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Phase 3 > Dermatology > Flashcards

Dermatology Flashcards

1
Q

Briefly describe normal skin anatomy

A
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2
Q

Describe the embryological process of skin development

A

Epidermis is derived from the ectoderm while the dermis is from the underlying mesenchyme

In the 5th week, the skin of the embryo is covered by simple cuboidal epithelium

In the 7th week there is a single squamous layer (periderm) and a basal layer

In the 4th month an intermediate layer containing several cell layers is interposed between the basal cells and the periderm

In the early foetal period, the epidermis is invaded by melanoblasts (cells of neural crest origin)

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3
Q

Describe the role of the immune system in the skin

A

Langerhans Cells (dendritic cells) reside in the basal layers of the skin

Acquire antigens in the periphery, transport them to regional lymph nodes to activate naive T-Cells and initiate an adaptive immune response

Activated T-Cells then initiate cytokine release cascade

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4
Q

Describe the effects of UV light on the skin

A

Direct effects include photoaging, DNA damage and carcinogenesis

p53 tumour suppressor genes are mutated by DNA damage (implicated in development of melanoma and non-melanoma skin cancers)

Chronic exposure can lead to loss of skin elasticity, fragility, abnormal pigmentation, haemorrhage of blood vessels, wrinkling and premature ageing

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5
Q

Describe the aetiology of Acne Vulgaris

A
  1. Sebaceous gland hyperplasia and excess sebum production, especially during puberty where androgens drive gland enlargement
  2. Abnormal follicular differentiation (keratinocytes are retained and accumulate)
  3. Propionibacterium Acnes colonisation, stimulate the production of pro-inflammatory mediators and lipases
  4. Inflammation and immune response leads to development of papules, pustules, nodules and cysts
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6
Q

Describe the management options for Acne Vulgaris

A
  • Reduce Plugging:
    • Topical Retinoid
    • Topical Benzoyl Peroxide
  • Reduce Bacteria
    • Topical Antibiotics (Erythromycin, Clindamycin)
    • Oral Antibiotics (Tetracycline, Erythromycin)
  • Reduce Sebum Production
    • Hormones - Anti-Androgens (Dianette/OCP)
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7
Q

Describe the role of Isotretinoin in the management of Acne Vulgaris

A

An oral retinoid (concentrated Vitamin A) for severe Acne Vulgaris

Reduces sebum production, plugging and bacterial colonisation

Standard course of 16 weeks at 1mg/kg

Causes remission in around 80% of teenagers

Trivial Side Effects - Dry Lips, Nose Bleeds, Dry Skin, Myalgia

Serious Side Effects - Deranged Liver Function, Raised Lipids, Mood Disturbance, Teratogenicity

(Must have regular pregnancy tests to prevent pregnancy while on therapy)

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8
Q

Describe how psoriasis may present in the skin

A

Extensive erythematous, circumscribed, scaly papules and plaques

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9
Q

Describe the immune mechanisms associated with psoriasis

A

Hyperproliferative disorder where cells migrate from the basal layer to the stratum corneum in just a few days

T-Cell mediated autoimmune response

Abnormal infiltration of T-Cells causes release of inflammatory cytokines including interferon, TNF and interleukins

Causes increased keratinocyte proliferation

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10
Q

Describe treatment options for psoriasis

A
  • Topical Creams and Ointments
    • Moisturisers help to reduce flaking and dryness
    • Steroids reduce immune response
  • Phototherapy Light Treatment
    • Non-Specific Immunosuppressant Therapy
    • Reduces T-Cell Proliferation
    • Encourages VitD to reduce skin turnover
    • Risk of burning and skin CA
  • Acitretin
  • Methotrexate and Ciclosporin
    • Immunosuppressants
  • Biologics
    • Etanercept, Infliximab, Adalimumab
    • (Anti-TNF)
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11
Q

Describe the different types of psoriasis

A
  • Chronic Plaque
    • Pink-red, well-demarcated plaques with a silver scale especially seen on extensor surfaces of the knees
  • Guttate
    • Raindrop like psoriasis most commonly seen in young adults and children characterised by an explosive eruption of very small circular or oval plaques over the trunk about 2 weeks after a streptococcal sore throat
  • Erythrodermic and Pustular
    • Can be life-threatening
    • Sterile pustules filled with inflammatory cells
    • Associated with malaise, pyrexia and circulatory disturbance
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12
Q

Describe the conditions associated with psoriasis, i.e. psoriatic arthritis and metabolic syndrome

A

Psoriatic Arthritis - Inflammatory disease often affecting the fingers and toes causing swelling

Metabolic Syndrome - Central Obesity, HTN, T2DM, Low HDL Levels and High Serum Triglycerides

