Dermatology Flashcards

Question

State 3 examples of emollients that may be used in eczema

Answer 1

* Work by reducing inflammation: decreased redness & itching * Steroid ointments= more oily therefore better for treating dry skin * Wash hands * Apply fingertip amount (last crease of finger to tip) this is enough to treat an area of skin the size of two hands with fingers together * Avoid applying steroids with emollients as this will dilute steroids * Wash hands afterwards

Answer 2

* Skin thinning (if use correctly risk is very low) * Weight gain (risk low as topical not systemic)

Answer 3

* Explain how emollients work: form layer on top of skin that prevents water loss and helps to keep skin moist * Diff types: (least water) ointments, creams and lotions (most water) * Always was or dry hands thoroughly * If emollient in tub, use spatula or clean spoon to decant emollient to prevent introduction of bacteria into tub * Apply in stroking motion in direction of hairs * How much: depends- if dry skin more the better. OFten advised 4/5 times a day if very dry.

Answer 4

Acneiform eruptions refer to the presence of one or more of the classical features of acne vulgaris. Those are comedones, papules, pustules and nodular cysts.

Answer 5

* Chronic, inflammatory skin condition affecting mainly **face, back and chest**; charcterised by **blockage and inflammation of pilosebaceous unit**. Presents wtih lesions that can be non-inflammatory (comedones), inflammatory (papules, pustules, nodules) or both. * Common in **adolescents**

Answer 6

* Follicylar hyperkeratinisation * Propionibacterium acne colonisation * Increased skin sebum production * Complex inflammatory response involving both innate and acquired immunity

Answer 7

* Rosacea * Perioral dermatitis * Folliculitis and boils * Drug induced acne * Keratosis pilaris

Answer 8

* Comedones * Open= black heads * Closed= white heads * Papules * Pustules * Nodules or cysts which are often deeper palpable lesiosn which are painful and fluctuant * Scarring * Pigmentation (depigmentation post inflam or hyperpigmentation) * Seborrhoea

Answer 9

* Mild= predominatly non-inflammed lesions * Moderate= more widespread with increased number of inflammatory lesions * Severe= widespread inflammatory lesions. Scarring may be present

Answer 10

Drugs: * Corticosteroids * Isoniazid * Ciclosporin * Lithium * Androgens Underlying conditions: * PCOS

Answer 11

* Advice: * Don't overclean face * Gentle cleansers * Avoid picking & squeezing spots * Healthy diet * Pharmacological: * _Comedonal acne:_ **topical retinoid** e.g. adapalene * _Mild inflammatory lesions:_ **topical antibiotics** (e.g. clindamycin or erythromycin), **topcial retinoids** & **topical benzoyl peroxide**. *Topical antibiotic ALWAYS presribed with benzyole peroxide.* **Azelaic acid may also be used as an adjunct/** * _Moderate inflammatory lesions:_ add **oral antibiotic** e.g. tetracycline & consider **anti-androgens or COCP** * _Severe, scarrring or treatment resistance:_ **dermatology review** & additional treatment e.g. **oral isotretinoin**)

Answer 12

* Comedolytic and anti-inflammatory. They **normalize follicular hyperproliferation and hyperkeratinization**. Topical retinoids reduce the numbers of microcomedones, comedones, and inflammatory lesions. * Examples include: **adapalene, tazarotene, and tretinoin** * Think stratum corneum & have been associated with photosensitivity therefore **advise on sun protection**

Answer 13

* Alopecia * Dry eyes * Headache * Arthralgia * Anaemia Need monitoring of LFTs and lipids

Answer 14

* Conglobate acne= extensive papules and nodules which coalesce to form sinuses & cysts on trunk & upper limbs * Acne fulminans= sudden severe inflammatory reactin with deep ulcerations and sometimes systemic effects e.g. pyrexia and athralgia

Answer 15

Chronic, inflammatory, relapsing skin condition predominantly affecting the convexities of the centrofacial region _Signs & symptoms:_ * Phymatous changes * Persistent erythema * Telangiectasia * Erythema acoss nose, cheeks, forehead and chin that comes and goes (facial flushing) * Burning or stinging sensation when using water or other products on face * Occular roseacea: *eye discomfort, dryness, itching, photophobia, blurred vision, chalazion*

