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MRCP P2 > Dermatology > Flashcards

Dermatology Flashcards

1
Q

What is this rash?

A

Erythema multiforme

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2
Q

What is Erythema Multiforme?

A

hypersensitivity reaction which is most commonly triggered by infections. It may be divided into minor and major forms.

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3
Q

Features of Erythema Multiforme

A
  • target lesions
  • initially seen on the back of the hands / feet before spreading to the torso
  • upper limbs are more commonly affected than the lower limbs
  • pruritus is occasionally seen and is usually mild
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4
Q

causes of Erythema Multiforme

A
  • viruses: herpes simplex virus (the most common cause), Orf*
  • idiopathic
  • bacteria: Mycoplasma, Streptococcus
  • drugs: penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill, nevirapine
  • connective tissue disease e.g. Systemic lupus erythematosus
  • sarcoidosis
  • malignancy

*Orf is a skin disease of sheep and goats caused by a parapox virus

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5
Q

What is this rash?

A

Dermatitis herpetiformis

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6
Q

What is dermatitis herpetiformis?

A

Dermatitis herpetiformis is an autoimmune blistering skin disorder associated with coeliac disease.

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7
Q

blistering disease with granular IgA deposition in dermis

A

dermatitis herpetiformis

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8
Q

What is dapsone?

A
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9
Q

Dermatitis herpetiformis management

A
  • gluten-free diet
  • dapsone
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10
Q
  • rash on hands and feet
  • nickel allergy
  • small blisters intensely itchy
A

Pompholyx is a type of eczema which affects both the hands (cheiropompholyx) and the feet (pedopompholyx). It is also known as dyshidrotic eczema.

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11
Q

Pompholyx features

A
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12
Q

Pompholyx management

A
  • cool compresses
  • emollients
  • topical steroids
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13
Q

A 23-year-old woman who is 10 weeks pregnant presents with a rapidly growing lesion on her finger. This has grown from the size of a ‘pin-prick’ when it first appeared 4 weeks ago.

A

Pyogenic granuloma

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14
Q

what are pyogenic granulomas?

A

relatively common benign skin lesion. The name is confusing as they are neither true granulomas nor pyogenic in nature. There are multiple alternative names but perhaps ‘eruptive haemangioma’ is the most useful.

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15
Q

pyogenic granulomas cause

A
  • trauma
  • pregnancy
  • more common in women and young adults
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16
Q

pyogenic granulomas features

A
  • most common sites are head/neck, upper trunk and hands. Lesions in the oral mucosa are common in pregnancy
  • initially small red/brown spot
  • rapidly progress within days to weeks forming raised, red/brown lesions which are often spherical in shape
  • the lesions may bleed profusely or ulcerate
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17
Q

pyogenic granuloma management

A
  • lesions associated with pregnancy often resolve spontaneously post-partum
  • other lesions usually persist. Removal methods include curettage and cauterisation, cryotherapy, excision
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18
Q

Dandruff, itchy scalp

A

Psoriasis

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19
Q

Chronic plaque psoriasis general management

A
  • regular emollients may help to reduce scale loss and reduce pruritus
  • first-line: NICE recommend:
    • a potent corticosteroid applied once daily plus vitamin D analogue applied once daily
    • should be applied separately, one in the morning and the other in the evening)
    • for up to 4 weeks as initial treatment
  • second-line: if no improvement after 8 weeks then offer:
    • a vitamin D analogue twice daily
  • third-line: if no improvement after 8-12 weeks then offer either:
    • a potent corticosteroid applied twice daily for up to 4 weeks, or
    • a coal tar preparation applied once or twice daily
  • short-acting dithranol can also be used
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20
Q

scalp psoriasis management

A

potent topical corticosteroids used once daily for 4 weeks

if no improvement after 4 weeks then either use a different formulation of the potent corticosteroid (for example, a shampoo or mousse) and/or a topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid

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21
Q

Face, flexural and genital psoriasis management

A

NICE recommend offering a mild or moderate potency corticosteroid applied once or twice daily for a maximum of 2 weeks

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22
Q

how do vitamin D analogues work in psoriasis?

