Dermatology Flashcards
What is Lichen nitidus
rare skin condition
Appears as tiny, skin-colored, glistening bumps on the skin surface
Results from abnormal inflammatory activity
Cause is unknown
Aetiology of Lichen planus
chronic inflammatory disorder
affects skin / genital / oral mucous membranes
Unknown pathogenesis
Symptoms of vulval Lichen planus
Itch/irritation soreness dyspareunia urinary symptoms vaginal discharge Can be asymptomatic
Signs of vulval lichen planus
1) Classical = papules on the keratinised anogenital skin
+/- striae on the inner aspect of the vulva Hyperpigmentation
2) Hypertrophic = Thickened warty plaques - perineum / perianal areas - may become ulcerated / infected/ painful. Can mimic malignancy
3) Erosive = most common subtype to cause vulval symptoms.
mucosal surfaces eroded
Wickham’s striae
Can lead to scarring and complete stenosis
There may be loss of vulvar architecture.
Small risk of squamous cell carcinoma developing in women with lichen planus (< 3%).
Complications of vulval lichen planus
Scarring
vaginal synaechia
Development of SCC (up to 3%)
Diagnosis of vulval lichen planus
clinical appearance
vulval biopsy
Biopsy is a necessity if diagnosis is uncertain or coexistent VIN/SCC suspected
What investigations should be performed as part of management of vulval lichen planus
Investigate for autoimmune disease - esp thyroid
Skin swab - exclude secondary infection - esp excoriated lesions
Patch testing - if contact dermatitis suspected
Biopsy - if diagnosis uncertain / VIN or SCC suspected
Treatment of vulval lichen planus
Inform of small risk of neoplastic change
Ultra-potent topical steroids, e.g. Clobetasol
+/- Maintenance treatment with weaker steroid / less frequent potent steroids
Vaginal corticosteroids: hydrocortisone PV(Colifoam) / Prednisolone suppositories for more severe cases
An ultra-potent topical steroid with antibacterial and antifungal, e.g. Dermovate NN - short term to clear secondary infection
When is onward referral recommended for vulval lichen planus
Refer to a multidisciplinary vulval clinic if
- erosive disease
- recalcitrant cases
- those in whom systemic therapy is considered
Systemic treatment options for lichen planus
no consensus Oral ciclosporin retinoids oral steroids new biological agents m
supervised by a dermatologist in the context of a specialised clinic
Follow-up of patients with vulval lichen planus
review at 2–3 months
assess response to treatment
Stable disease should be reviewed annually - can be with GP
Erosive lichen planus needs long-term specialised follow-up
Aetiology of vulval eczema
Atopic = the ‘allergic’ type - often seen in people who also have hay fever or asthma
Allergic contact = skin contact to a substance to which the individual is sensitive
Irritant contact = skin contact with irritating chemicals, powders, cleaning agents, etc
symptoms of vulval eczema
Vulval itch and soreness
Signs of vulval eczema
Erythema Lichenification Excoriation Fissuring Pallor or hyperpigmentation
Complications of vulval eczema
Secondary infection.
Follow up for vulval eczema
As clinically required
psychological support may be needed
Diagnosis of vulval eczema
Clinical presentation.
General examination of the skin
+/- biopsy if diagnosis uncertain
further investigations of suspected of vulval eczema
Patch testing
Biopsy – only if atypical features (e.g. asymmetric, localised or eroded) or failure to respond to treatment
Treatment of vulval eczema
Avoid precipitating factor(s)
Use of emollient soap substitute
Topical corticosteroid – preparation depending on severity - 1% Hydrocortisone or betamethasone 0.025% or clobetasol 0.05%
Combined preparation - antifungal and/or antibiotic may be required for short-term use
Aetiology of vulval lichen simplex
A response to the skin being repeatedly scratched or rubbed over a long period of time
Symptoms of vulval lichen simplex
Vulval itch and soreness
investigation of suspected vulval lichen simplex
Biopsy - if diagnosis uncertain
Screening for infection (e.g. Staphylococcus aureus, Candida albicans)
Dermatological referral for consideration of patch testing –
Ferritin
Treatment of vulval lichen simplex
Avoid of precipitating factor(s)
Use emollient
Use soap substitute
Topical corticosteroid – potent steroids are required when treating lichenified areas, e.g. betamethasone or clobetasol
Combined preparation - antifungal and/or antibiotic may be required if secondary infection suspected
A graduated reduction in frequency of application of topical steroid helpful, over 3–4 months
Mildly anxiolytic antihistamine such as hydroxyzine or doxepin at night is helpful.
