Dermatology/ Allergies Flashcards
Lichen planus
Feature
Location
Shape
Rx
- itchy, papular rash
- palms, soles, genitalia and flexor surfaces of arms
- Koebner phenomenon may be seen (new skin lesions appearing at the site of trauma)
- polygonal in shape, with a ‘white-lines’ pattern on the surface (Wickham’s striae)
Rx
- Topical steroids
- Oral lesions - benzydamine mouthwash
Lichen planus Drug causes (3)
- gold
- quinine
- thiazides
Acne rosacea Features (3) Location What can cause an exacerbation of symptoms? Mx
- Flushing, telangiectasia, rhinophyma
- Typically affects nose, cheeks and forehead
- Sunlight may exacerbate symptoms
Mx Mild 1. Topical metro 2. Topical brimonidine gel for pts with flushing but limited telangiectasia Severe 3. Oxytetracycline
Pemphigus vulgaris is an automimmune condition against? Which population? Describe the lesions Biopsy findings Rx (2)
- desmoglein 3
- Ashkenazi Jewish population
- Flaccid, easily ruptured vesicles and bullae, painful, not itchy
- acantholysis
Rx steroids, immunosuppressants
itchy, tense blisters typically around flexures
the blisters usually heal without scarring
there is usually no mucosal involvement
Rx
Bullous pemphigoid
Rx PO steroids
Difference between bullous pemphigoid and pemphigus vulgaris?
Nil mucosal involvement on bullous pemphigoid
Tense blisters in pemphigoid
Flaccid easily ruptured blisters in pemphigus
Itchy in pemphigoid, not itchy in pemphigus
Pemphigus Vulgaris - not itchy, mucosal, flaccid
Bullous pemphigoid - itchy, tense, nil mucosal involvement
Rash is typically maculopapular with target lesions being characteristic
May develop into vesicles or bullae
mucosal involvement
severe systemic symptoms: fever, arthralgia
starts with flu-like symptoms, followed by a painful rash that spreads and blisters
Stevens- Johnson syndrome
Stevens- Johnson syndrome
Causes
penicillin sulphonamides anti-epileptics lamotrigine, carbamazepine, phenytoin allopurinol NSAIDs oral contraceptive pill
Name the condition
Seen in which disease?
shiny, painless areas of yellow/red skin typically on the shin
often associated with telangiectasia
Necrobiosis lipoidica diabeticorum
Name the condition
Seen in which disease?
initially small red papule
later deep, red, necrotic ulcers with a violaceous border
Pyoderma gangrenosum
IBD
Name the condition
Seen in which disease?
symmetrical, erythematous lesions
shiny, orange peel skin
Pretibial myxoedema
Grave’s
Name the condition
symmetrical, erythematous, tender, nodules which heal without scarring
Erythema nodosum
Itchy, red skin lesions, lymphadenopathy, hepatosplenomegaly
Name the condition
What is it?
Mycosis fungoides
rare form of T-cell lymphoma that affects the skin
lesions tend to be of different colours in contrast to eczema/psoriasis where there is greater homogenicity
Psoriasis: exacerbating factors
What can exacerbate guttate psoriasis?
trauma
alcohol
drugs: BB, lithium, antimalarials, NSAIDs, ACEi, infliximab
withdrawal of steroids
Streptococcal infection may trigger guttate psoriasis.
BL. STAINS
Isotretinoin is used to treat which condition?
Severe acne
Young adult with an abdominal herald patch, followed by erythematous, oval, scaly patches in a ‘fir-tree’ distribution.
Associated with which virus?
Minority have a preceding viral illness
Mx
Pityriasis rosea
Self limiting 6-12 weeks
Herpes hominis virus 7 (HHV-7)
Differentiating guttate psoriasis and pityriasis rosea
Prodrome
Appearance
Treatment
Guttate: strep throat infection 2-4 weeks prior
Pityriasis: for exam situation, will unlikley to have a virus prior
Guttate:
‘Tear drop’, scaly papules on the trunk and limbs
Pityriasis: Herald patch followed 1-2 weeks later by multiple erythematous, slightly raised oval lesions with a fine scale confined to the outer aspects of the lesions. Fir tree appearance.
Guttate: self limiting 2-3 months
Pityriasis: self limiting 6 weeks
Zinc deficiency
Features
- perioral dermatitis: red, crusted lesions
- acrodermatitis
- alopecia
- short stature
- hypogonadism
- hepatosplenomegaly
- geophagia (ingesting clay/soil)
- cognitive impairment
What is vitiligo?
