Dermatology - Chronic Conditions Flashcards
Presentation of eczema.
- itchy papules
- dry, scaly patches
- affects flexor aspects
- lichenification
- pitting of nails
Causes of eczema.
- positive family history of atopy
- genetic defect in skin barrier
Management of eczema.
General measures.
- avoid known exacerbating agents
- frequent emollients
- bandages
- soap substitutes
Management of eczema.
Topical therapies.
Topical steroids for active areas.
Topical immunomodulators (e.g. tacrolimus) for maintenance therapy (steroid-sparing).
Management of eczema.
Oral therapies.
- antihistamines (symptomatic relief)
- antibiotics (2° bacterial infection)
- antivirals (eczema herpeticum)
Management of eczema.
Phototherapy and immunosuppressants.
Used in severe non-responsive cases.
Complications of eczema.
- impetigo
- molluscum contagiosum
- viral warts
- eczema herpeticum
What is eczema herpticum?
A severe skin infection in which eczema flares introduce breaks to the skin, by which HSV-1 can enter.
This results in a painful, blistering rash.
Management of eczema herpticum.
Emergency - admit to hospital for IV antivirals / antibiotics.
NB: do NOT use a steroid as this will make it worse.
Presentation of acne vulagris.
Inflammation of pilosebaceous follicle:
- open comedones
- closed comedones
- papules / pustules / nodules / cysts
Causes of acne vulagirs.
- hormonal (androgens)
- bacterial colonisation
- abnormal follicular keratinization
Management of acne vulgaris.
- Topical benzoyl peroxide (reduce inflammation)
- Topical retinoids (slow production of sebum)
- Topical antibiotics (e.g. clindamycin)
- Oral antibiotics (e.g. lymecycline)
- oral contraceptive pill (female)
- Oral retinoids
Considerations of retinoid prescription.
- strongly teratogenic (contraception required)
- photosensitivity of skin to sunlight
- suicidal ideation (screen for mental health issues)
- Stevens-Johnson syndrome / TEN
Complications of acne vulgaris.
- post-inflammatory hyperpigmentation
- scarring
- deformity
- psychological and social effects
What is psoriasis?
A chronic inflammatory skin disease due to hyperproliferation of keratinocytes, and inflammatory cell infiltration.
Presentation of psoriasis.
- well-dermacated scaly plaques
- itching / burning / pain
- extensor surfaces affected
- nail changes
- psoriatic arthropathy
Nail changes associated with psoriasis.
- pitting
- oncholysis
Köbner phenomenon.
The appearance of new skin lesions of a pre-existing dermatosis, upon areas of cutaneous injury in otherwise healthy skin.
Occurs in:
- psoriasis
- vitiligo
- lichen planus
Complications of psoriasis.
- erythroderma
- psychological and social effects
Management of psoriasis.
General measures.
- avoid known precipitating factors
- emollients to reduce scales
Management of psoriasis.
Topical therapies.
For localised and mild psoriasis:
- vitamin D analogues
- topical corticosteroids
- topical retinoids
Management of psoriasis.
Phototherapy.
For extensive disease.
Management of psoriasis.
Oral therapies.
Extensive or severe disease:
- methotrexate
- retinoids
- biologics
What is bullous pemphigoid?
A blistering skin disorder affecting the elderly.
Autoantibodies against antigens between the epidermis and dermis, causing a sub-epidermal split in the skin.
Presentation of bullous pemphigoid.
- tense, fluid-filled blisters
- erythematous skin
- itching
Management of bullous pemphigoid.
General measures - wound dressings, monitor for signs of infection.
Topical steroids.
What is pemphigus vulgaris?
A blistering skin disorder affecting the middle aged.
Autoantibodies against antigens within teh epidermis cause an intra-epidermal split in the skin.
Presentation of pemphigus vulgaris.
- painful lesions
- mucosal involvement
- flaccid, easily ruptured blisters
Management of pemphigus vulgaris.
General measures - wound dressings, monitor for signs of infection, oral hygiene.
Oral therapies - high dose steroids and immunosuppressive agents (e.g. methotrexate).
What is vitiligo?
An autoimmune disorder, whereby autoantibodies cause destruction of melanocytes.
This results in hypopigmentation of the skin.
Presentation of vitiligo.
- presentation at any age
- symmetrical depigmentation
- Köbner phenomenon
Management of vitiligo.
- minimise skin injury (Köbner phenomenon)
- topical treatments (e.g. steroids, calcineurin inhibitors)
- phototherapy
- oral immunosuppressants (e.g. methotrexate)
What is melasma?
Overproduction of melanin by melanocytes.
Triggers of melasma.
Genetic predisposition plus:
- sun exposure
- hormonal changes
- contraceptive pills
Presentation of melasma.
Symmetrical:
- brown macules
- irregular borders
Management of melasma.
- lifelong sun protection
- discontinuation of hormonal contraceptive pills
- cosmetic camouflage
- vitamin C
What is lichen lpanus?
