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dermatology passmed Flashcards

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1
Q

what is vitiligo

A

autoimmune condition which results in the loss of melanocytes and consequent depigmentation of the skin.

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2
Q

A 58-year-old woman presents with facial redness. This has been worsening since her holiday to Spain but she is otherwise asymptomatic.

She has a background of hypertension and takes amlodipine 5mg OD. She has no allergies and has not started any new medications recently.

On examination, telangiectasia are present with papules and pustules clustered around her nose and cheeks. She is afebrile.

What is the most likely diagnosis?

A

acne rosacea

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3
Q

what are the features of rosacea

A
  1. nose, cheeks and forehead usually middle age
  2. flushing, erythema, telangiectasia → later develops into papules and pustules
  3. worsened with exposure to sunlight
  4. rhinophyma (nose enlarged, red, bulbous)
  5. ocular involvement
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4
Q

what is erysipelas

A
  1. superficial cellulitis caused by group A beta-haemolytic streptococci
  2. characteristic butterfly distribution on the cheeks with a sharp raised border, skin appears firm, bright red and swollen.
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5
Q

what are the differences between acne vulgaris vs rosacea

A

acne Vulgaris = skin lesions in adolescence can additionally affect neck check and back (not just face)

rosacea = middle-aged, limited to face/nose/cheeks

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6
Q

describe the management of rosacea

A
  1. topical metronidazole in mild sx - limited no of papules and pustules, no plaques
  2. topical brimonidine gel - predominant flushing but limited telangiectasia
  3. more severe disease - systemic antibiotics e.g oxytetracycline
  4. daily application of a high-factor sunscreen recommended
  5. camouflage creams can help conceal redness
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7
Q

how should patients with rosacea and rhinophyma be managed

A
  1. manage rosacea
  2. refer to dermatology for rhinophyma
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8
Q

patients with rosacea with telangiectasia can be considered for

A

laser therapy

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9
Q

what skin disorders are associated with pregnancy

A
  1. atopic eruption of pregnancy
  2. polymorphic eruption of pregnancy
  3. pemphigoid gestationis
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10
Q

what is the commonest skin disorder found in pregnancy

A

atopic eruption of pregnancy

eczematous itchy red rash

no specific treatment is needed

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11
Q

what is Polymorphic eruption of pregnancy and how is it managed

A

pruritic condition associated with the last trimester
lesion appear in abdominal striae first

managed based on severity - emollients, mild potency topical steroids and oral steroids may be used

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12
Q

what is Pemphigoid gestationis and how it is managed

A

pruritic blistering lesions
seen in pregnancy (2nd or 3rd trimester)
in the peri-umbilical region, later spreading to the trunk, back, buttocks and arms

can be managed with oral corticosteroids

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13
Q

what is acanthosis nigricans

A

Brown, symmetrical plaques often on neck, axilla and groin

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14
Q

describe the causes of acanthosis nigricans

A
  1. t2dm
  2. gastrointestinal cancer
  3. obesity
  4. pcos
  5. acromegaly
  6. Cushing’s disease
  7. hypothyroidism
  8. familial
  9. drugs = cocp, nicotinic acid
  10. prader -Willi syndrome
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15
Q

describe the pathophysiology of acanthosis nigricans

A
  1. insulin resistance
  2. leading to hyperinsulinemia
  3. stimulation of keratinocytes and dermal fibroblast proliferation (via interaction with insulin-like growth factor receptor 1(
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16
Q

A 30-year-old female in her third trimester of pregnancy mentions during an antenatal appointment that she has noticed an itchy rash around her umbilicus. This is her second pregnancy and she had no similar problems in her first pregnancy. Examination reveals blistering lesions in the peri-umbilical region and on her arms. What is the likely diagnosis?

A

pemphigoid gestationis

possible differential is polymorphic eruption of pregnancy but this is not the asnwer as it is not associated with blistering

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17
Q

A 33-year-old woman visits the GP with joint pain for the last two weeks. The joint pain is limited to the distal interphalangeal joints, with significant erythema and swelling. She reports also having had significant pain and swelling across her left index finger a couple of months ago, although this has now resolved. On full examination, a scaly rash on her scalp is noted.

what is the likely dx and what features if seen in hx could support this

A

psoriatic arthritis

nail pitting and onycholysis are associated with psoriasis + psoriatic arthropathy

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18
Q

what nail changes can be seen in psoriasis

A
  1. pitting
  2. onycholysis
  3. subungual hyperkeratosis
  4. loss of the nail
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19
Q

A 27-year-old man presents to the emergency department with a 2-day history of fever, tiredness, and a tingling sensation in the lateral aspect of his right thigh. He has found the tingling was initially bearable but has become painful in the past 24 hours. On examination, the area described is erythematous with a macular rash appearing. His only past medical history is HIV for which he takes anti-retroviral therapy and has an undetectable viral load. He denies any cough, coryzal symptoms, focal neurological signs, or trauma to the site.