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13
Q

Describe the different subtypes of eczema

A
  • Atopic
    • Itch inflammatory skin condition
    • Associated with asthma, allergic rhinitis, conjunctivitys and hay fever
    • High IgE levels
    • 10-15% of infants affected, remission in 75% by 15 years
  • Contact
    • Precipitated by an exogenous agent
    • Type IV Hypersensitivity (Delayed T-Cell Response)
    • Common allergens include nickel, chromate, cobalt, fragrance
  • Seborrhoeic
    • Chronic,scaly inflammatory condition often on the scalp or face
    • Overgrowth of Pityrosporum Ovale yeast
  • Venous
    • Associated with underlying venous disease
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14
Q

Describe the management of eczema

A
  • Atopic
    • Emollients
    • Topical Steroids
    • Bandages
    • Antihistamines
    • Antibiotics/Anti-Virals
    • Avoidance of Exacerbating Factors
  • Seborrhoeic
    • Scalp - Mediated Anti-Yeast Shampoo
    • Face - Anti-Microbial, Mild Sterooid and Simple Moisturiser
  • Venous
    • Emollient
    • Mild/Moderate Topical Steroid
    • Compression Bandages/Stocking
    • Venous Surgical Intervention
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15
Q

Describe the association between eczema and diseases such as asthma, hay fever etc.

A

Atopic diseases

Associated with immune response and high IgE levels

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16
Q

Describe how eczema may present in the skin

A

Pruritic, erythematous and dry patches of skin

Often with a remitting/relapsing course

17
Q

Describe the effect of UV light on the skin

A

Direct action of UV light on target cells (keratinocytes) for neoplastic transformation via DNA damage

or

Effects of UV light on the host’s immune system (mainly immune suppression)

18
Q

Describe the clinical features, prognosis and management of Basal Cell Carcinoma

A

Most common type of skin cancer

Usually very indolent, rarely metastases or kills

Nodular BCC - >0.5cm raised lesion with a shiny pearly lesion, telangiectasia (blood vessels), and is often ulcerated centrally

Superficial BCC - Often involves only the most superficial layers of the epidermis

Pigmented BCC

Morphoeic/Sclerotic BCC

Managed by surgical excision with a 3-4mm margin

Excellent prognosis, 100% for BCC that has not progressed

19
Q

Describe the clinical features, management and prognosis of Squamous Cell Skin Carcinoma

A

Papule/nodule, often eroded at the centre and crusty

Usually in a sun-exposed area

Often a hard, scaly, dome-like structure

Can itch or bleed

Surgical Excision and/or Radiotherapy

<4 risk of metastasis

20
Q

Describe the clinical features, management and prognosis of malignant melanoma

A

Malignant tumours of melanocytes resulting in DNA damage, most commonly on the skin but also in the bowels or eyes

Features:

Asymmetry

Borders (irregular)

Colour (variable, multi-pigmented)

Diameter (greater than 6mm)

Evolving over time

For nodular melanoma; Elevated, Firm and Growing

Managed by surgical excision;

If Breslow <1mm - 1cm Margin

If Breslow >1mm - 2cm Margin

Adjuvant chemotherapy if metastatic spread

97% 5Yr SR for Breslow <1mm

71% 5Yr SR for Breslow >4mm

21
Q

Describe some tumour syndromes with cutaneous presentations

A
  • Gorlin’s Syndrome
    • Multiple BCCs, Jaw Cysts, Risk of Breast CA
  • Brook Spiegler Syndrome
    • Multiple BCCs, Trichoepitheliomas
  • Gardner Syndrome
    • Soft Tissue Tumours, Polyps, Bowel CA
  • Cowden’s Syndrome
    • Multiple Hamartomas, Breast CA
22
Q

Describe the emergency medical and surgical management of patients with severe skin and soft tissue infection

A

i.e. Necrotising Fasciitis

An immediately life-threatening soft tissue infection with deep tissue involvement

Presents with severe pain and systemic upset, visible necrotic tissue and fascial oedema and gas in soft tissues on imaging

Medical management with IV Flucloxacillin, Benzylpenicillin, Gentamicin, Clindamycin, Metronidazole

Emergency surgical intervention with extensive debridement

23
Q

Describe the pathology and management of cellulitis

A

Infection involving the dermis, most commonly beginning in the lower limbs

Often tracks through the lymphatic system and may involve local lymph nodes

Usually caused by beta haemolytic streptococci (often group A strep) or Staph. Aureus

Enron 1a - PO Flucloxacillin or Doxycycline

Enron Ib and II - IV Flucloxacillin or Vancomycin

Enron III and IV - Admission with IV Management and/or Surgical

24
Q

Describe the range of skin and soft tissue infections and their optimal management

