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Dermatology 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
What is the pathology in psoriasis?
* TIV hypersensitivity * Epidermal proliferation * T cell driven inflammatory infiltration
26
What histological features are seen in psoriasis?
* Acanthosis: thickening of the epidermis * Parakeratosis: nuclei in the stratum corneum * Munro's microabscesses: neutrophils
27
What are the triggers for psoriasis?
* Stress * Infections (especially streps) * Skin trauma: Köbner phenomenon * Drugs: beta blockers, lithium, anti malarials, EtOH * Smoking
28
What are the skin changes of psoriasis?
* Symmetrical well defined red plaques with a silvery scale * Extensors: elbows, knees * Flexures (no scales): axillae, groins, submammary * Scalp, behind ears, navel, sacrum
29
What are the nail changes of psoriasis?
* Seen in 50% * Pitting * Onycholysis * Sunungual hyperkeratosis
30
What are the features of psoriatic arthritis?
* 10-40% get seronegative arthritis * Mono/oligo arthritis - DIPs commonly involved * Rheumatoid-like * Asymmetrical polyarthritis * Psoriatic spondylitis * Arthritis mutilans * May lead to dactylitis
31
What are the common variants of psoriasis?
* 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
32
Which other conditions is psoriasis associated with?
* Major cardiac adverse events (MACE) * Arthropathy * Gout * Malabsorption * Lymphoma
33
What are the conservative management options ofr psoriasis?
* Avoid triggers * Soap substitutes - aqueous cream, dermol cream, epaderm ointment * Emollients - epaderm, dermol, diprobase
34
What are the topical treatment options for psoriasis beyond emollients?
* Vitamin D3 analogue: e.g. calcipotriol * Steroids e.g. betamethasone * Dovobet = calcipotriol + betamethasone * Tar: mainly for inpatient use * Dithranol * Retinoids: e.g. tazarotene
35
What are the non-topical treatment options for psoriasis?
* 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
36
What are the causes of the Köbner phenomenon?
* Psoriasis * Lichen planus * Vitiligo * Viral warts * Molluscum contagiosum
37
How does exzema present?
* Extremely itchy * Poorly demarcated rash * Acute: oozing papules and vesicles * Subacute: red and scaly * Chronic eczema -\> lichenification * Skin thickening with exaggeration of skin markings
38
What pathology is seen in eczema?
Epidermal spongiosus
39
What causes atopic eczema?
* TH2 driven inflammation with increased IgE production * Family history of atopy common * Allergens: house dust mite, animal dander * Diet: dairy products
40
Who gets atopic eczema?
* Affects 2% infants * Most group out of it by 13 years * Associated with asthma and hay fever
41
How does atopic eczema present?
* Face: especially around eyes, cheeks * Flexures: knees, elbows * May become secondarily infected * Staph -\> fluclox * HSV -\> aciclovir
42
What investigations can you consider in atopic eczema?
* IgE (raised) * RAST testing: identify specific antigen
43
What are some common causes of irritant contact dermatitis?
Detergents, soaps, oils, solvents, venous stasis
44
What are some causes of allergic contact dermatitis?
* Type IV hypersensitivity reaction * Common allergens: * Nickel * Chromates (leather) * Lanolin: creams, cosmetics
45
What test should you do to determine the cause of allergic contact dermatitis?
Patch testing
46
How does adult seborrhoeic dermatitis present?
* Red, scaly rash * Location: scalp (dandruff), eyebrows, cheeks, nasolabial folds
47
What is the cause of adult seborrhoeic dermatitis?
Overgrowth of skin yeasts (e.g. malassezia), pitysporum ovale
48
How do you treat adult seborrhoeic dermatitis?
Mild topical steroids/antifungals. Daktacort: miconazole + hydrocortisone
49
How do you manage atopic eczema?
* 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
50
What are the causes of pruritus?
* 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
51
What causes tinea?
Superficial mycosis caused by dermatophytes: * Microsporum * Epidermophyton * Trichophyton
52
How does tinea present?
* Round scaly lesion * Itchy * Central clearing * Scalp, body, foot, groin, nails
53
How do you treat tinea?
* Skin: terbinafine or topical ketoconazole/miconazole * Scalp: griseofulvin or terbinafine * Nails: terbinafine
54
What are the risk factors for candida?
Immunosuppression, antibiotics, steroid inhalers
55
How does candida present?
* Pink + white patches * Moist * Satellite lesions * Mouth, vagina, skin folds, toe web
56
How do you treat candida?
