogue)
      • 60-70% have no further recurrence
      • SE: teratogenic, hepatitis, high lipids, depression, dry skin, yalgia
      • Monitor: LFTs, lipids, FBC
    • Try OCP (Dianette) in women
90
Q

How does acne rosacea present?

A
  • Chronic relapsing remitting disorder affecting the face
  • Chronic flusing precipitated by alcohol or spicy foods
  • Fixed erythema: chin, nose, cheeks, forehead
  • Telangiectasia, papules, pustules (no comedones)
  • Dry, sensitive skin
91
Q

What is acne rosacea associated with?

A
  • Rhinophyma: swelling and soft tissue overgrowth of the nose in males
  • Blepharitis: scaling and irritation at the eyelashes
92
Q

How do you treat acne rosacea?

A
  • Avoid sun exposure
  • Tpical azelaic acid
  • Oral doxycycline or azithromycin
93
Q

What are the features of ocular rosacea?

A
  • Blepharitis
  • Conjunctivitis
  • Keratitis
94
Q

What are the 3 kinds of drug eruptions?

A

Maculopapular and urticarial, also erythema multiforme

95
Q

What are the features of maculopapular drug eruptions and what are some common causes?

A
  • Commonest type
  • Generalised erythematous macules and papules
  • ± fever and increased eosinophils
  • Develops within 2 weeks of onset of drug
  • Penicillins, cephalosporins, AEDs
96
Q

What are the features of urticarial drug eruption and what are some common causes?

A
  • Wheals ± angioedema and anaphylaxis
  • Rapid onset after taking drug
  • Immune (IgE)
    • Penicillins
    • Cephalosporins
  • Non-immune (direct mast cell degranulation)
    • Morphine
    • Codeine
    • NSAIDs
    • Contrast
97
Q

What are the features of erythema multiforme?

A
  • Symmetrical target lesions on palms, soles, and limbs but can occur anywhere
  • Occurs 1-2 weeks after insult
98
Q

What are the causes of erythema multiforme?

A
  • Idiopathic
  • Infections: HSV, mycoplasma
  • Drugs
    • Sulphonamides, NSAIDs, allopurinol, penicillin, phenytoin
99
Q

What are the features of SJS?

A

More severe variant of erythema multiforme - blistering mucosa (conjunctiva, oral, genital)

100
Q

What are the features of toxic epidermal necrolysis?

A
  • Extreme form of SJS
  • Nearly always a drug reaction
  • Severe mucosal ulceration
  • Widespread erythema followed by epidermal necrosis with loss of large sheets of epidermis
  • Leads to dehydration
  • Increased risk if HIV positive
101
Q

What are some drugs causing TEN?

A
  • Allopurinol
  • Sulphonamides
  • Penicillin
  • Carbamazepine
  • Phenytoin
  • NSAIDs
  • Gold
  • Salicylates
  • Barbiturates
102
Q

How do you treat TEN and what’s the prognosis?

A

Dexamethasone, IVIG

30% mortality

103
Q

What causes scabies?

A
  • Sarcoptes scabei
  • Highly contagious - spread by direct contact
  • Female mite digs burrows and lays eggs
104
Q

How does scabies present?

A
  • Burrows: short, serpiginous grey line, block dot
  • Hypersensitivity rash: eczematous, vesicles
  • Extremely itchy -> excoriation
  • Particularly affects finger web spaces (especially the first)
  • Also: axillae, groin, umbilicus
105
Q

How do you manage scabies?

A
  • Permethrin cream applied from the neck down for 24h
  • 2nd line: malathion
  • 3rd line: oral ivermectin
  • Treat all members of the household
106
Q

What causes headlice?

A

Pediculus humanus capitis - spread by head to head contact. Nits = empty eggs

107
Q

How does headlice present?

A

Itch and papular rash at the nape of the neck

108
Q

How do you treat headlice?

A

Malathion and combing

109
Q

What does erythema nodosum look like?

A

Painful blue-red lesions on anterior shins

110
Q

What causes erythema nodosum?

A
  • 3 S’s: sarcoid, strep infections and sulphonamides
  • Also: OCP, IBD and TB, Behcet’s
111
Q

What does pyoderma gangrenosum look like?

A
  • Wide (10cm), deep ulceration with violaceous border
  • Purulent surface
  • Undermined edge
  • Commonly occurs on legs
  • Heal with cribriform (pitted) scars
112
Q

Which conditions are associated with pyoderma gangrenosum?

A

IBD, AIH, Wegener’s, RA, leukaemia

113
Q

How do you treat pyoderma gangrenosum?

A

High dose systemic steroids

114
Q

What are the features of livedo reticularis?

A
  • Persistent mottled red/blue lesions that don’t blanch
  • Commonly found on the legs
  • Triggered by cold
115
Q

What are the causes of livedo reticularis?

A
  • Idiopathic
  • Vasculitis: RA, SLE, PAN
  • Obstruction: anti-phos, cryoglobulinaemia
  • Sneddon’s syndrome: LR and CVAs
116
Q

What are the skin manifestations of rheumatic fever?

A

Erythema marginatum

117
Q

What are the skin manifestations of lyme?

A

Erythema chronicum migrans

118
Q

What are the skin manifestations of Crohn’s?

A
  • Perianal ulcers and fistulae
  • EN
  • Pyoderma gangrenosum
119
Q

What are the skin manifestations of dermatomyositis?

A
  • Heliotrope rash on eyelids
  • Shawl sign (macular rash)
  • Gottron’s papules
  • Mechanic’s hands
  • Nailfold erythema, telangiectasia
120
Q

What are the skin manifestations of diabetes?

A
  • Ulcers
  • Candida
  • Kyrle disease
  • Acanthosis nigricans
  • Necrobiosis lipoidica (shins)
  • Granuloma annulare (hands, feet)
121
Q

What are the skin manifestations of sarcoidosis?

A
  • Erythema nodosum
  • Erythema multiforme
  • Lupus pernio
  • Hypopigmented areas
  • Red/violet plaques
122
Q

What are the skin manifestations of coeliac?

A

Dermatitis herpetiformis (elbows)

123
Q

What are the skin manifestations of Graves’?

A

Pre-tibial myxoedema (lat mal)

124
Q

What are the skin manifestations of rheumatoid arthritis?

A

Rheumatoid nodules, vasculitis (palpable purpura)

125
Q

What are the skin manifestations of SLE?

A

Facial butterfly rash

126
Q

What are the skin manifestations of systemic sclerosis?

A
  • Calcinosis
  • Raynaud’s
  • Sclerodactyly
  • Telangiectasia
  • Generalised skin thickening
127
Q

What are the skin manifestations of liver disease?

A
  • Palmar erythema
  • Spider naevi
  • Gynaecomastia
  • Decreased secondary sexual hair
  • Jaundice
  • Bruising
  • Excoriations
128
Q

What are the skin manifestations of end stage renal disease?

A
  • Associated with cause:
    • DM, vasculitis, sclero, RA, SLE
  • Associated with ESRD:
    • Pruritus, xerosis, pigment change, bullous disease
  • Associated with transplant:
    • Cushingoid, gingival hyperplasia, infections, BCC, SCC, melanoma, Kaposi’s
129
Q

What are the skin manifestations of neoplasia?

A
  • Acanthosis nigricans
  • Dermatomyositis
  • Thrombophlebitis migrans
  • Acquired ichthyosis
130
Q

Antibodies in drug induced lupus

A

Anti histone

Medical Finals (11 decks)

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