CBT may be helpful if co-existing mental health issues
Causes of lichen simplex
- Underlying dermatoses, i.e. atopic dermatitis, allergic contact dermatitis, superficial fungal (tinea and candidiasis) infections.
- Systemic conditions causing pruritus, i.e. renal failure, obstructive biliary disease, Hodgkin’s lymphoma, hyper- or hypothyroidism and polycythaemia rubra vera.
- Environmental factors: heat, sweat, rubbing of clothing and other irritants
- Psychiatric disorders: anxiety, depression, obsessive compulsive disorder and dissociative experiences
Appearance of vulval lichen simplex
Localised plaque of chronic eczematous inflammation
Lichenification / leathery appearance
Erosions and fissuring
Excoriations
Pubic hair may be lost in the area of scratching
or skin may be pale and wrinkled.
There may be labial swelling and erythema
Complications of vulval lichen simplex
Secondary infection.
Follow up for patients with vulval lichen simplex
Mild disease – follow up as clinically required. Severe disease (i.e. when using potent topical steroids) – review at one month then as required
Aetiology of psoriasis
chronic inflammatory epidermal skin disease
Affects ~ 2% of general pop.
Genital psoriasis may present as part of plaque or flexural psoriasis
Symptoms of Genital psoriasis
vulval itch
soreness
burning sensation
Signs of Genital psoriasis
Well-demarcated brightly erythematous plaques
Often symmetrical
Frequently affects natal cleft
Usually lacks scaling due to maceration.
Fissuring.
Involvement of other sites, e.g. scalp, umbilicus
Complications of Genital psoriasis
May be worsened due to Koebner effect by irritation from urine, tight-fitting clothes or sexual intercourse
Diagnosis of Genital psoriasis
Clinical presentation.
General examination of the skin and nails to look for other signs of psoriasis
Further investigation of Genital psoriasis
Skin punch biopsy if the diagnosis is in doubt.
Treatment of Genital psoriasis
Avoid irritating factors.
Use of emollient soap substitute.
Topical corticosteroid – weak to moderate steroids preferred - if insufficient then intensive short-term potent steroids
Combined preparation with antifungal and/or antibiotic may be required if secondary infection suspected
Weak coal-tar preparations – used alone / combined / alternated with topical steroids.
Vitamin D analogues such as Talcalcitol – alone / combination with corticosteroid
When is onward referral recommended for genital psoriasis
If unresponsive to treatment
those in whom systemic therapy is considered
Systemic treatments: if required for severe and extensive psoriasis may help genital lesions but not recommended for isolated genital psoriasis
Follow up for genital psoriasis
Mild disease – follow up as clinically required. Severe disease (i.e. when using potent topical steroids) – review at one month then as required
Aetiology of Vulval intrapeithelial neoplasia (VIN)
vulval pre-cancerous skin condition
May become cancerous if left untreated.
defined as low grade or high grade
Symptoms of Vulval intrapeithelial neoplasia (VIN)
lumps erosions burning itch/irritation pain may be asymptomatic
2 types of Vulval intrapeithelial neoplasia (VIN)
Low-grade change - usually associated with HPV and may resolve
High-grade change - generally not HPV related - occurs in conjunction with lichen sclerosis or lichen planus
Known as differentiated type
much greater risk of progression to SCC
Diagnosis of Vulval intrapeithelial neoplasia (VIN)
histological diagnosis - biopsy
Signs of Vulval intrapeithelial neoplasia (VIN)
Clinical appearance is very variable
Raised white / erythematous / pigmented lesions
May be warty / moist / eroded
Multifocal lesions are common
Complications of Vulval intrapeithelial neoplasia (VIN)
Development of SCC
Recurrence common - progression to cancer can occur following previous treatment.
