Dermatology/Skin lesions Flashcards
What is this
Nodular Basal Cell Carcinoma
What are treatments for a BCC?
Superficial BCC versus non superficial BCC types
(3)
- Excisional biopsy for all types with a 3-4 mm border sent away for histopathology
(referral for excision is appropriate if in an awkward area) - If superficial BCC you can try liquid nitrogen (2 x 20 second applications) on NEW lesions only
- If superficial consider Imiquod 5% cream topically, at night 5 times weekly for 6 weeks. In the morning, wash the treated area with mild soap and water
What are these? (1)
Actinic / Solar keratosis
When are solar keratosis a problem?
(2)
And what problem is that.
(1)
They can turn into SCCs.
A person with > 10 solar keratosis has a 10-15% risk that some will turn into SCCs
A tender, thickened, ulcerated or enlarging solar/actinic keratosis is more suspicious of turning into an SCC
Treatments for this ?
If medication- dosing not required
(3)
(this is a solar keratosis)
- first line: Liquid nitrogen
- Cutterage or shaving in specific cases
- Topical/Field treatments
Topical treatments for Actinic Keratosis (solar damage)?
Give dosing instructions
(2)
- fluorouracil 5% cream topically, once or twice daily for 2 to 4 weeks on the face or 3 to 6 weeks on arms and legs
- imiquimod 5% cream topically, at night 3 times weekly for 3 to 4 weeks. In the morning, wash the treated area with mild soap and water. Review patient 4 weeks after treatment ends. If any lesions persist, repeat treatment once only
Side effects of Field treatment? Especially 5-fluorouracil
Soreness/pain/discomfort
Itching
Burning sensation
Stinging sensation
Sores/ulcers
Crusting of the skin
Weeping
Skin cracking (?dryness)
Hyperpigmentation or erythema/redness
Scarring
Blistering
Skin peeling
Photosensitivity (increased sensitivity to the sun)
Contact dermatitis
Other than to expect pain/burning and tenderness, what other advice can you give to someone using field treatment for solar keratosis?
(6)
The complete healing process can take 1-2 months
Men- avoid cutting self when shaving
Advise proper sun protection: hat outside, broad-spectrum sunscreen everywhere OTHER THAN his face
If one reaches the ulceration stage, they can stop the treatment
Advise the reaction that follows is not an infection and antibiotics are not needed
The patient may need to take time off work.
In pregnancy or in women trying to conceive what is an appropriate oral medication to treat acne ?
Give full dosing
erythromycin 250 to 500 mg orally, twice daily until inflammation resolves (usually takes weeks)
Treatment for moderate to severe acne (in non-pregnant females or in males) for primarily comedomal acne
- Early referral to Dermatologist for oral isotetrenoin
Can consider anti-androgen in female patients (spironolactone or COPC) before referral.
How to treat inflammatory acne of moderate- severe in nature? (or even a mixed acne)
Male v. Female
- First line: (more in the mild cases)
benzoyl peroxide+clindamycin 5%+1% gel topically, once daily for 6 weeks then review - Second line
in Males: Doxycycline 50-100mg daily
in females: COPC or spironolactone or oral antibiotic as for males
3rd line: refer to dermatology for isotetrenoin
List some of the myths about Acne
MYTHS:
Acne is caused by a poor diet. high GI foods can exacerbate Acne, but does not cause it
Acne is due to a hormonal imbalance
Caused by poor hygiene
People grow out of acne
Non medical management of acne
Avoid hot steamy environments
Make sure cosmetics and sunscreen is non-comedomal
Oily skin care products can make acne worse
Do not pick or squeeze at the spots
Consell/assess for anxiety and depression caused by acne
Advice regarding treatment of Acne.
Use your prescribed treatment every day, unless directed otherwise.
Apply creams to the whole affected area, not just to the spots.
Use water-based or oil-free cosmetics and sunscreens.
Use a light moisturiser.
Try not to pick and squeeze the spots, because this causes scabs that make the skin look worse and may increase likelihood of scarring.
Be patient—most treatments take at least 6 to 12 weeks to work.
General measures to treat rosacea?
(8)
Avoid triggers of rosacea
Minimise factors that cause flushing
Use an emollient soap-free cleanser to reduce irritation
Regularly use an emollient to improve the skin condition
Avoid essential oils
Minimise sun exposure and use low irritate sunscreen
Avoid topical corticosteroids
Green tinted foundation can help mask redness
List a few rosacea triggers
Emotional stress
Hot/Cold weather
Sun exposure
Wind
Exercise
Hot drinks
alcohol consumption
Spicy foods
Diary products
Hot baths or showers
What is this, and what sub-classification is this condition?
How can you treat it?
Mild Rosacea- pustolopapular
first line:
ivermectin 1% cream topically, once daily
Second line
metronidazole 0.75% gel or cream topically, once or twice daily
How would you treat this?
This is SEVERE papulopustular rosacea.
Doxycycline 50 to 100 mg orally, once daily for up to 8 weeks, and repeat as required. If response is inadequate after 4 weeks, consider minocycline
What can be offered to treat background erythema and telengectasia in rosacea
Refer patients with permanent background erythema and telangiectasia to a specialist for consideration of vascular laser therapy. Vascular laser therapy does not relieve transient erythema, flushing, or inflammatory papules and pustules in rosacea
How do you treat ocular rosacea
First line: ocular lubricant
Daily eyelid hygiene
Firm eyelid massage towards margins
If these don’t work then use oral antibiotics
If oral Abx don’t work then refer to ophthalmologist
medications to trial for flushing?
(2)
propranolol 10 mg orally, twice daily or as required.
if that doesn’t work then
clonidine 25 to 50 micrograms orally, twice daily.
