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Year 4 > Dermatology > Flashcards

Dermatology Flashcards

1
Q

What is eczema?

A

Inflammation of the epidermis.
Usually due to a barrier defect, most commonly abnormal Filaggrin. Increased permeability and reduced microbial function.

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2
Q

What are some features of atopic eczema?

A

Symmetrical
in the inner folds such as front of elbow and behind the knees. cheeks and chin.
High levels of IgE

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3
Q

What are some complications of atopic eczema?

A

Bacterial infection

Viral infection - viral warts, molluscum, eczema herpiticum

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4
Q

What features describe seborrhoeic dermatitis and what causes it?

A

Overgrowth of pityrosporum ovale yeast

Chronic scaly inflammation of the face. scalp and eyebrows

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5
Q

What is the pathogenesis of alopecia areata?

A

T cells surround the hair follicles. CD8, NK cells release pro-inflammatory cytokines and chemokines that reject the hair.

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6
Q

What is erythroderma?

A

Intense and usually widespread reddening of the skin due to inflammatory skin disease. Associated with exfoliation.

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7
Q

What skin conditions commonly cause erythroderma?

A

Psoriasis
Drug eruptions
Dermatitis, especially atopic

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8
Q

What are complications of erythroderma?

A

Secondary skin infections such as cellulitis and impetigo
Red skin can cause high out-put heart failure
Hypothermia
dehydration and electrolyte abnormalities

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9
Q

What are sézary cells?

A

Cancerous T cells

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10
Q

What is sézary syndrome?

A

When>20% circulating sezary cells.

Cuatenous T cell lymphoma

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11
Q

What is the pathogenesis of acne?

A
  1. Basel keratinocyte proliferation in pilosebaceous follicle (increased sensitivity to androgens)
  2. Increased sebum production
  3. Propionibacterium colonisation
  4. Inflammation
  5. Comedones block secretions, nodules, cysts, papule.
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12
Q

How would you manage mild acne?

A

Topical Benzoyl peroxide or topical retinoid (e.g. Isotretinoin)
Or topical antibiotics
If poorly tolerated - Azelic acid
Tx takes 8 weeks to be effective

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13
Q

How would you manage moderate acne?

A
  1. Topical antibiotics + Topical benzoyl peroxide (TO REDUCE BACTERIAL RESISTANCE) or Topical retinoid
  2. Oral antibiotics (Lymecyclin, doxycyline, tetracycline) + Topical benzoyl peroxide
  3. Topical Benzoyl peroxide + Topical retinoid
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14
Q

How would you manage severe acne?

A

Refer to a specialist

  • Isotretinoin (oral retinoid, conc Vit A) PO 500mcg in 1-2 divided doses daily. 16 week course
  • Reduced sebum production and pituitary hormones
  • SE - dry skin and lips, myalgia, nose bleeds, teratogenic, depression, deranged LFTs
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15
Q

What is though to cause Rosacea?

A

High concentration of Cathelicidins, a normal antimicrobial peptide which causes infiltration of neutrophils into the dermis and vasodilation.
Neutrophils then releases nitric acid to further VD
Fluid from leaky vessels - oedema and pro inflammatory cytokines - increases inflammation, thickened, hardened skin
MMPs activate cathelicidins, such as collagnase and elastase
–> Cutaneous inflammation and thick hardened skin

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16
Q

What are some clinical features of Rosacea?

A

‘Chronic rash involving the centre of the face. Common in those with fair skin, blue eyes, Celtic origin
Red face - persistent redness or telangiectasia
Dry, flaky skin. Flushing of skin
Red papule/pustules on forehead, nose, cheeks and chin
Rhinophyma (nose)
Blepharophyma (eyelids) - conjictivitus, keratitis
Aggrevated by sun exposure and hot and spicy food and drink. and topical steroids, make up etc
Burning and stinging

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17
Q

Urticaria can be characterised by wheals ± angiodema, explain what these mean?