Psychosexual consequences
Diagnosis of Vulval intrapeithelial neoplasia (VIN)
Biopsy.
Multiple biopsies may be required as there is a risk of missing invasive disease.
Further investigations when Managing Vulval intrapeithelial neoplasia (VIN)
Ensure cervical cytology remains up-to-date – association with cervical intraepithelial neoplasia (CIN)
Refer for colposcopy to exclude CIN
For perianal lesions - referral for anoscopy is recommended
treatment of Vulval intrapeithelial neoplasia (VIN)
Local excision
Imiquimod cream 5% (not licensed in pregnancy) - unlicensed indication
Vulvectomy - Recurrence may occur, function + cosmesis will be impaired
Supervision – some lesions spontaneously regress, risk of progression
Local destruction - variety of techniques - carbon dioxide laser / ultrasonic surgical aspiration / photodynamic therapy /cryotherapy / laser - recurrence rates higher than for excision
Onward referral pathway for suspected or confirmed VIN
multidisciplinary vulval clinic
or input from gynaecology regarding assessment for surgical excision
Follow-up for Vulval intrapeithelial neoplasia (VIN)
Close follow-up is mandatory
Although resolution may occur VIN III has a significant rate of progression
biopsy features of lichen sclerosis
Initially a thickened epidermis
becomes atrophic with follicular hyperkeratosis
a band of dermal hyalinisation
with loss of the elastin fibres
perivascular lymphocytic infiltrate
Management of penile lichen sclerosus
Potent topical steroids - OD until remission, then gradually reduced, intermittent use may be required to maintain remission (e.g. clobetasol, betamethasone)
Treat secondary infection
Circumcision for phimosis
Surgery for meatal stenosis
follow up of patients with penile lichen sclerosus
Regular follow up if requiring potent topical steroids
Frequency of follow up depends on disease
activity + symptoms
Recommend at least annual follow up - due to risk of malignant transformation
What is Zoon’s balanitis
Zoon’s (plasma cell) balanitis
a disease of older uncircumcised men
thought to be due to irritation - partially caused by urine - within a ‘dysfunctional prepuce’
Symptoms of Zoon’s (plasma cell) balanitis
Change in appearance
Rarely bloodstained discharge
Signs of Zoon’s (plasma cell) balanitis
Clinical appearance variable
well circumscribed orange / red glazed areas on the glans
multiple pinpoint red spots “cayenne pepper spots”
Diagnosis of Zoon’s (plasma cell) balanitis
Clinical features
biopsy is advisable
management of Zoon’s (plasma cell) balanitis
Circumcision - reported to lead to resolution of lesions
Topical steroids +/- antibacterial agents
Hygiene measures
Follow up of patients with Zoon’s (plasma cell) balanitis
Dependent on clinical course and treatment
Follow up recommended if topical steroids are used long
term
Symptoms of penile psoriasis
change in appearance
Soreness or itching
Signs of penile psoriasis
red scaly plaques - if circumcised
scaling is lost + patches appear red and glazed - if uncircumcised
Diagnosis of penile psoriasis
Clinical
Look for psoriasis elsewhere
Biopsy may be necessary
Management of penile psoriasis
· Emollients
· Mild to moderate topical steroids (+/- antibiotic or
antifungal)
· Topical calcitriol
· Avoid strong coal tar as it increases risk of genital
cancers
What is Circinate balanitis
inflammatory condition
occurs in Reiter’s disease
post infective syndrome triggered by urethritis / enteritis
in genetically predisposed individuals
overlap with psoriasis in some cases
has been reported in association with HIV
Appearance of Circinate balanitis
greyish white areas on the glans which coalesce to form “geographical” areas with a white margin
+/- associated with other features of Reiter’s syndrome but can occur without
