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Year 3 > Dermatology > Flashcards

Dermatology Flashcards

1
Q

Define urticaria (acute, chronic)

A

Urticaria is characterised by appearance of intensely pruritic erythematous plaques.

Pruritic, pale, blanching swellings of the superficial dermis lasting up to 24hrs.

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2
Q

Explain the aetiology / risk factors of urticaria (acute, chronic)

A

Urticaria and angiooedema involve mediator release by mast cells and basophils in the epidermis (urticaria) and deeper dermis (angio-oedema).

Many mediators released but mostly histamine, leading to:

  • swelling
  • pruritus
  • vasodilation

ACUTE urticaria/angiooedema:

  1. Allergy. Mostly IgE-mediated type I hypersensitivity. Many agents activate mast cells (through IgE and also directly) e.g. foods, medication (Abx e.g. penicillin), stinging insects (e.g. Hymenoptera family incl. bees, wasps, hornets, and bed bugs), latex (particularly in patients chronically exposed e.g. spina bifida)
  2. Direct mast cell activation (non-immunological) e.g. foods (young kids have urticarial reaction to fruit and veg e.g. tomatos and strawbs, can also cause IgE in some patients), medications (opioids, NSAIDS), radiocontrast media
  3. Infection e.g. viral/bacterial infections responsible for urticaria/angiooedema in the majority of children with acute urticaria.
    Viral: Viruses causing URTI and gastroenterirtis RSV, rhinovirus, rotavirus AND urticaria can precedeactive disease caused by chronic and indolent viral entities, such as hepatitis, cytomegalovirus (CMV), and Epstein-Barr virus (EBV).
    Bacterial: those causing resp infections and gastroenteritis e.g. streptococcal agents and H. Pylori.
    ParasiticL e.g. strongyloides, Toxocara and Fasciola (travel hisotry)
  4. Systemic disease. Rarely, urticaria/angio-oedema precedes development of systemic diseases e.g. autoimmune diseases, malignancies , endocrinopatihies, autoinflammatory syndromes
  5. Physical causes:
    Water, increase in core body temp with exercise or emotion (=cholinergic) , cold, heat, pressure, sunlight.

Other:

  • Serum sickness (immune complex formation can activate mast cells and basophils)
  • Progesterone associated urticaria (women on HRT/some patients in menstrual cycle)
  • Mastocytosis (high numbers of mast cells in skin and other organs)

CHRONIC urticaria/angio-oedema (=persistance for more than 6 WEEKS):

  1. Acute urticaria lasting more than 6 weeks.
    - Infection (most bacterial and viral infections resolve in 6 weeks, but hepatitis, EBV and CMV may be ass. w chronic urticaria).
    - Foods (if food antigens hidden in processed foods and patients unknowingly continue to ingest them)
    - Medications
    - Latex
    - Systemic (may be indolent and subclinical for long time)
    - Progesterone associated: urticaria may be chronic but symptoms will often wax and wane with hormone fluctuations.

BUT

In health people and with absence of identifiable triggers:
In more than 90% of cases this is chronic idiopathic urticaria (CIU). Half of these may have an anti-IgE receptor antibody resulting in chronic release of mast cell mediators.

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3
Q

Summarise the epidemiology of urticaria (acute, chronic)

A

CIU can be associated with family or personal history of autoimmunity (e.g., autoimmune thyroiditis, vitiligo, pernicious anaemia, rheumatoid arthritis, insulin-dependent diabetes, alopecia areata), but can also occur in its absence.

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4
Q

Recognise the presenting symptoms of urticaria (acute, chronic)

A

Pruritic, pale, blanching swellings of the superficial dermis

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5
Q

Recognise the symptoms of urticaria (acute, chronic) on physical examination

Sites of angiooedema

A

pruritic, pale, blanching swellings of the superficial dermis that generally last well under 24 hours

NO overlying flaking or scaling

Angiooedema: colorless, non-pitting induration of the extremities, lips, and genitals.

Chronic MORE THAN 6 WEEKS

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6
Q

Identify appropriate investigations for urticaria (acute, chronic) and interpret the results

A

Acute:
Usually diagnostic testing not recommended, careful history enough.
But skin test/IgE may be useful for allergy, streptococcal antigen testing for urticaria w pharyngitis, ANA, ESR, dsDNA in systemic disease

Chronic: 
Complete blood count with differential
Serum chemistry, including liver function testing
ESR
Urinalysis
Thyroid studies.
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7
Q

Define basal cell carcinoma

A

Commonest form of skin malignancy aka “rodent ulcer”

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8
Q

Explain the aetiology / risk factors of basal cell carcinoma

A

Ass. with pathched/hedgehog signalling cascade, as seen in Gorlin syndrome (naevoid basal cell carcinoma syndrome)

Risk factors: 
Prolonged sun exposure/UV radiation 
Photosensitizing pitch
Tar 
Arsenic

Pathophsyiology:
Small, dark blue staining basal cells growing in well-defined aggregates. Apopotic and mitotic bodies seen

Invades dermis and potential to invade and destroy local tissues.