A

Wheal - Superficial ,skin coloured or pale skin swelling, usually surrounded by erythema, lasts from few min - 24hr Itchy & burning sensation. Few mm - cm, Widespread

Angioedema - Deeper swelling within skin or mucous membranes, can be red or skin coloured and usually resolves within 72hr. Itchy, painful, usually asymptomatic. Localised - Hands, feet, genitals, face

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18
Q

What causes wheal and angiodema in the skin? (Think of chemicals etc)

A

In wheals, histamine, platelet activating factor and cytokines are released from basophils and mast cells. These activate sensory nerve which cause VD of the BV and so leakage of fluid into the surrounding tissues.

Angioedema is caused by bradykinin release

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19
Q

What is acute and chronic urticaria?

A

Acute < 6 weeks duration and usually resolves within hours to days
Chronic > 6 weeks and usually episodic or daily wheals

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20
Q

What rash is associated with an Islet cell tumour of the pancreas?

A

Necrolytic migratory erythema
AKA glucagonoma syndrome
Erythematous, scaly plaques on acral, periorifical and intertriginous areas

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21
Q

What rash is described as ‘Reddened concentric bands of whorled woodgrain pattern’ and what is it linked to?

A

Erythema gyratums repens
Lung cancer*
But also breast, cervical and GI

Pruitis and peripheral eosinophilia

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22
Q

What is Acanthosis nigricans and its types?

A

Smooth, velvet like hyperkeratotic plaque on the intertriginous areas.
Type 1 - Adenocarcinoma usually gastric cancer - sudden onset and more extensive
Type 2 - familial, AD, no malignancy, present at brith
Type 3 - Obesity and insulin resistance - most common

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23
Q

What skin change may indicate ovarian cancer?

A

Erythema annular (red ring like pattern)

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24
Q

What is sweets syndrome?

A

Also known as acute febrile neutrophilic dermatosis.

Present with a fever and inflamed and blistered skin and mucosal lesions, indicating leukaemia could be present

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25
Q

What skin changes occur in Vit B deficiency? (B6, B12, B3)

A

B6- Pyridoxine - Dermatitis
B12 - cobalamin - Angular cheilitis
B3 - Niacin - Pellagra - Dermatitis, dementia and diarrhoea

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26
Q

What skin change can occur in Zinc deficiency?

A

Acrodermatitis enteropathica
Mutation in SLC39A - an intestinal zinc transporter
Pustules, bullae and scaling in acral and perioral regions

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27
Q

Typically cellulitis is caused by strep pyogenes, what antibiotic would you use to treat it?

A

Ampicillin or Flucloxacillin

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28
Q

Pus forming cellulitis may be caused by s.aureus or MRSA, what antibiotics would you use for these?

A

S.aureus - Flucloxacillin

MRSA - Vancomycin

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29
Q

What organisms can cause Necrotising fasciitis and what treatment and antibiotics would you use?

A

Strep e.g. pyogenes, staph e.g. aureus, E.coli, Pseudomonas, clostridium perfringes
Fluid resus
IV Abx - Come Feel My Penis Girl
Clindamycin, flucloxacillin, metronidazole, penicllin, gentamicin,
SURGERY - debridement

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30
Q

What is Necrotising fasciitis?

A

A rapidly spreading infection of the subcutaneous fascia, over hours. Toxin mediated.
A medical emergency

Initial pain becoming painless, 
Rapid spread, 
Systemically unwell. 
Colour change from red-purple to dusky blue/grey with necrosis. 
May have skin crepitus
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31
Q

What is Erysipelas?

A

Superficial form of cellulitis involving the upper dermis and superficial lymphatics.
Involves ears - Milians ear sign. Can cause a Butterfly rash
Streptococcal Pyogenes - Elevated levels of anti-streptococcal antibody titre at 10days

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32
Q

What is impetigo?

