Dermatology Flashcards
Derm
What is a malignant melanoma?
Invastive malignant tumour of the epidermal melanocytes which have a potential to metastasise
What is the epidemiology of malignant melanomas?
Least common skin cancer
Average age 63, can affect people in their 30s
What are the risk factors for malignant melanomas?
Excessive UV exposure Fitzpatrick skin type 1 (always burns, never tans) Hx multiple/atypical moles FHx melanoma Hx melanoma
What are the characteristics of a malignant melanoma?
A-F
Asymmetry Border irregularity Colour irregularity Diameter 7mm+ Evolution of lesion (size) Funny looking mole (nodular)
What are the symptoms of a malignant melanoma?
Inflammation Oozing Change in sensation On legs (F) On trunk (M)
What is the scoring criteria for a malignant melanoma?
NICE 7 point checklist
What is the scoring for the NICE 7 point checklist?
Asymmetry: 2 [Border irregularity] Colour irregularity: 2 Diameter 7mm+: 1 Evolution of lesion (size): 2 Inflammation: 1 Oozing: 1 Change in sensation: 1
At what score of the NICE 7 point checklist do you send the Pt for a 2 week wait referral?
3+
What are the subtypes of malignant melanomas?
LANS
Lentigo maligna
Acral lentiginous
Nodular
Superficial spreading
What are the characteristics of a lentigo maligna melanoma?
Present in the elderly
Common on the face
Chronic UV exposure
What are the characteristics of an acral lentiginous melanoma?
Common in darker skin types
Found on palm of hand, sole of foot, or under the nails
What are the characteristics of a nodular melanoma?
Poor prognosis
Vertical spread
What are the characteristics of a superficial spreading melanoma?
Most common subtype
What are some melanocytic lesions?
Seborrheic warts Congenital naevi Junctional naevi Compound naevi Intradermal naevi
What are the characteristics of seborrheic keratoses?
Present in the elderly
Often multiple
Wart-like, greasy
Stuck on appearance
What are the characteristics of congenital naevi?
Large
Pigmented
Hairy
What are the characteristics of junctional naevi?
Small
Flat
Dark
What are the characteristics of compound naevi?
Raised
Warty
Hairy
What are the characteristics of intradermal naevi?
Dome shaped nodule
What are the investigations for melanomas?
2WW referral Examine with dermatoscope Full thickness excisional biopsy Take photo and review in 3/12 if atypical If risk of mets: -CXR -Liver US -CT CAP -Brain MRI
What is a basal cell carcinoma?
Slow growing local invasive tumour of basal cells of the dermis.
What are the risk factors of BCCs?
Skin type 1 Age Male Immunosuppression Hx/FHx skin cancer Excessive UV exposure Frequent sunburns in childhood
Are BCCs likely to metastasise?
No
Where do BCCs commonly present?
Around the head and neck
What are the characteristics of a nodular BCC?
Small Skin coloured Surface telangectasia Pearly rolled edge \+/- ulcerated centre
What are the investigations for a BCC?
Routine derm referral (not 2WW)
Examine with a dermatoscope
Excise the lesion
What is a squamous cell carcinoma?
Locally invasive malignant tumour of the epidermal keratinocytes/its appendages, with the potential to metastasise
What are the risk factors of SCCs?
Excessive UV exposure
Pre-malignant skin conditions (actinic keratoses)
Chronic inflammation (eg leg ulcer, would scar)
Immunosuppression
FHx
What are the characteristics of a SCC?
Keratotic (scaly, crusty) Ill-defined nodule May ulcerate Non-healing lesion Everted edges
WhWhat are the investigations for a SCC?
Refer to dermatology (2WW)
Examine with a dermatoscope
Biopsy/complete excision
What is molluscum contagiosum?
A viral skin infection
What is the epidemiology of molluscum contagiosum?
Pre-school children age 1-4
What are the risk factors for molluscum contagiosum?
Close contact/swimming pools/sexual contact
HIV infection
Atopic eczema
What is the presentation of molluscum contagiosum?
Dome shaped Flesh coloured Pearly white papules Central umbillication May be >100 if immunocompromised Systemically well
What are the investigations for molluscum contagiosum?
No investigations
Clinical diagnosis
What is cellulitis?
Acute bacterial infection of the dermis and subcutaneous tissue
What is erysipelas?
Distinct form of superficial cellulitis which is sharply demarcated
What are the common causative organisms of cellulitis/erysipelas?
Streptococcus pyogenes
Staphylococcus aureus
Haemophilus influenzae (periorbital)
What are the risk factors for cellulitis/erysipelas?
Immunosuppression
Woulds/ulcers
IV cannulation
Cut/scratch/insect bite
What are the signs and symptoms of cellulitis/erysipelas?