Considering the likely diagnosis, what is the appropriate management for the patient

A

aciclovir

suspected shingles should be treated with antivirals within 72hrs of onset

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20
Q

A 27-year-old man presents to the emergency department with a 2-day history of fever, tiredness, and a tingling sensation in the lateral aspect of his right thigh. He has found the tingling was initially bearable but has become painful in the past 24 hours. On examination, the area described is erythematous with a macular rash appearing. His only past medical history is HIV for which he takes anti-retroviral therapy and has an undetectable viral load. He denies any cough, coryzal symptoms, focal neurological signs, or trauma to the site.

what is the likely diagnosis, why and how should the patient be managed

A

pateitn has systemic viral illness symptoms (fever and malaise) with tingling and pain over the L2 dermatomal distribution (lateral aspect of his thigh).

an immunosuppressive condition (HIV),

he should be managed with antivirals, such as aciclovir, to reduce the risk of post-herpetic complications

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21
Q

what is shingles

A
  1. herpes zoster infection - an acute unilateral painful blistering rash
  2. caused by reactivation of VZV
  3. following primary infection with VZV (chickenpox), the virus lies dormant in the dorsal root or cranial nerve ganglia
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22
Q

what are the risk factors of shingles

A
  1. increasing age
  2. HIV - x15 more likely
  3. other immunosuppressive conditions (steroids, chemotherapy)
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23
Q

what are the most affected dermatomes in shingles

A

T1-L2

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24
Q

what are the features of shingles

A
  1. prodromal period -
    a) burning pain over the affected dermatome for 2-3 days
    b) pain may be severe and interfere with sleep
    c) around 20% of patients will experience fever, headache, lethargy
  2. rash
    initially erythematous, macular rash over affected dermatome, becomes vesicular
    well demarcated and does not cross the midline
    can be bleeding in adjacent areas
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25
Q

how is the diagnosis of shingles made

A

clinical

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26
Q

how is shingles managed

A
  1. remind pt they are potentially infectious
  2. analgesia. paracetamol and NSAIDs. neuropathic agents second line - amitriptyline. oral corticosteroids third line in first 2 weeks in immunocompromised adults if pain severe and not responding to 1 and 2 line
  3. antivirals, aciclovir
    reduces the risk of post-herpetic neuralgia esp in elderly people
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27
Q

what are the complications of shingles

A
  1. post-herpetic neuralgia (resolves within 6 months, may last longer)
  2. herpes zoster ophthalmicus - shingles affected ocular divisions of the trigeminal nerve -
  3. herpes zoster oticus - Ramsay hunt syndrome = can lead to ear lesions and facial paralysis
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28
Q

ear-old female attends her general practice with a 2-day history of burning pain and rash on the left side of her chest. She also reports feeling generally unwell. She has no past medical history and takes no regular medication.

On examination, there is an erythematous rash with multiple clear vesicles on the left side of the torso. The rest of the clinical examination including an ophthalmic examination is normal.

Based on the most likely diagnosis, what is the most appropriate first-line management?

A

first-line oral antiviral is famciclovir or valacyclovir and these should be given for 7 days

second-line option is oral aciclovir

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29
Q

During a 6-week baby check, you notice a flat, 30x20mm, pink-coloured, vascular skin lesion over the nape of the baby’s neck, which blanches on pressure. On further questioning, this area has been present since birth and has not changed significantly. They are developing normally.

What is the most likely underlying diagnosis?

A

salmon patches are a vascular birthmark which usually self resolve
within a few months though marks on neck may persist

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30
Q

A 36-year-old woman presents to clinic with a 4 month history of intermittent bloating and loose stools. She has never passed any blood but has lost a few kilograms in weight.

Over the past week, she has noticed some itchy, vesicular rashes on her elbows that won’t seem to go away. You send off some routine blood tests which come back as normal except for one positive result.

Anti-TTG Positive

What is the dermatological condition that she describes?

A

dermatitis herpetiformis

associated with coeliac disease

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31
Q

what is dermatitis herpetiformis

A

autoimmune blistering skin disorder associated with coeliac disease. It is caused by deposition of IgA in the dermis.

