Dermatology Flashcards
What is the difference between a papule and a nodule?
papule is small bump (<5mm)
nodule is larger (5-10mm) and are usually solid and raised with deeper components
What is the proper name for scratch marks and for thickening of skin with exaggerated skin markings?
scratch= excoriations thickening= lichenification
What is a NON-palpable flat topped lesion of <2cm and >2cm called?
<2cm= macule >2cm= patch
What is the difference between and erosion and an ulcer?
erosion is only loss of epidermis (superficial), ulcer is loss of epidermis and dermis (deep)
What words can be used to describe the distribution of a rash?
generalised (all over), widespread (extensive), localised, flexural/ extensor, pressure areas, dermatomal, photosensitive
What virus usually causes viral warts?
human papillomavirus
How should viral warts be managed? (inc when should secondary care refferal be made)
- theyll usually resolve on own on time
- can use salicylic acid or cryotherapy if want to get rid but often reoccurs
- reffer when persistent symptomatic warts, immunocompromised, facial or extensive warts
- secondary care treatments inc bleomycin, 5FU and laser therapy
Whats the difference between epidermoid and pilar cysts?
- clinically indistinguishable
- pilar cysts contain keratinous material, are usually multiple and often inherited
How should cysts be managed?
- if uncomplicated, leave as may resolve spontaneously
- if infected–> flucoxacillin
- excision if troublesome or frequently infected
What syndrome is associated with multiple cysts
gardeners syndrome
describe a seborrheric keratosis
Soft, flat topped or warty looking lesions which appear stuck onto skin, usually pigmented with well circumscribed boarder. Seen in elderly. Usually asymptomatic but may become irrirtated, itchy, inflamed or bleed after minor trauma
How can seborrheic keratosis be managed?
- usually no treatment required
- remove when cosmetic dislike, repeated irritation, chafing or diagnostic uncertainty
- remove by cryotherapy, curettage and cautery or shave excisions
What does a dermatofibroma look like?
- single nodules, often on lower legs which are free moving, fire/ hard and between 0.5-1cm in diameter, they tend to remain static after an initial period of growth
- the overlying skin is generally smooth or sometimes scaly and may be tethered, causing it to dimple when pinched
- skin colour over the lesion varies from pink/ red- cream- brown- normal
how are dermatofibromas managed?
- generally no treatment required
- remove if cosmetic dislike, symptomatic or diagnostic uncertainty but often reoccur
- remove by elliptical excision or punch biopsy
when should a suspected lipoma be ultrasound scanned?
If ? lipsoscaroma
- >5cm, fast growing, deep, in extremities or invading bone or nerves
How is comedomal acne managed?
1st: topical retinoids (adapalene) +/- benzyl peroxide
2nd: azelaic acid
Describe the primary care steps to managing mild- moderate papular/ pustular acne
1st: adapalene + benzyl peroxide (epiduo)
2nd: clinadmycin + benzyl peroxide (duac gel)
3: systemic abx (continue topical tx (not duac)):
- lymecycline or doxycyline
- if not tolerated or contraindicated can give clarithromycn, erythromycin or trimethoprim
- if macrolide not tolerated & <12= trimethoprim
- stop after 3 months if no help
- Give 1st line if spread over chest and back
What is dianette?
- a type of COCP used in females if acne is related to menstrual cycle
- effective as contraception, but not sole indication
- increased risk of VTE compared with other COCPs (avoid is fhx)
- stop it 4-5 menstrual cycles after acne has resolved
When should GPs refer acne to secondary care
- severe acne
- moderate acne only partially responding to oral abx
- when scars or hyperpigmented lesions are staring to form
- if severe psychosocial stress
What treatments can secondary care physicians offer for acne
- prolonged and high dose courses of abx
- dianette with extra cyproteron acetate
- oral steroids
- retinoids (isotretinoin)
list 5 adverse effects of isotretinoin
- dry skin, lips and eyes
- fragile skin (avoid waxing)
- increased risk of skin infection and slow wound healing
- light sensitivity
- deranged LFTs and lipids
- myalgia
- arthralgia
- depression
- suicide
- teratogenic
- interactions with tetracycline, methotrexate, vit A supplements and POP
What types of emollients are available and what are their relative potencies
oitments like hydromol are stongest but very greasy so only for night really
creams like driprobase are less potent
lotions like E45 are least potent (more water, less lipids)
How should emollients be used
liberally 2-4 times per day, esp after washing
What general advice is important for eczema
Identify and avoid triggers (soaps, detergents, over heating, rough clothing, skin infections, pollens, foods, house dust mites, stress)
Avoid shower gels, use moisturisers to wash
Name and give an example of each of the 4 strengths of steroid creams
Hydrocortisone< clobetasone butyrate (eumovate)< betamethasone valerate (betnovate) < clobetasol propinoate (dermovate)
How long should steroid creams be used for before a review?