Diagnosis of Circinate balanitis
clinical appearance in association with other features of Reiter’s syndrome
Biopsy - spongiform pustules in upper epidermis
STI screening - including STS and HIV
Management of Circinate balanitis
· Emollients
· Mild to moderate topical steroids (+/- antibiotic or
antifungal)
· Topical calcitriol
· Avoid strong coal tar as it increases risk of genital
cancers
+/- STI treatment
Symptoms of irritant / allergic balanitis
Symptoms associated with irritants e.g. soaps history of atopy, itching dry skin mild erythema oedema
diagnosis of irritant / allergic balanitis
Patch tests + intradermal skin tests
referral to dermatologist
Biopsy - eczematous with spongiosis and nonspecific
inflammation
Management of irritant / allergic balanitis
Avoidance of precipitants - especially soaps
Emollients
Emollients as a soap substitute
Hydrocortisone 1% OD - BD until resolved
+/- antifungal / antibiotics
What is a fixed drug eruption?
uncommon
distinctive type of cutaneous drug reaction
characteristically recurs in the same locations upon re-exposure
precipitants include tetracyclines, salicylates, paracetomol, phenolphthalein, some hypnotics.
the penis = one of the more commonly affected areas
Rarely can occur when sexual partner has taken the drug - assumed toxic component of drug passed through vaginal fluid
signs of a fixed drug eruption
well demarcated erythematous lesions
can be bullous with subsequent ulceration
As inflammation settles - skin becomes brown
Management of a fixed drug eruption
will settle without treatment
Topical steroids e.g. mild to moderate BD until resolution
Rarely systemic steroids - if lesions severe
What is Erythroplasia of Queyrat
a premalignant condition affecting the penis
usually glans / prepuce / meatus
estimated up to 30% progress to invasive cancer
suggested it is triggered by coinfection with multiple types of HPV
Signs of Erythroplasia of Queyrat
red / velvety / well circumscribed area on the glans
May have raised white areas
BUT induration would suggest frank squamous cell carcinoma
Diagnosis of Erythroplasia of Queyrat
Biopsy
essential to exclude squamous carcinoma in situ
Management of Erythroplasia of Queyrat
Recommended = Surgical excision
- Local excision
- Mohs’ surgery
Alternative Regimens · Fluorouracil cream 5% · Cryotherapy · Imiquimod 5% cream (unlicensed) · Photodynamic therapy
Follow up of Erythroplasia of Queyrat
Obligatory Follow up
because of risk of recurrence
Minimum annual appointments
What is Bowen’s disease
cutaneous carcinoma in situ
Signs of Bowens disease
Scaly
discrete
erythematous
plaque
Complications of Bowens disease
20 % develop frank squamous carcinoma
Diagnosis of Bowens disease
Biopsy - essential - appearance can be variable
Management
Recommended = Local excision
Alternative regimens · Imiquimod cream (unlicenced) · Photodynamic therapy · Laser resection · 5 Fluorouracil cream
Follow up for Bowens disease
Obligatory - possibility of recurrence
Minimum of annual appointments
What is bowenoid papulosis
A form of carcinoma in situ
linked to HPV infection - particularly type 18
Signs of bowenoid papulosis
Lesions range from discrete papules to plaques
often pigmented
Complications of bowenoid papulosis
Development of squamous cell carcinoma
Diagnosis of bowenoid papulosis
Biopsy is essential
Management of bowenoid papulosis
Recommended = Local excision
Alternative regimens · Imiquimod cream (unlicensed) · Cryotherapy · laser resection · 5 Fluorouracil cream · Some lesions regress spontaneously
What is penile intraepithelial neoplasia? (PIN)
a rare pre-cancerous disease of the epidermis of the penis
Includes:
Erythroplasia of Queyrat
Bowens disease
squamous cell carcinoma in-situ