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32
Q

what are the featurse of dermatitis herpetiformis

A

itchy, vesicular skin lesions on the extensor surfaces (e.g. elbows, knees, buttocks)

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33
Q

how is a dx of dermatitis herpetiformis made

A

skin biopsy: direct immunofluorescence shows deposition of IgA in a granular pattern in the upper dermis

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34
Q

how is dermatitis herpetiformis managed

A

gluten-free diet
dapsone

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35
Q

A 4-year-old boy develops multiple tear-drop papules on his trunk and limbs. He is otherwise well. A diagnosis of guttate psoriasis is suspected. What is the most appropriate management?

A

reassurance and topical treatment if lesions are symptomatic
most cases resolve spontaneously within 2-3 months

no firm evidence that the use of abx eradicates streptococcal infection

topical agents as per psoriasis

UVB phototherapy

tonsillectomy may be necessary with recurrent episodes

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36
Q

what is guttate psoriasis

A

more common in children and adolescents

may be precipitated by a streptococcal infection 2-4 weeks prior to the lesions appearing

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37
Q

what are the features of guttate psoriasis

A

tear drop papules on the trunk and limbs

  • gutta is Latin for drop
  • pink, scaly patches or plaques of psoriasis

tends to be acute onset over days

38
Q

differences in guttate psoriasis and pityriasis rosea prodrome

A

guttate psoriasis = classically preceded by strep sore throat 2-4 weeks

39
Q

differences in guttate psoriasis and pityriasis rosea apperance

A

teardrop appearance, scaly papule on trunk and limbs vs

herald patch followed by 1-2 weeks later by multiple erythematous, slightly raised oval lesions with a fine scale confined to the outer aspects of the lesions in pityriasis rosea

40
Q

differences in guttate psoriasis and pityriasis rosea treatment/ natural history

A

in guttate psoriasis - Most cases resolve spontaneously within 2-3 months. Topical agents as per psoriasis. UVB phototherapy

vs in pityriasis rosacea
Self-limiting, resolves after around 6 weeks

41
Q

A 16-year-old attends the GP surgery seeking advice about managing her acne. She reports her skin being particularly bad at the moment as she is very stressed with her impending GCSE exams and is eating more fast-food and smoking cigarettes to cope with the stress. She has a past medical history of polycystic ovarian syndrome and is currently on dianette treatment. On examination, she is overweight with a few erythematous papules and pustules on her cheeks and forehead. Which factor is most likely to be contributing to her acne?

A

polycystic ovarian syndrome

endocrinological cause of acne vulgaris

Poor hygiene: there is no evidence that acne is improved by cleaning. Excessive washing can exacerbate acne.
Stress: poor evidence that stress causes acne.
Smoking can affect the general health of the skin but necessarily cause acne.
Diet has little or no effect on acne vulgaris.

42
Q

what is acne vulgaris

A

common skin disorder which usually occurs in adolescence.

typically affects the face, neck and upper trunk

characterised by the obstruction of the pilosebaceous follicles with keratin plugs which results in comedones, inflammation and pustules.

43
Q

how is acne vulgaris classified

A

mild, moderate or severe:

44
Q

what is mild acne

A

mild: open and closed comedones with or without sparse inflammatory lesions

45
Q

what is moderate acne

A

moderate acne: widespread non-inflammatory lesions and numerous papules and pustules

46
Q

what is severe acne

A

severe acne: extensive inflammatory lesions, which may include nodules, pitting, and scarring

47
Q

describe the management of acne vulgaris

A
  1. single topical therapy (topical retinoids, benzoyl peroxide)
  2. topical combination therapy (topical antibiotic, benzoyl peroxide, topical retinoid)
  3. oral antibiotics
  4. combined oral contraceptives (COCP) are an alternative to oral antibiotics in women
  5. oral isotretinoin
48
Q

describe the role of dietary modification in patients

A

there is no role for dietary modification in patients with acne.

49
Q

what may occur in long term antibiotic use in acne vulgaris and how is it managed

A

gram negative folliculitis
manage with high dose oral trimthoprim

50
Q

how should oral isotretinoin be used and what are the contraindications

A

under specialist supervision

pregnancy is contraindicated to topical and oral retinoid treatment

51
Q

describe the use of COCP in acne vulgaris

A

as with antibiotics, they should be used in combination with topical agents

Dianette (co-cyrindiol) is sometimes used as it has anti-androgen properties.