DOES NOT METASTASIZE

No pre-cursor lesion for BCC

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9
Q

Summarise the epidemiology of basal cell carcinoma

A

Common in those with fair skin and areas of high sunlight exposure, common in the elderly, rare before the age of 40 years. Lifetime risk in Caucasians is 1:3.

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10
Q

Recognise the presenting symptoms of basal cell carcinoma

A

A chronic slowly progressive skin lesion usually on the face but also on the scalp, ears or trunk.

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11
Q

Recognise the signs of basal cell carcinoma on physical examination

(3 types- which is more aggressive?)

A
  1. Nodulo-ulcerative: Small glistening translucent skin over a coloured papule that slowly enlarges (early) or a central ulcer (rodent ulcer) with raised pearly edges.

Fine telangiectatic vessels often run over the tumour surface. Cystic change may be seen in larger more protuberant lesions.

  1. Morpheic: Expanding, yellow/white waxy plaque with an ill-defined edge (more aggressive).
  2. Superificial: Most often on trunk, multiple pink/brown scaly plaques with a fine whipcord edge expanding slowly; can grow to more than 10 cm in diameter.

Pigmented: Specks of brown or black pigment may be present in any type of basal cell carcinoma

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12
Q

Identify appropriate investigations for basal cell carcinoma and interpret the results

In which places is a BCC more likely to lead to complications

A

Biopsy rarely necessary- diagnosis on clinical suspicion

The central face and behind the ears are danger areas. BCC at embryological fusion lines may invade deeply making the risk of recurrence higher. Excision of tumour with clear margins is necessary in these areas.

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13
Q

Which is the commonest form of skin cancer

A

BCC

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14
Q

Define erythema nodosum

A

Panniculitis (inflammation of the subcutaneous fat tissue) presenting as red or violet subcutaneous nodules.

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15
Q

Explain the aetiology / risk factors of erythema nodosum

A

Delayed hypersensitivity reaction to antigens associated with various infectious agents, drugs, and other diseases.

Infection:

  • Bacterial (Streptococcus, TB, Yersinia , rickettsia, Chlamydia , leprosy),
  • viral (EBV),
  • fungal (histoplasmosis, blastomycosis, coccidioidomycosis),
  • protozoal (toxoplasmosis).

Systemic disease: Sarcoidosis, IBD, Behcets disease.

Malignancy: Leukaemia, Hodgkin’s disease.

Drugs: Sulphonamides, penicillin, oral contraceptive pills.

Pregnancy. 25 % of cases have no underlying cause identified.

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16
Q

Summarise the epidemiology of erythema nodosum

A

Female to male 3:1. Usually young adults

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17
Q

Recognise the presenting symptoms of erythema nodosum

A

Tender red or violet nodules develop bilaterally on the shins and occasionally on the thighs and forearms.

Fatigue, fever, anorexia, weight loss and arthralgia are often also present.

Symptoms of the underlying aetiology.

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18
Q

Recognise the signs of erythema nodosum on physical examination

A

Crops of red or violet dome-shaped nodules usually present on both shins (occasionally involving thighs or forearms) which are tender to palpation.

Low-grade pyrexia.

Joints may be tender and painful on movement.

Signs of the underlying aetiology.

The majority of cases resolve over 3– 6 weeks leaving bruise marks.

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19
Q

Identify appropriate investigations for erythema nodosum and interpret the results

A

Anti-strepsolysin-O titre 2-4 weeks later to assess for antecedent streptococcal infection. FBC, U&Es, CRP, ESR, LEFTs, serum ACE

Throat swab and culture

Mantoux/heaf skin testing for TB

CXR: To look for hilar adenopathy or other evidence of pulmonary sarcoidosis, TB and fungal infection

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20
Q

Why would you want to test form serum ACE in erythema nodosum

A

Sarcoidosis increases the level of this

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21
Q

Causes of pemphigus vulgaris, and where would antibodies be seen

Compare the blisters with bullous pemphigoid

A

IgG antibodies against desmosomes located on the surface of keratinocytes (desmoglein 1 and 3)

The following triggers of PV have been reported: thermal burns, infections, emotional stress, and drugs including penicillamine, captopril, cephalosporins, and NSAIDs

PV results in intra-epidermal blisters that are fragile and easily broken, manifesting as painful, flacid bullae and erosions on exam. This is in comparison with the tense bullae of bullous pemphigoid. As in this patient, the bullae demonstrate Nikolsky’s sign, in which gentle pressure to the bulla causes the epidermis to separate off.