Answer 16

Aged 30-50yrs, more common in those with fair skin

Answer 17

Rosacea should be diagnosed and managed using a 'phenotype approach', based on the presenting features in each person if there is at least one 'diagnostic' or two 'major' clinical features present: * _Diagnostic features_ — **phymatous changes, persistent erythema** * _Major features_ — **flushing/transient erythema, papules and pustules, telangiectasia, eye symptoms** (ocular rosacea) * _Minor features_ — **skin burning and/or stinging sensation, skin dryness, oedema**

Answer 18

* _Education & lifestyle_: * Identify & avoid triggers * Sun protection * Signpost to sources of information * Eyelid hygiene information & lubricating drops * Camouflage creams * _Papulopustular lesions:_ * Topical ivermectin * Plus oral antibiotics if severe (e.g. tetracycline or erythromycin) * _For erythema:_ * Topical brimonidine * _Referral to dermatologist, plastic surgeon or opthalmologist (if suspsect keratitis) for specialist treatment_ e.g. CO2 laser ablation for rhinophyma

Answer 19

* **Allergic contact dermatitis:** *type IV hypersensitivity reaction to contact with allergens. Prior sensitisation needed.* * **Irritant contatct dermatitis:** *non-immunological localised skin reaction due to direct contact with irritant. No prior sensitisation needed.*

Answer 20

Irritatnt contact dermatitis (80%)

Answer 21

Allergy to nickel (e.g. in jewellery)

Answer 22

* **Pruritic erythemmatous scaly rash** * Usually develops **hours-days** after contact with irritatnt * **Location of rash** helps identify irritant e.g. cosmetics & eyelids, jewellery and fingers, wrists etc... Common causes: cosmetics, topical medications, rubber additives, epoxy resin adhesives, plants

Answer 23

* **Skin patch testing** (patch tests with suspected allergens applied to skin and observe for reaction) * \*NOTE: latex allergy is diagnosed with skin prick testing as it causes a type I hypersensitivity reaction (contact uritcaria) which presents within minutes of contact*

Answer 24

1. **Identify & avoid stimulus** 2. If **acute** contact dermatitis, use **emollients** liberally and **topical corticosteroids** *(increase potency if response is poor)* and **consider short term systemic steroids in severe** cases 3. **Identify & treat any secondary infection** 4. **Phototherapy & immunosupressants** e.g. ciclosporin, methotrexate 5. Advice to speak to **health & safety/occupational health** if it is occupational contact dermatitis

Answer 25

* Skin prick testing: detects type I hypersensitivity * Skin patch testing: detetecs type IV hypersensitivity

Answer 26

* Usually presents within **48hrs of exposure** (to either strong irritants or repeated exposure to weak irritants) * **Erythematous scaly rash** on site of exposure * Rash usually **burns & stings** ***Common causes: water, detergents, soaps, solvents, machining oils, reducing agents, acids, soil, dust***

Answer 27

*\*\*\*SIMILAR TO ALLERGIC CONTACT DERMATITIS* 1. Identify & avoid stimulus 2. If acute contact dermatitis, use emollients liberally and topical corticosteroids (increase potency if response is poor) and consider short term systemic steroids in severe cases 3. Identify & treat any secondary infection 4. Advice to speak to health & safety/occupational health if it is occupational contact dermatitis 5. Consider skin patch testing if think allergic contact dermatitis

Answer 28

* Chronic, inflammatory relapsing skin disorder with a predilection for regions that are rich in sebaceous glands e.g scalp, chest, nasolabila folds, eyebrows... * Common in children \<3 months (cradle cap) and adults 30-60, more commonly in those with HIV and Parkinson's disease. More prevelant in winter * Presentation: * Scaly erythemaouts patches/plaques associated with mild dandruff or dense adhesive scale in seborrhoeic regions * In infants (cradle cap) look like large, greasy yellow brown scales-crusts * Infantile disease usually clears in few weeks whereas in adults it is chronic relapasing

Answer 29

* Wash scalp regularly with baby shampoo * Brush scalp gently with soft brush * Scales can be soaked in olive oil, baby oil or petroleum jelly * Topical imidazole (e.g. clotrimazole) if above doesn' work

Answer 30

_Scalp_ 1. **First line= ketoconazole 2% shampoo** *(can also use selenium sulphide shampoo or shampoo containing salicyclic acid or coal tar)* 2. **Second line=** **add in topical corticosteroid if severe itching for max of 4 weeks** *e.g.betamethasone valerate 0.1%* _Face & Body_ 1. **Topical imidazole e.g. ketoconazole** 2. **Add in mild corticosteroid e.g. hydrocortisone 0.5% for short duration**