A chronic inflammatory condition affecting the skin and mucosal surfaces.
Result of autoimmune destruction of keratinocytes.
Risk factors for lichen planus.
- genetic predisposition
- physical / emotional stress
- ## contact allergy
Symptoms of cutaneous lichen planus.
- itching
- papules
- clusters
- common on wrist, lower back and ankles
Symptoms of oral lichen planus.
- painless white streaks
- painful erosions and ulcers
- diffuse redness of gums
- inflammation of gums
Complications of lichen planus.
- progression to SCC
How is lichen planus diagnosed?
Clinical diagnosis - skin biopsy to confirm the diagnosis and look for cancer.
General management of lichen planus.
- avoid soaps
- use emollients regularly
- sedating antihistamines for nocturnal itch
Medical management of lichen planus.
- topical corticosteroids
- topical retinoids
What is rosacea?
A chronic inflammatory skin condition, predominantly affecting the convexities of the centrofacial region.
Risk factors for rosacea.
- genetics
- smoking
- alcohol
- emotional stress
Diagnostic clinical features of rosacea.
Phymatous changes - facial skin thickening.
Persistent erythema.
Symptoms of rosacea.
- flushing / transient erythema
- telangiectasia
- ocular manifestations
- burning sensation
- stinging sensation
- oedema
What is pityriasis rosea?
A generalised, self-limiting rash that has an unknown cause.
May be caused by HHV-6 or HHV-7.
Presentation of pityriasis rosea.
Herald patch
Other symptoms:
- generalised itch
- low grade pyrexia
- headache
- lethargy
Disease course - pityriasis rosea.
Rash resolves without treatment within 3 months.
It can leave discolouration of the skin where the lesions were, but this will resolve within a few months.
Management of pityriasis rosea.
No treatment for rash - resolves spontaneously.
Patient education and reassurance is all that is required - it is not contagious.
Emollients, topical steroids or sedating antihistamines can be used to treat itching.
Indications of emollients.
Rehydrate skin and re-establish the surface lipid layer.
Useful for dry, scaling conditions and as soap substitutes.
Side effects of emollients.
Reactions may be irritant or allergic (e.g. due to preservatives or perfumes in creams).
Examples of topical steroids:
a) mildly potent
b) moderately potent
c) potent
d) very potent
a) hydrocortisone
b) clobetasone (Eumovate)
c) betamethasone (Betnovate)
d) Clobetasol (Dermovate)
Indications of topical steroids.
Anti-inflammatory and anti-proliferative effects.
Useful for allergic and immune reactions, inflammatory skin conditions, blistering disorders, connective tissue diseases and vasculitis.
Side effects of topical corticosteroids.
- skin atrophy
- telangiectasia
- striae
- skin infections
- acne
- perioral dermatitis
- allergic contact dermatitis
Side effects of oral corticosteroids.
- Cushing’s syndrome
- immunosuppression
- hypertension
- diabetes
- osteoporosis
- cataracts
- psychosis
- peptic ulceration
Indications of aciclovir.
Viral infections due to herpes simplex or herpes zoster virus.
Side effects of oral aciclovir.
- GI upset
- raised liver enzymes
- neurological reactions (reversible)
- haematological disorders
Examples of antihistamines:
a) nonsedative
b) sedative
a) cetirizine, loratadine
b) chlorpheniramine; hydroxyzine
Indications of oral anithistamines.
Block histamine receptors to produce an anti-pruritic effect.
Useful for type 1 hypersensitivity reactions and eczema.
Side effects of antihistamines.
Antimuscarinic effects:
- dry mouth
- blurred vision
- urinary retention
- constipation
Sedative antihistamines can cause sedation - caution driving and working with heavy machinery.
Examples of oral retinoids.
- isotretinoin
- acitretin
Indications of oral retinoids.
Used last line for:
- acne vulgaris
- psoriasis
- disorders of keratinisation
Side effects of oral retinoids.
- dry skin, lips and eyes
- disordered liver function
- hypercholesterolaemia
- hypertrigylceridaemia
- myalgia / arthralgia
- depression / suicidal ideation
- teratogenic
Contraception considerations for
a) isotretinoin
b) acitretin
Both are teratogenic therefore double contraception used.
a) 1 month before, during, and 1 month after isotretinoin
b) 1 month before, during, and 2 years after acitretin
Examples of biological therapy.
- infliximab
- etanercept
- interluekins
Indications of biological therapy.
Usually last line in psoriasis and atopic dermatitis.
Local side effects of biological therapy.
Delivered via injection:
- redness
- swelling
- bruising
Systemic side effects of biological therapy.
- allergic reactions
- antibody formation
- flu-like symptoms
- hepatitis
- demyelinating disease
- heart failure
- rare reports of lymphoma
Patient education for emollients.
- apply liberally and regularly.
Patient education for topical corticosteroids.
- apply thinly and only for short-term use (1-2 weeks)
- apply only hydrocortisone to face, neck and flexures
- fingertip unit