1-2 weeks
Give 4 side effects of topical steroid use
- skin thinning
- telangiectasia
- striae
- acne
- contact dermatitis
- can be masking/ exacerbating infections
How should infected eczema be managed?
- rule out eczema herpeticum (send to hosp if suspected) and make sure well
- can do nothing (abx + steroids have little benefit compared to steroids alone)
- if systemically well can give flucloxacillin or topical fusidic acid if localised
- refer urgently (within 2 weeks) if infected eczema not responding to tx
What can be done in primary care if pt is getting frequent flare ups of their eczema (7)
- check compliance
- consider weekend steroid regime (high dose steroids on areas prone to flaring at weekends only)
- swab skin and nose- if staph a +ve give bactroban for 1 week)
- consider allergic dermatitis secondary to topical treatments
- topical immunomodulators eg protopic or elidel (dont give in acute infection)
- secondary care refferal
How can scalp eczema be managed?
tar based shampoo if <18months
water based topical steroid scalp applications bg betacap
When should eczema get reffered to secondary care?
- diagnostic uncertainty
- severe
- moderate- severe and only partially responding to high dose steroids +/- protopic
- possible contact dermatitis
What further treatments can secondary care offer for eczema?
- methotrexate
- azathioprine
- ciclosporin
- light therapy
What are the 4 cornerstones to psoriasis management in primary care?
- assess for possible psoriatic arthritis (refer to rheum if needed) and CVD (modifiy risk factors)
- emollients
- topical steroids and vit D analogues
- refer to dermatology if not controlled
What steroids should be used for psoriasis and for how long
Devobet or enstilar foam for plague psoriasis for 8-12 weeks.
Mild- moderate potency steroids (eumovate) for 1-2 weeks if flexural, genital or facial lesions
How should topical vit d analogues (eg calcipotriol and calcitriol) be used in psoriasis?
- only combine with steroids for short term as skin atrophy risk
- safe and well tolerated when used alone long term
- can irritate skin in sensitive areas (face and folds)
- dont exceed limit as causes hypercalcaemia
- dont give in pregnancy or breast feeding
What treatments can secondary care offer for psoriasis?
- phototherapy
- Apremilast
- Dimethyl fumerate
- methotrexate/ ciclosporin
- biologics
- acitretin
What types of light therapy are used for psoriasis?
- narrow band UVB
- UVA +psoralen
Amount you can have depends on previous sun exposure but is usually 3 times a week for 5-10 weeks
Give 3 short term and 2 long term side effects of phototherapy
Short: red burnt skin, dry and itchy skin, folliculitis, col sores, nausea
Long: premature skin ageing, skin cancer risk
when are biologics used in psoriasis?
when methotrexate and ciclosporin have failed/ not tolerated/ contraindicated and large physcial/ psychosocial impact or extensive or severely localsied disease with functional impairment
How is scalp psoriasis managed?
- potent corticosteroidsonce daily sclap application for 4 weeks (betacap)
- descaling may be needed prior to steroids with diproscalic
- then try potent corticosteroids with calcipotriol (dovobet gel) for 4 weeks
- then very potent corticosteroid shampoo (etrivex) or coal tar (sebco scalp ointment)
Give 5 common triggers for urticaria
- allergens (food, bites, stings, meds)
- viral infections
- skin contact with chemicals
- nettles
- latex
- physical stimuli (dermatographism)
How should acute urticaria be managed?