A

Staphylococcal infection of the epidermis
Honey coloured crust, usually perioral
1. Remove crust gently
2. Flucloxacillin

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33
Q

What might you suspect in a patient with recurrent or multiple boils?

A

PVL producing Staph aureus

PVL toxin destroys WBC

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34
Q

What might a scarlet fever rash look like and why might it occur?

A

Occurs after a sore throat or impetigo
Group A strep exotoxins or erythrogenic toxins
Tiny pink/red spots covering the whole body.
Strawberry tongue, fever
Occlusion of sweat glands give it a sandpapery touch

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35
Q

What is acne fulminans?

A

A severe sudden onset ± fever and arthralgia

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36
Q

What treatment is used in severe acne vulgaris?

A 
Oral Isotretinoin (Oral retinoid) 
Concentrate form of Vitamin A
Reduces sebum plugging and bacteria 
16 week course 
SE - nose bleed, dry lips, dry skin, myalgia
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37
Q

What is Psoriasis?

A

Chronic relapsing, remitting scaly skin disease.
might have PSORS gene on Chromosome 6
Overproduction of skin cells - Red, scaly patched.
T cell mediated AI - produces inflammatory cytokines increasing Keratinocyte proliferation.

38
Q

What is it called when psoriasis forms at the point of scars and trauma?

A

Koebner phenomenon

39
Q

What treatment is available for psoriasis?

A
  1. Topical therapy and creams
    - Vit D analgoue (Slow keratinocyte proliferation& coal tar)
    - Steroids - Reduce redness, inflammation and itching
    - Moisturiser to reduce dryness and flaking
    - Salicyclic acid (dissolve thick, dead skin)
  2. Phototherapy (UVB)
    - Reduced T cell proliferation, encourages Vit D and reduced skin turnover
  3. Systemic therapy
    - Immunosuppression: Methotrexate or cyclosporin
    - Dimethyl fumerate
    - Apremilast
    - Acitretin (Oral retinoid)
  4. Biologics
    - Adalimumab (anti-TNF) or Ustekinumab (anti-IL12/23)
40
Q

What pathways may lead to skin cancer?

A
  1. Direct effects of UV damage on keratinocytes and neoplastic transformation due to damaged DNA
  2. Effects of UV on the immune system
41
Q

What is the most common type of skin cancer and what is the mutation?

A

Basal cell carcinoma
Slow growing on the face. Due to basal Cell DNA mutation
PTCH gene may predispose

42
Q

What treatment is available for basal cell carcinoma?

A

Gold standard - Surgery 3-4mm margin
Curettage and Cautery - scrap and apply heat
Cryotherapy - freeze it
Photodynamic therapy - stimulate bodies immune system
Topical imiquimod / 5-FU - stimulate bodies immune system to target tumour cells
Mohs micrographic surgery - microscope checks margins

43
Q

What are the subtypes of basal cell carcinoma?

A
  1. Nodular: >0.5mm raised, shiny, central ulceration, telangiectasia
  2. Superficial: flat, broken lightening bolt vessels
  3. Pigmented: shiny, pigmented, curved edges
  4. Morphoeic/sclerotic - harder to see
44
Q

What is the second most common skin cancer?

A

Squamous cell carcinoma
Arises from keratinocytes
Scaly, yellow, keratin crust
Occurs on areas regularly exposed to sunlight to UV
Risk of mets 10-30% to ears, lips or burns

45
Q

What skin cancer has premalignant variants and what are they?

A

Squamous cell
Actinic keratosis - crumbly, yellow, white crust
Bowens disease - red/brown scaly plaque (e.g. on lower legs)

46
Q

How would you treat Squamous cell carcinoma?

A

Gold standard - Surgery - 4mm margin

47
Q

Mutation to what cells can cause melanoma?

A

Melanocytes
BRAF or NRAS
Spread via lymphatics

48
Q

How can you stage a melanoma?