Features (2)
Location (1)
autoimmune condition which results in the loss of melanocytes and consequent depigmentation of the skin
- well-demarcated patches of depigmented skin
- peripheries
- trauma may precipitate new lesions (Koebner phenomenon)
Vitiligo associated conditions
- type 1 diabetes mellitus
- Addison’s disease
- autoimmune thyroid disorders
- pernicious anaemia
- alopecia areata
Vitiligo
Mx
- Topical steroids can reverse it if used early
- Sunblock
- Phototherapy/ topical tacrolimus
Venous ulceration is typically seen where?
Mx
Above medial malleolus
Mx
1. Compression bandaging
2. Oral pentoxifylline (improves healing rate)
Venous ulceration
Ix
ABPI
Normal range 0.9 - 1.2, low or high could indicate arterial disease
Difference between arterial and venous ulcers
Arterial lateral malleolus, end of toes, tops of feet
Venous medial malleolus
Arterial punched out, necrotic, black, deep, or pale/ light pink, well demarcated
Venous edges irregular, deep pink to red, shallow
Arterial, dry, little drainage
Venous skin will be tight, drainage present, brown pigmentation
symmetrical, brown, velvety plaques that are often found on the neck, axilla and groin
Acanthosis nigricans
Acanthosis nigricans
Causes
type 2 diabetes mellitus gastrointestinal cancer obesity polycystic ovarian syndrome acromegaly Cushing's disease hypothyroidism Prader-Willi syndrome drugs: oral contraceptive pill, nicotinic acid
It may be precipitated by a streptococcal infection 2-4 weeks prior to the lesions appearing.
tear drop papules on the trunk and limbs
Age group
Mx (4)
Guttate psoriasis
children and adolescents
Self limiting 2-3 months
topical agents as per psoriasis
UVB phototherapy
tonsillectomy may be necessary with recurrent episodes
'golden', crusted skin lesions typically found around the mouth very contagious = Caused by which two bacterium? Location
Impetigo
- Staph Aureus
- Strep pyogenes
tend to occur on the face, flexures and limbs
Impetigo Mx (3) If extensive (1) Pen allergy (1) School - can they go?
Not systemically unwell
1. hydrogen peroxide 1% cream
2. topical fusidic acid
3. topical mupirocin should be used if fusidic acid resistance is suspected
If extensive
1. Oral fluclox, if pen allergic, erythro
children should be excluded from school until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment
Pellagra Features (3) Deficiency in what? Common in which group of people? Describe the dermatitis, what is the name?
Pellagra 3D's dementia, dermatitis, diarrhoea Niacin deficiency More common in alcoholics Dermatitis (brown scaly rash on sun-exposed sites - termed Casal's necklace if around neck)
seen in children with atopic eczema and often presents as a rapidly progressing painful rash.
O/E: monomorphic punched-out erosions (circular, depressed, ulcerated lesions) usually 1–3 mm in diameter
=?
Rx
Eczema herpeticum
HSV 1 or HSV2
Rx IV aciclovir = life threatening
An elderly woman develops a reticulated, hyperpigmented rash after using a hot water bottle excessively
over exposure to infrared radiation
Which condition
If not treated at risk of which condition?
Erythema ab igne
Risk of SCC
atrophy of the epidermis with white plaques forming itch Which condition Mx Risk of which condition?
Lichen sclerosis
Mx topical steroids + emollients
Risk of vulval cancer
eczematous lesions on the sebum-rich areas: scalp (may cause dandruff), periorbital, auricular and nasolabial folds
otitis externa and blepharitis may develop
Seborrhoeic dermatitis
Seborrhoeic dermatitis
Associated with which conditions?
HIV
Parkinson’s disease
Seborrhoeic dermatitis
Scalp mx
Everywhere else mx
Scalp
- over the counter preparations containing zinc pyrithione (‘Head & Shoulders’) and tar (‘Neutrogena T/Gel’)
- Ketoconazole
Everywhere else
topical antifungals: e.g. ketoconazole
topical steroids: best used for short periods
difficult to treat - recurrences are common
large variation in colour from flesh to light-brown to black
have a ‘stuck-on’ appearance
keratotic plugs may be seen on the surface
Name the condition
Management
Seborrhoeic keratoses
Mx
- Reassurance - benign
- options for removal include curettage, cryosurgery and shave biopsy
Cysts that have a punctum?
