Dermatology - Conditions & Management

Question 1

What are the clinical features of acne?

Answer 1

Non-inflammatory lesions.
Inflammatory lesions.
Scarring.
Seborrhoea.
Pigmentation.

Question 2

What are the features of the different stages of acne?

Answer 2

Mild acne — predominantly non-inflamed lesions (open and closed comedones) with few inflammatory lesions.
Moderate acne — more widespread with an increased number of inflammatory papules and pustules.
Severe acne — widespread inflammatory papules, pustules and nodules or cysts. Scarring may be present.

Question 3

What must be present for a diagnosis of acne to be made?

Answer 3

Comedones.

Question 4

What are examples of inflammatory lesions?

Answer 4

Papules and pustules – superficial raised lesions (less than 5 mm in diameter).
Nodules or cysts (larger than 5mm in diameter) – deeper, palpable lesions which are often painful and may be fluctuant. In very severe acne nodules may track together and form sinuses

Question 5

What should be included in a history taking for a patient with suspected acne?

Answer 5

Duration, type and distribution of lesions.
Previous treatment (including over-the-counter medications) and response.
Exacerbating factors such as flares with menstruation, contraceptives, cosmetics, face creams or hair pomades.
Systemic features.
Family history including endocrine disorders, polycystic ovarian syndrome, acne and other skin conditions.
Possible underlying causes:
Drug history
Hyperandrogenism

Question 6

What is the management of acne in primary care? (Advice, mild-moderate, moderate-severe).

Answer 6

The possible reasons for acne.
Treatment options, including over-the-counter treatments if appropriate.
The benefits and drawbacks associated with treatments.
The potential impact of acne.
The importance of adhering to the treatment as positive effects can take 6–8 weeks to become noticeable.
Relapses — when and how to obtain further advice and treatment options.

Advice:
- Avoid oil based skin products.
- Avoid over-cleaning
- Use non-alkaline detergent cleansing product 2/7
- Avoid itching or picking at skin -> scarring.

Mild-Moderate:
Offer a 12-week course of one of the following first-line options to be applied once daily in the evening:
A fixed combination of topical adapalene with topical benzoyl peroxide (0.1% or 0.3% adapalene with 2.5% benzoyl peroxide).
A fixed combination of topical tretinoin with topical clindamycin (0.025% tretinoin with 1% clindamycin).
A fixed combination of topical benzoyl peroxide with topical clindamycin (3% or 5% benzoyl peroxide with 1% clindamycin).

Moderate-Severe:
Offer a 12-week course of one of the following first-line options:
A fixed combination of topical adapalene with topical benzoyl peroxide to be applied once daily in the evening.
A fixed combination of topical tretinoin with topical clindamycin to be applied once daily in the evening.
A fixed combination of topical adapalene with topical benzoyl peroxide to be applied once daily in the evening, together with either oral lymecycline 408 mg or oral doxycycline 100 mg once daily.
Topical azelaic acid (15% or 20%) applied twice daily, with either oral lymecycline 408 mg or oral doxycycline 100 mg once daily.

Question 7

What should be discussed with patients that have the potential to become pregnant?

Answer 7

That topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy.
That they will need to use effective contraception, or choose an alternative treatment to these options.

Question 8

When should a patient with suspected acne be referred to dermatology?

Answer 8

There is diagnostic uncertainty.
They have acne conglobata.
They have nodulo-cystic acne.
Mild to moderate acne has not responded to two completed courses of treatment.
Moderate to severe acne has not responded to previous treatment that includes an oral antibiotic.
They have acne with scarring.
They have acne with persistent pigmentary changes.
Their acne of any severity, or acne-related scarring, is causing or contributing to persistent psychological distress or a mental health disorder.

Question 9

When should a follow-up be planned for initiation of acne treatement?

Answer 9

12 weeks.

Question 10

What should be asked about in a history for suspected eczema?