Acute onset
Red hot painful swollen skin
Well defined borders (ersipela)
Fever/malaise/rigor
Periorbital- painful swollen skin around eye
Orbital- visual impairment/limited movement (clinical emergency)
What are the investigations for cellulitis/erysipelas?
Mainly clinical diagnosis
Can look at WCC
Skin swabs not routinely recommended
What is the management for cellulitis/erysipelas?
Draw around leg Oral fluids Paracetamol/ibuprofen Oral ABx according to local policy Admit if septic (confused, tachycardia/pnoea, hypotensive)
What are the complications of cellulitis/erysipelas?
Local necrosis Abscess Septicaemia Necrotising fasciitis Orbital cellulitis
What is necrotising fasciitis?
Infection of the deep fascia with secondary tissue necrosis
Which pathogen causes necrotising fasciitis?
Group A beta-haemolytic streptococcus
What are the risk factors for necrotising fasciitis?
Surgical wounds
Skin breakage
Medical co-morbidities
50% occur in healthy people
What are the signs and symptoms of necrotising fasciitis?
Severe pain
Erythematous blistering, necrotic skin
Fever/tachycardia
Crepitus (subcutaneous emphysema)
What are the investigations you would do for necrotising fasciitis?
FBC- WCC U+E- high urea CRP, CK Blood and tissue cultures XR/CT- soft tissue gas
What is eczema?
Chronic itchy inflammatory skin condition
What is the epidemiology of eczema?
10-30% of children
What are the risk factors for eczema?
Atopy- hay fever, food allergies, asthma
Urban environment, small family
Type 1 reaction (IgE mediated)- atopic dermatitis
Type 4 reaction (T cell mediated)- contact dermatitis
What is the presentation of eczema?
Itchy dry skin affecting flexures
Can affect face/extensor surfaces in small infants
Lichenification (chronic itching)
What are the characteristics of atopic dermatitis?
Lichenification
Flexures
Type 1 hypersinsitivity (IgE mediated)
What are the characteristics of seborrheic dermatitis?
Yellow greasy scales
Can cause nappy rash
Adults- dandruff, plaques on nasolabial fold, eyebrows
Associated with malassezia yeasts
What are the characteristics of contact dermatitis?
Nickel/chromate/perfume/latex/plant hypersensitivity
Type 4 reaction (T cell mediated)
What are the characteristics of dyshidrotic/pompholyx dermatitis?
Vescicles/blisters
Hands and feet
Related to sweating
What are the characteristics of discoid/nummular eczema?
Scattered round patches
Itchy
Hx of atopic eczema/skin injury
What are the characteristics of eczema herpeticum?
Herpes simplex infection in an eczema sufferer
Medical emergency
What are the investigations for atopic eczema?
Clinical diagnosis
What are the investigations for contact dermatitis?
Skin patch test
What is psoriasis?
Chronic inflammatory skin disease due to hyperproliferation of keratinocytes
What is the epidemiology of psoriasis?
2%, peak age 20yrs
What are the risk factors of psoriasis?
Genetic/environmental factors
Triggers: smoking, alcohol, stress
What is the presentation of psoriasis?
Red/silver scaly plaques on extensor surfaces
Itchy/painful
Nail pitting/onycholysis
Symmetrical polyarthritis
Koebner phenomenon (lesions on traumatised skin)
Auspitz sign (removal of scale causes bleeding)
What are the nail changes in psoriasis?
POSh
Pitting
Onycholysis
Subungal hyperkeratosis
What does chronic plaque psoriasis look like?
Silver scales
What does palmar plantar psoriasis look like?
Red dry thick skin
Fissures
What can long term psoriatic arthritis present with?
Telescoping
What does pustular psoriasis look like?
Generalised lesions around body
Palmar plantar presentation
What does guttate psoriasis look like?
After a strep throat infection
Salmon-pink
Drop-like lesions
What does erythroderma look like?
Generalised red inflamed skin
1/3 due to worsening psoriasis
What is erythema multiforme?
Acute self-limiting inflammation of skin and mucous membranes
What is the epidemiology of erythema multiforme?
Any age group, common in children/young adults
M:F 2:1
What are the risk factors of erythema multiforme?
Viral (HSV), bacterial (mycoplasma, chlamydia), fungal (histoplasmosis) Rheumatoid arthritis, SLE, sarcoid Leukaemia, lymphoma, myeloma Pregnancy Sulphonamides, penicillin
What is the presentation of erythema multiforme?
Prodromal symptoms
Target lesions
Itching/burning/painful
May fade -> pigmentation
What are the investigations for erythema multiforme?