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22
Q

What type of rash is associated with coeliac disease

A

Dermatitis herpetigormis, which are highly pruritic papules, vesicles and plaques located primarily on the extensor surfaces

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23
Q

Skin manifestations related to HIV infection

A

Skin manifestations of acute HIV are in the form of a generalized, pruritic papular eruption

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24
Q

Skin rash associated with HSV?

A

Erythema multiforme is a type IV hypersensitivity reaction with strong association with HSV. Targetoid rash beginning on extremities

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25
Q

State the causes of erythema multiforme

A

HSV, mycoplasma, penicillin, sulfonamides, autoimmune diseases, and malignancies.

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26
Q

Skin rash with insulin resistance

A

Insulin resistance is associated with acanthosis nigricans which is characterized by epidermal hyperplasia with a darkened appearance in areas of the skin, typically in the axilla and groin. Another important association of acanthosis nigricans is malignancy, especially gastric carcinoma.

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27
Q

What is associated with acanthosis nigricans

A

Insulin resistance and malignancy, especially gastric carcinoma.

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28
Q

Compare epidermal cyst with a ganglion cyst

A

Epidermoid (sebaceous) cyst: usually benign swelling in the skin arising in the sebaceous gland, typically filled with yellowish sebum. These are usually easily seen as they lead to a swelling of the skin.

Ganglion cyst or synovial cyst: a non-neoplastic soft-tissue collection that may occur in any joint but most often develops in dorsum of wrist hand

https://www.medicinenet.com/cyst/article.html (GREAT LINK FOR CYSTS!)

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29
Q

Lump on the dorsum of the wrist that transilluminates. Reduced sensation on the lateral side of the hand

A

A ganglion cyst is a benign tumor which most often develops in the dorsum of the wrist and hand. It is a compressible, moveable cyst which transilluminates and can cause pain or paresthesia if it compresses the ulnar or median nerve. It can be left untreated or treated with surgery.

(in this case the ulnar nerve is affected!)

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30
Q

What kind of lumps usually develop in the following conditions:

  • Osteoarthritis
  • Tenosynovitis
A

Osteoarthritis:

Development of nodes in the PIP and DIP joints, called Bouchard’s and Heberden’s nodes respectively.

It is also characterized by pain and stiffness in the joints, and would be detected on an X-ray which would show osteophytes, joint space narrowing, subchondral cysts, and subchondral sclerosis.

Tenosynovitis:
Tenosynovitis is inflammation of a tendon and its sheath, and is a result of infection or inflammation caused by diabetes, overuse, or arthritis.
It usually causes swelling, pain, and a fever if infectious. The absence of swelling and any signs of infection in this woman make this diagnosis unlikely.

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31
Q

Are giant cell tumours of tendon sheath malignant or benign?

A

Benign

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32
Q

Patient has a lump near the DIP joint of the left infex finger. It is immobile and does not transilluminate.

A

Giant cell tumors of the tendon sheath are benign tumors which are typically painless. In most cases, these masses develop near the DIP joints of the index and long fingers. The lesions are firmly fixed to the underlying structures and do not transilluminate.

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33
Q

Actinic keratosis description?

A

Very common, non-malignant skin lesion that occurs due to sun damage.

It has a thick crust surface

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34
Q

What is keratoacanthoma.

T/F is spreads slowly and metastasises

A

A keratoacanthoma is a variant of SCC which grows rapidly but does
not metastasise.

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35
Q

Kaposi’s sarcoma caused by which agent

A

Kaposi’s sarcoma is a systemic disease caused by infection with human herpesvirus
8 (HHV-8),

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36
Q

T/F Kaposi’s sarcoma is a late complication in HIV

A

F
It is an AIDS-defining illness that is
often the first AIDS-related complication in HIV patients.

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37
Q

Explain the distribution of Kaposis sarcoma

A

Lesions appear mainly on
the extremities, but can occur on the trunk, back, face and mucous membranes.

Organ involvement is sometimes present in the gastrointestinal and respiratory tract
and can result in death.

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38
Q

What type of virus causes molluscum contagiosum

A

Pox virus

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39
Q

What are the mechanism of spread in children vs adults. Who does it more commonly occur in

A

virus. It mainly occurs in
children (90%!) and is spread via skin-to-skin contact.

In adults, it tends to be transmitted via
sexual contact and occurs on the lower abdomen and genital area.

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40
Q

Describe the lesion in molluscum contagiosum. How long does the lesion last

A

dome-shaped, firm and smooth with an umbilicated centre.

The lesions will last for around 8 months.

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41
Q

Define squamous cell carcinoma

Compare with marjolins ulcer

A

Malignancy of the epidermal keratinocytes of the skin.