A 
Clarks staging and breslows thickness. 
For 5 year survival 
Stage 1 = Epidermis
2 =  into the papillary dermis
3 = into papillary - reticular junction 
4 = into the reticular dermis
5 = into the subcutaneous tissue
49
Q

What is the most common type of melanoma?

A

Superficial spreading malignant melanoma

50
Q

What is the premalignant melanoma called?

A

Lentigo maligna - pigmented

51
Q

What systemic therapy can you use in treating melanoma?

A

Pembrolizumab

52
Q

What treatment can you use in melanoma?

A

Surgical excision (<1mm breslow thickness - 1cm margin, >1mm - 2cm margin)
Immunotherapy - Ipilimumab, Nivolumab
Biologica - Debrafanib - BRAF inhibitor

53
Q

What causes Erythema infectiosum and what is it also known as?

A

Fifths disease (slapped cheeks)
Human parvovirus B19 via respiratory droplets
Runny nose, fever, headache, pruritic rash

Arthropathy, glove and socks syndrome characterised by popular, purpuric eruptions in the hands and feet.
Acute cessation of RBC production - Aplastic crisis, chronic red cell aplasia, hydrops fetalis, congenital anaemia

54
Q

What causes hand, foot and mouth disease?

A

Coxsackie Virus A16
Highly contagious virus in the first few weeks
Oral and distal extremities affected
Fever, headache, oropharyngeal ulcers, sore throat, loss of appetite, rash

55
Q

What rash characterises measles?

A

3 days into infection - Koplik spots (on buccal mucosa)
3-5 days = Maculopapular rash
Starts on face and hair line as flat spots

56
Q

Where does the herpes simplex virus remain latent?

A

Sensory nerve ganglia

HSV rash- Vesicular and painful

57
Q

Where does the varicella zoster virus causing shingles remain dormant?

A

Dorsal root ganglion

Dermatomal distribution

58
Q

What are some primary skin lesions/ Derm terms?

A

Macule - flat, not raised, less than 1cm e.g. petechia
Patch - flat, not raised, greater than 1cm e.g. vitiligo
Plaque - flat, elevated, greater than 1cm e.g. psoriasis
Papule- elevated, solid, less than 1cm e.g. angioma, wart
Nodule - elevated, solid, greater than 1cm e.g. epidermal inclusion cyst
Pustule - elevated, pus filled, less than 1cm e.g. acne
Vesicle - elevated, fluid filled, less than 1cm e.g. herpes
Bulla - Elevated, fluid filled, greater than 1 cm e.g. bullous pempighoid

59
Q

What are secondary skin changes?

A

As a result of scratching, inflammation or the break down of skin.
Excoriation, crust, scale, ulcer, fissure, lichenification, striae, scar

60
Q

What is a rash?

A

A collection of multiple primary skin lesions ± secondary skin changes
4 main types:
Maculopapular, erythematous, vesico-bullous, petechial/purpura

61
Q

What is the cause of a salmon pink patches affecting the upper back that only appears when pyrexial?

A

Adult onset stills disease -

Inflammatory arthritis - Rash, Fever and joint pain (particularly wrists)

62
Q

What is a Herald patch, and what is it seen in?

A

A single plaque appearing 1-20days before the generalised rash.

Pityriasis Rosea - Viral rash lasting 6-12weeks. Following an URTI. In teens and young adults.
Oval, pink, scaling, edge looks like a collaret

63
Q

What is Kawasaki disease?

A

Medium vessel vasculitis!
Acute febrile illness with inflammation of the small and medium blood vessels particular the coronary arteries.

Fever, swelling of hands and feet, lymphadenopathy, oral or ocular signs

64
Q

How would you describe SJS?

A

< 10% of the body surface area affected plus widespread erythematous/ purpuric macular rash or flat atypical targets

65
Q

What scoring tool is used in SJS and TEN?

A

SCORTEN -

HR, age, presence of malignancy, urea, glucose, bicarbonate, % epidermal detachment

66
Q

What is the SJS TEN over lap?