Answer 10

The presence of itching (yes)
The pattern, time of onset, and natural history of the rash (usually starts in infancy and is episodic in nature).
A family or personal history of atopy (allergic rhinitis and asthma).
Any treatments(s) tried and the response to the treatment(s).
Possible trigger factors (irritant or allergic).

Question 11

What are the usual examination findings for adult eczema rash?

Answer 11

Generalized dryness and itching, particularly with exposure to irritants. Eczema on the hands may be the primary manifestation.

Question 12

What is the most common examination finding for children and adults with long-standing eczema?

Answer 12

Often localized to the flexure of the limbs.

Question 13

What are the usual features of eczema present in infants?

Answer 13

Primarily involves the face, the scalp, and the extensor surfaces of the limbs. The nappy area is usually spared.

Question 14

What are the clinical features of acute eczema flares?

Answer 14

Ranges from poorly demarcated redness to fluid in the skin (vesicles), scaling, or crusting of the skin.

Question 15

What are the clinical features of chronic eczema?

Answer 15

Characterized by thickened (lichenified) skin resulting from repeated scratching.
Follicular hyperkeratotic papules (keratosis pilaris) that are typically asymptomatic may be present on the extensor surfaces of the upper arms, buttocks, and anterior thighs.

Question 16

When should a secondary bacterial infection of eczema be considered?

Answer 16

If the eczema is weeping, crusted, or there are pustules, with fever or malaise.

Question 17

What are the NICE criteria for eczema diagnosis?

Answer 17

Itchy skin condition + 3 or more of:
Visible flexural eczema involving the skin creases, such as the bends of the elbows or behind the knees (or visible eczema on the cheeks and/or extensor areas in children aged 18 months or younger).
Personal history of flexural eczema (or eczema on the cheeks and/or extensor areas in children aged 18 months or younger).
Personal history of dry skin in the last 12 months.
Personal history of asthma or allergic rhinitis (or history of atopic disease in a first-degree relative of a child aged under 4 years).
Onset of signs and symptoms before the age of 2 years (this criterion should not be used in children younger than 4 years of age).

Question 18

What are some of the common triggers for eczema?

Answer 18

Irritant allergens
Irritant clothing
Skin infections e.g. Staphylococcus aureus. Other organisms implicated include streptococcus species, Candida albicans, Pityrosporum yeasts, and herpes simplex.
Contact allergens
Consider the possibility of allergic contact dermatitis in people with an exacerbation of previously controlled atopic eczema, or with reactions to topical treatments.
Inhalant allergens e.g. ask about symptoms around pets and pollen. Sensitivity to airborne allergens may result in presentations with flares on the head and neck.
Hormonal triggers
Climate
Dietary factors e.g. Suspect food allergy in children with atopic eczema who have reacted previously to food, with immediate symptoms, or in infants and young children with moderate or severe atopic eczema that has not been controlled by optimum management.

Question 19

What are the different categories of eczema?

Answer 19

Clear — if there is normal skin and no evidence of active eczema.
Mild — if there are areas of dry skin, and infrequent itching (with or without small areas of redness).
Moderate — if there are areas of dry skin, frequent itching, and redness (with or without excoriation and localized skin thickening).
Severe — if there are widespread areas of dry skin, incessant itching, and redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking, and alteration of pigmentation).
Infected — if eczema is weeping, crusted, or there are pustules, with fever or malaise.

Question 20

How is the psychological impact of eczema cateogorised?

Answer 20

None — no impact on quality of life.
Mild — little impact on everyday activities, sleep, and psychosocial well-being.
Moderate — moderate impact on everyday activities and psychosocial well-being, and frequently disturbed sleep.
Severe — severe limitation of everyday activities and psychosocial functioning, and loss of sleep every night.

Question 21

What is the management of mild eczema in primary care?

Answer 21

Prescribe generous amounts of emollients, and advise frequent and liberal use.
Consider prescribing a mild topical corticosteroid (such as hydrocortisone 1%) for areas of red skin. Treatment should be continued for 48 hours after the flare has been controlled.
Avoid scratching.
Avoid triggers.