Answer 31

* Eczema associated with **chronic venous insufficiency** * Exact mechanism unknown but thought that venous hypertension results in blood constituents leaking into surroudning tissues resulting in activation of inflammatory cells and fibroblasts * Risk factors: obesity, physical inactivity, hypertension, diabetes, older age, PMH DVT * Presents as **erythematous scaly rash involving gaiter** regions * Investigations: * Peripheral cardiovascular examination; palpate for pedal pulses to assess for arterial insufficiency * Ankle-brachial index * Venous duplex ultrasound to confirm venous insufficiency * Swabs if think secondary bacterial infection present * Management: * **General advice** e.g. elevate legs, lifestyle changes * **Emollients** * **Topical steroids for acute flares** * **Venous compression stockings** (once ruled out arterial insufficiency) * Treat any **secondary bacterial infections with antibiotics**

Answer 32

* Psoriasis is an immune mediated, inflammatory genetic disorder mainfesting in the skin, or joints or both; typically has a relapsing & remitting course * Epithelial hyperproliferation resulting in improper maturation of epithelial cells of skin which is mediated by macrophages, dendritic cells, T cells, cytokines etc...

Answer 33

* Stress * UV light * Smoking * Alcohol * Drugs e.g. corticosteroid withdrawal, beta blockers, lithium * Hormonal changes * Trauma *(Koebner phenomenon is when psoriatic lesions occur at injury site- including sunburn)*

Answer 34

* Psoriatic arthritis * Metabolic syndrome * Inflammatory bowel disease (particularly Crohn's disease) * Anxiety and depression.

Answer 35

Streptococcal URTI

Answer 36

* **Chronic plaque psoriasis:** well demarcated erythematous plaques covered by silvery white scales often found on extensor surfaces, scalp, retroauricular, perianal and periumbilical regions. Lesions are usually asymptomatic. * **Inverse/flexural psoriasis:** affects flexural regions. Usually less scaley due to moisture at these sites. * **Guttate psoriasis:** scaly, raindrop-shaped plaques on the trunk commonly following a streptococcal URTI * **Pustular psoriasis:** white coalescing pustules which can be localised e.g. hands & feet or generalised * **Erythrodermic psoriasis:** when psoriasis affects \>90% of body- potentially life threatening * **Nail psoriasis:** thickening of nail plate, pitting, ridging, oncholysis, subungal hyperkeratosis

Answer 37

* **Examine full body** *(including scalp, nails, retroauricular, periumbilical & perianal regions)* * **Assess for psoriatic arthritis** * **Consider assessing for features of metabolic syndrome (e.g. check bp, diabestes screen etc...) as often associated with psoriasis** * Use **PASI** (psoriasis area & severity index score) to assess severity * Use **DLQI** (dermatology life quality index) questionnaire may be done to assess impact of psorasis on this patient

Answer 38

* **General lifestyle advice:** * Weight reduction * Smoking cessation * Avoiding triggers * **Management of associated conditions** e.g. stress & anxiety _Pharmacological_ * **Emollient use** * _First line:_ **Po****tent topcial steroid & topical calcipotriol (vit D analogue)** * _Second line:_ **if above doesn't work, stop topcial steroid and continue calcipotriol cream** * _Third line:_ **other topical treatments e.g. coal tar, dithranol cream** * _Fourth line:_ refer to specialist for specialist treatments e.g. phototherapy (narrow band UVB), ciclosporin, methotrexate. They may also try biologics e.g. adalimumab *

Answer 39

Urgent referral to dermatology

Answer 40

* Ciclosporin: hypertension & renal toxicity * Methotrexate: hepatotoxicity & bone marrow supression

Answer 41

* Self-limiting skin condition characterised by erythematous oval scaley eruption predominantly affecting the trunk * Young adults (10-35yrs), females \> males * Typical presentation: * Usually, but not always begins as a herald patch (salmon coloured plaque/patch with peripheral collarette scaling * Within days to 3 weeks multiple smaller lesions of similar appearance develop over turnk & proximal limbs symmetrically. Lesions follow Langer lines giving christmas tree appearnce on back and V shape on upper chest * Some pts may have mild pro-dromal period with flu like symptoms * May be pruritic