A
  • examples of vitamin D analogues include calcipotriol (Dovonex), calcitriol and tacalcitol
  • they work by ↓ cell division and differentiation → ↓ epidermal proliferation
  • adverse effects are uncommon
  • unlike corticosteroids they may be used long-term
  • unlike coal tar and dithranol they do not smell or stain
  • they tend to reduce the scale and thickness of plaques but not the erythema
  • they should be avoided in pregnancy
  • the maximum weekly amount for adults is 100g
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23
Q

how does Dithranol work?

A
  • inhibits DNA synthesis
  • wash off after 30 mins
  • adverse effects include burning, staining
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24
Q

lesion that dimples on pinch test

A

Dermatofibroma

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25
Q

what is a dermatofibroma?

A

(also known as histiocytomas) are common benign fibrous skin lesions. They are caused by the abnormal growth of dermal dendritic histiocyte cells, often following a precipitating injury. Common areas include the arms and legs.

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26
Q

prognostic markers in eczema

A
  • onset at age 3-6 months
  • severe disease in childhood
  • associated asthma or hay fever
  • small family size
  • high IgE serum levels
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27
Q

eczema management

A
  • emollients
  • topical steroids
  • UV radiation
  • immunosuppressants: e.g. ciclosporin, antihistamines and azathioprine
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28
Q

Diagnosis?

A

Lentigo maligna

29
Q

Topical steroid strengths

A

HEBD

30
Q

topical steoid amount in 1 finger tip unit

A

0.5g

sufficient to treat a skin area about twice that of the flat of an adult hand

31
Q

diagnosis?

A

Basal cell carcinoma

Lesions are also known as rodent ulcers and are characterised by slow-growth and local invasion. Metastases are extremely rare. BCC is the most common type of cancer in the Western world.

32
Q

BCC features

A
  • many types of BCC are described. The most common type is nodular BCC, sun-exposed sites, especially the head and neck account for the majority of lesions
  • initially a pearly, flesh-coloured papule with telangiectasia
  • may later ulcerate leaving a central ‘crater’
33
Q

BCC management

A
  • Derm referral
  • surgical removal
  • curettage
  • cryotherapy
  • topical cream: imiquimod, fluorouracil
  • radiotherapy
34
Q
A

molluscum contagiosum

35
Q

molluscum contagiosum causes

A

molluscum contagiosum virus (MCV), a member of the Poxviridae family. Transmission occurs directly by close personal contact, or indirectly via fomites (contaminated surfaces) such as shared towels and flannels. The majority of cases occur in children (often in children with atopic eczema), with the maximum incidence in preschool children aged 1-4 years.

36
Q

Molluscum contagiosum features

A
  • characteristic pinkish or pearly white papules
  • central umbilication
  • up to 5 mm in diameter
  • Lesions appear in clusters in areas anywhere on the body (except the palms of the hands and the soles of the feet).
  • In children, lesions are commonly seen on the trunk and in flexures, but anogenital lesions may also occur.
  • In adults, sexual contact may lead to lesions developing on the genitalia, pubis, thighs, and lower abdomen.
  • Rarely, lesions can occur on the oral mucosa and on the eyelids.
37
Q

Molluscum contagiosum management

A

Self-care advice:

  • Reassure people that molluscum contagiosum is a self-limiting condition.
  • Spontaneous resolution usually occurs within 18 months
  • Explain that lesions are contagious, and it is sensible to avoid sharing towels, clothing, and baths with uninfected people (e.g. siblings)
  • Encourage people not to scratch the lesions. If it is problematic, consider treatment to alleviate the itch
  • Exclusion from school, gym, or swimming is not necessary
  • Squeezing (with fingernails) or piercing (orange stick) lesions may be tried, following a bath. Treatment should be limited to a few lesions at one time
  • Cryotherapy may be used in older children or adults, if the healthcare professional is experienced in the procedure
  • Eczema or inflammation can develop around lesions prior to resolution. Treatment may be required if:
  • Itching is problematic; prescribe an emollient and a mild topical corticosteroid (e.g. hydrocortisone 1%)
  • The skin looks infected (e.g. oedema, crusting); prescribe a topical antibiotic (e.g. fusidic acid 2%)
38
Q

When to refer molluscum contagiosum

A
  • For people who are HIV-positive with extensive lesions urgent referral to a HIV specialist
  • For people with eyelid-margin or ocular lesions and associated red eye urgent referral to an ophthalmologist
  • Adults with anogenital lesions should be referred to genito-urinary medicine, for screening for other sexually transmitted infections
39
Q

A 78-year-old woman presents with a number of blistering lesions on her torso. Around one week prior to the skin lesions developing she noticed widespread mouth ulceration.

A

Pemphigus vulgaris

40
Q

Pemphigus vulgaris cause

A

autoimmune disease caused by antibodies directed against desmoglein 3, a cadherin-type epithelial cell adhesion molecule. It is more common in the Ashkenazi Jewish population.

41
Q

pemphigus vulgaris features

A
  • mucosal ulceration is common and often the presenting symptom. Oral involvement is seen in 50-70% of patients
  • skin blistering - flaccid, easily ruptured vesicles and bullae. Lesions are typically painful but not itchy. These may develop months after the initial mucosal symptoms. Nikolsky’s describes the spread of bullae following application of horizontal, tangential pressure to the skin
  • acantholysis on biopsy
42
Q

pemphigus vulgaris management

A
  • General measures – wound dressings where required, monitor for signs of infection, good oral care (if oral mucosa is involved)
  • Oral therapies – high-dose oral steroids, immunosuppressive agents (e.g. methotrexate, azathioprine, cyclophosphamide, mycophenolate mofetil, and other)
43
Q

scabies cause

A

mite Sarcoptes scabiei and is spread by prolonged skin contact. It typically affects children and young adults.

44
Q

why is scabies itchy?

A

The intense pruritus associated with scabies is due to a delayed-type IV hypersensitivity reaction to mites/eggs which occurs about 30 days after the initial infection.

45
Q

scabies features

A
  • widespread pruritus
  • linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist
  • in infants, the face and scalp may also be affected
  • secondary features are seen due to scratching: excoriation, infection
46
Q

scabies management

A
  • permethrin 5% is first-line
  • malathion 0.5% is second-line
  • give appropriate guidance on use (see below)
  • pruritus persists for up to 4-6 weeks post eradication
  • apply the insecticide cream or liquid to cool, dry skin
  • pay close attention to areas between fingers and toes, under nails, armpit area, creases of the skin such as at the wrist and elbow
  • allow to dry and leave on the skin for 8-12 hours for permethrin, or for 24 hours for malathion, before washing off
  • reapply if insecticide is removed during the treatment period, e.g. If wash hands, change nappy, etc
  • repeat treatment 7 days later

Patient guidance on treatment (from Clinical Knowledge Summaries)

  • avoid close physical contact with others until treatment is complete
  • all household and close physical contacts should be treated at the same time, even if asymptomatic
  • launder, iron or tumble dry clothing, bedding, towels, etc., on the first day of treatment to kill off mites.
47
Q

Scabies and HIV (Dx and Mx)

A

Crusted Scabies

Crusted scabies is seen in patients with suppressed immunity, especially HIV.

The crusted skin will be teeming with hundreds of thousands of organisms.