Name two types and location
Sebaceous cysts
- Epidermoid (face, neck, trunk - can be be anywhere)
- Pilar (mainly scalp)
Scabies mx
Advice (3)
- permethrin 5% is first-line (8-12hrs)
- malathion 0.5% is second-line (24hrs)
Repeat treatment 7 days later
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.
potentially life-threatening skin disorder that is most commonly seen secondary to a drug reaction. In this condition, the skin develops a scalded appearance over an extensive area
systemically unwell e.g. pyrexia, tachycardic
positive Nikolsky’s sign: the epidermis separates with mild lateral pressure
Toxic epidermal necrolysis
TEN (Toxic epidermal necrolysis)
Causes
phenytoin sulphonamides allopurinol penicillins carbamazepine NSAIDs
PSPCAN
TEN
Mx
- IVIG
2. immunosuppressive agents (ciclosporin and cyclophosphamide), plasmapheresis
usually not present at birth but may develop rapidly in the first month of life. They appear as erythematous, raised and multilobed tumours.
Female infants, premature infants and those of mothers who have undergone chorionic villous sampling are more likely to be affected
Mx
Strawberry naevus/ capillary haemangioma
- Topical BB e.g timolol
What is a Cavernous haemangioma?
a deep capillary haemangioma
Acne vulgaris
Classification
Mild
open and closed comedones with or without sparse inflammatory lesions
Moderate
widespread non-inflammatory lesions and numerous papules and pustules
Severe
extensive inflammatory lesions, which may include nodules, pitting, and scarring
Acne vulgaris
Mx
Step up regime
1. single topical therapy (topical retinoids, benzoyl peroxide)
- topical combination therapy (topical antibiotic, benzoyl peroxide, topical retinoid)
- PO tetracycline e.g lymecycline, oxytetracycline, doxycycline (max three months)
(if pregnant use erythro) - COCP (in combination with topical rx)
- oral isotretinoin
Why is minocycline no longer used in treatment of acne vulgaris?
Risk of irreversible pigmentation
Most common long term complication of long term abx use in acne vulgaris?
Mx
Gram-negative folliculitis
Mx trimethoprim
Erythema nodosum
Causes
streptococci tuberculosis sarcoidosis inflammatory bowel disease Behcet's malignancy/lymphoma penicillins sulphonamides combined oral contraceptive pill pregnancy
target lesions
initially seen on the back of the hands / feet before spreading to the torso
upper limbs > lower limbs
pruritus
Triggered by an infection
Nil mucosal involvement, if it does it is called?
Most commonly caused by?
Erythema multiforme
Erythema multiforme major
herpes simplex virus
premalignant skin lesion
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
Mx (6)
Actinic keratoses
Mx
- Avoid sun exposure
- fluorouracil cream: typically a 2 to 3 week course
- Topical hydrocortisone
- Topical diclofenac
- Topical imiquimod
- Cryo/ curretage/ cautery
caused by Malassezia furfur most commonly affects trunk patches may be hypopigmented, pink or brown more noticeable following a suntan scale pruritus
Pityriasis versicolor
Mx
1. Topical ketoconazole
if not responsive, send scrapings +/- + oral itraconazole
Name the condition Pruritus particularly after warm bath 'Ruddy complexion' Gout Peptic ulcer disease
polycythaemia
Name the condition Pruritus Night sweats Lymphadenopathy Splenomegaly, hepatomegaly Fatigue
lymphoma
vascular birthmarks that tend to be unilateral. They are deep red or purple in colour
often darken and become raised over time
Rx
Port wine stains
Rx
- Cosmetic camouflage
- Lasertherapy
may be precipitated by humidity (e.g. sweating) and high temperatures.
