Dernatology Flashcards
What is Cellulitis ?
Acute spreading infection of the skin.
(involved dermis & subcutaneous tissue.
Erysipelas - is the superficial form with notable lymphatic involvement.
(typically affects face , lower limbs - bright red raised skin (well demarcated (bordered))
CHARCTERISTICS
- acute onset of red , painful , swollen skin.
(area usually has poor borders and is diffuse but may have good borders - but if there are multiple lesion with good border suggests something else)
(MOSTLY OCCURS ON LEG) - usuallly unilateral - bilateral leg cellulitis is rare. - Orange peel appearence (Peau d’orange- pits appear on the skin link on an orange peel - caused by superficial oedema around hair follicles)
- blisterring within areas of cellultis
- Bleeding (superfical - may present as petechiae or ecchymoses (bruising occurs from bleeding underneath)
- Fever (above 38 indicates severe infection)
- Malaise
- swollen lymph nodes
- Lymphangitis - indicates spread along lymphatics to lymph nodes.
if there toe - web abnormalities e.g . tinea pedia , fissures , scaling - could indicate point of entry of pathgen .
RISK FACTORS
- Injury
- Weakened immune system
- Skin condition e.g eczema , athlete’s foot , shingles
- chronic swelling of arms or legs.
- Obesity
- Diabetes (Diabetic foot infections)
- Hx of cellulitis.
Cellulitis can develop into sepsis if untreated.
Diagnosis of Cellulitis ?
FBC 0 ESR 0 CRP 0 U & E 0 Blood culture & sensitivities. (if the patient needs admitting & is systemically unwell : fever , hypertension , tachycardia etc) , immunocomprimised , may have unusual organisms (immersion injury))
CONSIDER:
Skin swab - when showing systemic illness & obvious open wet wound , skin break , ulcer.
and :
There is a :
0 penetrating injury,
or
0 exposure to water-borne organisms,
or
0 infection acquired outside the UK.
(this applies also skin aspirate (withdrawal of skin fluid from lesion)
SKIN BIOPSY ARE RARELY TAKEN - may be done for differential diagnosis .
X RAY
Cellulitis can develop into osteomylelitis (infection of the bone ) ——–> so X ray can be used if Osteomyelitis suspected .
if Underlying Osteomyelitis present do MRI.
THERE IS OVERLAP BTW OSTEOMYELITIS & CELLULITIS.
Treatment of cellulitis ?
(if there is a star , and then another star it means this is where that text continues)
SUSPECTED SEPSIS -
1ST LINE
- follow sepsis protocol
SEVERE - ANY SITE (NOT NEAR NOSE OR (EYES)
- Empirical antibiotics
(1ST LINE - IV Flucoxacllin
if penicillin allergy (IV Clarithromycin) *
(For site near ears and eyes (ANY SEVERITY)
(1ST LINE - Amoxicillin/clavulanate
2ND LINE - Clarithromycin (or another macrolide antibiotics)- if allergic to penicillin or 1st line combination not possible.) - whether it is IV or oral depends on severity and where oral is tolerated) - if systemic symptoms (IV)
NON SEVERE - ANY SITE NOT NEAR EARS & EYES.
- Oral Flucoxacllin
if penicillin allergy (Clarithromycin , Doxycycline) *
The following applies to both the severe & non- severe any site section and areas near ears and eyes.
*
Consider :
- Analgesia (Para , NSAIDS first and susquent pain analgesia ladder)
-MRSA cover
(Vancomycin
Teicoplanin
Linezolid (for specialist use only).)
- Fresh water exposure - aeromonas hydrophilla antibiotic cover
(Ciprofloxacin
Doxycycline
Trimethoprim/sulfamethoxazole.) - Saltwater exposure
(Vibro vulnificus anti-biotic cover)
(Doxycycline)
Re - assess patient for after 48hrs of oral anti-biotics before discharging (if considering discharge)
also re - assess if :
Symptoms worsen, for example:
Significant redness and swelling spreading beyond 48 hours after initial presentation
Pain becomes severe
You suspect systemic involvement
There is no improvement within 2 to 3 days.
ONGOING -
Frequent relaspses
manage predosping factors increasing risk of cellulitis e.g. tinea pedia , eczema , obesity etc.
Consider :
- Antibiotic prophylaxis.
Caution with Fluoroquinone antibiotics ??
They use has been restricted due to irreversible adverse effects : Musculoskeletal or nervous system.
restricted to serious life threatening infections only (not used for self limiting infections)
Should be discontinued at the first signs of a serious adverse reacttion e.g. tendon pain , tendinitis , tendon rupture, inflammation.
EX - - Ciprofloxacin - Levofloxacin -moxifloxacin olofloxacin etc. (end in floxacin)
Avoid use with corticosteriods - could exacerbate fluroquinolone induced tenditis
Report adverse reactions to yellow card scheme.
What is Erythema nodosum ?