Mouth: nystatin Vagina: clotrimazole cream and pessary
57
What causes pityriasis versicolor?
Malassezia furfur
58
How does pityriasis versicolor present?
* Common in hot and humid environments * Circular hypo/hyper pigmented patches * Fine white scale * Itchy * Back of neck and trunk
59
What investigation diagnoses pityriasis versicolor?
Spaghetti and meatballs appearance with a KOH stain
60
How do you treat pityriasis versicolor?
Selenium sulphate or ketoconazole shampoos
61
What is impetigo?
Contagious superficial skin rash caused by staph aureus
62
How does impetigo present?
* Peak at 2-5 years * Honey coloured crusts on erythematous base * Common on face
63
How do you treat impetigo?
* Mild: topical antibiotics (fusidic acid, mupirocin) * More severe: fluclox PO
64
What is erysipelas?
* Sharply defined superficial infection by strep pyogenes * Often affects the face * High fever and raised WCC
65
How do you treat erysipelas?
Benpen IV or pen V and fluclox PO
66
What are the common causes of cellulitis?
Beta haemolytic strep and staph aureus
67
How does cellulitis present?
* Deeper and less well defined than erysipelas * Pain, swelling, erythema and warmth * Systemic upset * ± lymphadenopathy
68
How do you treat cellulitis?
* Empiric: fluclox IV * Confirmed strep: benpen or pen V * Pen allergic: clindamycin
69
What causes warts?
HPV infection
70
How do you treat warts?
* Expectant * Destructive * Topical salicylic acid * Cryotherapy * Podphyllin * Imiquimod
71
What are the features of molluscum contagiosum?
* Pox virus * Pink papules with umbilicated central punctum * Resolve spontaneously
72
What are the features of herpes zoster/shingles?
* 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
How do you treat shingles?
Aciclovir or famciclovir PO if severe
74
What are the features of herpes simplex skin infection?
* 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
How do you treat herpes simplex skin infection?
Acyclovir or famciclovir indicated if immunosuppressed or recurrent genital herpes
76
What causes pityriasis rosea and how does it present?
HHV-6/7; herald patch precedes rash, mainly on the trunk
77
How does lichen planus present?
* 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
How do you treat lichen planus?
Mild: topical steroids Severe: systemic steroids
79
What is bullous pemphigoid?
An autoimmune blistering disease due to auto-antibodies against hemidesmosomes
80
How does bullous pemphigoid present?
* Mainly affects the elderly * Tense bullae on an erythematous base * Can by itchy * Limbs, trunk, flexures, rarely mouth
81
What does a biopsy show in bullous pemphigoid?
Linear IgG along the basement membrane and subepidermal bullae
82
How do you treat bullous pemphigoid?
Clobetasol (dermavate)
83
What is pemphigus vulgaris and what causes it?
* Autoimmune blistering disease due to auto-antibodies against desmosomes * May be precipitated by drugs: * NSAIDs * ACEi * L dopa
84
How does pemphigus vulgaris present?
* Younger patients * Large flaccid bullae which rupture easily * Nikolsky's sign positive * Mucosa is often affected first - skin lesiosn sometimes months later
85
What is the pathology in pemphigus vulgaris?
Intraepidermal bullae
86
How do you treat pemphigus vulgaris?
* Prednisolone * Rituximab * IVIg
87
What is the pathophysiology of acne vulgaris?
* Increased sebum production: androgens and CRH * Propionibacterium acnes - skin commensal that flourishes in the anaerobic environment of the blocked follicle * -\> inflammation
88
How does acne vulgaris present?
* Inflammation of pilosebaceous follicles * Comedones (white- or black-heads), papules, pustules, nodules, cysts * Face, neck, upper chest and back
89
How do you treat acne vulgaris?
* 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
How does acne rosacea present?
* 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
What is acne rosacea associated with?
* Rhinophyma: swelling and soft tissue overgrowth of the nose in males * Blepharitis: scaling and irritation at the eyelashes
92
How do you treat acne rosacea?
* Avoid sun exposure * Tpical azelaic acid * Oral doxycycline or azithromycin
93
What are the features of ocular rosacea?
* Blepharitis * Conjunctivitis * Keratitis
94
What are the 3 kinds of drug eruptions?
Maculopapular and urticarial, also erythema multiforme
95
What are the features of maculopapular drug eruptions and what are some common causes?
* Commonest type * Generalised erythematous macules and papules * ± fever and increased eosinophils * Develops within 2 weeks of onset of drug * Penicillins, cephalosporins, AEDs
96
What are the features of urticarial drug eruption and what are some common causes?