Can take 4-6 weeks to assess response to therapy as flushing is usually intermittent anyway.
How do you treat this
This is granuloma annulare
Tends to be more common in diabetes
Treat with
betamethasone dipropionate 0.05% ointment topically, twice daily for a minimum of 4 to 6 weeks
what are these lesions? and what are some non-pharmacological treatments?
Pityriasis Rosea
Apply moisturising creams/emollients to area
Use soap substitutes
Gradual exposure to sun (without burning)
Takes about 6-10 weeks to resolve
This started with a herald patch and is completely itchy. How can you treat this? Conservative measures have failed
Triamcinolone acetonide 0.02% cream or ointment topically, once or twice daily.
Mainly for the itch
Can use an oral antihistamine too
What organism is responsible for pityriasis versicolour?
And what would you use to treat it?
Malassezia yeasts
ketoconazole 2% shampoo topically, once daily (leave for 3 to 5 minutes and wash off), for 5 days
Which of these is this?
And why?
How to prevent it?
Pityriasis rosea
Pityriasis versicolor
Pityriasis alba
Pityriasis Alba
Usually seen in children
Low grade dermaitis
Use sunscreen to prevent
no treatment necessary
can use emollient
can use mild steroid for face
can take months to years to clear
What can predispose to Melasma?
Sun exposure
Tends to occur in pregnancy
Also tends to occur in those takin HRT
Give three steps to treatment of this
This is Melesma
- Switch or stop contraception, or change from COCP to POP
- Topical depigmenting- hydroquinone 2% cream topically, once or twice daily for 2 to 4 months
- Referral to dermatology for consideration of other treatment such as topical tretinoin or laser therapy
What general advice would you give for management of this?
- Cautious Sun exposure is beneficial
- Avoid irritants
- Use soap substitutes to wash self
- No specific diet works. If patient has coeliac then avoidance of gluten should prevent worsening.
What might trigger this rash?
A streptococcal infection either in the pharynx or perianal
Treat the infection if it is still active
Otherwise treat the rash with milder steroids for the trunk/limbs
(this is guttate psoriasis)
What three classes of topical treatment are available to treat this?
It is only mildly itchy.
This is psoriasis
Tar preparations
Steroid Creams
Vitamin D derivatives (Calcipotriol) - not for use on the face
What is the first line treatment for this chronic condition?
Knee- (limb psoriasis)
LPC 4 to 8%+salicylic acid 3% cream or ointment topically, twice daily for 1 month
LPC stands for liquor picis carbonis- which is basically a tar solution
For an acute flare of psoriasis on the trunk or limbs, what can you use as a topical agent?
methylprednisolone aceponate 0.1% cream, ointment or fatty ointment topically, once daily until skin is clear (usually 2 to 6 weeks)
also to be used for long term management if LPC is not enough
what is the main caution with using long term calcipitriol?
Be cautious when treating widespread psoriasis; limit use of calcipotriol ointment or foam to less than 15 g per day or 100 g per week to reduce the risk of hypercalcaemia resulting from systemic absorption
what is this? what are the first, second and third line treatments?
Pustular Psoriasis
- betamethasone dipropionate 0.05% ointment topically, once daily until skin is clear (usually 2 to 6 weeks)
- Use optimised vehicle
- If still not resolved after 2 months then calcipotriol+betamethasone dipropionate 50+500 micrograms/g ointment or foam topically, once daily until skin is clear (usually about 6 weeks).
Then refer
What should you do with this rash?
urgent referral to hospital for assessment and management by a dermatologist for generalised pustular psoriasis
What is this?
Patient complains of recurrent lesions and multiple lesions at once with discharge at times.
How do you treat this pharmacologically?
3 points to note
Hidradenitis Suppurativa
- Use a antiseptic wash like benzyl peroxide 5% when bathing
- Clindamycin 1% solution to be applied twice daily to BOTH axillae for 3 months
Or
- Doxycycline 50-100mg orally once daily for 6-12 weeks OR minocycline 50-100mg orally once daily for 6-12 weeks (1)
(additionally if on a COPC or progesterone only option, switch to an anti-androgenic COPC like ethinylestradiol + cyproterone)
What is this?
List 4 non pharmacological management options.
(hidradenitis suppurativa)
- Encourage smoking cessation, if smoker
- Encourage weight loss to achieve a body mass index within the normal range / Encourage to lose 5 - 10% of body weight if appropriate
- Advise to avoid tight-fitting clothing
- Screen for depression/anxiety/mental health concerns
A young aboriginal girl (8years old) presents with multiple lesions on her body, they are intensely itchy especially at night.
The lesions are widespread (hands, soles, arms, legs, torso but not face) with some lesions crusted or oozing.
What is this specifically?
How would this be treated?
Infected Scabies
Management
1. permethrin 5% cream to be applied topically to the whole body (dry skin) from the neck down for 8 hours
- repeat topical permethrin in 7 days time
- Prescribe oral Cephalexin 12.5mg/kg six hourly for five days to treat the secondary infection
- For itchy you can provide a steroid ointment of moderate strength, e.g betamethasone valerate, 0.05% ointment), to be applied 2 - 3 times daily
What do you do with
a melanoma that has this reported after you’ve performed the initial excisional biopsy?
The initial biopsy for a suspected skin cancer should be 2mm.
With a breslow thickness of 1.9mm you NEED to refer to a specialist for a wide excisional biopsy and consideration of a sentinel node biopsy.
If you do the Wide Local excision in General practice the patient cannot receive the SNB
“Sentinel lymph node biopsy should be considered for all patients with melanoma greater than 1 mm in thickness and for patients with melanoma greater than 0.75 mm with other high risk pathological features to provide optimal staging and prognostic information and to maximise management options for patients who are node positive.”