Answer 42

For most people with pityriasis rosea, **no treatment is required.** The rash may worsen before it resolves, with new crops of lesions continuing to appear for up to 6 weeks. It will usually settle without treatment within **2–3 months, but may take up to 5 months to disappear.** If itchy, can offer an **emollient, sedating antihistamine or mild topical corticosteroid** (if severe itch). Canr refer to dermatology and they may do phototherapy but htis only shortens course of disease by a few weeks. **Pregnant women must be urgently referred to secondary care** as in the first 15 weeks of pregnancy it has been associated with adverse outcomes including miscarriage and premature delivery.

Answer 43

Show diretion of the lowest naturally occuring skin tension. Incision along langer lines results in better wound healing.

Answer 44

* Chronic inflammtory disease that involves **skin, scalp, mucous membranes & nails** * Predilection for **african americans** * Considred to be **T cell mediated**; these attack altered self antigens which are expressed on babsal keratinocytes. Associated with hep C vrius and some drugs e..g antihypertensives, antibiotics

Answer 45

Cutaneous lesions are described the 6 P's; **pruritic, planar** (flat topped), **purple, polygonal, papules** or **plaques:** * Pruritic, flat topped papules & plaques covered by **Wicham striae** (white reticular lines) involving extremeties e.g. ventral wrists, forearms, ankles, legs, oral cavity, genitalia * Displays Koebner phenomenon * Nail changes: longitudinal riding, scaring, splitting * Scalp involvement may lead to scarring alopecia

Answer 46

* Superficial swelling of skin (epidermis & mucous membranes) that results in red, raised, itchy rash * May be idiopathic, immune mediated (IgE, autoimmune or immune complex mediated) or non-immune mediated. Can be triggered by foods, stiings/bites, drugs, physical stimuli, chemicals etc..

Answer 47

Urticaria can be classified according ot its duration: * Acute: \< 6 weeks * Chronic: \>6 weeks Chronic urticaria can then be further classified: * Chronic spontaneous urticaria (chronic idiopathic urticaria): no identifiable external cause but may be aggravated by heat, stress, drugs and infections * Autoimmune urticaria: IgG autoantibodies to the high affinity receptor for IgE FceR1. * Chronic inducible urticaria (physical urticaria): occurs in response to physical stimuli and can be further classified according to it's cause e.g. solar, cold, heat,, delayed pressure, contact, aquagenic etc...

Answer 48

* Time of onset * Frequency, duration and pattern on recurrence of weals * Triggers: exlpore occurence in relatio to menstrual cycle, foreign travel, work, hobbies etc.. * Treatments tried and response * If the weals are itchy or painful * Family history of urticaria or atopy * Co-exisiting conditions * Any GI symptoms

Answer 49

* Transient (resolves 24hr) * Non-scaley, smooth plaques with surrounding erythema * May be associated with angioedema & anaphylaxis

Answer 50

* Skin prick testing reserved for pts with a history that suggests IgE mediated * For spontaneous urtiaria (idiopathic chronic) consider tests such as FBC, ESR, TFTs, LFTs to help identify underlying cause e.g. autoimmun thyroiditis, lupus * Urticarial vasculitis require biopsy and vasculitic screen

Answer 51

* **Identify & avoid triggers** * **Non-sedating antihistamine** *(can double standard of the licensed dose i.e. give off-label- this is widely practiced)* * **Try an alternative non-sedating antihistamine** * **Adding topical antipruritic agent e.g. calamine lotion** * **Add sedating antihistamine at night if interfering with sleep** * If **severe give short course of oral corticosteroids** * **Refer to dermatologist** if vasculitic urticaria is suspected (if urticaria is painful & persistent) or if food or latex allergy or form of CINDU that may be difficult to manage in primary care e.g. solar or cold uritcaria * If have food allergies or anaphylaxis refer to immunologist

Answer 52

* BCC is slow growing, locally invasive epidermal skin tumour arising from the basal cell * Accounts for 80% of all skin cancer * Risk factors: * Fitzpatrick skin types I & II * UV exposure * Increasing age * Male * Smoking * Immunosuppresion

Answer 53

Basal cell naevus (Gorlin) syndrome

Answer 54

_Low risk_ * Nodular * Superficial _High risk_ * Morpheic/sclerosing * Basosquamous