EN
Type of panniculitis ( inflammatory disorder effecting subcantaneous fat) - self limiting ( if no underlying cause)
CHARACTERISTICS
Erythematous (red ) , tender nodules
(nodule - growth of abnormal tissue (lump above 1cm - can be felt)
Found most commonly at shin / pre tibial area—————————————————–>
These areas then fade into pigmented patches before resolving.
(these different types of lesion can co-exist at different stages as new nodules form and old fade)
Nodule locations
- Shin/ pre-tibial area
- thighs
- calves
- buttocks
- upper extremities
- face.
- Areas do ulcerate & completely heal
Can be accompied by :
- Fever
- joint pain
- malaise
RISK FACTORS
- Streptococcal infection - most common cause
0 Sarcoidosis ( EN can be a symptom of this )
0 Tuberculosis - common cause in developing countries
0 Opportunistic infections - all 3 edemic to US
- Histoplasmsosis
- Blastoycosis (fungi infection - pulmonary disease (fungi spores inhaled ) - least common of 3 opportubistic infections
- Coccidiomycosis ( valley fever - endemic to US and those with history of dessert camping or digging) - caused by Coccidioides immitis (fungi)
-Behcet's disease - rare inflammation oof BV and other parts of the body typical signs : O Mouth ulcers O genital ulcers O recurrent eye inflammation. EN can be a cutaneous manifestation
- leprosy
-
Diagnosis of EN?
FBC ( Leuckocytosis - often present)
Anti - streptolysin - O - titre - elevated in streptococcal infection.
CXR -
Bilateral hilar adenopathy - inidactes sacrodosis
Unilateral hilar adenopathy indicates Tubercolosis , HIstoplasmosis , Coccidiodomycosis brucellosis.
(hilar adenopathy = enlargement of the lymph nodes of the pulmonary hila) - found along bronchi.
Tubercullin skin test , inferferon gamma release assay - postive -Tuberculosis
CONSIDER
Serum ACE levels - elevated in sarcodosis.
skin test for other organsism if other opportunistic infection suspected
Treatment of EN ?
Mild to moderately severe
1ST LINE
Bed rest & leg elevation + NSAID + Treatment of underlying cause.
- have to assess for risk of DVT & if needed give compression socks.
2ND LINE
Oral Potassium Iodide
(Thyroid function should be monitored with long term use due to risk of hypothyroidism due to iodide uptake)
Hyperkalemia -also possible side effect
3RD LINE
Intraleasional corticosteriod injection - Triamcinolone acetonide.
ADJUNCT - Analgesia (aspirin & NSAIDS preffered to Para)
relevant for all above lines of treatment
ERYTHEMA NODOSUM MIGRANS
(variant - nodules migrate )
1ST LINE - Systemic corticosteriods - oral prednisolone
SEVERE REFRACTORY SYMPTOMS
1ST LINE
- Systemic corticosteriods + treatment of underlying cause (oral prednisolone)
PLUS
Bed rest & leg elevation
ADJUNCT - Analgesia
What is paroncyia ?
Paronchyia (Inflammation of the nail appartus)
TYPES
Acute version - Infection on nail folds & periungal tissues (occur around the fingernail/toenail - periungual)
(acutely painful, purulent infection)
Chronic - Barrier damage to nail tissues (cuticle , prximal & lateral nail folds.———————-> this predisposes nail to irritant dermatitis from soap, water , chemicals & microbes etc.
CAUSATIVE ORGANISM
- Staphylococcus aureus (most common) - can be caused by others , strptococcus & Virus (Herpes Simplex virus ) & Fungi (Candida albicans)
SIGNS /SYMPTOMS - ACUTE
0 Pain
0 Swelling
0 Purulent nail fold.
0
CHRONIC
0 Nail plate irregularities
0 Swelling / redness of nail folds.
0 Missing cuticle
0 Underlying nail plate abnormaities.
RISK FACTORS
- Micro/macroscopic injury to nail folds - ACUTE
- Occupational risks (work related trauma (portal of entry) or disruption to nail barrier due to exposure to chemicals )
- Barrier damage to nail folds , cuticle (CHRONIC)
- Ingrown nail
- Chemotherapeutic agents.
Diagnosis of Paronchyia ?
0 Swab for gram stain , culture & sensitvity.
0 Swab for Tzank smear - Checks for Herpes Simplex Virus
CAN CONSIDER :
0 Potassium hydroxide or fungal culture ( looking for candida colonisation (not infection)
0 X - ray /MRI -(atypical / resistant cases - checking for osteomyelitis)
Skin / bone biopsy - resistant / atypical cases - check for maligancy & to remove chronically inflame tissue.
Treatment of Paronychia ?