Usually clinical diagnosis FBC raised WCC ESR, CRP HSV serology Throat swab CXR (sarcoid, atypical pneumonia)
What is Stevens-Johnson syndrome?
Lesion in two mucosal sites (conjunctiva, mouth, lips, oesophagus…)
What is the presentation of Stevens-Johnson syndrome?
Systemically unwell
Sore throat, fever, cough, headache, diarrhoea, vomiting
Shock (hypotension, tachycardia)
What are the investigations for Stevens-Johnson syndrome?
Usually clinical diagnosis FBC raised WCC ESR, CRP HSV serology Throat swab CXR (sarcoid, atypical pneumonia)
A 64 year old man presents with a lesion on his upper ear that has been present for months but has now begun to ulcerate. On examination: non-pigmented, hyperkeratotic, crusty lesion with raised everted edges on the pinna.
What is the most likely diagnosis?
A. Basal call carcinoma B. Malignant melanoma – superficial spreading type C. Malignant melanoma – nodular type D. Non-healing scab E. Squamous cell carcinoma
E. Squamous cell carcinoma
Hints: Age Classic site Non-pigmented Hyperkeratotic, crusty Everted edges
A 64 year old man presents with a lesion on his upper ear that has been present for months but has now begun to ulcerate. On examination: non-pigmented, hyperkeratotic, crusty lesion with raised everted edges on the pinna.
How should the GP proceed?
A. Provide sun exposure advice B. Monitor for changes with serial follow up C. Treat in primary care D. Dermatology referral - routine E. Dermatology referral – 2 week wait
E. Dermatology referral – 2 week wait
Hints:
Diagnosis = SCC
Potentially malignant spread
Must refer urgently, as for melanoma
A 32-year old professional surfer had a seizure three days ago. He has no history of epilepsy and reports headaches for the past 5 months. The headaches are worse when he goes to bed. On examination, a dark irregular skin lesion is found on the back of his neck. An MRI scan shows multiple lesions across both cerebral hemispheres.
What is the most likely diagnosis?
A. Acoustic neuroma B. Glioblastoma multiforme C. Meningioma D. Metastases E. Neurofibromatosis type I
D. Metastases
Hints:
Signs of raised ICP (brain mets)
Lesion suspicious of melanoma
Significant sun exposure
A 76-year-old woman has recently attended her GP because of a ‘spot that won’t go away’. The lesion is on her nose and has pearly, rolled edges with telangiectasias.
What is the most likely diagnosis?
A. Squamous cell carcinoma B. Molluscum contagiosum C. Basal cell carcinoma D. Acne rosacea E. Acne vulgaris
C. Basal cell carcinoma
Hints:
Classic site
Features of BCC
A 4-year old girl presents to the GP with multiple lesions on her face. The lesions are raised and shiny, non-tender, non-erythematous, and 3 mm in diameter. They have an umbilicated centre. The patient is known to be HIV positive.
What is the most likely diagnosis?
A. Chicken pox B. Molluscum contagiosum C. Atopic eczema D. Eczema herpeticum E. Herpes simplex virus
B. Molluscum contagiosum
Hints:
Classic appearance
HIV
A 52-year-old woman presents to the GP with redness and swelling of her right cheek. On examination the area of erythema is well-demarcated and warm to touch. Her temperature is 37.9 and she feels unwell.
What is the most appropriate management plan for this patient?
A. Cold compress, reassure, home
B. Admit to intensive care unit
C. Take skin swabs, blood cultures, and give paracetamol
D. Draw around the lesion, give pain relief, oral fluids and antibiotics
E. Emergency dentist referral
D. Draw around the lesion, give pain relief, oral fluids and antibiotics
Hints:
Well-demarcated & systemic upset – probably erysipelas
A 12-year-old girl presents with dry, itchy skin that involves the flexures in front of her elbows and behind her knees. She has symptoms of hay fever and was diagnosed with egg and milk allergy at 6 months old.Her mother has asthma.
What is the most likely diagnosis?
A. Seborrheic dermatitis B. Atopic dermatitis C. Psoriasis (chronic plaque) D. Psoriasis (guttate) E. Urticaria
B. Atopic dermatitis
Hints: Age Flexures Allergies FHx atopy
A 23-year-old man was recently given penicillin for a throat infection (now resolved). He now complains of sore red ‘targetoid’ lesions on his extremities. Later he develops ulcers around his lips and conjunctiva.
What is the diagnosis?
A. Erythema multiforme B. Chicken pox C. Herpes simplex virus D. Stevens-Johnson’s syndrome E. Toxic epidermal necrolysis
A. Erythema multiforme
Hints:
Target lesions
TWO mucosal sites affected!