Answer 55

_Nodular BCC_ * **Pearly**, shiny nodule with **telangiectasia**- usually on **head & neck region**. Tend to ulcerate with time resulting in a **rolled edge**. _Superficial BCC_ * **Slow growing erythematous patch or plaque** that is usually found on **trunk** _Morpheic/sclerosing & basosquamous_ * Can only distinguish between these two histologically * **Shiny, scar-like plaque with ill defined border**

Answer 56

* Diagnosis usually made clinically * Do biopsy when there is clinical doubt or when histological subtype may influence treatment & prognosis

Answer 57

Refer via routine pathway (not 2 week cancer referral) unless concerns that delay may have significant impact e.g. due to size, position... Treatment then involves: * _MOST BCCs:_ **surgical excision with histological assessment of magins** (target excision depends on subtype e.g. 3mm for nodular BCC) * _SOME LOW RISK BCCs_: destructive surgical techniques e.g. curettage & cautery, cryosurgery. Destructive non-surgical techniques include **topcial imiquimod** (more for sBCC) & photodynamic therapy * Others: radiotherapy, Mohs microsurgery *

Answer 58

* Cutaneous carcionma arsing from the keratinocytes of the epidermis or its appendages * Second most common skin cancer. Men \> women * May arise de novo or from precursors e.g. actinic keratosis, Bowen disease * Risk factors: * Chronic UV radiation * Skin phototype * Immuonosupression * Co-carcinogens e.g. smoking for lower lip SCC, HPV for genital or anal SCC

Answer 59

* **Indurating** (hardened) **keratinising (scaley) or crusted plaques or nodules at sun exposed sights** * **Lesion often symptomatic:** pain, discomfort, bleeding, ulcerating, sensory changes

Answer 60

* Refer via 2 week cancer referal * Treatment involves surgical excision with wide borders. May also use radiosurgery, curettage & cautery, cyrotherapy * Advise on sun protection

Answer 61

* _AK=_ mutiple asymptomatic erythematous scaley macules and papules; these may be very hyperkeratotic sclaes some with **cutaenous horn** * _Bowen's disease=_ asymptomatic **well defined** erythematous patches/plaques with a finer scale

Answer 62

ABCDE rules: * Asymmetry * Border irregular * Colour- multicoloured * Diamter \>0.6cm * Evolution (changed) *NOTE: radially growing have potential to progress into vertical growth phase which carries higher metastatic risk*

Answer 63

May not exhibit ABCDE features and may instead follow EFT rule: * Elevation * Firm * Growing *\*Prognosis is poorer as vertical growth phase starts earlier*

Answer 64

_Predominantly radially growing_ * Supeficial spreading melanoma (SSM) * Acral lentiginous melanoma (ALM) * Lentigo maligna melanoma (LMM) _Predominalty vertically growing_ * Nodular melanoma

Answer 65

Remember the ABCDE and EFG rules for melanomas. Symptoms of skin malignancy may include: bleeding, ulceration, pain, itching, oozing & crusting). Remember some melanomas may be amelanotic (therefore be pink in colour). For all melaonas, be aware of the **ugly duckling sign** (lesion that stands out from others): * _Superficial spreading melanoma (SSM)_: *begins as hyperpigmented patch growing radially, which may be asymmetric and have numerous colours* * _Acral lentiginous melanoma (ALM)_: *occurs on palms, soles or nails. May have Hutchinson sign.* * _Lentigo maligna melanoma (LMM):_ *occurs most frequenlty on face & sun exposed lesions. Typically starts as irregularly shaped, may become raised or change colour.* * _Nodular melanoma (NM):_ *hyperpigmented blue-black/amelanotic firm papule, nodule or plaque*

Answer 66

Extension of pigment under the nail gold; raises supsicion of subungal melanoma. It is not associated with sun exposure and is more common in Afro-Carribean & Asian ethnicities.