A

10-30% body surface area involvement with widespread purpuric macules or flat atypical targets

TEN >30% epidermal detachement

67
Q

What are the 5 patterns of psoriatic arthropathy?

A 
Asymmetrical mono- or oligoarthritis 
Symmetrical poly arthritis 
Spodyloarthritits
Distal interphalangeal arthritis 
Arthritis Mutalins
68
Q

What nail signs do you need to look out for in psoriasis?

A

Pitting, onycholysis, subungual hyperkeratosis, leukonychia, oil drops (yellow orange spots)

69
Q

What are the patterns of psoriasis?

A

Plaques (most common)
Erythrodermic
Guttate (often triggered by strep throat, numerous small red patches. in children and adolescents)
Flexural - Anogenital fold and submammary axilla. Pink/red, may have superimposed candida
Palmoplantar - scaling on palms and soles
Pustular - generalised pustular psoriasis is a dermatological emergency

70
Q

What is a concern about severe allergic urticaria?

A

May lead to anaphylactic shock - broncospam and collapse

71
Q

What is Vasculitis?

A

An AI, inflammatory disease of the blood vessel walls causing destruction (aneurysm or rupture) or stenosis

72
Q

What are the ANCA associated vasculitis’?

A

Granulomatosis with polyangitis
Eosinophilic grnaulomatosis with polyangitis
Microscopic polyangitis

73
Q

What are some clinical features seen in Giant cell arteritis?

GCA - Rare < 50, peak 70-79
Females

A

Temporal headache with tenderness - noticed scalp tenderness when brushing hair
Jaw claudication - pain on chewing, relieved when stop
Polymyalgia Rheumatica
Visual symptoms - complication: Acute ischaemic optic neuritis - SUDDEN PAINLESS IRREVERSIBLE VISUAL LOSS - interrupted flow in the posterior ciliary artery - isachamia of the optic nerve
Constitutional upset - Weight loss, fever, myalgia, malaise

74
Q

What investigations can you do for Giant cell arteritis?

A

Look for Temporal artery asymmetry, thickening, loss of pulsility?
GOLD STANDARD - Temporal artery biopsy - Remove a long segment as the internal elastic lamina has interrupted* inflammatory infiltrate such as multinuclear giant cells. Segmental*
Temporal artery USS - Hypoechoic halo sign

75
Q

How would you manage giant cell arteritis?

A

If suspected IMMEDIATELY start steroids to prevent progression to visual loss!!
60mg Prednisolone for 1 month then try to taper to 15mg by 12 weeks, then try stop by 1-1.5y
If relapse - Methotrexate, tocrilizumab (anti-IL-6), mycophenolate mofetil

76
Q

What is a small vessel vasculitis that can be seen in children and is ANCA negative?

A

Henoch- Schönlein Purpura - IgA vasculitis
Triggered by an URTI. Self-limiting 4-16weeks
Seen in children, but mean age 43, M>F
IgA depositions in BV

Palpable purpura on bum and legs
Joint pain - arthralgia
Abdomina pain, Diarrhoea
Renal involvement - IgA nephropathy

77
Q

What is characteristic about granulomatosis with polyangitis or Wegners granulomatosis?

A

TRIAD: Involved Upper and lower respiratory tract and kidneys. -
Granulomatous necrotising inflammatory lesions of the URT (e.g. rhinitis, chronic sinusitis, saddle nose deformity) and LRT (alveolar haemorrhage)
Pauci-immune glomerulonephritis
ANCA positive - PR3 (c-ANCA)
Constitutional Sx.

78
Q

What does p-ANCA with strong MPO suggest?

A

microscopic polyangitis or eosinophilic granulomatosis with polyangitia

c-ANCA with strong PR3 - GPA

79
Q

How would you manage GPA?

