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Dermatology Flashcards

1
Q

What is psoriasis?

A

Autoimmune, inflammatory and proliferative skin disease?

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2
Q

What is the epdemiology of psoriasis?

A

Two peaks: young adults, or 60s/70s.

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3
Q

What is the pathophysiology of psoriasis?

A

Abnormal T cell recruitment - cytokine mediated.

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4
Q

What are the sub-types of psoriasis?

A

Chronic plaque
Guttate
Generalised pustular
Palmo-plantar pustular

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5
Q

Which sites of the body are most likely to be affected by psoriasis?

A

Scalp
Face
Flexures
Genitalia

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6
Q

What is the management of psoriasis?

A 
Emollients
Vitamin D analogues (e.g. dovobet)
Topical tar preparations (e.g. exorex lotion)
Topical de-scaling agent
2nd line:
Phototherapy (UVB)
Ciclosporin
Methotrexate
Acitretin
3rd line:
Biological therapy
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7
Q

What are the complications of psoriasis?

A

Arthropathy

Spondyloarthropathy

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8
Q

Which systemic disease is psoriasis linked with?

A

Inflammatory bowel disease
Cardiovascular disease
Non-alcoholic fatty liver disease

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9
Q

What are the 2 main categories of skin cancer?

A

Cutaneous (malignant) melanoma

Non-melanoma

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10
Q

What are the risk factors for malignant melanoma?

A

Skin: type, multiple moles >2mm, atypical moles
UVA and UVB exposure (especially childhood)
Genetics
Increasing age

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11
Q

What is the clinical assessment of a mole?

A

Asymmetry - one half does not match the other half
Border - uneven borders
Colour - variety of colours like brown, tan, or black
Diameter - grows larger than the size of a pencil eraser
Evolution - change in size, shape, colour, elevation, another trait or new symptom

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12
Q

What are the types of cutaneous melanoma?

A 
Superficial spreading
Nodular
Lentigo maligna
Acral lentigrous
Desmoplastic
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13
Q

What is the staging score of a melanoma?

A 
Breslow depth:
<1.0 mm
1 - 2 mm
2-4 mm
>4mm
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14
Q

What is the management of a melanoma?

A 
Lymphatic examination
Wide local excision of biopsy site (1cm margin if <1mm thick, 1-2cm if 1-2mm thick)
If it has spread:
Adjuvant radiotherapy
Immunotherapy
BRAF and MINK inhibitors
Palliative care input
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15
Q

How is TNM classification of a melanoma carried out?

A

Sentinal node biopsy

Imaging (CT-head/CAP)

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16
Q

What is the follow up of a melanoma?

A

Stage 0: no follow up after initial treatment
Stage 1A: 2-4 reviews over 12 month period
Stage 1B-IIC: 3 monthly reviews for 3 years, 6 monthly reviews for 2 years
Stage III >: 3 monthly reviews for 5-10 years

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17
Q

What is a squamous cell carcinoma?

A

Epidermal tumour (arises from keratinising cells or epidermal appendages).

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18
Q

What does a squamous cells carcinoma look like?

A

Nodular keratinising or crusted tumour, that may ulcerate or an ulcer without evidence of keratinisation.

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19
Q

What are the risk factors for developing a squamous cell carcinoma?

A

Fair skin
UV/ionising radiation exposure
Immunosuppresion
HPV infection

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20
Q

What is the management of a squamous cell carcinoma?

A

Cryotherapy
Surgical excision
Radiotherapy
Chemotherapy

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21
Q

What are the risk factors for a basal cell carcinoma?

A

UV exposure
Fair skin
Age

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22
Q

What is the management of a basal cell carcinoma?

A 
Superficial:
Cryotherapy
Topical creams
Excision biopsy
Deeper:
Mohs micrographic surgery
Radiotherapy
Chemotherapy.
Sun protection
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23
Q

What is Bowen’s disease a precursor to?

A

Squamous cell carcinoma

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24
Q

What is actinic keratoses a precursor to?

