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.
Treatment of atopic dermatitis / eczema ?
I have another card that says something different.
MILD
1ST LINE
Emollients
+ consider mild corticosteriod
MODERATE
Emollients + topical corticosteriods
2ND LINE - calneurin inhibitors (tarcolimus , pircolimus (pircolimus-mainly used for face & neck ezcema where further steriod use ca cause atrophy etc)
SEVERE
Emollients + topical corticosteriods
2ND LINE - Calneurin inhibitors
3RD LINE - systemic immunosuppressie agents ( Oral corticosteriod)
ADJUNCT - if severe itch or utritcaria (non - sedating anti-histamine e.g. certirizine, loratadine, fexofenadine)
ADJUNCT- consider antiobiotics if infection suspected
(BEWARE OF EZCEMA HERPETICUM)
CONSIDER : IF resistant to corticosteriods (after increasing potency ) or calcneurin inhibitors use UV Light therapy. )
What is kerion
Abscess caused by fungal infection
- can be seen as a complication of tinea capitis , corporis.
What is rosacea ?
Long term skin condition - mainly effects face. (can resemble acne) Primarily effects : - central face (cheeks, chin, nose , forehead) but can extend upper trunk
SIGNS/SYMPTOMS
- Facial flushing
- Redness (eythema) (can be transient but may become persistent as condition develops)
- papules & pustules
- Telangiectases (superfical capillaries - hallmarks of condition)
- roughened skin
- rhinophyma
0 ocular manifestation (describe having foerign body sensation in eye with tearing , pain and blurry vision.
- Keratitis
- episcleritis (inflammation of the episcleral tissue btw conjunctiva and sclera)
- scleritis
- horedeolum (stye - small lump caused by infection of glands of eyelid)
- conjunctivitis
- Blepharitis (red , swollen , itchy eyes)
Some experience :
telangiectases and erythema of eyelid margin with scaling or none.
- ## plaque formation
- MAY OR MAY NOT CO-EXIST WITH ACNE VULGARIS
RISK FACTORS
- Fair skin
- hot baths / showers
- temperature extremes
- sunlight
- hot drinks, emotional stress (trigger for flushing)
Diagnosis of Rosecea ?
Clinical
Consider :
skin biospy
- antinuclear antibody titre - rule out SLE.
Treatment of roseca ?
ERYTHEMA SUBTYPE -
1ST LINE
Topical brimonidine 0.5 gel.
MILD TO MODERATE PASTULES / PAPULES
- Topical ivermectin (antihelminthics - kill helminthics - worm like parasites e.g tapeowrms , roundworms , flukes etc)
2ND LINE - Tpical metronidazole , azeliac acid
(if ivermectin - not possible /tolerated e.g pregnancy)
IF MODERATE - use Ivermectin + oral doxcycline.
(if Iver not possible metro or azeliac) (If doxy not possible - oxytetracycline , tetracycline , or ethyromycin for pregnant or breastfeeding)
PHYMATOUS PHENOTYPE -
1ST LINE - Antibiotic
( Oral doxycycline)
OCUCLAR MANIFESTATIONS
- lid hygeine measures ,
- artifical tears (eye dryness present)
What is Seborrhoeic Keratosis ?
Multiple benign tumours of the skin
COMMON LOCATION
0 Forehead 0 Torso ( Chest & back)
APPEARENCE
(Overall - well - circumscribed stuck on plaques or papules or may look like warts- not usually need treatment (bcc benign) but if they become irritated , itchy or displeasing can be treated.
0 Multiple Lesion - stuck on appearence
- can be slightly raised or flat.
- lesions are normally painless
0 Wart-like texture
0 Yellow to light brown colour
(can also be grey black)
0 can sometimes see some yellow white horn pearls on surface of esions
0 Itchy
- CAN LOOK LIKE MALIGANT MELANOMA - Some features differientitate it .
RISK FACTORS
- Age over 50 years (80-100%)
- White skin
- family history
- sun/UV expsoure
Diagnosis of SK?
