Dermatology: Common Chronic Skin Conditions Flashcards
What is eczema?
At what ages is it prevalent?
- Atopic eczema is a chronic, inflammatory skin condition due to defects in continuity of skin barrier.
- It can affect people of all ages although 70-90% present under 5 yrs with a high incidence in 1st year
Briefly outline pathophysiology of eczema
Defects in skin barrier which allows irritants, microbes and allergens to enter skin and cause an immune response resulting in inflammation & associated symptoms
State the7 different types of eczema and discuss how you can distinguish between them
- Atopic dermatitis:typical widespread itchy, erythematous, dry eczema
- Contact dermatitis: eczema in response to contact with iritant or allergen
- Neurodermatitis: usually confined to one or two patches of skin- continued scratching can irritate nerve endings in skin, intensifying both itching and scratching
- Dyshidrotic eczema: small, intensely itchy blisters on the palms of hands, soles of feet and edges of the fingers and toes
- Nummular eczema: scattered circular, often itchy and sometimes oozing patches
- Seborrheic dermatitis: appears on the body where there are a lot of oil-producing (sebaceous) glands like the upper back, nose and scalp
- Stasis dermatitis: gravitational dermatitis, venous eczema, and venous stasis dermatitis, happens when there is venous insufficiency, or poor circulation in the lower legs
It is possible to have more than one type of eczema on your body at the same time. Each form of eczema has its own set of triggers and treatment requirements, which is why it’s so important to consult with a healthcare provider who specializes in treating eczema. Dermatologists in particular can help identify which type or types of eczema you may have and how to treat and prevent flare-ups.
What are signs & symptoms of eczema?
- Pruritic, erythematous rash
- Usually in flexural distribution (however in infants can involve face, scalp & extensor surfaces)
- Itchy papules, often weepy (acute presentation)
- Dry, scaly skin (chronic presentation)
- Excoriations
- History of atopy
What might make you suspect that someone’s eczema is infected?
Yellow crusting, signs of systemic infection e.g. pyrexia
Discuss the management of eczema
Management can be thought of as maintenance and flares. Broadly speaking, maintenance is centred around creating artificial barrier over skin using emollients; controlling environmental factors (e.g. allergens) can also help. Flares are treated with thicker emollients, wet wraps, topical steroids & abx if required.
- Education regarding triggers & management
- First line= emollients (and use these as soap substitutes)
- Second line= topical corticosteroids- use once a day initially can increase to twice a day if needed
- Mild= Hydrocortisone 0.1-2.5%
- Moderate= Eumovate (active ingredient= clobetasone butyrate)
- Strong= Betnovate (betamethasone 17-valerate)
- Very strong= Dermovate (clobetasol propionate)
- Third line= non-sedating antihistamine
- Fourth line= oral corticosteroids (would be with specialist at this point)
- Antibiotics e.g. flucloxacillin if infected
- Wet wraps of emollients (put thick emollient on and apply wrap to keep moisture locked in overnight)
- Other specialist treatments: zinc impregnated bandages, topical tacrolismus, phototherapy, systemic immunosuppressants (e.g. methotrexate, azathioprine, ciclosporin)
What advice would you give patients about the use of topical steroids?
- 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
State 3 examples of emollients that may be used in eczema
Thin creams:
- E45
- Diprobase cream
- Oilatum cream
- Aveeno cream
- Cetraben cream
- Epaderm cream
Thick, greasy emollients:
- 50:50 ointment (50% liquid paraffin)
- Hydromol ointment
- Diprobase ointment
- Cetraben ointment
- Epaderm ointment
What concerns do patients commonly have about topical steroids?
- Skin thinning (if use correctly risk is very low)
- Weight gain (risk low as topical not systemic)
**Thinning of skin can make skin more prone to flares, bruising, tearing, stretch marks & telangiectasia. Risk of steroids need to be balanced against risk of poorly controlled eczema
What advice would you give to patients in regards to emollient use?
- 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.