- calamine lotion is good topical anti pruritic
- non sedating antihistamines (cetirizine)- can use up to 4x normal dose
- oral steroids can be used for acute flares but not usually necessary
Give 4 common drugs causing stevens johnson syndrome
allopurinol, carbamazepine, sulfasalazine, trimethoprim, phenytoin, lamotrigine, NSIADs, salicylates, sertraline
Other causes inc infections and immunisations
Describe the development of stevens johnsons syndrome
- usually starts with URTI symptoms
- then non pruritic lesions develop over 2-4 weeks on palms, soles of feet and dorsum of hand
- rash usually begins as macules which develop into papules, vesicles, bullae, urticarial plaques or confluent erythema
How should stevens johnson syndrome be managed?
- remove cause
- supportive: airway and haemodynamic stabilisation, pain control, manage fluid loss, eye care
- treat secondary infections
- still debate over best treatment but steroids, ciclosporin, cyclophosphamide, anit TNFa mabs, plasmapheresis and immunoglobulins are usually tried
What is erythroderma? what are the main causes
red hot itchy erythematous skin affecting >90% body surface, pt is usually systemically unwell
AKA exfoliative dermatitis/ psoriatic dermatitis
Main causes are eczema, psoriasis, drug eruptions and malignancies
How should erythroderma be managed?
- emergency admission
- bed rest in warm room
- emollients and cool wet dressings
- treat complications
- nutritional support
- ciclosporin and infliximab usually initially as fastest acting
- acitrein and methotrexate slower acting first line choices
give 4 complications of erythroderma
- dehydration
- hypothermia
- cardiac failure
- overwhelming infection
- protein loss
- odema
- anaemia
- lymphadenopathy
- death
What causes erythema nodosum? (list 5 causes)
- Its a hypersensitivity reaction
- often to: group a B haemolytic strep, primary TB, pegnancy, malignancy, sarcoidosis, IBD, chlamydia and leprosy
How does erythema nodosum present?
Discrete tender nodules, usually on the shins, which may become confluent, they may persist for 1-2 weeks and leave a bruise like discolouration as they resolve
What is eczema herpeticum and what does it look like?
- when atopic eczema gets infected with herpes simplex virus
- extensive monomorphic punched out papules/ blisters or erosions with crusting
- theyre usually sysemically unwell with fever and malaise
How is eczema herpeticum managed?
- acyclovir
- pain relief
- abx for secondary infections
What are the warning signs for necrotising fasciitis?
- mimic cellulitis in early stages
- however has pain and tenderness out of proportion of clinical signs
- systemic illness
- develops over 1-2 days
- bullae and ecchymotic skin lesions not normally seen with cellulitis
- crepitus from subcut gas
What is commonest causative organisms for necrotising fasciitis
- group a B haemolytic strep
- staphyloccocus
How is necrotising fasciitis managed?
- haemodynamic stabilisation
- ITU input
- IV abx
- urgent surgical debridement
- skin grafts or vacuum assisted closure is often needed
Give 4 complications of necrotising fasciitis
- septic or toxic shock
- vascular occlusion
- tissue necrosis
- nerve damage
- skin grafts
- reconstructive surgery
- amputation
- death (20-40% mortality rate)
How can staphylococcal scalded skin syndrome be diagnosed?
- clinical diagnosis
- frozen sections from skin biopsies of the lesions can confirm
- swabs often taken of vesicle fluid for sensitivities
How is staphylococcal scalded skin syndrome managed?
- hospitalisation usually needed
- fluid management
- moist bare areas should be lubricated with blant emollient
- paracetamol for pain relief
- enteral nutrition of low oral intake
- topical therapy should be fusidic acid or mupirocin if proven resistance
- first line systemic therapy is flucloxacillin
- manage complications such as dehydration, sepsis and pneumonia
Describe the clinical features of bullous pemphigoid
- autoiummune reaction
- usually in elderlu
- itchy bullaes of trunk and limbs
How is bullous pemphigoid managed?
- oral steroids and abx
- immnuosurpression may be required
Describe the clinical features of pemphigus vulgaris
- easily ruptured vesicles/ bullae which are often painful and can affect skin and mucosal areas
- usually affects middle aged people
- also thought to be autoimmune
How is pemphigus vulgaris managed?