Dermoscopy -n
(looks for features of seborrhoeic keratosis (e.g horn pearls / Mila -like cyst (white or yellowish round structures that are intra-epidermal keratin filled cysts.)
0 Biopsy & histopathology examination
0 Reflectance confocal keratosis (RCM) form of non-invasive imaging
- RCM features that indicate the diagnosis of seborrhoeic keratosis are: cerebriform surface structures; keratin-filled invaginations; corneal pseudocysts; a regular honeycomb pattern at epidermal layers; cords and polymorphous papillae at the dermo-epidermal junction; melanophages and looped vessels at the papillary dermis; and the absence of RCM features suggestive of malignancy.
Treatment of SK?
Treatment is not usually needed unless irritated , itchy or dispeasing to patient.
Irritated or itching lesions
1ST LINE - corticosteriods
RAISED SEBORRHOEIC KERAROSIS
1ST LINE - Curettage or cautery
FLAT SK
1ST LINE -Cryotherapy
2ND LINE - Curettage
3RD LINE - laser , dermabrasion , chemical peels or tretinoin.
SK VS Malignant melanoma ?
Shape
0 SK - round or oval shaped
0 MM - may have sides that do not match in size or shape.
- borders fuzzy , ragged , blurred edges.
0 COLOUR
SK - Can be light brown , yellow (flesh coloured ) & brown or black .
MM - Brown or black
(can be a variety of colours within the same mole.
EVOLUTION
0 SK - lesions typically stays the same colour & shape
0 MM - Clour & size can change over time
OTHER FEATURES
0 MM - may bleed or ooze
0 SK - can have horn pearls in lesions
What is Leukoplakia
White plaques of the mouth - pre-maligant condition.
(diagnosed when other conditions causing white lesions have been ruled out. - DIAGNOSIS OF EXCLUSION
0 Candida & linchen planus *( are differential diagnoses- these white lesions can be wiped/rubbed off whilst leukplakia cannot.
linchen planus - rash affects body including mouth - leaves white patches in gums , tounge , cheeks also raised , shing red purple blotches on arms , leg/body etc amongst other things.
LOCATION - in mouth
0 e.g . Tounge , inside cheeks , buccal / labial mucosa , under tounge etc.
TYPES
0 Homogeneous Leukoplakia - uniform white lesions - most common
0 NON HOMOGENOUS
0 Speckled leukoplakia - (predominately white lesion - fissured appearence with area of red atrophic areas ireehuarly scattered with keratotic white comonent
0 Nodular - red & white lesion
0 Erythroleukoplakia (white and red lesions)
0 Ploliferative verrucous leukoplakia ( most risk of maligant transformation )
- LEAST COMMON TYPE
0 Sublingual Leukoplakia.
other types
- Oral hairy LP - caused by EBV (epstein barr virus) - patches look hairy.
- the higher the degree of dysplasia (change in cells - & maligant transformation , the more dangerous and potential for cancer development)
RISK FACTOR
- Male
- Age > 40 years
- tobacoo use]- alchohol
- genetic pred isposition
- Immunosuppression
- Fanconi’s anaemia.
Treatment of Leukoplakia ?
1ST LINE
Removal f contributory factors ( somking cessation , alcohol abstinence / reduction. , emilation of bete lquid use (some sort of smoking concotion)
Treatment of Leukoplakia ?
1ST LINE
FOR ALL
Removal f contributory factors ( smoking cessation , alcohol abstinence / reduction. , emilation of bete lquid use (some sort of smoking concotion)
HOMOGENEOUS LP
1ST LINE
Removal of CF + Observation with biopsy as needed (can do repeat incisional biopsy if changes occur - with excision of any confirmed dysplasia.
SUBLINGUAL LP
1ST LINE
Removal of CF + excision or ablation e.g scalpel excision , laser ablation , cyrotherapy.
SPECKLED OR PLOLIFERATIVE VERRUCOUS LEUKOPLAKIA
1ST LINE
- Removal of CF + Excision or ablation.