Ivermectin is the treatment of choice and isolation is essential

48
Q

4 types of melanoma

A
  1. Superficial spreading
  2. Nodular
  3. Lentigo maligna
  4. Acral lentiginous
49
Q

Most common melanoma

A

Superficial spreading

50
Q

Features of the 4 types of melanoma

A
51
Q

Major criteria melanoma

A

Change in size

Change in shape

Change in colour

52
Q

Minor criteria melanoma

A

Diameter >= 7mm

Inflammation

Oozing or bleeding

Altered sensation

53
Q

melanoma treatment

A
  • Suspicious lesions should undergo excision biopsy. The lesion should be removed in completely as incision biopsy can make subsequent histopathological assessment difficult.
  • Once the diagnosis is confirmed the pathology report should be reviewed to determine whether further re-excision of margins is required
54
Q

margins in Melanoma

A

Lesions 0-1mm thick: 1cm

Lesions 1-2mm thick: 1- 2cm (Depending upon site and pathological features)

Lesions 2-4mm thick: 2-3 cm (Depending upon site and pathological features)

Lesions >4 mm thick: 3cm

55
Q

Melanoma 5-year survival by TNM

A
  • stage 1 (T <2mm thick, N0, M0) - 90%
  • stage 2 (T>2mm thick, N0, M0) –– 80%
  • stage 3 (N≥1, M0) – 40- 50%
  • stage 4 (M ≥ 1) – 20-30%
56
Q

Melanoma recurrence rate

A

based on Breslow thickness (thickness of tumour)

  • <0.76mm - low risk
  • 0.76-1.5mm - medium risk
  • >1.5mm thick – high risk
57
Q

A 30-year-old man is investigated for recurrent nose bleeds and iron deficiency anaemia. You notice a number of erythematous lesions on his skin.

A

hereditary haemorrhagic telangiectasia (HHT)

58
Q

What casues HHT?

A

autosomal dominant condition characterised by (as the name suggests) multiple telangiectasia over the skin and mucous membranes. Twenty percent of cases occur spontaneously without prior family history.

59
Q

Diagnostic criteria HHT

A

There are 4 main diagnostic criteria. If the patient has 2 then they are said to have a possible diagnosis of HHT. If they meet 3 or more of the criteria they are said to have a definite diagnosis of HHT:

  1. epistaxis : spontaneous, recurrent nosebleeds
  2. telangiectases: multiple at characteristic sites (lips, oral cavity, fingers, nose)
  3. visceral lesions: for example gastrointestinal telangiectasia (with or without bleeding), pulmonary arteriovenous malformations (AVM), hepatic AVM, cerebral AVM, spinal AVM
  4. family history: a first-degree relative with HHT
60
Q

actinic keratosis v chondrodermatitis nodularis helicis

A

Chondrodermatitis nodularis helicis is usually painful.

61
Q

what is actinic keratoses?

A

common premalignant skin lesion that develops as a consequence of chronic sun exposure

62
Q

features actinic keratosis?

A
  • small, crusty or scaly, lesions
  • may be pink, red, brown or the same colour as the skin
  • typically on sun-exposed areas e.g. temples of head
  • multiple lesions may be present
63
Q

management actinic keratosis?

A
  • prevention of further risk: e.g. sun avoidance, sun cream
  • fluorouracil cream: typically a 2 to 3 week course. The skin will become red and inflamed - sometimes topical hydrocortisone is given following fluorouracil to help settle the inflammation
  • topical diclofenac: may be used for mild AKs. Moderate efficacy but much fewer side-effects
  • topical imiquimod: trials have shown good efficacy
  • cryotherapy
  • curettage and cautery
64
Q

Itchy lesion on hand

A

Discoid eczema

65
Q

Discoid eczema features

A
  • typically present as round or oval plaques on the extremities
  • the lesions are extremely itchy
  • central clearing may occur giving a similar appearance to tinea corporis
66
Q

discoid eczema management

A

Management is similar to normal eczema, although co-existent bacterial infection is common and may require treatment.

67
Q
A
68
Q
A

MRCP P2 (15 decks)

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