52
Q

describe the use of abx in acne vulgaris

A

tetracyclines: lymecycline, oxytetracycline, doxycycline

tetracyclines should be avoided in pregnant or breastfeeding women and in children younger than 12 years of age

erythromycin may be used in pregnancy

minocycline is now considered less appropriate due to the possibility of irreversible pigmentation

a single oral antibiotic for acne vulgaris should be used for a maximum of three months

53
Q

which abx should be avoided in pregnancy in acne vulgaris, which one can be used

A

tetracyclines should be avoided in pregnant or breastfeeding
women and in children younger than 12 years of age

erythromycin may be used in pregnancy

54
Q

what should be co prescribed in acne vulgaris with antibiotics

A

a topical retinoid (if not contraindicated) or benzoyl peroxide should always be co-prescribed with oral antibiotics to reduce the risk of antibiotic resistance developing.

Topical and oral antibiotics should not be used in combination

55
Q

what advise is given for use of dinette (co-cyrindiol) in acne vulgaris

A

used as cocp alternative to abx in acne vulgaris

but it has an increased risk of venous thromboembolism compared to other COCPs

therefore it should generally be used second-line, only be given for 3 months and women should be appropriately counselled about the risks

56
Q

what skin condition are renal transplant patients at risk of

A

Renal transplant patients - skin cancer (particularly squamous cell) is the most common malignancy secondary to immunosuppression

57
Q

why is scc a common risk in renal transplant patients

A

patients who undergo renal transplantation must be commenced and remain on immunosuppression therapy for the rest of their life to prevent the risk of transplant rejection.

As an adverse effect, this immunosuppression therapy results in patients having an increased risk of carcinomas as their immune system is less able to identify and destroy newly formed cancer cells or prevent infections that may cause cancer.

Squamous cell carcinoma of the skin has been shown to be the most common malignancy associated with immunosuppression.

58
Q

what are the risk factors of SCC of the skin

A

excessive exposure to sunlight / psoralen UVA therapy
actinic keratoses and Bowen’s disease
immunosuppression e.g. following renal transplant, HIV
smoking
long-standing leg ulcers (Marjolin’s ulcer)
genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism

59
Q

what is the treatment for scc

A

urgical excision with 4mm margins if lesion <20mm in diameter.

If tumour >20mm then margins should be 6mm.

Mohs micrographic surgery may be used in high-risk patients and in cosmetically important sites.

60
Q

describe good prognostic factors in patients with scc

A

well-differentiated tumours
less than 20mm diameter
less than 2mm deep
no associated diseases

61
Q

describe poor prognostic factors in patients with scc

A

poorly differentiated tumours
more than 20mm in diameter
more than 4mm deep
immunosuppression for whatever reason

62
Q

what is erythema multiforme

A

Erythema multiforme is a hypersensitivity reaction that is most commonly triggered by infections.

63
Q

what are the 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

64
Q

what are the causes of erythema multiforme

A

viruses: herpes simplex virus (the most common cause), Orf* (skin disease of sheep and goats caused by a parapox virus)

idiopathic

bacteria: Mycoplasma, Streptococcus

drugs: penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill, nevirapine

connective tissue disease e.g. Systemic lupus erythematosus
sarcoidosis

malignancy

65
Q

what is erythema multiforme major associated with

A

mucosal involvement

66
Q

what is alopecia areta

A

presumed 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

67
Q

describe the management of alopecia areata

A

explain to patients that hair regrows within 1 year for 50% of patients and eventually will grow back in 80-90% of patients

other treatements

topical or intralesional corticosteroids
topical minoxidil
phototherapy
dithranol
contact immunotherapy
wigs

68
Q

what is management for venous ulceration

A

compression bandaging

although without surgery for the underlying varicose veins the ulcers are likely to either fail to heal or recur.

compression bandaging, usually four layer (only treatment shown to be of real benefit)

oral pentoxifylline, a peripheral vasodilator, improves healing rate

small evidence base supporting use of flavinoids

little evidence to suggest benefit from hydrocolloid dressings, topical growth factors, ultrasound therapy and intermittent pneumatic compression

69
Q

where are venous normally seen

A

above medial malleolus

70
Q

what investigations are required in venous ulceration

A

abpi to assess poor arterial flow especially in non-healing ulcers

71
Q

how is abpi interpreted

A

a ‘normal’ ABPI may be regarded as between 0.9 - 1.2. Values below 0.9 indicate arterial disease. Interestingly, values above 1.3 may also indicate arterial disease, in the form of false-negative results secondary to arterial calcification (e.g. In diabetics)

72
Q

What are the features of dermatitis herpetiformis

A

itchy, vesicular skin lesions on the extensor surfaces (e.g. elbows, knees, buttocks)

73
Q

How is herpetiformis dermatitis diagnosed

A

skin biopsy: direct immunofluorescence shows deposition of IgA in a granular pattern in the upper dermis

74
Q

What the management for dermatitis herpetiformis

A

gluten-free diet
dapsone

75
Q

What are the side effects of isotretinoin

A

Most common = dry skin = dry eyes, lips, mouth

Teratogenicity = females should ideally be using two forms of contraception (e.g. Combined oral contraceptive pill and condoms)

Low mood

Raised triglycerides

Hair thinning

Nose bleeds due to drying of nasal mucosa

Intracranial hypertension - isotretinoin treatment should not be combined with tetracyclines for this reason

Photosensitivity

76
Q

A 63-year-old man presents to his general practitioner with a three-week history of an itchy rash over the face and upper chest. His only past medical history is HIV for which he is poorly compliant with his anti-retroviral medications.

