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Phase 3B > Dermatology Secondary Care > Flashcards

Dermatology Secondary Care Flashcards

1
Q

What is bullous pemphigoid?

A

A chronic, autoimmune, subepidermal blistering skin disorder.

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2
Q

How does bullous pemphigoid differ from pemphigus?

A

Pemphigus - intra-epidermal blistering, painful not pruritic

Pemphigoid - sub epidermal blistering, painful and pruritic

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3
Q

What is the median age of onset in bullous pemphigoid?

A

80 years

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4
Q

What is the autoantigen in bullous pemphigoid and what is its function?

A

Type XVII collagen (COL17)

in the basement membrane

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5
Q

What are three risk factors for bullous pemphigoid?

A

Lichen planus/psoriasis
NSAIDS/furosemide/captoptil
Radiotherapy

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6
Q

How does bullous pemphigoid present?

A

Urticarial/erythematous rash on limbs precedes blisters - urticarial prodrome
Blisters/bullae occur in skin flexures, are fluid filled
Post inflammatory hyperpigmentation/milia
Patient is otherwise well

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7
Q

How is bullous pemphigoid diagnosed?

A

Skin biopsy followed by direct immunofluorescence (DIF)

Deposit of IgG and C3 on the epidermis side of the dermal/epidermal junction

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8
Q

What is seen on the histology of a bullous pemphigoid patient?

A

Subepidermal blister with fibrin and inflammatory infiltrate and eosinophilic predominance. Intact epidermis

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9
Q

What is the management of bullous pemphigoid?

A

Urgent referral to secondary care/admission
Dermovate cream
If more severe, PO prednisolone

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10
Q

If systemic steroid treatment lasts more than one month, what is given?

A

PPI and bisphosphonates

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11
Q

What is a complication of bullous pemphigoid?

A

Secondary infection and sepsis

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12
Q

What is pemphigus?

A

A group of autoimmune disorders where there is blistering of the skin and/or mucosal surfaces.

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13
Q

What is the pathophysiology of pemphigus?

A

Circulating IgG autoantibodies bind to antigens (desmosomes) on the surface of keratinocytes leading to acantholysis (keratinocytes separate from each other)

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14
Q

What are some risk factors for pemphigus?

A

Female
Older age
Asian and Ashkenazi Jews
Pregnancy and stress

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15
Q

What are the main three subtypes of pemphigus?

A

Pemphigus vulgaris
Pemphigus foliaceus
Paraneoplastic pemphigus

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16
Q

How does the skin symptoms of pemphigus present?

A

Blisters on normal or erythematous skin and are flaccid
Affected skin is painful but rarely pruritic
Intertriginous areas - granulation and crusting

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17
Q

What are the other symptoms of pemphigus?

A

Nail changes
Burst gingival, buccal, and palatine bullae that are painful and slow healing.
Conjunctivae, oesophagus, and genitalia

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18
Q

How is pemphigus definitively diagnosed?

A

Skin biopsy from the edge of a blister, histology and DIF/IDIF
ELISAs for DSG1 and DSG3 in serum

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19
Q

What are the three phases of management of pemphigus?

A

Control, consolidation, maintenance.

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20
Q

What are the treatment options in the control phase of pemphigus management?

A

PO prednisolone
2nd line: plasmaphresis 3xw w/ azathioprine or cyclophosphamide
3rd line: IVIG

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21
Q

Describe the consolidation and maintenance phases of management of pemphigus.

A

Step down regime and tapering after 80% lesions have healed

Steroid sparing agents sometimes used to further reduce dose

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22
Q

What are the complications of pemphigus?

A

Secondary infection
Effects of corticosteroids
Malignancy immunosuppression

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23
Q

Give four differences between pemphigus and bullous pemphigoid

A

Pemphigus: younger, flaccid epidermal bullae, not pruritic
Pemphigoid: Older, tense subepidermal bullae, pruritic

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24
Q

What is lichen planus?

A

A pruritic, popular eruption characterized by its violaceous colour and polygonal shape.

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25
Q

What are the five Ps of lichen planus?

A 
Purple
Pruritic
Polyangular
Planus (flat-topped)
Papules
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26
Q

Where is the rash of lichen planus found?

A

Flexor surfaces of extremities, upper>lower
Genitalia
Mucous membranes

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27
Q

What are some characteristic signs of lichen planus?

A

Lacy white lesions on mucous membranes

Intensely itchy 2-5mm red/violet shiny flat-topped papular with Wickham’s Striae

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28
Q

What occurs when papules clear in lichen planus?

A

They are replaced by brown discolouration

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29
Q

What are the nail and scalp changes seen in lichen planus?

A

Longitudinal ridges

Scarring alopecia

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30
Q

What are the potential causes of lichen planus?