Answer 67

Two week referral via dermatology cancer pathway where they will: * **Excisional biopsy** to produce pathology report; report will include variuos prognostic factors e.g. Breslow thickness, Clark level, lymphatic/vascualr invasion etc... * **Consider sentinel lymph node biopsy** * **TNM staging** * **Consider CT head, chest, abdomen & pelvis in those with stage IIIb or IIIc** * **Consider PET scan in those with stage IV**

Answer 68

* **Gold standard= surgial excision with varying surgical margins** dependnt on type of melanoma and Breslow thickness * Radical lymph node resection * Chemo & radio for selected pts * Review regularly if invasive melanoma * Advise on sun protection *\*Breslow thickness= vertical thickness of melanoma in mm. Clark level= refers to level of invasion of melanoma into anatomical layers of skin.*

Answer 69

Superficial fungal infection of keratinised tissues caused by dermatophytes. Dermatophytes are a specific group of fungi known as ring worms or tineas. Various names dependent on location of fungal infection:

Answer 70

ALL dermatophytosis has similar presentation- name is lesion dependent. Asymmetrical erythematous scaley annular plaque with central clearing and advancing scaley edge. * **Tinea capitis:** *scaling & itching of scalp, pathes of hair loss, scalp erythema, associated fungal infections at other sites* * **Tinea corporis:** *asymmetrical erythematous scaley annular plaque with central clearing and advancing scaley edge- found on body (no specific region)* * **Tinea pedis:** *often found interdigitally, itching, scaling, white/cracked areas, areas of maceration, malodorous. Various subtypes.* * **Tinea unguium/onychomycosis:** *thickened & yellow nail*

Answer 71

* **Interdigital** — most common; affects the lateral toe web spaces first; usually caused by Trichophyton rubrum. * **Moccasin or dry** — diffuse chronic scaling and hyperkeratosis affecting the sole and lateral foot; usually caused by Trichophyton rubrum. * **Vesicobullous —** least common; multiple small vesicles and blisters mainly on the arches and soles of the feet; usually caused by Trichophyton interdigitale.

Answer 72

* Hot/humid climate * Occlusive footwear * Hyperhidrosis * Walking on contaminated surfaces * Immunocompromised

Answer 73

* Children aged 6 months - 12yrs * Immunocompromised

Answer 74

* Diagnosis **largely clinical** * Skin scrapings or nail clipping for microscopy & culture useful if uncertain of diagnosis

Answer 75

_Tinea Capitis_ * Advise to soften & remove crust * Educate on transmission/infectivity e.g. don't share towels * **Ketoconazole shampoo in combination with oral antifungal e.g. terbinafine** _Tinea corporis_ * Advice on self-care strategies * **First line= topical antifungal e.g. terbinafine or imidazole e.g. clotrimazole** * If associated inflammation, can prescribe **mild topical corticosteroid** e.g. hydrocortisone * If **severe or extensive disease, consider oral antifungal e.g. terbinafine as first line** _Tinea pedis_ * Self care (non-occlusive footwear, good foot hygiene, cotton absorbent socks, dry thoroughly, wear protective footwear to reduce transmission in e.g. swimming pools) * First line mild, non-extensive disease= **topical antifungal** e.g. terbinafine or imidazole e.g. clotrimazole * If associated inflammation, can consider prescribing **mild topical corticosteroid** e.g. hydrocortisone * If severe or extensive disease, consider **oral antifungal** e.g. terbinafine as first line _Onychomycosis_ * Self care management e.g. keep nails short, non-occlusive footwear * If superficial/early infection can try **amorolfine nail lacquer (antifungal)** * If initial management not successful/more advanced need **oral antifungals**- may require these for weeks to months: * Dermatophytes: terbinafine * Candida: itraconazole

Answer 76

Abscess caused by fungal infection which most commonly occurs in tinea capitis. Will require urgent referral to dermatologist and prolonged treatment with oral terbinafine

Answer 77

* Supeficial fungal infection of skin caused by **yeast** (of the genus Malassezia). They are normal skin flora but can cause disease when converted to thei pathogenic hyphal form * Common in **teens & young adults** (due to increased sebum production) and more common in **tropical countries and in summer**

Answer 78

* Well demarcated thin plaques with fine scaling * Plaques may be hyperpigmented, hypopigmented or erythematous * Usually involves torso (can involve face) * Can become confluent & widespread * Post-inflammatroy pigmentary changes may persist for months despite eradication of infection

Answer 79

* Diagnosis usually clinical * Can do microscopy to help if uncertain- seee **spaghetti & meatballs appearance**

Answer 80

* **Education**: *condition is not contagious & skin discolouration may persist for weeks* * Pharmacological: * Antifungals * For **large areas= antifungal shampoo e.g. ketoconazole shampoo.** Make into lather and apply to body, leave for 5 mins, rinse * For **smaller areas= topical imidazole** e.g. clotrimazole * Consider second topical therapy before using oral antifungal e.g. itraconazole or fluconazole * If topical antifungal ineffective, consider oral antifungal e.g. itraconazole