On examination, areas of erythema over the eyebrows, nasolabial folds, and upper chest are noted. Excoriations surrounding the rash are present.

A

Seborrhoeic Dermatitis

Manage with topical ketoconazole

77
Q

What are the features of seborrhoeic dermatitis in adults

A

eczematous lesions on the sebum-rich areas: scalp (may cause dandruff), periorbital, auricular and nasolabial folds

otitis externa and blepharitis may develop

78
Q

What diseases are associated with seborrheic dermatitis

A

HIV
Parkinson’s disease

79
Q

Describe the management of seborrhoeic dermatitis in adults

A

Scalp = over the counter preparations containing zinc pyrithione (‘Head & Shoulders’) and tar (‘Neutrogena T/Gel’) are first-line
second-line agent is ketoconazole

Face and body management = topical antifungals: e.g. ketoconazole

80
Q

A 45-year-old man presents to his general practitioner with a one-week history of a rash. He has recently returned from a holiday in Spain. He does not have any significant past medical history and does not take any regular medications.

On examination, there is a rash affecting his trunk, consisting of multiple hypopigmented patches, which are slightly scaly.

Based on the likely diagnosis, what is the appropriate treatment?

A

Pityriasis versicolor

Use ketoconazole

81
Q

Describe the management of pityriasis versicolor

A

Ketoconazole shampoo first line

Consider alternative dx if fails to respond to topical treatment - send off scrapings + oral antifungals

82
Q

what are the features of vitiligo

A

well-demarcated patches of depigmented skin
the peripheries tend to be most affected
trauma may precipitate new lesions (Koebner phenomenon)

83
Q

what are the features of vitiligo

A

well-demarcated patches of depigmented skin
the peripheries tend to be most affected
trauma may precipitate new lesions (Koebner phenomenon)

84
Q

what are the associated conditions

A

type 1 diabetes mellitus
Addison’s disease
autoimmune thyroid disorders
pernicious anaemia
alopecia areata

85
Q

describe the management of vitiligo

A

sunblock for affected areas of skin
camouflage make-up
topical corticosteroids may reverse the changes if applied early
there may also be a role for topical tacrolimus and phototherapy, although caution needs to be exercised with light-skinned patients

86
Q

A 39-year-old female has a pigmented mole removed from her leg, which histology shows to be a malignant melanoma. What is the single most important prognostic marker?

A

invasion depth of melanoma
breslow depth

87
Q

describe breslow thickness for melanoma

A

Breslow Thickness Approximate 5 year survival
< 0.75 mm 95-100%
0.76 - 1.50 mm 80-96%
1.51 - 4 mm 60-75%
> 4 mm 50%

88
Q

Solitary firm papule/nodule that dimples on pinching →

A

dermatofibroma
Dermatofibromas occur following injury, which in this case is a cut whilst shaving.

89
Q

A 26-year-old woman has been referred to the dermatology clinic with a 4-week history of skin rash.

Past medical history includes mild asthma. Regular medications include folic acid 400micrograms OD and over-the-counter vitamin supplements due to pregnancy.

She feels well in herself but states she had a mild cold when the lesions first developed.

On examination, she has multiple, discrete, raised erythematous lesions on the arms and legs ranging from 8cm in diameter to 12cm in diameter. There is pain on active and passive joint movement.

What is the likely diagnosis?

A

erythema nodosum

can occur in pregnancy

90
Q

what is erythema nodosum

A

inflammation of subcutaneous fat
typically causes tender, erythematous, nodular lesions
usually occurs over shins, may also occur elsewhere (e.g. forearms, thighs)
usually resolves within 6 weeks
lesions heal without scarring

91
Q

what are the features of SK

A

large variation in colour from flesh to light-brown to black
have a ‘stuck-on’ appearance
keratotic plugs may be seen on the surface

92
Q

describe the management of sk

A

reassurance about the benign nature of the lesion is an option
options for removal include curettage, cryosurgery and shave biopsy

dermatology (6 decks)

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