Question 22

What is the management of moderate eczema in primary care?

Answer 22

Prescribe a generous amount of emollients, and advise frequent and liberal use (more than usual).
If the skin is inflamed, prescribe a moderately potent topical corticosteroid to be used on inflamed areas. Treatment should be continued for 48 hours after the flare has been controlled.
For delicate areas of skin (such as the face and flexures), consider starting with a mild potency topical corticosteroid and increase to a moderate potency corticosteroid only if necessary. Aim for a maximum of 5 days’ use.
If there is severe itch or urticaria, consider prescribing a one-month trial of a non-sedating antihistamine (such as cetirizine, loratadine, or fexofenadine).
Consider prescribing a maintenance regimen of topical corticosteroids to control areas of skin prone to frequent flares

Question 23

What follow-up should be considered for patients with moderate eczema?

Answer 23

Review emollient use on an annual basis to ensure optimal usage.
Review maintenance therapy with topical corticosteroids at 3–6 months to assess effectiveness.
Review the use of non-sedating antihistamines every 3 months (treatment can be stopped, then restarted if symptoms worsen).

Question 24

What safety-netting advice should be given to all patients with eczema?

Answer 24

The early or prodromal signs and symptoms of a flare. Should this occur, advise immediate and aggressive treatment using an agreed stepped-care plan.
The symptoms and signs of eczema herpeticum, which is a medical emergency.
The symptoms and signs of infected eczema.

Question 25

What is the management of severe eczema in primary care?

Answer 25

Prescribe a generous amount of emollients and advise frequent and liberal use (more than usual).
If the skin is inflamed, prescribe a potent topical corticosteroid to be used on inflamed areas.
For delicate areas of skin such as the face and flexures, use a moderate potency corticosteroid. Aim for a maximum of 5 days’ use.
If there is severe itch or urticaria, consider prescribing a one-month trial of a non-sedating antihistamine (such as cetirizine, loratadine, or fexofenadine).
If itching is severe and affecting sleep, consider prescribing a short course (maximum of two weeks) of a sedating antihistamine (such as chlorphenamine).
If there is severe, extensive eczema causing psychological distress, consider prescribing a short course of an oral corticosteroid, 30 mg prednisolone taken in the morning for 1 week.
Consider prescribing a maintenance regimen of topical corticosteroids to control areas of skin prone to frequent flares

Question 26

What follow-up should be considered for patients with severe eczema?

Answer 26

Review emollient use on an annual basis to ensure optimal usage.
Topical corticosteroids require regular review if there is heavy usage. Review maintenance therapy with topical corticosteroids at 3–6 months to assess effectiveness.
Review the use of non-sedating antihistamines every 3 months (treatment can be stopped, then restarted if symptoms worsen).
For all people who have had a severe and extensive flare requiring treatment with oral corticosteroids or oral antibiotics, review after the course has finished, and consider the need for referral.

Question 27

When should an urgent 2-week wait referral be made to dermatology for a patient with severe eczema?

Answer 27

If eczema is severe and has not responded to optimum topical treatment after 1 week.

Question 28

What is the management of infected eczema in primary care?

Answer 28

Antibiotics are not routinely offered to patients with infected eczema who are systemically well.
If antibiotics are offered:
Flucloxacillin is the first-line choice.
Prescribe clarithromycin (penicillin allergy, flucloxacillin resistance). Prescribe erythromycin (penicillin allergy, pregnant)
If there are localized areas of infection, consider prescribing topical fusidic acid.
Prescribe new supplies of topical products (emollients and corticosteroids) for use after the infection has cleared, and advise the person to discard the old products.

Question 29

What should be done for patients with secondary bacterial infection of eczema that is occurring frequently?

Answer 29

Send a skin swab for microbiological testing and
Consider taking a nasal swab and starting treatment for decolonization.