Answer 81

* **Papillomas** *(remember papilloma is a benign epithelial tumour)* caused by **HPV** * Common in **childhood** * Spread via direct contact or via environment * Risk factors: *immunosupression, walking bare foot in public/shared spaces, biting nails etc...* * Subtypes & presentation: * **Plantar warts:** thick hyperkeratotic plaques beneach pressure points on sole * **Verruca vulgaris:** hyperkeratotic papules often on hands * **Planar warts:** flat topped papules commonly occuring on face * **Condyloma acuminata** (anogenital warts): cauliflower like plaques over anogential area *\*\* Presence of thrombosed capillaries especially after paring is charcteristic of viral warts*

Answer 82

* Can persist for years and are generally asymptomatic * Spontaenous clearance in children within 1-2yrs is common; much slower in adults

Answer 83

* Educate pt on how to lower risk of transmission e.g. don't share towels, avoid scratching or biting, cover with plaster when swimming * If aymptomatic and in non-cosmetically sensitive area consider no treatment * If treatment is required: * **First line= topical salicyclic acid for up to 12 weeks** * **Second line= cyrotherapy with liquid nitrogen** every 2 weeks up to 6 times. Can also continue to use salicyclic acid & parring once scabbing from cyrotherapy has resolved * Third line= topical imiquimod, intralesion bleomycin, cautery etc... * Patients with **anogenital warts should be reffered to genitourinary medicine**

Answer 84

* **Immune mediated mucocutaenous condition most commonly caused by HSV**. EM major refers to EM with mucosal involvement, EM minor only involves skin * Young adults, slight female predilection * **Infection causes around 90% of EM**; most common infectious agent is **HSV followed by Mycoplasma pneumoniae**. Drug induced EM \<10% cases; common drug causes are **NSAIDs, sulphonamides, anti-epileptics & antibiotics**

Answer 85

* Classically presents as **acrally** (affecting peripheries- typically hands) * **Targetoid lesions** with 3 zones: dusky central disc, pale oedematous ring, erythematous outermost ring (some lesions may only have 2 zones) * May have **mild prodromal symptoms** * Lesions may **coalesce** * May have **mucsosal erosions** * **May be slightly pruritic**

Answer 86

* Antihistamine & emollients for itching * **If HSV associated or idiopathic recurrent EM= antiviral therapy for 6 months e.g. aciclovir** * Identify & remove any causes e.g. **if drug induced stopping causative drugs, abx for Mycoplasma pneumoniae infection** * If there is mucosal involvement: * Mild: high potency topical steroids, oral antiseptic wases or oral anaesthetic solutions * Severe: systemic steroids * In treatment ressitant recurrent EM consider immunosupression

Answer 87

Toxic epidermal necrolysis (TEN)

Answer 88

SJS and TEN are considered **two ends of spectrum** of **severe epidermolytic adverse cutanous drug reactions.** * **SJS \<10%** body surface area involved * **TEN \>30%** of body surface involved *\*(when inbetween 10 and 30% conditions overlap)*

Answer 89

HIV positive patients

Answer 90

* Allopurinol * Sulphnoamides * Antibiotics * Anticonvulsants * NSAIDS (oxicam-type)

Answer 91

* Onset within **2 months** of commencing causative drug * **Painful, dusky erythema with blisters & erosions** * Rapidly progress into confluent erythema with **sheet-like epidermal detachment** * **Nickolsky sign** (epidermis detached by mechanical pressure) * **Prodromal symptoms** * **Mucosal involvement** is common

Answer 92

* Skin biopsy: confirm SJS/TEN * Direct immunofluorescence to rule out autoimmune blistering diseases * Blood tests to identify complications & prognosis: * FBC * U&Es * LFTs * ABG * Blood cultures * Magnesium * Phosphate

Answer 93

* Stop causative drug * Supportive care best delivered in ICU or burns unit (e.g. fluids, electrolyte management, wound mangement) * Dressings, topical antibacterials& emollients * Analgesia * IV immunoglobulin for TEN * Treatment of sequale e.g. opthalmoloy review for eye involvement

Answer 94

* SJS= 1-5% * TEN= 25-35%