A

T-cell mediated
Kobner’s phenomenon
RF: hepatitis C, PBC, female

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31
Q

What are the variations of lichen sclerosis?

A 
Hypertrophic
Atrophic
Erosive/ulcerative
Follicular
Vesicular/bullous
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32
Q

What is seen on skin biopsy and histology in lichen planus?

A

Saw tooth pattern of epidermal hyperplasia and vacuolar alteration of the epidermis
T lymphohistioctic infiltration
Reduced melanocytes - Wickham’s striae
Globular deposits of IgM

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33
Q

What is the treatment of lichen planus?

A

Symptomatic itch treatment - potent corticosteroids and topical antifungals
Psoralen and PUVA radiation treatment
Systemic steroids

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34
Q

What is lichen simplex chronicus?

A

Localized area of skin becomes thickened and leathery due to chronic rubbing

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35
Q

What is the treatment of lichen simplex chronicus?

A

Superpotent corticosteroid ointment

Less potent if genital skin

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36
Q

50% of melanomas result following which mutation?

A

BRAF V600 on C7q34

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37
Q

What are five risk factors for malignant melanoma?

A 
Previous history of melanoma
More than 100 naevi
Sun exposure
Skin type 1 or 2
Solar keratoses
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38
Q

Name three subtypes of malignant melanoma.

A

Lentigo maligna melanoma
Superficial melanoma
Nodular melanoma

39
Q

What is the weighed 7 point checklist for suspicious moles?

A

Major features (2 pts):

  • Change in size
  • Irregular shape
  • Irregular colour

Minor features (1pt):

  • Largest diameter>7mm
  • Inflammation
  • Oozing
  • Change in sensation
40
Q

What score on the weighted 7 point checklist for moles indicates a 2ww referral?

A

3 or more

41
Q

How is malignant melanoma diagnosed?

A

Full thickness excisional biopsy with lateral excision margin of 2mm normal skin
Sentinel lymph node biopsy
CT and MRI

42
Q

What is the primary treatment of malignant melanoma?

A

Wide local excision

43
Q

What are some other treatments in malignant melanoma?

A

Vitamin D supplementation
Topical imiquimod
Lymhadenectomy
Adjuvant radiotherapy

44
Q

What biologic therapies can be used to treat BRAF V600 positive malignant melanoma?

A

Dabrafenib and vemurafenib

45
Q

What is the Breslow thickness?

A

Depth of invasion of melanoma at diagnosis

Strongly correlates with survival

46
Q

Where do squamous cell carcinomas arise from?

A

Keratinizing cells of the epidermis

47
Q

What are the risk factors for SCC and BCC of the skin?

A

Chronic UVR exposure, skin types 1 and 2, previous history. immune deficiency

48
Q

Name two pre-malignant conditions which may lead to SCCs.

A

Bowen’s disease

Solar keratoses

49
Q

How do squamous cell carcinomas present?

A

Indurated nodular keratinizing or crusted tumour that may ulcerate
Mostly head and neck
Tumour may bleed

50
Q

How is squamous cell carcinoma diagnosed?

A

Excisional biopsy with wide margins

If in a cosmetically sensitive area, can be incisional/punch biopsy

51
Q

How are SCCs managed?

A

Curettage and cautery
Cryotherapy
Electrochemotherapy

52
Q

What are the topical treatments of superficial SCC or pre cancerous lesions?

A

Imiquimod 5% cream
Fluorouracil (Efudix 5%) cream
Diclofenac gel

53
Q

What is the name of the technique where excision of the skin lesion is carried out in stages and each stage checked histologically?

A

Moh’s micrography

54
Q

Which cancer is Mohs’ micrography used more often for?

A

Basal cell carcinomas

55
Q

What are basal cell carcinomas?

A

Slow growing locally invasive malignant epidermal skin tumours that are thought to arise from hair follicles

56
Q

What are the features of Gorlin’s syndrome?

A 
Basal cell naevus and multiple BCCS
Cataracts
Jaw cysts
Pitting of the hands and soles
Calcification of the falx cerebri
57
Q

What do early lesions of BCCs look for?

A

Small
Translucent or pearly
May have a raised area with telangiectasia

58
Q

What is a rodent ulcer?

A

A large nodular BCC with a necrotic centre

59
Q

What are the 5 subtypes of BCCs?

A 
Nodular
Superficial
Morphoeic/sclerosing
Pigmented
Basosquamous
60
Q

What is the cause of psoriasis?

A

Skin is inflamed and proliferates at 10x the normal rate

T-lymphocyte driven disorder

61
Q

What are the genetic components of psoriasis?

A

PSORS1-9 genetic loci

62
Q

What are the trigger factors of psoriasis?