State some potential ADRs of emollients
- Skin reactions
- Occlusive effects → folliculitis
- If high paraffin content → fire risk
What is the most common causative organism in infected eczema?
Staphylococcus aureus
For eczema herpeticum, discuss:
- What it is
- Who is it more commonly seen in
- Typical presentation
- Management
- Potential complications
- Skin infection caused by HSV 1 or 2
- More commonly seen in children with eczema
- Presentation of rash:
- Widespread
- Rapidly progressing
- Erythematous
- Painful
- ?itchy
- Vesicles containing pus (may see punched out ulcers if these have burst)
- Management:
- Aciclovir (mild or moderate may be treated with PO but severe treated with IV. **PASSMED says should be admitted for IV aciclovir)
- Complications:
- Potentially life-threatening
- Bacterial superinfection
What is acne?
Describe the pathophysiology
Chronic, inflammatory skin condition affecting mainly face, back and chest; characterised 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
Pathophysiology
- Adrenergic hormones increase production of sebum; increased production of sebum leads to trapping of keratin
- Also get hyperkeratinisation of hair follicle epithelial cells
- Both of the above leads to blockage of pilosebaceous unit
- Causes swelling & inflammation of pilosebaceous unit (swollen & inflamed pilosebaceous units= comedones)
- Also thought that excessive growth of Propionibacterium acnes can exacerbate acne
State some signs & symptoms of acne vulgaris
Usually presents as erythematous, inflamed, sore spots typically on face, back & upper chest in puberty & adolescence. Specific skin changes/signs include:
- Comedones
- Open= black heads
- Closed= white heads
- Papules
- Pustules
- Macules (hyperpigmented)
- Nodules or cysts which are often deeper palpable lesions which are painful and fluctuant
- Scarring (ice prick, hypertrophic or rolling)
- Pigmentation (depigmentation post inflam or hyperpigmentation)
- Seborrhoea
**Ice prick scars= small indentations in skin after acne lesion healed, hypertrophic scars= small lumps in skin that remain after acne lesion healed, rolling scars= irregular, wave-like scars that remain after acne lesion healed
There is no universally agreed scoring system for acne however we can categorise into mild, moderate and severe; discuss these categories
- Mild= predominatly non-inflammed lesions
- Moderate= more widespread with increased number of inflammatory lesions
- Severe= widespread inflammatory lesions. Scarring may be present
State soem drugs and underlying conditions which can exacerbate acneform rashes
Drugs:
- Corticosteroids
- Isoniazid
- Ciclosporin
- Lithium
- Androgens
Underlying conditions:
- PCOS
What are aims of acne management?
- Reduce symptoms
- Reduce risk of scarring
- Minimise psychosocial impact
Discuss the management of acne vulgaris
- Advice:
- Don’t overclean face
- Gentle cleansers
- Avoid picking & squeezing spots
- Healthy diet
- First line is topical treatments:
- Topical retinoid (e.g. adapalene) + topical benzoyl peroxide
- Topical retinoid (e.g. tretinoin) + topical macrolide abx (e.g. clindamycin)
- Topical benzoyl peroxide + topical macrolide abx (e.g. clindamycin)
- IF PERSON DOES NOT WANT retinoid or abx can try topical benzoyl peroxide monotherapy
- Azelaic acid may also be used as an adjunct
- Second line: add oral tetracycline abx (e.g. lymecycline, doxycycline) *DO NOT use topical & oral abx in combination. Always prescribe topical benzoyl peroxide or topical retinoid to reduce risk antibiotic resistance. Tetracycline should be avoided in pregnancy, breast feeding or child <12 yrs therefore give erythromycin instead.
- Third line: add COCP (co-cyprindiol is most effective due to anti-androgen effect)
- Fourth line: add oral isotretinoin (specialist)
How does benzoyl peroxide work in acne vulgaris?
Toxic to Propionibacterium (so kills bacteria) and helps the pores shed dead skin cells and excess sebum
How do topical retinoids work?