Marjolin’s ulcer is a squamous cell carcinoma that arises in an area of chronically inflamed/scarred skin (it’s aggressive)

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42
Q

Explain the aetiology / risk factors of squamous cell carcinoma

Differentiate it from actinic keratosis and bowen’s disease

A

Risk factor:

  • UV radiation from sunlight exposure (leading to actinic keratoses=precancerous lesions)
  • Radiation
  • Carcinogens (tar derivative, cigarette smoke, soot)
  • Chronic skin disease (lupus)
  • HPV
  • Long term immunosupression (transplant recipients and HIV)
  • DNA repair genetic defect (xeroderma pigmentosum)

Actinic keratosis (squamous cells begin to produce too much keratin, and are premalignant)–> bowen’s disease (squamous carcinoma in situ) –> squamous cell carcinoma

Bowen’s disease is intra-epidermal carcinoma in situ (proliferation of atypical keratinocytes JUST IN THE EPIDERMIS, BASEMENT MEMBRANE is intact) and may be seen as solitary or multiple red-brown scaly patches.

In squamous cell carcinoma the malignant keratinocytes invade locally into the dermis and even hypodermis and can then spread to local lymph nodes and distally metastasise e.g. lungs, liver. Staging is based on the TNM system.

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43
Q

Recognise the presenting symptoms of squamous cell carcinoma

Treatment mechanisms?

A

Surgery and reconstruction
and radiotherapy (the lesions are RADIOsensitive, NOT chemosensitive)

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44
Q

Recognise the signs of squamous cell carcinoma on physical examination

A

Variable appearance: ulcerated, hyperkeratotic, crusted or scaly, nonhealing lesion, often on sun-exposed areas. Palpate for local lymphadenopathy.

Actinic keratosis- “sand-paper like lesions”

Bowen’s disease- “small, well-circumscribed, red elevations with scaly plaques”

As the lesion turns cancerous and enlarges, the centre becomes necrotic and can turn into an ulcer

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45
Q

Identify appropriate investigations for squamous cell carcinoma and interpret the results

A

Skin biopsy:
Confirms malignancy and distinguishes it from other skin lesions. Form pearls in the most aggressive part, under microscopy (don’t confuse with BCC!’s pearly macroscopic appearance).
Deep biopsy including subcutaneous tissue is needed.
Squamous cell carcinoma cells on microscopy:
-pleomorphic
-hyperchromatic nuclei
-numerous mitoses

Actinic keratosis: partial thickness of the epidermis dysplasia
Bowen’s disease

Bowen’s disease: full thickness dysplasia of the epidermis (BM intact)

Fine-needle aspiration or lymph node biopsy: Only necessary if suspicion of metastasis.

Staging: CT and/or MRI, PET scanning

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46
Q

Define molluscum contagiosum

A

Skin infection caused by the molluscum contagiosum virus that often occurs on the trunk, face and genitalia

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47
Q

Explain the aetiology / risk factors of molluscum contagiosum

Modes of transmission? Type of virus?

Describe the skin lesions

Risk factors?

A

DNA poxvirus

Transmission:

  • Direct skin contact (contact sports, STIs)
  • Autoinoculation (scatching or touching lesion e.g. whilst shaving)
  • Fomites (e.g. on bath sponges/towels)

Smooth, dome-shaped papules with central umbilication

RISK FACTORS:
Immunosuppression ,

Active atopic dermatitis (in children) ,

hot and humid climates,

Crowded living conditions

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48
Q

Summarise the epidemiology of molluscum contagiosum

A

Male more commonly than female

It is more common in childhood as well as early adolescence, particularly in males, and is usually transmitted at this age via skin contact and autoinoculation.

In adults, it is considered a sexually transmitted infection.

Prevalence
More common in warm and humid climates or areas with poor hygiene
Up to 18% of HIV-positive patients and up to 33% if CD4 cell count is < 100 cells/μL

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49
Q

Recognise the presenting symptoms of molluscum contagiosum

Location in children vs adults?

The healing?

A

Individual lesions may be painful/pruritic but usually non-tender

2-5mm, but in immunocompromised may go up to >15mm

In children: face , trunk , and extremities (e.g., axilla, antecubital and popliteal fossa)

In adults: lower abdomen, groin, genitalia, and proximal thighs

In healthy patients, molluscum contagiosum is generally self-limiting and heals spontaneously after several months.

However, in immunosuppressed individuals, lesions can be very large, widespread, and persistent.