A

Squamous cell carcinoma

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25
Describe a keratoacanthoma.
Rapid growth | Central depression
26
What is pathophysiology of eczema?
Skin barrier breakdown: - filaggrin gene mutations - defective keratinocytes on outer epidermis Immune dysregulations: - secondary to enhanced antigen penetration through defective epidermal barrier
27
What are the key diagnostic features of eczema?
Itch Onset <2 years old Flexural sites affected Personal or family history of atopy
28
What is the management of eczema?
``` Regular emollients (creams/gels/ointments): applied downwards, in direction of hairgrowth. Ointments less well tolerated, but no preservatives. Bath/shower using emollients (antiseptic/anti-pruritic properties) instead of soaps/gels Avoid coarse clothes/extreme cold/triggers ```
29
What is the management of acute flares of eczema?
Moderate/potent topical steroid e.g. elocon (mometasone) cream - lowest appropriate potency for site/severity, apply steroid cream 30 mins before emollient Antihistamine Consider need for systemic antibiotic
30
Which immunomodulators can be used in eczema?
``` Topical protopic (tacrolimus) and elidel (pimecrolimus). - calcineurin inhibitors ```
31
When should immunomodulators be considered?
If skin atrophy, large surface area affected, skin around eyes affected
32
What are the second line treatments for eczema?
``` Phototherapy Immunosuppressants: - oral steroids - azathiprine - ciclosporin - alitretinoin - monoclonal antibodies ```
33
What are the complications associated with eczema?
Secondary infections: - staph aureus - viral warts - molloscum - eczema herpeticum
34
Describe the presentation of eczema herpeticum?
``` Clustered vesicles/punched out monommorphic erosions Fever Pain Lethargy Rapid progression ```
35
What is the management of eczema herpeticum.
PO aciclovir | Consider opthalmological assessment.
36
What is acne?
Inflammatory disease of pilosebaceous follicle.
37
What percentage of teenagers are affected by acne?
80%
38
What is the pathophysiology of acne?
Hormonally driven: | Flares at start of menstrual cycle/pregnancy
39
Which conditions are associated with acne?
PCOS | Endocrine disturbances
40
What are the modifiable risk factors for acne?
Drugs, especially anabolic steroids. | Cosmetics (oil-based)
41
What are the clinical findings in acne?
``` Greasy skin (seborrhoea) Non-inflamed lesions (comedones) Inflammed lesions (papules/pustules/nodules) Scarring ```
42
What is the first line management of acne?
``` Cleanse no more than twice a day (soap and water) Non greasy moisturiser, if skin dry Topical anti-microbial Topical retinoid Systemic antibiotic ```
43
What is the second line management of acne?
Anti-androgens in females (typically Dianette) Oral isotretinoin (Roaccutane) High dose oral antibiotics Short course of corticosteroids
44
What is the management of scarring due to acne?
Topical silicone gels Topical steroids Ablative and pulsed dye laser therapy Intradermal collagen injections
45
What is rosacea?
Chronic rash involving central face
46
What is the typical onset of rosacea?
30-60 years old
47
What aggravates rosacea?
Facial creams/oils | Topical steroids
48
What is the first line management of rosacea?
``` Avoid topical steroids Avoid oil based moisturisers/make up Sunscreen Tetracycline antibiotics (6-12 week courses) ```
49
What is the second line management of rosacea?
Topics - metronidazole gel or azelaic acid cream/lotion NSAIDs Isotretinoin (usually a lose dose long term to control acne) Anti-flushing agents (clonidine, carvediolol)
50
What is the scarring management in rosacea?
Pulsed light or laser therapy for telangiectasia | Carabon dioxide laser for rhinophyma
51
What is a blister?
A fluid filled lesion: vesicle <5mm bullae >5mm
52
What causes acute onset blisters?
Burn Trauma Allergic Infection
53
What causes chronic blisters?
Autoimmune Inflammatory Metabolic Genetic
54
What is the investigations and management of blistering skin conditions?
A-E management Bloods: inflammatory markers, coeliac serology, autoantibody screen Blood cultures Swabs (bacterial/viral) Porphyrin testing (urine, stool, blood) Skin biopsy (intact blister and normal skin): pathology and direct immunofluorescence
55
What are the commonest aetiologies of blisters?
Infective: - impetigo - herpes simplex - herpes zoster Autoimmune: - bullous pemphigoid - pemphigoid vulgaris Physical: - bites - burns - trauma - inflammatory
56
What is impetigo?
Acute bacterial skin infection with s. aureus
57
What does impetigo look like?
Pustules and honey coloured erosions
58
What is the pathophysiology of impetigo?
Bullae develops due to staph toxins, which target desmosomes
59
Who is most at risk of impetigo?
School-children | Immunosuppressed
60
What are the complications of impetigo?
``` Cellulitis Rheumatic fever Staphylococcal scalded skin syndrome Toxic shock syndrome Post strep glomerulonephritis ```
61
What is the treatment of impetigo?
Anti-septics | Antibiotics
62
What are the two subtypes of herpes simplex?
HSV-1: oral/facial | HSV-2: PV/PR