Question 30

What are the characteristic features of weals in urticaria?

Answer 30

A central swelling of variable size (red or white in colour), almost invariably surrounded by an area of redness (flare).
Associated itching or, sometimes, burning sensation.
A fleeting nature, with the skin returning to its normal appearance, usually within 1–24 hours.

Question 31

What are some examples of triggers of urticaria?

Answer 31

Stress, drug treatments, insect bites and stings, exercise, and certain foods.

Question 32

What clinical score is used to assess the severity of urticaria?

Answer 32

UAS7

Question 33

What is the management of urticaria in primary care?

Answer 33

Identify and manage underlying causes and triggers; in patients with identifiable triggers = self-limiting.
Offer a non-sedating antihistamine (for example cetirizine, fexofenadine, or loratadine) for up to 6 weeks.
If symptoms are severe, give a short course of an oral corticosteroid in addition to the non-sedating oral antihistamine.
If it is likely that symptoms will be persistent or recurrent prescribe daily antihistamine treatment for 3–6 months, then review.
If symptoms were short-lived and frequent recurrence thought unlikely, prescribe treatment to be taken as required or prophylactically.

Question 34

What are the options for a patient with urticaria that has not responded to first-line treatment?

Answer 34

In adults, gradually increase the dose of the first-line antihistamine to up to four times the standard licensed dose (off-label use). Consider seeking specialist advice if this approach is being considered in a child.
Switch to an alternative non-sedating antihistamine.
Consider prescribing a leukotriene receptor antagonist (such as montelukast or zafirlukast) in addition to the non-sedating anti-histamine.
Prescribe a topical antipruritic treatment (such as calamine lotion or topical menthol aqueous cream) to relieve itch.
Prescribe an additional sedative antihistamine (such as chlorphenamine) at night, if itch is interfering with sleep.
Refer the person to a dermatologist or immunologist.

Question 35

When should a referral to dermatology be made for a patient with urticaria?

Answer 35

People with urticaria that is painful and persistent (suspect vasculitic urticaria).
People whose symptoms are not well controlled on antihistamine treatment.
People with angioedema and no weals, that do not respond to first-line treatment.
People with acute severe urticaria which is thought to be due to a food or latex allergy.
People with forms of chronic inducible urticaria that may be difficult to manage in primary care, for example, solar or cold urticaria.

Question 36

What are the characteristics of psoriasis on examination?

Answer 36

Distribution — psoriasis often occurs on extensor surfaces (elbows and knees), trunk, flexures, sacral and natal cleft, scalp and behind the ears, and umbilicus.
Size and shape of lesions — plaque psoriasis generally presents as large plaques, whereas guttate psoriasis presents as smaller ‘droplet’ lesions. There is usually a clear delineation between normal and affected skin.
Number of lesions — some people will have only a few lesions (for example chronic plaque psoriasis affecting only the extensor surfaces), but others will have many (for example, numerous small lesions of guttate psoriasis).
Surface features — whether smooth, scaly, or pustular.
Colour — may be pink or red, but in people with pigmented skin, this may not be obvious. Scale is typically silvery in colour.
Auspitz sign — the observation of pinpoint bleeding when adherent psoriatic scales are scraped away.
Involvement of other areas — such as signs of joint tenderness or swelling suggesting psoriatic arthritis, or nail changes.

Question 37

What are the different types of psoriasis?

Answer 37

Pustular psoriasis.
Erythrodermic psoriasis.
Chronic plaque psoriasis.
Scalp psoriasis.
Facial psoriasis.
Flexural psoriasis.
Guttate psoriasis.
Nail psoriasis.

Question 38

What are the clinical features of chronic psoriasis?