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50
Q

Recognise the signs of molluscum contagiosum on physical examination

A

Non-tender, skin coloured, pearly, dome shaped papules with central umbilication

Papules contain a caseous plug (squeezing produces white cheesy fluid consisting of molluscum bodies)

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51
Q

Identify appropriate investigations for molluscum contagiosum and interpret the results

What does it show on histology

A

Clinical diagnosis

Seek out underlying aetiologies (HIV testing) if lesions are widespread

A biopsy is usually not necessary, but consider in cases of immunosuppression, as the diagnostic differential is wide

Histology:

  • Localised to epidermis
  • Acanthosis (thickened epidermis)
  • Cup-shaped invagination (epidermis invaginated into the dermis)
  • Molluscum bodies: keratinocytes with eosinophilic intracytoplasmic inclusion bodies containing viral particles
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52
Q

When is treatment indicated for molluscum contagiosum, and what would the first treatment option nbe

A

If treatment is indicated (e.g., for sexually transmitted molluscum contagiosum), cryotherapy with liquid nitrogen is usually the first treatment option.

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53
Q

Large, persistent, widespread dome-shaped papules with central umbilication?

A

Suspect molluscum contagiosum which is widespread DUE TO AIDS

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54
Q

Complication of molluscum contagiosum

A

Chronic follicular conjunctivitis may occur as molluscum contagiosum viral particles spread into the conjunctiva of the eye.

Secondary bacterial infections

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55
Q

What diameter of lesion is worrying for a melanoma

A

6mm

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56
Q

What else must you examine in a patient with malignant melanoma

A

Cervical lymph nodes

Remainder of the skin

It is crucial to always examine the skin of the patient fully as there may be more lesions – do not forget to look behind ears, between toes and any skin folds.

57
Q

What are the prognostic factors for malignant melanoma

What Breslow thickness indicates 5 year survival?

A

The Breslow depth is the depth of the lesion and

Clarke’s level the number of layers of epithelium penetrated

Involved regional nodes, indicating metastatic spread

A Breslow depth of ≤ 0.75mm gives a 90% 5 year survival.

58
Q

Where are the most common sites of melanoma on men and women

A

Men- torso

Women- legs

59
Q

How does melanoma metastasise

A

Via blood stream AND lymphatics

60
Q

What is a sign of psoriasis

A

Red spots or patches which characteristically become scaly

61
Q

Associated issues with psoriases

A

Patients with psoriasis are also more prone to develop obesity, joint problems, psychological problems and are more likely to have risk factors for cardiovascular disease.

62
Q

Most common type of psoriasis?

A

Plaque- affects 75-90% of people with psoriasis.

63
Q

In pustular psoriasis are the pustules localised, generalised or either

A

Can be localised or generalised.

64
Q

In pustular psoriasis where are pustules usually localised

A

To the hands and feet

65
Q

What type of psoriasis is a medical emergency and why

A

Generalised pustular psoriasis is a medical emergency as it can be fatal. Here, you have widespread erythema and non-follicular pustules which can coalesce. The patient often has fever, malaise, a raised heart rate and is systemically unwell. They should be immediately referred and managed in secondary care.

Erythrodermic psoriasis is also potentially life threatening and should be immediately referred (see below)

66
Q

What is guttate psoriasis

When does it occur

A

In guttate psoriasis most of the body is usually covered with multiple tiny teardrop-like psoriatic patches. It often follows a bacterial throat infection.

67
Q

What does flexular psoriasis look like- is it plaques?

Where does it occur

A

No. It is red and shiny

It affects areas such as the groin, axillae, inframammary folds etc.

68
Q

What is erythrodermic psoriasis

A

Erythrodermic psoriasis presents with widespread painful red skin – severe psoriasis with more than 90% of the body affected#

It is a serious condition and is potentially life threatening – It requires immediate referral and treatment in secondary care.

69
Q

Which medications may cause a psoriasis flare up

A

Lithium, beta-blockers, anti-malarials, ACE inhibitors and withdrawal of steroids may also cause a flare-up.

70
Q

T/F UV light is usually beneficial in psoriasis

A

T.

Ultraviolet light is usually beneficial except in cases of photosensitive psoriasis.

71
Q

What other factors might precipitate psoriasis

A

Bacterial (strep) and fungal infection

Meds

Recent skin injury

Hormonal changes (female patients might find it worse during puberty and menopause)

Smoking and alcohol

72
Q

What physiological state might improve psoriasis

A

Pregnancy seems to improve it!

73
Q

What treatment can be used in community for psoriasis

What about by specialists?

A

Emollients

Vit D based creams

Salicylic acid (helps to lift off the scales)

For severe psoriasis:

  • PUVA oral psoralen
  • UV light
  • Methotrexate
  • Anti-TNF (etancercept)
74
Q

What could be use in the management of atopic eczema

A

Topical steroids, emollients and soap substitutes.

Diprobase (an emollient)

Eumovate is moderate potency topical steroid

Dermovate is ultrapotent and too strong

Oral pred is revered for several flares

75
Q

What is the treatment of eczema herpeticum

A

HSV infection of eczema which can spread rapidly. Especially if they’re on a topical steroid.