small blisters on the palms and soles pruritic often intensely itchy sometimes burning sensation once blisters burst skin may become dry and crack
Mx (3)
Pompholyx
Mx
cool compresses
emollients
topical steroids
eczematous, itchy red rash in pregnancy
most common skin condition in pregnancy
Atopic eruption of pregnancy
pruritic condition associated with last trimester
lesions often first appear in abdominal striae
Rx (3)
Polymorphic eruption of pregnancy
Rx
- Emollients
- Topical steroids
- PO steroids
pruritic blistering lesions in pregnancy
often develop in peri-umbilical region, later spreading to the trunk, back, buttocks and arms
Rx
Pemphigoid gestationis
PO steroids
Skin disorders associated with malignancy
Gastric cancer
Acanthosis nigricans
Skin disorders associated with malignancy
Ovarian and lung cancer
Dermatomyositis
Skin disorders associated with malignancy
Pancreatic cancer
Migratory thrombophlebitis
Skin disorders associated with malignancy
Myeloproliferative disorders
Pyoderma gangrenosum
papular lesions that are often slightly hyperpigmented and depressed centrally
In a ring form
Granuloma annulare
Fungal nail infections
Mx
Do not need to be treated unless patient’s prefer
Diagnosis to be confirmed on microbiology before starting treatment
- PO terbinafine/ itraconazole
Fingernails 6 weeks - 3 months
Toenails 3 - 6 months
If candida
- Topical Amorolfine
- PO itraconazole if more severe 12 weeks
If topical treatment
Fingernails 6 month
Toenails 9-12 months
Early keloid scars can be treated with?
triamcinolone
What is erythroderma?
Causes:
when more than 95% of the skin is involved in a rash eczema psoriasis drugs e.g. gold lymphomas, leukaemias idiopathic
a premalignant condition which presents as white, hard spots on the mucous membranes of the mouth. It is more common in smokers.
Can become malignant and form which cancer?
Leukoplakia
SCC
What is telogen effluvium?
hair loss following stressful period e.g. surgery
What is alopecia areata and it’s treatment?
Autoimmune condition causing localised, well demarcated patches of hair loss. At the edge of the hair loss, there may be small, broken ‘exclamation mark’ hairs
Topical steroids
pearly, flesh-coloured papule with telangiectasia
may later ulcerate leaving a central ‘crater’
slow-growth and local invasion =
Mx
BCC
Routine referral
surgical removal
painful nodule on the ear
caused by persistent pressure on the ear
Mx
Chondrodermatitis nodularis helicis
reducing pressure on ear
cryotherapy, steroid injection, collagen injection
surgical treatment if high recurrence rate
Type of contact dermatitis
- Irritant - usually on hands following use of detergents
- Erythema is typical, crusting and vesicles are rare - Allergic - treat with topical steroids, usually following hair dyes
- acute weeping eczema
Coeliacs patient
autoimmune blistering skin disorder
itchy, vesicular skin lesions on the extensor surfaces (e.g. elbows, knees, buttocks)
Mx
Dermatitis herpetiformis
Mx
gluten-free diet
dapsone
Hereditary haemorrhagic telangiectasia (HHT)
Diagnostic criteria
Also known as?
AD/AR
2 out of 4
- FH first degree relative
- Epistaxis
- Telangiectasia multiple locations
- Visceral lesions e.g AV malformations, GI telangiectasia
Osler-Weber-Rendu syndrome
AD
SCC RFs
- excessive exposure to sunlight / psoralen UVA therapy
- actinic keratoses and Bowen’s disease
- immunosuppression
- smoking
- long-standing leg ulcers (Marjolin’s ulcer)
- genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism
SCC Mx
<20mm in diameter
excision with 4mm margin
> 20mm in diameter
excision with 6mm margin
What is the single most important factor in determining prognosis of patients with malignant melanoma?
invasion depth of a tumour (Breslow depth)
well demarcated red, scaly patches affecting the extensor surfaces, sacrum and scalp
plaque psoriasis
name the type of psoriasis
commonly occurs on the palms and soles
pustular psoriasis
Complications of psoriasis
psoriatic arthropathy
increased incidence of metabolic syndrome
increased incidence of cardiovascular disease
increased incidence of venous thromboembolism
Nail changes in psoriasis
pitting
onycholysis
subungual hyperkeratosis
loss of nail
Children with a new purpuric rash ddx (2)
- meningococcal septicaemia
2. ALL
Causes of pyoderma gangrenosum (7)
Rx
- Idiopathic
- IBD
- RA
- SLE
- Lymphoma/ leukemia
- Myeloproliferative disorders
- PBC
Rx steroids
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
Rx
Pyogenic granuloma
If in pregnancy - will resolve on its own post partum
Otherwise cautery/ curretage/ cryo
What is Hyperhidrosis?