State some examples
What advice should be given to someone using topical retinoids?
- Vitamin A derivatives that normalize follicular hyperproliferation and hyperkeratinisation (to help unclog pores)
- Examples include: adapalene, tazarotene, and tretinoin
- Advice:
- Teratogenic hence pts must be on effective contraception
- Think stratum corneum & have been associated with photosensitivity therefore advise on sun protection
State some side effects of topical retinoids
- Retinoid dermatitis (dry, erythematous, peeling, Pruritis)
- Increased sensitivity to UV light
How does oral isotretinoin (retinoid) work in acne?
Who can prescribe it?
What advice must be given to pts? (Not really advice, it’s law)!
- Vitamin A derivative that works by:
- Reducing production of sebum
- Reducing inflammation
- Reducing bacterial growth
- Prescribed by a dermatologist
- Strongly teratogenic hence pt must be on pregnancy prevention programme; involves being on contraception, having regular pregnancy tests etc… must stop isotretinoin at least 1 month before becoming pregnant
Pathophysiology of psoriasis is multifactorial; state some factors associated with psoriasis
Multifactorial and not yet fully understood
- Know that abnormal T cell activity stimulates keratinocyte proliferation
- Genetic associations
- Environmental associations (e.g. triggered by stress, trauma, Streptococcal infection in guttate psoriasis but improved by e.g. sunlight)
State, and briefly describe, the 4/5 subtypes of psoriasis- highlighting which is most common
- Chronic plaque psoriasis: well demarcated erythematous plaques covered by silvery white scales often found on extensor surfaces, scalp, retro auricular, perianal and periumbilical regions (MOST COMMON)
- Inverse/flexural psoriasis: affects flexural regions. Usually less scaly due to moisture at these sites.
- Guttate psoriasis: multiple red, 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
Describe typical presentation of chronic plaque psoriasis (as this is most common subtype)
- Erythematous plaques covered with silvery-white scale
- Typically on extensor surfaces (but may also be on scalp, trunk, buttocks or peri-umbilical area)
- Auspitz’s sign (if scale removed then red membrane with pinpoint bleeding points may be seen)
- Koebner phenomenon (skin lesions appear at site of injury)
- Nail changes (pitting, onycholysis, subungual hyperkeratosis, loss of nail)
- Arthritis
Discuss how you should assess a pt with suspected psoriasis
- 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
Discuss the management of guttate psoriasis
- Reassure: self-limiting & typically resolves within 3–4 months of onset & not infectious
- Can either give no treatment if mild or give topical agents as per CPP guidance
For vitamin D analogues used in psoriasis, discuss:
- Mechanism of action
- ADRs
- Contraindications
- Reduce cell division & differentiation to reduced epidermal proliferation. (NOTE: they tend to reduce scale and thickness but not erythema)
- ADRs are uncommon but may include skin reaction
- Contraindications:
- Avoid in pregnancy
What regions of face does rosacea commonly affect?
State signs & symptoms of rosacea
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
State some common triggers for rosacea
Describe the presentation of lichen planus
- Commonly on palms, soles, genitalia, flexural surfaces of arms
- Papules & polyglonal plaques
- Wickham’s striae
- Koebner phenomenon
- Oral involvement (50%)
- Nail involvement (thin nails with longitudinal ridges)
Discuss the management of seborrheic dermatitis of scalp (cradle cap) in infants
- 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
Discuss the management of seborrheic dermatitis of scalp in adults
Discuss the management of seborrheic dermatitis of face and body in adults
Scalp
- First line= OTC shampoos (can also use selenium sulphide shampoo or shampoo containing salicyclic acid or coal tar) or ketoconazole 2% shampoo
- Second line= add in topical corticosteroid if severe itching for max of 4 weeks e.g.betamethasone valerate 0.1%
Face & Body
- Topical imidazole e.g. ketoconazole (can also use ketoconazole shampoo as body wash)
- Add in mild corticosteroid e.g. hydrocortisone 0.5% for short duration