A 
They activate the APC-dendritic or Langerhans cell.
Trauma
UV light
Beta blockers
Infection
Smoking/alcohol
63
Q

What is the most common type of psoriasis?

A

Chronic plaque

64
Q

How does Kobner Phenomenon feature in psoriasis?

A

New plaques at the site of trauma

65
Q

When does flexural psoriasis present?

A

In later life

66
Q

What are the features of guttate psoriasis?

A

Raindrop like plaques on trunk
Children
2 weeks post strep throat

67
Q

What is the name of the most severe form of psoriasis?

A

Erythrodermic and pustular

68
Q

What are the systemic features of erythrodermic/pustular psoriasis?

A

Malaise
Pyrexia
Circulatory disturbance

69
Q

What are the associated nail features of erythrodermic/pustular psoriasis?

A

Nail pitting
Onycholysis
Subungal hyperkeratosis

70
Q

7% of psoriasis patients develop a seronegative arthropathy. What are the different forms?

A 
Mono/oligoarthritis
Psoriatic spondylitis
Asymmetrical polyarthritis
Rheumatoid like polyarthritis
Arthritis mutilans
71
Q

What is the first line treatment of psoriasis?

A

Potent corticosteroid OF and Vit D analogue OD
e.g. betamethasone and calcitrol
Applied separately - one in the morning and one in evening

72
Q

What is the second line treatment of psoriasis?

A

As above but Vit D analogue BD

73
Q

What is the third line treatment of psoriasis?

A

Potent corticosteroid BD and vit D analogue BD

OR add coal tar to the above

74
Q

What are the indications for referral in psoriasis?

A

Child or young person
Psoriasis is severe or covers 10% of body
Uncontrolled
Acute guttate psoriasis - requires phototherapy

75
Q

What are some other treatments of psoriasis that can be initiated in secondary care?

A

Phototherapy (narrow band ultraviolent B (UVB) therapy)
Methotrexate
Infliximab/adalimumab/Certolizumab pegol

76
Q

Name five conditions which can cause alopecia.

A 
Seborrheic dermatitis
Lichen planus
Discoid SLE
Iron deficiency
Thyroid disease
77
Q

What are some possible over the counter or private treatments for androgenetic alopecia in males?

A

Minoxidil topical

Finasteride PO

78
Q

What is alopecia areata?

A

A chronic inflammatory disease which affects hair follicles and sometimes nails

79
Q

What is pathognomic of alopecia areata?

A

Exclamation mark hairs

80
Q

How is alopecia areata managed?

A

Spontaneous self resolution in 80%
Topical potent/very potent steroid
Some dermatologists may consider topical immunotherapy or minoxidil, or PUVA therapy

81
Q

What is telogen effluvium?

A

Hair loss caused by physiological or hormonal stress

Hair is triggered to move into the telogen (dormant) phase

82
Q

Give three causes of telogen effluvium.

A

Childbirth
Crash dieting/anorexia
Severe infection

83
Q

What is the treatment of telogen effluvium?

A

Treat the cause and hair will return in a matter of months

84
Q

What is the name of the condition where hair production is arrested in the anagen phase, caused by chemotherapy or radiotherapy?

A

Anagen effluvium

85
Q

What is the management of burns?

A

IV fluid if burns>15% body surface area (10% if child)
Analgesia and urinary catheter
Escharotomy if circumferential burns
Excision and skin grafting

86
Q

What are some complications of burns?

A 
Curling's stress ulcer
Rhabdomyolysis
Compartment syndrome
DIC
Respiratory failure
87
Q

What does dermatitis herpetiformis look like?

A

Itchy, vesicular lesions on the extensor surfaces e.g. elbows, knees, buttocks

88
Q

How is dermatitis herpetiformis diagnosed?

A

Skin biopsy: DIF showed deposition of IgA in the upper dermis

89
Q

How is dermatitis herpetiformis managed?

A

Dapsone

Gluten free diet (Coeliac’s)

90
Q

What is acne rosacea?

A

Chronic skin disease of erythema, papules, and pustules, on the nose, cheeks, and forehead
Rhinophyma

91
Q

What is the treatment of acne rosacea?

A

Topical metronidazole

Severe: oral tetracycline

92
Q

What is the treatment of actinic keratoses?

A

Fluorouracil cream
Topical diclofenac
Topical imiquimod

93
Q

What are the causes of erythema nodosum?

A

Sarcoidosis
Pregnancy
Drugs
IBD

94
Q

What are the symptoms of hereditary haemorrhagic telangiectasia?

A

Pulmonary, hepatic, cerebral, and spinal AVMs

Nosebleeds, haemoptysis and dyspnoea, anaemia

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