- wound dressings
- high dose oral steroids
- immunosurpression
Describe the clinical features of rosacea
- Recurrent epidsodes of facial flushing with persistent erythema, telangiectasia, papules and pustules
- Flushings may have number of triggers
- Associated with rhyinophyma but only in men
- Commonest in white males age 30-60
- Erythema needs to have been present for at least 3 months
How is rosacea managed?
general: avoid precipitating factors, facial massage may reduce odema, suncream, avoid topical steroids
Mild- Moderate:
- If there is persistent erythema, consider prescribing topical brimonidine 0.5% gel (a topical alpha-adrenergic agonist)
If there are mild-to-moderate papules and/or pustules, prescribe topical ivermectin (an antihelmintic and insecticidal preparation)
- azelaic acid gel and topical metronidazole are alternatives
Mod- severe:
- oral abx- doxycycline 1st, oxytetracycline/ tetracylcine are alternatives
- can combine these with topical treatments
- isotretinoin can be used in refractory cases
- laser treatments for telangiectasia
- rhinophyma often required surgery
When should rosacea get reffered?
- persistent symptoms causing psychological or social stress
- papulopustular rosacea not responding to 12 weeks oral plus topical treatment
- uncertain diagnosis
- severe phymtaous disease or prominent rhinophyma indicated referral to surgeon
Describe the clincial features of vitiligo
- Patchy loss of melanin from epidermis causing well demarcated areas of pale skin which do not tan
- May also be melanin less from hair follicles causing hair to be white/ grey (leukotrichia)
- RFs inc fhx, fhx autoimmune diseases, pernicious anaemia, addisons and diabetes
- Possible triggers: emotional stress, childbirth, skin trauma/ injury, exposure to chemicals
- Patches are usually bilateral and symmetrical
- Usually present before age 20
- Can also affect retina
How should vitiligo be investigated?
- clinical diagnosis
- check for associated disease eg thyroid disease, diabetes, pernicious anaemia, addisons
- a woods light can be helpful to exclude fungal infections (these fluoresce under the UV light)
Give 3 differentials for vitiligo
- tinea vesicolour (lesions are dry, slightly scaled when scratched, less defined)
- piebaldism (white forelock (fringe) which is present at birth)
- idiopathic guttate hypomelanosis: numerous small white macules (<5mm) symetrically on trunk, arms and legs, defined borders, different under woods light
- potent topical steroid use
- tuberous sclerosis
- post inflammatory hypopigmentation
- pityriasis alba (not total depigmentation)
How is vitiligo managed?
- avoid sun burn as patches at higher risk
- minimise skin injury that could cause new patches
- camouflage with fake tan
- topical corticosteroids if affects <10% body and for <2 months
- topical calcineurin inhibitors (tacrolimus) for head and neck and for 6 months of longer is effective
- phototherapy: narrow band UVB or psoralen plus UVA
- can permanently depigment all the skin with monobenzeone ethyl cream
When should vitiligo be referred to secondary care?
- There is diagnostic doubt.
- For a child affected by vitiligo who requires treatment.
- Segmental vitiligo which requires treatment.
- Treatment is required during pregnancy.
- More than 10% of the body area is affected.
- Significant distress is caused by the condition.
- There is facial involvement and treatment is desired.
- The initial treatment strategy has failed.
- The potential adverse effects of topical corticosteroids are unacceptable.
How should folliculitis be managed?
- avoid inappropriate clothing and high humidity
- grow beard or shave with grain
- moisturising shaving products and clean instuments
- good skin hygiene and non allergenic cleaning agents
- topical fucidin
- topical antiseptics
- oral or topical abx such as flucloxacillin if infected or deeper
How is cellulitis managed?
- rest and elevation
- draw round it and monitor
- analgesia (NSAIDs)
- flucloxacillin 1st line
- coamox if face involved
- assess tetanus risk
- assess for nec fasc, sepsis, abscess, gangrene and send to hospital if unsure
give 5 complications of cellulitis
- Abscess
- Gangrene
- Thrombophlebitis
- Leg odema
- Nec fasc
- Compartment syndrome
- Osteomyeltitis
- Endocarditis
- Sepsis
- Streptococcal toxic shock syndrome
- Acute GN
What is erysipelas?
- superficial form of cellulitis where boarder are sharply demarcated and has firey red appearance
- usually affects face or legs
- treated as cellulitis
What causes molluscum contagiosum?
pox virus - transmitted by direct skin contact, 2-8 week incubation period
describe the clinical features of molluscum contagiosum?