A
  • Impetigo
    • Golden encrusted skin lesions with inflammation localised to the dermis
    • Caused by S. Aureus and is usually mild and self-limiting
    • Can treat with topical fusidic acid or systemic antibiotics
  • Tinea
    • Superficial fungal infection of the skin or nails, very common particularly on the feet
    • Most common causes include Microsporum, Eidermophyton and Trichophyton
    • If skin alone, treat with topical terbinafine and if severe or hair/nail involvement then systemic itraconazole or terbinafine
  • Soft Tissue Abscess
    • Infection within the dermis or fat layers with development of walled off infection and pooled pus
    • Best treatment is surgical drainage
25
Q

Give examples of skin changes seen in endocrine disease

A
  • Thyroid
    • Dry Skin (Hypo)
    • Thyroid Dermopathy (Pretibial Myxedema, Grave’s Disease)
    • Thyroid Acropachy
  • Diabetes
    • Necrobiosis Lipoidica
      • Waxy, yellow
      • Often affects the shins and may ulcerate and scar
    • Scleredema
    • Leg Ulcers
    • Granuloma Annulare
  • Cushing’s
    • Acne, Striae, Erythema, Gynaecomastia
  • Addison’s
    • Hyperpigmentation, Acanthosis Nigracans
26
Q

Describe the features of erythema nodosum and state some of the diseases it may be associated with

A

Tender, red nodules under the skin

Inflammation of the fat underlying the skin

Commonly on the shins

Associated with EBV, Strep Infection, TB, IBD, Sarcoidosis, Pancreatic CA, Non-Hodgkin Lymphoma

27
Q

Give examples of skin changes seen in nutritional deficiencies

A
  • Vit B6 - Dermatitis
  • Vit B12 - Angular Chelitis
  • Vit B3 - Pellagra
  • Zinc - Acrodermatitis Enteropathica
    • Pustules, bullae or scaling
  • Vit C - Scurvy
    • Punctuate Purpura
    • Corkscrew Spiral Curly Hair
    • Dry Skin and Hair
    • Inflamed Gums
    • Patchy Hyperpigmentation
28
Q

Describe the features of pyoderma gangrenosum and state the disease it is associated with

A

A rare, severe skin disease in which progressive ulceration develops spontaneously or after skin trauma

Causes deep ulcers, usually on the legs

Associated with IBD, RA and Myeloma

29
Q

Describe the skin changes seen in internal malignancy

A
  • Necrolytic Migratory Erythema
    • Erythematous, scaly plaques on acral, intertriginous and periorificial areas
    • Associated with an islet cell tumour
  • Erythema Gyratum Repens
    • Reddened concentric bands in a whirled woodgrain pattern
    • Severe pruritic and peripheral eosinophilia
    • Strongly associated with lung CA
  • Acanthosis Nigricans
    • Smooth, velvet-like, hyperkeratotic plaques in intertriginous areas
30
Q

Describe Steven Johnson Syndrome and Toxic Epidermal Necrolysis

A

A severe, mainly drug-induced, blistering disorder

Dermatological emergency

Disease spectrum from SJS –> TEN

(SJS if <10% skin involvement)

Stop offending drug

For TEN: Inpatient derm management, analgesia, fluid balance, infection prophylaxis, special mattress, non-adherent dressing

(TEN may have an up to 50% mortaility)

31
Q

Describe Erythema Multiforme

A

A self limiting allergic reaction

Associated with HSV, EBV and occasionally drugs

Characterised by target lesions on the skin

Never progresses to TEN

32
Q

Describe the acute blistering disorders

A
  • Bullous Pemphigoid
    • Tense and blood filled blisters
    • Typically on flexure surfaces
  • Pemphigus
    • Superficial and flaccid blisters
    • Typically on the trunk, scalp, mouth
  • Treatment of Above
    • Immunosuppression (azathioprine, oral steroids)
    • Infection control
    • Burst any blisters
  • Dermatitis Herpetiformis
    • Associated with coeliac
    • Common on elbows, knees, upper back
    • Treated with gluten free diet, topical steroid and oral dapsone
33
Q

Describe urticaria

A

Non-scarring, itchy wheals with each lesion lasting <24 hours

Most common skin disorder presenting to A&E

Acute <6 weeks, Chronic >6 weeks

May be immune-mediated (type IgE immune response) or non-immune-mediated (direct mast cell degranulation)

Causes include viral infection, NSAIDs, parasitic infection, opiate

Treated with antihistamines, steroids, immunosuppression or omiluzimab

Phase 3 (14 decks)

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