* Wheals ± angioedema and anaphylaxis * Rapid onset after taking drug * Immune (IgE) * Penicillins * Cephalosporins * Non-immune (direct mast cell degranulation) * Morphine * Codeine * NSAIDs * Contrast
97
What are the features of erythema multiforme?
* Symmetrical target lesions on palms, soles, and limbs but can occur anywhere * Occurs 1-2 weeks after insult
98
What are the causes of erythema multiforme?
* Idiopathic * Infections: HSV, mycoplasma * Drugs * Sulphonamides, NSAIDs, allopurinol, penicillin, phenytoin
99
What are the features of SJS?
More severe variant of erythema multiforme - blistering mucosa (conjunctiva, oral, genital)
100
What are the features of toxic epidermal necrolysis?
* 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
What are some drugs causing TEN?
* Allopurinol * Sulphonamides * Penicillin * Carbamazepine * Phenytoin * NSAIDs * Gold * Salicylates * Barbiturates
102
How do you treat TEN and what's the prognosis?
Dexamethasone, IVIG 30% mortality
103
What causes scabies?
* Sarcoptes scabei * Highly contagious - spread by direct contact * Female mite digs burrows and lays eggs
104
How does scabies present?
* 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
How do you manage scabies?
* Permethrin cream applied from the neck down for 24h * 2nd line: malathion * 3rd line: oral ivermectin * Treat all members of the household
106
What causes headlice?
Pediculus humanus capitis - spread by head to head contact. Nits = empty eggs
107
How does headlice present?
Itch and papular rash at the nape of the neck
108
How do you treat headlice?
Malathion and combing
109
What does erythema nodosum look like?
Painful blue-red lesions on anterior shins
110
What causes erythema nodosum?
* 3 S's: sarcoid, strep infections and sulphonamides * Also: OCP, IBD and TB, Behcet's
111
What does pyoderma gangrenosum look like?
* Wide (10cm), deep ulceration with violaceous border * Purulent surface * Undermined edge * Commonly occurs on legs * Heal with cribriform (pitted) scars
112
Which conditions are associated with pyoderma gangrenosum?
IBD, AIH, Wegener's, RA, leukaemia
113
How do you treat pyoderma gangrenosum?
High dose systemic steroids
114
What are the features of livedo reticularis?
* Persistent mottled red/blue lesions that don't blanch * Commonly found on the legs * Triggered by cold
115
What are the causes of livedo reticularis?
* Idiopathic * Vasculitis: RA, SLE, PAN * Obstruction: anti-phos, cryoglobulinaemia * Sneddon's syndrome: LR and CVAs
116
What are the skin manifestations of rheumatic fever?
Erythema marginatum
117
What are the skin manifestations of lyme?
Erythema chronicum migrans
118
What are the skin manifestations of Crohn's?
* Perianal ulcers and fistulae * EN * Pyoderma gangrenosum
119
What are the skin manifestations of dermatomyositis?
* Heliotrope rash on eyelids * Shawl sign (macular rash) * Gottron's papules * Mechanic's hands * Nailfold erythema, telangiectasia
120
What are the skin manifestations of diabetes?
* Ulcers * Candida * Kyrle disease * Acanthosis nigricans * Necrobiosis lipoidica (shins) * Granuloma annulare (hands, feet)
121
What are the skin manifestations of sarcoidosis?
* Erythema nodosum * Erythema multiforme * Lupus pernio * Hypopigmented areas * Red/violet plaques
122
What are the skin manifestations of coeliac?
Dermatitis herpetiformis (elbows)
123
What are the skin manifestations of Graves'?
Pre-tibial myxoedema (lat mal)
124
What are the skin manifestations of rheumatoid arthritis?
Rheumatoid nodules, vasculitis (palpable purpura)
125
What are the skin manifestations of SLE?
Facial butterfly rash
126
What are the skin manifestations of systemic sclerosis?
* Calcinosis * Raynaud's * Sclerodactyly * Telangiectasia * Generalised skin thickening
127
What are the skin manifestations of liver disease?
* Palmar erythema * Spider naevi * Gynaecomastia * Decreased secondary sexual hair * Jaundice * Bruising * Excoriations
128
What are the skin manifestations of end stage renal disease?
* 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
What are the skin manifestations of neoplasia?
* Acanthosis nigricans * Dermatomyositis * Thrombophlebitis migrans * Acquired ichthyosis
130
Antibodies in drug induced lupus
Anti histone

Medical Finals (11 decks)

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