Answer 38

Monomorphic, erythematous plaques covered by adherent silvery-white scale, usually on the scalp, behind the ears, trunk, buttocks, periumbilical area, and extensor surfaces.
White skin = the plaques are pink or red
Deeply pigmented skin = grey colour and may cause marked post-inflammatory hyperpigmentation.
Most lesions are 1 cm to several centimetres in diameter, with an oval or irregular shape.
There is usually a clear delineation between normal and affected skin.
Scale is usually present — it is usually silver-white in colour, but less commonly can be a waxy yellow or orange-brown.

Question 39

What are the clinical features of scalp psoriasis?

Answer 39

The whole scalp can be affected, or individual plaques may be visible. Plaques may be very thick, particularly in the occipital region.
It may be associated with areas of non-scarring alopecia in some people, particularly if there is:
Thick, adherent scale extending up the hair shaft.
Erythrodermic psoriasis — this can cause severe alopecia.
Repeated scratching of the scalp due to itch (usually reversible).

Question 40

What is the distribution of flexural psoriasis? Who is at increased risk?

Answer 40

Itchy psoriasis lesions affecting areas such as the groin, genital area, axillae, inframammary folds, abdominal folds, sacral and gluteal cleft.

The elderly, immobile, and people who are overweight or obese are at increased risk of being affected

Question 41

What are the clinical features of guttate psoriasis?

Answer 41

Small, scattered, round or oval (2 mm to 1 cm in diameter - water drop appearance) scaly papules, which may be pink or red.
Multiple lesions which may occur all over the body over a period of 1–7 days, particularly on the trunk and proximal limbs.
Lesions may occur on the face, ears, and scalp, but rarely affect the soles of the feet.
Guttate psoriasis mostly occurs in children, teenagers and young adults, although it can also occur in older adults.
A first presentation of psoriasis (classically after acute streptococcal upper respiratory tract infection), or as an acute exacerbation of plaque psoriasis.

Question 42

What are the symptoms suggestive of nail psoriasis?

Answer 42

Nail pitting (depressions in the nail plate) is the most common finding.
Discolouration (for example the ‘oil drop sign’) — orange-yellow discolouration of the nail bed.
Subungual hyperkeratosis — hyperproliferation of the nail bed, with accumulation of keratinocytes under the nail.
Onycholysis — detachment of the nail from the nail bed, which may allow bacteria and fungi to enter and cause infection.
Complete nail dystrophy.

Question 43

Which types of psoriasis can be life-threatening?

Answer 43

Erythrodermic psoriasis.
Pustular psoriasis.

Question 44

What is the management of psoriasis in primary care? (excluding medications)

Answer 44

Offer advice on the nature of psoriasis, and explain that treatment is aimed at control of symptoms rather than cure, and that complete clearance of skin lesions may not be possible.
Lifestyle: reduce smoking, drinking and weight.
Creams, lotions, or gels are suitable for widespread psoriasis.
Ointments are suitable for areas of skin with thick scale.
Lotions, solutions, or gels are suitable for hair-bearing areas.

Question 45

When is the use of topical corticosteroids appropriate for chronic plaque psoriasis (trunk/limbs)?

Answer 45

Topical corticosteroids are only suitable for treating localized areas of psoriasis.

Question 46

What are the principles of medical management of chronic plaque psoriasis?

Answer 46

Emollients = relieve itch
Corticosteroids (+ topical vitamin D).
Salicylic acid = scale is a problem.

Question 47

What are the principles of medical management of scalp psoriasis?

Answer 47

A potent topical corticosteroid (applied once a day).
A vitamin D preparation alone (applied once a day).
A coal tar shampoo, but should not be used alone for people who have severe scalp psoriasis.

Question 48

What are the principles of medical management of facial/flexural/genital psoriasis? What are the risks of treatment?

Answer 48

An emollient to reduce scale and help relieve itch.
Advise the person to avoid soap where possible if there is flexural or genital psoriasis, as soap is likely to irritate inflamed skin.
A short-term mild- or moderately-potent topical corticosteroid preparation (applied once or twice daily) for up to two weeks.