- firm, smooth, umbilicated papules, 2-5mm in diameter, may be white, red, translucent, yellow or skin colour
How should molluscum contagiosum be managed?
- most will spontaneously resolve within 18 months
- if lesions very troublesome you can squeeze or pierce after bathing or use crytotherapy
- give abx if secondary bacterial infection
- refer to ophthalmologist if eyes involved
What is dermatophytosis?
fungal infection of dead keratin- name depends on location. tinea corporis if trunk/ arms, tinea pedis if feet, tinea capitis if scalp etc
What organism commonly causes dermatophytosis
Trichophytons rubrum
Describe the clinical features of dermatophytosis
- commoner in those playing contact sports
- annular red scaly plaques with raised edges and paler centre
- may have vesicles or pustules
How is dermatophyosis managed?
- imidazole cream (ketoconazole), continue for 1-2 weeks after resolution
- dont share towels or touch lesions
Describe the clinical features of pityriasis vesicolour?
- usually affects teenagers and young adults
- when sebaceous glands are more active (hot, humid times of the year)
- macular lesions and patches of altered pigmentation, usually on trunk first then spread to neck, upper arms and abdomen
- superficial scales which can be seen by scraping or stretching skin
- itching is mild if present
How can pityriasis vesicolour be confirmed if diagnosis unsure
- skin scrapings sent for diagnosis if unclear
- yellow/ greeny fluorescence may be seen under woods light
How should pityriasis vesicolour be managed?
- topical antifungals (ketoconazole) initially as shampoo- leave as lather and leave for 4-5 mins daily for 5 days
- itraconazole or fluconazole orally can then be tried
- can take several months for colour to return to normal
- antifungal treatment should be repeated when scaly component reoccurs (common)
- can get ketoconazole shampoo prophylaxis
Describe the clinical features of pityriasis rosea?
- acute self limiting rash, starting as a herald patch (which looks similar to tinea corporis lesion)
- then generalised itchy rash develops over 1-2 weeks and lasts 5-8 weeks
- lesions are oval, dull pink and tawny and have xmas tree distribution (trunk, upper arms and legs)
- commonest in children and young adults
How should pityriasis rosea be managed? inc when to refer to derm
- reassure it will go in 6 weeks or so
- can give emollients, topical steroids or sedating antihistamines if itching is a problem
- refer to derm if persists> 3 months, severe itch or diagnosis unclear
What is the pregnancy prevention programme for isotetrinoin?
- all females must sign up to it
- at least 1 effective (non barrier) contraceptive for at least 1 month before, during and after (note: isotet interacts with POP)
- pregnancy tests on each hospital visit
What monitoring is needed for isotetrionin and when should it be stopped?
- TFT, lipids 1 month before, 1 month in and 3 monthly while on it
- stop if: TAG>9 (pancreatitis risk), severe skin peeling, haemorrhage diarrhoea, visual or psych disturbances
Describe the course of a chicken pox lesion?
starts as macule then papuple then clear itchy vesicle then crusts
process takes about 8 hrs
need lesions at all stages in one region of body for diagnosis
give 4 complications of varicella zoster infection// chicken pox
- pneumonitis
- meningitis
- pneumonia
- VZ opthalmicus
- cellulitits/ bacterial super infection
- thrombocytopenia
-dehydration/ malnutrition
increased likely hood in smoker, immunocompromised, pregnancy and elderly
How is chicken pox managed in healthy person, pregnancy, neonate, immunocompromised and breast feeder?
Healthy: calamine lotion, paracetamol, chlorphenamine, stay off till lesions crusted over, seek help if complication, cut nails to reduce harm from scratching, keep hydrated, abx if infected
Pregnant: obestetic advise, oral aciclovir and serial USS if have it, IvIg if exposure and no IgG
Neonate: seek specialist advice
Immunocompromised: admit, IVIg, aciclovir
Breast feeding: aciclovir, ?stop feeding
How is shingles managed?
- all get aciclovir unlesss immunocompetent child/ adolescent (rarely happens)
- paracetamol/ nsaids/ neuropathic pain drugs
- vaccine to prevent at 70
- look for hutchinson sign which indicated nasociliary involvement