According to the BASHH guidelines when should a biopsy be performed for persistent balanitis
Biopsy when balanitis persists >6 weeks despite simple
treatment
factors presdisposing to candidal balanitis
systemic illness
diabetes
Treatment of candidal balanitis
1% clotrimazole cream
+/- HC
what is tinea cruris
dermatophyte fungus
appearance similar to ring worm
very itchy
treatment of tinea cruris
clotrimazole 1% cream BD for 14/7
differential diagnosis for Kaposi sarcoma
hard to distinguish from - Bacillary angiomatosis
biopsy to confirm diagnosis
haematoma haemangioma dermatofibroma pyogenic granuloma purpura
what virus is associated with Kaposi sarcoma
human herpes virus 8
What causes seborrheic eczema
hypersensitivity to malassezia fur fur
inflammatory condition
more common in HIV +ve patients
Treatment = clotrimazole HC
or ketoconazole shampoo for scalp
most common cause of vulval itching
Contact dermatitis = inflammatory reaction
- itch
- lichenification
- hyperpigmentation
can be caused by:
- Proprietary creams (esp containing local anaesthetics)
- Topical antibiotic preparations (e.g. neomycin)
- Barrier contraceptives or lubricants.
- Perfumes, soaps, bubble baths, wet wipes.
- Detergents, fabric conditioners, bleaches, or dyes.
why does genital psoriasis have a different appearance to classical psoriasis
due to the moisture and friction of skin folds
the classic psoriatic lesion (well-demarcated border, with erythematous plaques and silvery scale) is replaced with
a poorly demarcated
erythematous plaque
with minimal scale
shiny texture.
Look for typical psoriasis lesions elsewhere on the body (elbows, knees, scalp)
What is lichen sclerosus
An inflammatory skin condition
Affects the anogenital area more often than other cutaneous surfaces.
Most often diagnosed in women > 50 years
Any area from the clitoral hood to the perianal area can be affected, but the vagina is not affected
Appearance of lichen sclerosus
Hypopigmented-to-white,
crinkled,
fragile plaques
classically distributed in a figure eight pattern around the vulva, perineal body, and perianal skin.
Bruises, blood blisters or ulcers may appear after scratching, or from minimal friction.
Purpura (ecchymosis) is common.
Scarring may cause loss of vulvar architecture,
resorption of the labia minora,
fusing in the midline with burying,
but not loss of the clitoris.
Small risk of squamous cell carcinoma developing in women with lichen sclerosus (< 5%).
What is Fox–Fordyce disease
very rare — small dome-shaped flesh-coloured to reddish papules which affect all hair follicles in the area.
Intensely itchy
often presenting as lichenification
Mainly occurs in women aged 13–35 years
sometimes affects men and children
what is Hailey–Hailey disease
very rare — blistering disease.
Inherited autosomal dominant condition
Also known as ‘familial benign chronic pemphigus’
Mainly affecting the skin folds
Moist, fissured, malodorous plaques and blisters.
Vesicles erupt causing pruritus
+/- involvement of the axillae and sides of the neck
what is Darier disease
very rare
persistent
greasy / scaly papules
which are firm and may feel like sandpaper.
If papules coalesce they form warty plaques - may be macerated and malodorous.
Sites affected include seborrhoeic areas of the trunk, flank, face and skin folds
what is symptomatic dermographism
a form of localized urticaria
triggered by a direct firm touch, scratching, or rubbing.
5% of women with pruritus vulvae are affected by dermographism
Which infections and infestations can cause pruritus vulvae?
Candidiasis Trichomoniasis Bacterial vaginosis Genital herpes simplex Pubic lice (Pediculus pubis) Scabies (Sarcoptes scabiei)
Which malignant conditions may cause pruritus vulvae?