What is Molluscum contagiosum?
Skin infection caused by Molluscum contagiosum virus (MVS) causes lesions .
- Contagious (skin to skin , sexual transmission , indirectly - formite surface e.g towels , flannels.
(THIS CONDITION COMMON IN CHILDREN , YOUNG ADULTS)
SELF - LIMITING , SPONTANEOUS RESOLUTION usually IN 1-2 YEARS.
APPEARANCE -
0 Pinkish , pearly white papules
0 Umblicated lesion (have a central depression)
0 up to 5mm in diameter.
0 erythema can surround papules
0 can have pruritus
RISK FACTORS
- Close /sexual contact with infected individual
- Atopic dermatitis (impaired skin barrier)
- Immunocomprised
- Tropical climate
Diagnosis of M contagiosum?
0 Dermoscopy - can be used to confirm diagnosis .
0 Cutterage isopsy - can be used to confirm Diagnosis.
0 Hematotoxylin and eosin staining - provides definite diagnosis (find henderson - patterson bodies)
Full sexual health screen (including HIV)- for anogenital lesions & refractory/extensive disease.
Treatment of M contagiosum?
1ST LINE
Observation - self limiting condition .
2ND LINE - Topical treatment (for those who desire treatment (anxiety , discomfort , appearence etc).
- Potassium hydroxide topical (1st)
other options - salicyclic acid , benzoyl peroxide topical, tretinoin topical.
3RD LINE - Cryotherapy
IF THEY HAVE ANOGENTITAL LESIONS -
Treatment of M contagiosum?
- anogenital lesions
1ST LINE - conservative measures + sexual health screen
2ND LINE - Cryotherapy , cautery or curettage
(conditions for treatment of anogential lesions include if patient prefernce , extensive/persistent disease , cosmetic , fearing of spreading /scarring , symptomatic e.g itchy , inflammation)
3RD LINE - Topical treatment e.g. potassium hydroxide , imiquimod , podophyllotoxin.
Treatment of M C ?
- Atopic dermatits ?
- eyelid lesions
1ST LINE - Optimise treatment of dermatitis
- adjunct - consider referral to dermatology
Eyelid lesions - observation and consider referral to ophthalmology.
Treatment of M C?
- Immuncomprised
and those who are immunocomprimised with anoogenital lesions , eye lesions , atopic dermatitis
can be immunocomprised sue to HIV infection , immunosupression , SLE , sarcodosis , neoplasia.
JUST IMMUNOCOMPRISED
1ST LINE - Treat underlying condition
- consider topical treatment or physical (cutterage , cautery , cyrotherapy )
e. g
IF HIV cause - ART - Antiretroiral (cidofovir topical) can also use other topicals e.g. podophyllotoxin therapy used. —–> if does not work physical treatments.
ANOGENITAL LESIONS -
1ST LINE - Treat Underyling cause
Adjunct - topical or physical therapy
( if few , discrete lesions - physical therapy more apporiate)
IF HIV Cause - treatment said earlier.
ATOPIC DERMATITIS - optimal treatment of AD.
- refer to dermatology
EYELID Lesion
- refer to opthalmology
Shingles treatment ?
MILD pain - paracetamol , co- codamol or NSAID.
Oral antiviral treatment
e.g aciclovir , valaciclovir , famciclovir with 72 hours of rash onset- (if 72hours not possible within 1 week), if have not be admitted to hospital or need specialist treatment .
ALSO need any of this criteria:
0 Immunocomprimised
0 Non-truncal involvement (e.g involves the neck , libs or perinum)
0 Moderate to severe rash
0 Moderate to severe pain
(SO DONT TREAT IF PAIN/RASH IS MILD)
- Consider oral corticosteriods in combination with oral antiviral (only used together) in first 2 weeks in immunocomptent people with localised shinges & severe pain
- also consider in over 50s to reduce risk of post - herpetic neualagia ( pain persistin or appearing more than 90 days after rash onset) - most common complication of shingles
(Shingles caused by Herpes Zoster)
MILD pain - paracetamol , co- codamol or NSAID.