63
What does herpex simplex look like?
Painful vesicles, ulcers, redness and swelling with fever and lymphadenopathy
64
How can a diagnosis of herpex simplex be confirmed?
PCR viral swab
65
What are the complications of herpes simplex?
Eczema herpeticum Erythema multiforme Meningitis
66
What is the treatment of herpes simplex?
Supportive | Oral/IV antivirals
67
What does herpes zoster (shingles) look like?
Localised, blistering, painful rash.
68
What is the distribution of herpes zoster?
Dermatomal
69
Who gets herpes zoster?
Adults | Immunosuppressed
70
What are the typical areas to get herpes zoster?
Chest Neck Forehead Lumbar/sacral
71
What are the complications of herpes zoster?
Eye Facial nerve palsy Encephalitis Post-herpetic neuralgia
72
What is the treatment of herpes simplex?
Antivirals Capsaicin cream Analgesia
73
What is the pathophysiology of bullous pemphigoid?
Autoantibodies form against antigens between epidermis and dermis
74
Who gets bullous pemphigoid?
Elderly
75
What does bullous pemphigoid look like?
Tense blisters | Erythema
76
Where on the body is bullous pemphigoid found?
Trunk | Limbs
77
What is the treatment for bullous pemphigoid?
Wounds dressings Topical steroids Nicotinamide Immunosuppressants (methotrexate)
78
What are the triggers for bullous pemphigoid?
Spironolactone Neuroleptics UVB
79
What is the pathophysiology of pemphigus vulagaris?
Autoantibodies against epidermal antigens (intra-epidermal split)
80
Who is most likely to get pemphigus vulgaris?
Middle-aged people
81
What does pemphigus vulgaris look like?
Flaccid | Erosions/crusts
82
What is the treatment of pemphigus vulgaris?
High dose oral steroids Immunosuppressants (methotrexate) Plasmapheresis IV-immunoglobulins
83
What are the triggers for pemphigus vulagaris?
Drugs (ACEi) | Paraneoplastic (lymphoma)
84
What is dermatitis herpetiforms?
Extremely itchy rash. | Intact vesicles
85
What is dermatitis herpetiforms exacerbated by?
Gluten
86
What should investigations look for in suspected dermatitis herpetiforms?
IgA anti-endomysial antibody | TTG auto-antibodies
87
What is the treatment for dermatitis herpetiforms?
Dapsone (itching will subside in 48-72 hours) | Gluten-free diet
88
What are the commonest examples of blistering and acute skin failure?
Eczema herpeticum Staphylococcal scalded skin syndrome Severe mucocutaneous adverse reactions
89
Give 5 examples of severe mucocutaneous adverse reactions.
1. Anaphylaxis/angio-oedema 2. Red man syndrome 3. Steven-Johnston syndrome 4. Toxic epidermal necrolysis 5. D.R.E.S.S.
90
Who is most at risk of staphylococcal scalded skin syndrome?
Infants/children Elderly Immunosuppressed
91
What is the pathophysiology of staphylococcal scalded skin syndrome?
Staph release epidermolytic toxins, cleaves the skin high in epidermis
92
What is seen on examination in staphylococcal scalded skin syndrome?
Erythroderma (flexures/periorbital), superficial blisters (differentiates from TEN)
93
What is the treatment of staphylococcal scalded skin syndrome?
Flucloxacillin
94
What are the clinical features of severe mucocutaneous adverse reactions?
``` Airway swelling Wheeze/stridor/dyspnoea Hypotension Pyrexia (<40C) Distress/pain Mucocutaneous - erythroderma +/- scale, swelling, urticaria, erosions, lymphadenopathy Vasculitis: purpura ```
95
What is found on investigation of severe mucocutaneous adverse reactions?
Eosinophilia Lymphocytosis LFTs deranged
96
What is the general management of severe mucocutaneous adverse reactions?
Withdraw offending drug Urgent skin biopsy Supportive management
97
What is the clinical presentation of red man syndrome?
``` Erythema Fushing Itch Angio-oedema Dyspnoea Chest pain Hypotension ```
98
What is the pathophysiology of red man syndrome?
Anaphylactoid (not IgE-mediated) reaction | Histamine release from mast cells/basophils
99
What are typical offending drugs of red man syndrome?
Ciprofloxacin Rifampicin Teicoplanin
100
When does red man syndrome tend to occur?
Several weeks after offending drug started | Can occur acutely (post-vancomycin infusion)
101
What is stevens-johnson syndrome?
Painful, erythematous 'drug rash' with mucosal involvement
102
What is found on examination of stevens-johnson syndrome?
Tender 'erythema-multiforme' like rash. Severe mucosal blistering and erosions May also involve respiratory/GI tract.
103
When does stevens-johnson syndrome or severe epidermal necrosis occcur?
2-3 weeks after drug started
104
Which drugs can cause stevens-johnson syndrome or severe epidermal necrosis?
Allopurinol NSAIDs AEDs Penicillins/cephalosporins
105
What is the diagnostic criteria for D.R.E.S.S. (drug rash, eosinophilia, systemic symptoms)
``` Acute drug rash (variable) Pyrexia >38 Lymphadenopathy Eosinophilia +/- lymphocytosis Systemic involvement (hepatitis, nephritis, pneumonitis, pericarditis, arthritis) ```
106
When does D.R.E.S.S develop?
1-2 months after drug started.
107
Which drugs tend to cause D.R.E.S.S.?
Dapsone AEDs Allopurinol Calcium-channel blockers
108
What is the mortality rate in D.R.E.S.S.?
10%

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