Squamous cell carcinomas - 90% of malignant disease of the vulva. Perianal intraepithelial neoplasia Basal cell carcinoma Melanoma Carcinoma of Bartholin's gland
Vulval cancer can affect women of all ages
Most frequent in women aged 65–75 years
Human papillomavirus (HPV) is responsible for about 60% of squamous cell carcinomas of the vulva
Which pre-malignant conditions may cause pruritus vulvae?
VIN = pre-malignant skin lesion of the vulva.
Types
= bowenoid papulosis - low grade VIN - spontaneously regresses
= High grade squamous intraepithelial lesion (usual-type)
= Extramammary Paget disease (very rare)
Squamous cell carcinomas commonly arise from what
Squamous cell carcinomas often arise from pre-existing background disease.
e.g Vulval lichen sclerosus or lichen planus
Presentation of VIN
VIN may be completely symptom-free
Most women present with:
- Mild to severe vulval itching.
- Mild to severe vulvar burning.
- One or more slightly raised, well-defined skin lesions that may be pink, red, brown, or white.
VIN progress to cancer
If left untreated VIN may:
- resolve spontaneously (especially the low-grade VIN - aka ‘Bowenoid papulosis’
- or develop into an invasive cancer
On average, it takes > 10 years for VIN to progress to cancer
presentation of squamous cell carcinomas
rarely itchy
usually present as a lump or ulcer
usually tender
What % of SCC of the vulva is caused by HPV
about 60%
Average age of presentation of VIN
May occur in women of all ages
Average age is 45–50 years
Types of VIN
Low grade VIN = bowenoid papulosis
High grade squamous intraepithelial lesion (usual-type)
Intraepithelial neoplasia (differentiated-type) — associated with lichen sclerosus.
Risk factors for high grade squamous intraepithelial VIN
often caused by HPV
RF incude:
Smoking
Immunosuppression
What is extramammary Paget disease
very rare
a cutaneous neoplasm
with a chronic eczema-like rash
affects the anogenital region and vulva.
features of extramammary paget disease
mild to intense itching of a lesion found around the groin, genitalia, perineum, or perianal area.
Pain and bleeding may occur from scratching
Thickened plaques may form
can become red, scaly, and crusty.
Plaques are fixed (unchanging over a few weeks)
with sharply demarcated margins
Usually asymmetric
Fail to clear up with topical steroid creams
What hormonal changes can cause pruritus vulvae?
Atrophic vulvovaginitis
Atrophic vulvovaginitis
- peri- and postmenopausal women - declining oestrogen contribute to vulvovaginal itching, dryness, and burning.
Pregnancy
- Increased hormone levels are associated with
increased physiological vaginal discharge
and increased risk of candidal vulvovaginitis
What gastrointestinal conditions can cause pruritus vulvae?
Gastrointestinal disease — irritable bowel syndrome, Crohn’s disease, ulcerative colitis, other inflammatory bowel disease, anal fissures - may lead to prolonged contact of stool with the vulval skin due to faecal incontinence or poor perianal hygiene.
Urinary and faecal incontinence — this can result in vulvar inflammation
What systemic conditions may cause pruritus vulvae?
Drug reactions - e.g. doxycycline and NSAIDs
Systemic diseases - e.g. renal or hepatic disease, diabetes, iron deficiency anaemia, lymphoma, other haematological abnormalities and thyroid dysfunction.
Psychological problems — occasionally present as pruritus vulvae
Stress — may be a cause of itch, or an exacerbating factor causing prolongation of symptoms or a flare-up
why is corticosteroid ointment preferred over cream for vulvo-vaginal dermatoses
Corticosteroid ointments are preferred as they have a reduced need for preservatives, which may cause secondary contact allergy.
Creams also have more water content than ointments and may sting when applied.
Management of CIN
CIN 1 - most regress within 18m - repeat cytology in 12m
CIN 2 - as per CIN 3
CIN 3 - LLETZ / cone biopsy / ablative techniques
Women treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for ‘test of cure’ repeat cytology
Hysterectomy considered if repeated treatment fails