You should:

  • STOP topical steroids
  • Give oral acyclovir
  • Give flucloxacillin (to prevent a secondary bacterial infection)
76
Q

What are the features of discoid eczema

A

Aka nummular eczema

Weepy multiple lesions
Erythematous lesions
Well dermarcated
They have a dry cracked surface or a bumpy, blistered or crusted surface.

Can start at the site of insect bite or other injury

77
Q

Which type of reaction can lead to discoid eczema generalising to the rest of the body

A

The skin between the patches is usually normal, but may be dry and irritable.

Severe discoid eczema may generalise, with numerous small to large itchy lesions appearing all over the body due to autoeczematisation reaction.

78
Q

What may happen to the skin following discoid eczema lesions

A

The patches may clear up without leaving a sign. However, in darker skins, marks may persist for months.

These may be dark brown (postinflammatory hyperpigmentation) or paler than surrounding skin (postinflammatory hypopigmentation).

79
Q

Which steroid cream is safe for daily use if necessary

A

Hydrocortisone.

Note that eumovate is more potent than hydrocortison. Dermovate is more potent still.

80
Q

T.F oral histamines may be useful for eczema

A

T

Antihistamine pills may reduce the itching, and are particularly helpful at night-time. They do not clear the dermatitis.

81
Q

Define the following:

  • Patch
  • Papule
  • Nodule
  • Plaque
  • Ulcer
  • Naevus
A
  • Patch is larger flat area of altered colour/texture
  • Papule- solid raised lesion <0.5cm
  • Nodule- solid raised lesion >0.5cm
  • Plaque- a scaly raised lesion >0.5cm
  • Ulcer- loss of epidermis and dermis (heals with scarring)
  • Naevus- localised malformation of tissue structures (basically a mole)
82
Q

What are the different types of melanoma

A

Lengito maligna

Acral lentiginous (palms, soles, nailbed)

Nodular (younger and middle aged group)

Superficial spreading (MOST COMMON)

83
Q

What is type of eczema appearing on hands and feet

A

Dyshidrotic eczema, or dyshidrosis, is a skin condition in which blisters develop on the soles of your feet and/or the palms of your hands.

The blisters are usually itchy and may be filled with fluid.

84
Q

To differentiate psoriasis with eczema?

A

On the extensor surface of the elbow rather than inside

85
Q

Steven Johnson syndrome skin reaction

A

Affects 2 mucosal sites with ulcers (conjunctiva, lips, mouth, eosophagus)

Systemically unwell

Shock: hypotension, tachycardia

Targetoid lesions (differentiate from erythema multiforme)

86
Q

What is seborrheic eczema and where does it usually affect

A

Seborrhoeic eczema (also known as seborrhoeic dermatitis) most commonly affects areas rich in sebaceous glands such as the scalp, eyebrows and nasolabial folds.

It is thought to be caused by an inflammatory reaction to an overgrowth of Pityrosporum yeast and usually begins on the scalp as dandruff.

Later progresses to redness and irritation with yellow, greasy scales overlying inflamed skin.

87
Q

What is pomphoylx eczema

A 
Dishydrotic eczema (=pomphoylx) eczema consists of fluid-filled blisters restricted to the palms of the hands
and soles of the feet.
88
Q

Maculopapular rash following administration of amoxicillin for a sore throat

A

Could be infectious mono.

The non-specific flu-like symptoms (fever, malaise, sore throat) along with cervical
lymphadenopathy and splenomegaly is typical of infectious mononucleosis (also
known as glandular fever). Ampicillin and amoxicillin should NOT be given to
patients with suspected infectious mononucleosis because it causes a widespread
maculopapular rash in nearly all of these patients.

89
Q

Target-shaped red lesions on the skin?

A

Erythema multiforme

90
Q

Target shaped lesions on the skin and systemically unwell.

What drug is this condition most commonly associated with

A

Stevens-Johnson
syndrome is a severe form of erythema multiforme resulting in bullous lesions and
necrotic ulcers. It is most commonly associated with the use of anti-epileptic drugs
(e.g. lamotrigine).

91
Q

Thyroid disease and ring of purple skin lump on the back of the hand?

A

Granuloma annulare is a peculiar skin condition that looks like a ring of pink-purple
skin lumps most often found on the backs of the hands and feet. It is associated with
diabetes mellitus and thyroid disease; however, it can occur spontaneously in normal
people.

92
Q

Acanthosis nigricans Ddx

A

Endocrine: T2DM, cushings, PCOS

Paraneoplastic syndrome due to GI cancer

93
Q

Diabetic with reddish-brown patches on shin

A

Diabetic dermopathy

94
Q

Diabetic with 3 areas of raised, reddened and hardened skin with a yellowish centre.