Do not prescribe potent- or very-potent topical corticosteroids to the face, flexures, or genital areas. Corticosteroid application to these areas may cause skin irritation, and there is a greater risk of adverse effects, such as skin atrophy, compared with use in other areas of the body.

Question 49

What are the principles of medical management of guttate psoriasis?

Answer 49

An emollient to reduce the scale and help relieve itch.
A potent topical corticosteroid plus a topical vitamin D preparation (both applied once a day, but at different times of day).
Consider a salicylic acid preparation if the scale is problematic.

Question 50

What advice should be given to a patient with nail psoriasis?

Answer 50

Keep their nails short — this avoids exacerbating onycholysis and reduces the accumulation of material under the nail.
Avoid manicure of the cuticle — this may provoke paronychia.
Avoid prosthetic nails.

Question 51

What are the clinical features of cellulitis?

Answer 51

Acute bacterial infection of the dermis and subcutaneous tissue.
Most commonly lower limb.
Characterized by pain, warmth, swelling, and erythema.
Blisters and bullae may form.
Fever, malaise, nausea, and rigors may accompany or precede the skin changes.

Question 52

What are the risk factors for cellulitis?

Answer 52

Skin trauma, ulceration, and obesity.

Question 53

What are the most common causative microorganisms for cellulitis?

Answer 53

Staphylococcus aureus.
Streptococcus pyogenes.

Question 54

What are the complications of cellulitis?

Answer 54

Necrotizing fasciitis
Sepsis
Persistent leg ulceration
Recurrent cellulitis.

Question 55

What is the classification score for cellulitis and what does it consist of?

Answer 55

The Eron classification of cellulitis is a useful guide for making management decisions:
Class I — there are no signs of systemic toxicity or uncontrolled comorbidities.
Class II — the person is either systemically unwell or systemically well but with comorbidity which may complicate or delay resolution of infection.
Class III — the person has significant systemic upset or unstable comorbidities that may interfere with a response to treatment, or a limb-threatening infection due to vascular compromise.
Class IV — the person has sepsis or a severe life-threatening infection, such as necrotizing fasciitis.

Question 56

Which classification of cellulitis can be managed by primary care?

Answer 56

I

Question 57

What are the basic principles of management of adult cellulitis (I) in primary care?

Answer 57

Take paracetamol or ibuprofen for pain and fever.
Drink adequate fluids.
Seek immediate medical advice if antibiotics are not tolerated, the cellulitis becomes worse, or if systemic symptoms develop or worsen.
Elevate the leg for comfort and to relieve oedema (where applicable).
Avoid the use of compression garments during acute cellulitis.

Prescribe flucloxacillin four times daily for 5–7 days.
Penicillin allergy:
Clarithromycin twice daily for 5–7 days.
Doxycycline for a total of 5–7 days.
Erythromycin (in pregnancy) for 5–7 days.

Question 58

When should a patient with suspected cellulitis be reviewed after initiation of antibiotic treatment?

Answer 58

2-3 days

Question 59

What are the clinical features of seborrhoeic dermatitis?

Answer 59

It typically presents as erythematous patches with scale which may be white or yellow, oily or dry.

Question 60

What are the principles of management of seborrhoeic dermatitis in the scalp and beard?

Answer 60

Use of ketoconazole 2% shampoo (in adolescents and adults), or an over-the-counter anti-dandruff shampoo, shampoo should be left on for 5 minutes before rinsing off.
For adults with severe itching of the scalp, a potent topical corticosteroid scalp application (such as betamethasone valerate) can be added for 4 weeks.

Question 61

What are the principles of management of seborrhoeic dermatitis in the face and body?

Answer 61

Application of ketoconazole 2% cream (adults only) or other topical imidazoles (such as clotrimazole or miconazole) — an antifungal shampoo such as ketoconazole 2% can be used as a body wash in adolescents and adults.
Addition of a mild topical corticosteroid cream such as hydrocortisone for flares to settle inflammation.