A

In severe disease
Induction (3-6 months)
Prednisolone + cyclophosphamide
Maintenance (2+ years) - Methotrexate, azathioprine or mychophenolate mofetil

Non-severe - induction (3-6m) Methotrexate + Pred
maintenance - methotrexate

80
Q

What is cellulitis?

A

A bacterial infection of the lower dermis and the subcutaneous tissue.
Strep progenies, Staph aureus
Risks- Diabetes, CKD, CLD, alcoholism, obesity, HIV, tattoos, bites, venous insufficiency, burns

Red, painful, swollen skin with systemic Sx (bacteraemia, first presentation of cellulitis may be unwell - rigors, fever, chills, before becoming a localised skin lesion)

81
Q

What organism might cause cellulitis due to entry through a puncture wound?

A

Pseudomonas aeruginosa

82
Q

What are some complications of severe or rapidly progressive cellulitis?

A 
Necrotising fasciitis 
Gas gangrene 
Severe sepsis 
Infection - pneumonia, osteomyelitis, meningitis
Endocarditis
83
Q

What clinical features are seen in cellulitis?

A

Peu d’orange, warmth, blistering, abscess, purpura, erosion and ulceration, abscess formation

84
Q

What is an abscess?

A

A collection of pus surrounded by a pyogenic membrane

Red, hot, tender swelling. Its generally unwell

85
Q

What is a leg ulcer?

A

A full thickness loss of the leg below the knee or foot due to any cause that usually takes > 2 weeks to heal.
Arterial, venous, neuropathic, pressure

86
Q

What are the risk factors for leg ulcers?

A

Chronic venous insufficiency, chronic arterial insufficiency, Diabetes, HTN

CVI - improper functioning of valves, reflux, poor pumping action of calves - pooling of blood. Inc venous pressure - fibrin deposits around cap, barrier to flow of O2 and nutrients - ulceration

CAI - poor circulation to lower foot and leg due to Atherosclerosis - narrowing, fail to deliver blood and nutrients to tissue - death of tissue - ulcer

87
Q

Describe venous and arterial ulcers.

A

Venous - Between lower calf and medial malleolus. Associated with varicose veins, lipodermatosclerosis, phlebitis, DVT. Shallow and flat, mod-heavy exudate, slough and granulation tissue. Haemosiderin stained, thickened skin. Painless. Relieved when resting and elevated. Compression banding helps.

Arterial - Feet, heels, toes. Atherosclerosis. Punched out deep with irregular borders, some necrotic tissue. Little exudate. Reduced or absent pulses, reduced CRT, shiny, pale, cool, hairless skin. Intermittent claudication. Painful, esp at night when legs at rest and elevated. Relieved with feet on floor when gravity allows better blood flow. Revascularise, anti-platelets, Tx risk factors

88
Q

What is a pressure ulcer?

A

Caused by uninterrupted pressure on the skin leading to ulcers and extensive, painful SC destruction, e.g. on heel, sacrum, greater trochanter and elbows
Implicating factors:
- Shearing forces from sliding down the bed
- Moisture from incontinence
- Friction when dragged across a bed sheet

89
Q

What is a complication of a pressure ulcer?

A

Osteomyelitis

90
Q

What are the types of burns?

A

Superficial/1st - Epidermis only - dry/red, painful, blanched on pressure. healing <7days
Partial thickness/2nd - Epidermis and dermis - painful, blisters, heals <21d, Abx/surgery/graft
Full thickness/3rd - to subcutaneous tissue - non-blanching, painless - surgery
4th degree - to muscle/bone/fascia - surgery

91
Q

What is bullous pemphigoid?

A

Chronic blistering disorder. in Elderly
IgG to hemidesmosomes, Subepidermial bullae on a erythematous or utricarical base
Associated with stroke or dementia

92
Q

What is bullous pemphigus?

A

In younger people - Due to ACEi, NSAIDs

IgG to desmosomes so keratinocytes separate

Year 4 (14 decks)

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