A

Necrobiosis lipoidica diabeticorum

95
Q

What are the 4 subtypes of melanoma

A

The most common is superficial spreading melanoma - these tend to arise from a pre-existing naevus and are often described as a slowly changing mole

The second most common is nodular melanoma which tend to
grow rapidly out of an area of skin with no pre-existing naevi (de novo)

Acral lentiginous
melanomas are restricted to the soles of the feet and palms of the hands.

Lentigo maligna
melanoma is the least common subtype, arising from lentigo maligna (melanoma in
situ) usually on sun-exposed skin. These are large, dark and can be nodular.

96
Q

Plummers nails?

A 
(separation of the nail from the 
nail bed
, particularly on the 4th and 5th fingers. e.g. onycholysis affecting 4th and 5th finger) are associated with 
thyroid problems
, 
psoriasis
, trauma and 
contact dermatitis
.
97
Q

What is psoriasis

A

A chronic inflammatory skin disease, which has characteristic lesions and may be complicated by arthritis.

98
Q

Associations for each of the following types of psoriasis.

Guttate
Paloplantar pustolosis
Generalised pustular

A

Guttate: streptococci sore throat

Paloplantar pustolosis: smoking, middle aged women, AI thyroid disease, SAPHO (synovitis, acne, palmoplantar pustulosis, hyperostosis on radiographs, osteitis)

Generalised pustular: hypoparathyroidism

99
Q

What are the skin features of psoriasis

A

Hyperkeratinisation
Parakeratosis (retention of nuclei)
Thickened projections of the prickle cell layer of keratinocytes (psoriasiform hyperplasia).
There is no granular layer. Polymorphonuclear leukocytes and lymphocytes infiltrate dermis (CD8+) and epidermis (CD4+).

100
Q

Localised spots of bleeding in psoriasis

A

Auspitz sign

101
Q

Hx of psoriasis

A

Itching or occasionally tender skin.

Pinpoint bleeding with removing scales (Auspitz phenomenon).

Skin lesions may develop at the site of trauma/scars (Koebner phenomenon).

102
Q

Examination of:

Discoid (nummular psoriasis)

A

Symmetrical well-demarcated erythematous plaques with silvery scales over extensor surface (knee, elbows, scalp, sacrum).

103
Q

Examination of:

Flexular psoriasis

A

Less scaly plaques in axilla, groins, perianal and genital skin.

(remember, this is not the main subtype we think of, which is scaly plaques on the extensors)

104
Q

Examination of:

Guttate psoriasis

A

Small (1cm) drop-like lesions over trunk, limbs

105
Q

Examination of:

Palmoplantar psoriasis

A

Erythematous plaques with pustules on palms and soles.

106
Q

Examination of:

Generalised pustular psoriasis

A

Pustules distributed over limbs and torso.

107
Q

Extra-dermal signs of psoriasis

A

Nail signs: pitting, onycholysis, subungual hyperkeratosis, “salmon patch” on the nail.

JOINTS

108
Q

What is the most common manifestation of psoriatic arthritis

A

Oligoarthritis (most common, accounting for 70% of cases): typically with involvement of both the distal and proximal interphalangeal joints

The spine is involved up to 40% of the time

109
Q

When does psoriatic arthritis usually present

A

Psoriatic arthritis usually begins years after psoriasis but may, in rare cases, precede the onset of psoriasis

110
Q

Other possible mainfestations of psoriatic arthritis

A

. dactylitis (interphalangeal arthritis and flexor tenosynovitis); . rheumatoid arthritis-like (symmetrical polyarthritis); . arthritis mutilans (telescoping of the digits); and . ankylosing spondylitis.

111
Q

Pencil in cup deformity in imaging of joint?

A

rare bone disorder primarily associated with a severe form of psoriatic arthritis (PsA) called arthritis mutilans. It can also occur with rheumatoid arthritis (RA) and scleroderma.

112
Q

Investigations for guttate psoriasis?

A

Anti-streptolysin-O titre, throat swab.

as associated with GAS

113
Q

Investigations for flexural lesions in psoriasis?

A

Skin swabs (exclude candidiasis).

114
Q

Investigations for joint involvement with psoriasis

A

Rheumatoid factor (negative), radiographs (distal interphalangeal joints), erosions, periarticular osteoporosis, “pencil-in-cup” deformity (whittling and cupping of the phalanges); sacroiliitis.

115
Q

T/F psoriasis requires biopsy to confirm

A

F, it is a clinical diagnosis

Order skin biopsy only when diagnosis is in doubt, but biopsy does not always show classic pathological features.