- ACUTE
Acute
Mild bacterial inflection
1ST LINE - Soaks
(warm saline or aluminium acetate soaks)
+ Topical antibacterial - (mupirocin, - bacitracin,
- fusidic acid
- polymyxin B/bacitracin/neomycin
+ incision & Drainage (of pus - this the sent for gram stain , culture & sensitivity)
If MRSA positive culture - Oral antibiotic therapy
Severe bacterial infection or more tissue involved
1ST LINE - same as mild but Oral antibiotics are defintely used.
Herpertic infection
Ora; antiviral therapy (aciclovir , valaciclovir , famiciclovir (clovir’s))
Treatment of Paronychia ?
CHRONIC
Moisture & irritant avoidance
+ Topical corticosteriof
(Fluocinonide , Clobetasol.)
Treatment of secondary colonisation by yeast or bacteria.
(Clomrimazole solution , ciclopirox suspension - until nail normalised)
2ND LINE
- intra-lesional corticosteriods
(Triamcinolone acetonide)
3RD LINE- Surgery
- IF UNRESPNOSIVE TO ALL THERAPIES - BIOPSY INDICATED TO RULE OUT MALIGANCY (squamous cell or amelanotic melanoma)
What is retronchyia ?
ingrowth of the proximal nail plate into the proximal nail fold.
-suspected when there is peristent paronchyia
TREATMENT
1ST LINE - Nail plate avulsion (remobe nail plate & relieve pressure)
+/- NSAID (Ibu)
Penicillin allergic signs / symptoms ?
0 Riased , itchy skin (Hives /uticaria)
0 Coughing
0 Wheezing
0 Tightness of throat - can cuase breathing difficulties.
Severe - analphylaxis reaction - life threatening.
may see:
- lightheadness
- breathing difficulties (fast, shallow)
- wheezing
- a fast heartbeat
- clammy skin
- confusion & anxiety
- collasping/losing conciusness.
Which groups are susceptible to amoxicillin induced skin rash ?
People with:
- Glandular fever (infectious mononuclesis )
- Chronic / acute lymphocyctic leukaemia
prescribe with caution - if occurs stop.
rash in this group does not indicate a true penicillin allergy
- note - amoxicillin is contra-indicated in renal failure.
Treatment of vitiligo ?
SEGMENTALL OR LIMITED VITILIGO (cover 2-3% of body surface)
1ST LINE
Topical corticosteriod and/or tarcolimus
mometasone topical , clobestasol topical , taroclimus
2ND LINE - phototherapy
3RD LINE - Surgery e.g punch grafting, epidermal blister grafting , ultrathin epidermal sheet grafting.
WIDESPREAD VITILIGO - more than 3%
1ST LINE - Phototherapy + topical or oral corticosteriod or topical tarcolimus
2ND LINE
Oral cortiosteriod
3RD LINE - Surgery
4TH LINE - Depigmentation therapies
(mequinol/tretinoin topical or monobenzone topical ) -last option or if very widespread (>50 %) or recalcitrant & high visible i.e. face , hands.
PLUS-Supportive therapies - cosmetic camoflage etc. (For all lines of treatment. Limited & widespread)
Diagnosis is clinical.
What is Virtiligo ?
Aquired loss of melanocytes causing areas of depigmentat .
RISK FACTORS
<30 years
0 Fhx of vertilgo
0 auto - immune disease
0 chemical contact.
Signs of infected atopic dermatitis?
Complications of infected AD?
Infected AD can present with widespread erythema in usual sites of AD.
Infected AD is painful & itchy while normal AD is just itchy.
Bacterial infection
0 fluid oozing from the skin
0 a yellow crust on the skin surface
0 small yellowish-white spots appearing in the eczema
0 Swollen , sore skin
0 feeling hot and shivery and generally feeling unwell
Viral infection
Herpes simplex virus - usually causes cold sores ————————> can develop into ezcema herpeticum (SERIOUS - EMERGENCY- ADMIT TO HOSPITAL IF SUSPECTED)
Ezcema herpeticum (Clusters of itchy blisters or punched out lesions - most common around mouth. )
Ezcema herpeticum is often condused with impetigo ( pl impetigo are often do not feel unwell)
0 areas of painful eczema that quickly get worse
0 groups of fluid-filled blisters that break open and (leave small, shallow open sores)
0 feeling hot and shivery and generally feeling unwell, in some cases
Treatment - Antiviral therapy - aciclovir etc.
may be given antibiotic prophylaxis - if damage to skin normally harmless bacteria on skin can infect it. (secondary bacterial infection)
Treatment of infected AD?
Bacterial infection
In people who are not systematically unwell antibiotics are not given rountinely but can be given if thought to be of benefit.
1ST LINE- Flucloaxcillin (or clarithrymocin - in penicillin allergies or resistance to flucloxacillin)
if pregnant & allergic to penicillin - erythromycin
if 1st line does not work prescribe alternative.
IF LOCALISED AREAS OF INFECTION - Topical fuidic acid.
- prescribe topical emollients , steriods for use after infection has cleared up.
REFER URGENTLY IF Infection not responded to treatment.