Mx
Excessive sweating
- topical aluminium chloride S/E skin irritation
- iontophoresis useful in palmar, plantar and axillary hyperhidrosis
- botulinum toxin: currently licensed for axillary symptoms
- surgery: e.g. Endoscopic transthoracic sympathectomy
said to look like a volcano or crater
initially a smooth dome-shaped papule
rapidly grows to become a crater centrally-filled with keratin
Benign
Mx
Keratoacanthoma
Mx
Can resolve on their own within 3 months
However similar looking to SCC therefore excision
What is the assessment for hirsutism?
Ferriman-Gallwey scoring system: 9 body areas are assigned a score of 0 - 4, a score > 15 is considered to indicate moderate or severe hirsutism
Hirsutism mx
- Weight loss
- Waxing/bleaching
- Dianette/ Yasmin (not for long term use given risk of VTE)
- topical eflornithine for facial hirsutism
Causes of hypertrichosis
drugs: minoxidil, ciclosporin, diazoxide
congenital hypertrichosis lanuginosa, congenital hypertrichosis terminalis
porphyria cutanea tarda
anorexia nervosa
characteristic pinkish or pearly white papules with a central umbilication, which are up to 5 mm in diameter. In clusters in areas anywhere on the body (except the palms of the hands and the soles of the feet)
In children - trunk and flextures
sexual contact may lead to lesions developing on the genitalia, pubis, thighs, and lower abdomen
Molluscum contagiosum
Molluscum contagiosum
Mx
When to refer?
- Self limiting 18 months
- Contagious, do not share towels etc, nil exclusion from school necessary
- Squeezing post bath
- Cryo
- HIV +ve –> refer to HIV specialist
- Eyelid involvement –> refer to ophthalmologist
- Ano-genital lesions –> refer to genito-urinary medicine for screening for other STIs
Prodromal period - burning pain over a dermatome followed by a rash =
Mx
Complications (3)
HZV = shingles
Contagious until they are crusted over, avoid pregnant people, cover it up.
Mx
- Paracetamol + NSAIDs for pain
- PO aciclovir if presenting within 72h hours
Complications
- post herpetic neuralgia
- herpes zoster ophthalmicus
- herpes zoster oticus (Ramsay Hunt syndrome) - ear lesions and facial paralysis
Affects children. More common in atopic patients with a history of eczema
Soles become shiny and hard. Cracks may develop causing pain
Worse during the summer
Juvenile plantar dermatosis
Affects people who sweat excessively
Patients may complain of damp and excessively smelly feet
Usually caused by Corynebacterium
Heel and forefoot may become white with clusters of punched-out pits
Pitted keratolysis
May be acquired or congenital
Describes a thickening of the skin of the palms and soles
Keratoderma
Secondary to the human papilloma virus
Firm, hyperkeratotic lesions
Pinpoint petechiae centrally within the lesions
May coalesce with surrounding warts to form mosaic warts
Verrucas
Psoriasis
Mx
Plaque psoriasis
(4)
Plaque psoriasis
- Emollients + topical corticosteroids + vit D analogue OD for four weeks
- If no improvement after 8- 12 weeks, vit D analogue BD
- If no improvement after 8-12 weeks, topical corticosteroids BD for 4 weeks or coal tar prep OD/BD
- dithranol
Exampled of vit D analogue
How long can they be used for?
How do they work?
calcipotriol (Dovonex), calcitriol and tacalcitol
can be used long term
reduce the scale and thickness, but not the erythema
Not to be used in pregnancy
100g max weekly
Time between potent steroids
How long can very potent steroids be used for?
How long can potent and topical steroids be used for?
Topical steroids on scalp, face, flexures - how long can they be used for?
4 weeks between potent steroids
4 weeks
8 weeks
1-2 weeks/ month
Secondary care management of psorasis
- Phototherapy three times per week
- MTX - good for joint disease
- Biologics
loss and thinning of hair in response to severe stress Options Trichotillomania Androgenetic alopecia telogen effluvium alopecia totalis
Telogen effluvium
complete loss of all hair of the head and face. Options Trichotillomania Androgenetic alopecia telogen effluvium alopecia totalis
alopecia totalis
a disorder where people pull their own hair out, would give asymmetrical, uneven hair loss, and might be preceded by other psychiatric complaints.
Options Trichotillomania Androgenetic alopecia telogen effluvium alopecia totalis
Trichotillomania
female-pattern baldness, would be suggested by a family history of the same, and is more likely in an older patient.
Options Trichotillomania Androgenetic alopecia telogen effluvium alopecia totalis
Androgenetic alopecia