116
Q

Histology for each of the main types of skin cancer

A 
Histology of 
melanoma
 shows abnormal 
melanocytes
 randomly distributed outside the 
basal layer
 of the epidermis with possible invasion into the 
dermis
. In contrast, classic histology findings for 
squamous cell carcinoma
 include 
keratin
 pearls, while those of 
basal cell carcinoma
 include palisading nuclei.
117
Q

Dermatits herpetiformis is assocaited with which condition. What type of rash and what is seen on histology

A 
Celiac disease
 is associated with 
dermatitis herpetiformis
, a pruritic, vesicular 
skin rash
 caused by 
IgA
 deposition in the 
papillary dermis
.

IT IS ITCHY. Extensor surfaces of knees, elbows, buttocks and back

118
Q

How is dermatitis herpetiformis diagnosed

A 
Diagnosis is made by a skin biopsy with 
direct immunofluorescence
 showing 
IgA
 in the 
papillary dermis
, which results in skin lesions by causing an 
immunologic
 cascade after deposition.
119
Q

Treatment of dermatitis herpetiformis

A 
Treatment is a 
gluten-free diet
 and 
dapsone
 for 
refractory
 or severe cases.
120
Q

What can cause pompolyx

A

crops of intensely itchy sago grain-like vesicles on the palms and sides of the fingers, and sometimes on the soles of the feet. It often appears to be a stress reaction, but can arise as a dermatophytide, i.e., eczema in response to the presence of an inflammatory tinea infection somewhere (usually the feet).

121
Q

Define eczema

A

Apruriticpapulovesicularskinreactiontoendogenousorexogenousagents

122
Q

Outline the types of eczema under the following:
Exogenous induced
Endogenous

A

Exogenous: Irritant, contact, phototoxic

Endogenous: atopic, seborrheic, pompholyx, varicose lichen simplex

123
Q

Differentiate irritant vs contact dermatitis

A

Irritant: Prolonged skin contact with a cell-damaging irritant (e.g. ammonia in nappy rash)

Contact: Type IV delayed hypersensitivity to allergen (e.g. nickel, chromate, perfumes, latex and plants).

124
Q

What organisms seems to have a role in seborrhoeic eczema

A

Pityrosporum yeast seems to have a central role

125
Q

Hx of contact/irritant eczema

A

Eczema reaction occurs where irritant/allergen comes into contact with the skin.

In some cases, autosensitization (spread to other sites) can occur in contact eczema

126
Q

Hx of seborrhoeic eczema

A

Yellow greasy scales on erythematous plaques, particularly in the nasolabial folds, eyebrows, scalp and presternal area

127
Q

Hx of pomphoylx eczema

A

Acute and often recurrent painful vesiculobullous eruption on palms and soles

128
Q

Hx of nummular (discoid) eczema

A

Coin shaped, on legs and trunk.

129
Q

Hx of asteototic eczema

A

Dry, “crazy paving” pattern.

Old people shin, winter

130
Q

Diagnosis of eczema

A

Primarily a clinical diagnosis

Allergy testing may be beneficial in assisting the patient to avoid exacerbating allergens, but up to 60% of children with eczema do not have demonstrable IgE-mediated sensitivity to allergens

Swab for infected lesions

131
Q

What is a dermoid cyst

A

A desmoid lump is a connective tissue lump whereas a dermoid lump occurs at points of anatomical fusion.

132
Q

A rare lump not present at birth but appearing early in life, containing glary fluid and cholesterol crystals.

A

Branchial cyst

133
Q

This lump presents in early infancy. It consists of many lymph-filled spaces and is brilliantly translucent. It increases in size upon coughing.

A

Cystic hygroma

134
Q

An uncommon lump that frequently occurs at the angle of the eyebrow.

A

Dermoid cyst

135
Q

The commonest salivary tumour that is benign.

A

Pleomorphic adenoma

136
Q

Branchial cyst?

A remnant of which branchial cleft?

Is it tender?

Which triangle?

Why might it enlarge?

A

A branchial cyst is a remnant of the second branchial cleft, which normally involutes during embryonic development.

It commonly presents in young adults as a smooth, non-tender, fluctuant swelling in the anterior triangle anterior to the border of the sternocleidomastoid at the junction of its upper and middle thirds (this position is characteristic).

It may become enlarged and inflamed with upper respiratory tract infections.

137
Q

Neck lump which is hard and fixed to underlying muscle in a baby, and the baby’s head is tilted towards it?

A

Sternocleidomastoid tumour (not malignant)

138
Q

What is a cystic hygroma

Which triangle?

Classic feature?

A

A cystic hygroma is a congenital benign collection of lymphatic sacs. The cysts contain clear fluid and characteristically transilluminate brightly. It presents as a soft, fluctuant lump just beneath the skin and usually occurs in the posterior triangle of the neck.

Year 3 (18 decks)

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