(SEVERE pain - if treatment with opiod is being considered e.g morphine refer to specialist)
2ND LINE - Amitriptyline , duloxteine , gabapentin or pregabalin.
In childern - trail of Para , aviod NSAIDS.
When do you admit someone with shinges to hospital ?
0 Immunocomprimsed child
0 Immunocomprised adult , with or without severe rash , widespread rash , systemically unwell.
0 Visual symptoms
0 Unexplained red eye
0 Shingles in opthalmic part of trigeminal nerve especially if :
- Hutchinson’ sign - rash on tip of nose , side , root of nose (in dermatome of nasocillary nerve —————–> can lead to eye inflammation & permanent corneal denervation)
Define these key terms ?
- Exanthem
- Macule
Exanthem - rash or eruption of rash.
macule - flat , distinct discoloured area of skin.
What is Verruca Vulgaris
OTHER NAMES - Common warts
Verruca - wart of any kind
vulgaris (means the normal / most common form a certain disease e.g. most common wart disease)
CAUSES
- HPV - human papillomavirus
SIGNS / SYMPTOMS
0 (Appearence)
- Round raised papule (characteristic appearance of common wart )
- Rough , scaly appearence e.g. Hyperkeratosis (thickening of outer layer of skin) - MAY BE SEEN
- Fissuring (fissure , bleeding —> pain) - MAY BE SEEN
0 Colour - greyish - white , light brown - characteristic.
0 Size - average 5mm ( up to 1 cm)
0 Location - most commonly found around hand, fingers or periungual area (around finger nail or toenail)
- can have sati;ite lesions (smaller ones around bigger one )
- may see tiny black dots - thrombosed capillaries.
- immunocomprised patients - tend to have more lesions , increased lesions size , different morpholgies.
RISK FACTORS
- Water immersion (swimming , regular dishwashing etc.)
- Occupations involving handling meat or fish.
- Nail biting (risk of periunginal lesions)
(may cause warts to spread to mouth & face also) - Age - under 35 (most common in children & young adults ) - CAN HAPPEN AT ANY AGE.
- Immunocompromised
Diagnosis of Verruca vulgaris ?
Clinical diagnosis
if unsure - consider :
0 Skin biopsy - Histopathology- G - to rule out other differential diagnosis (HPV - induced squamous cell carcinoma , seborrhoeic keratosis , fibrokeratoma etc.
0 Immunoperoxidase stain - presence of HPV antigen
0 Skin culture - done to rule out deep fungal , bacterial etc in immunocomprimsed patients with severe lesions.
Treatment of Verruca vulgaris ?
Most people do not need treatment ( may resolve spontaneously within months/2 years. (can take much longer for some)
If treatment needed (due to pain , being unslightly , persisting , requested by patient:
1ST LINE
0 Cryotherapy with liquid nitrogen (only for adults & older children) - NOT YOUNG CHILDREN
or Topical salicyclic acid (up to 12 weeks )
2ND LINE - (Often 1st tried in primary care - if dont work refered to secondary care and these methods can be used :
- Physical ablation (surgery , laser treatment , photodynamic treatment)
- Immunomodulatory treatments e.g. Topical Imiquimod 5% , intralesional interferon , topical sensitizers (Squaric acid)
- Anitimiotic agents (disrupting mitosis ) e.g.
0 Topical /oral retinoids
0 Topical Podophyllotoxin
0 intralesional Bleomycin - Virucidal treatments - fomaldehyde and Glutaraldehyde.
- Cantharidin (potent blistering agent )
- Advice to avoid
- sharing towel , socks (contagious)
- biting nails
FACIAL WARTS NOT ROUTINELY TREATED IN PRIMARY CARE - REFER TO DERMATOLOGY
What is Haemanigioma?
OTHER NAMES :
- Cherry angioma
- Campbell - De Morgan spot
- Senile Angiomas
Type of Benign vascular lesions
PATHOPHYSIOLOGY - Hemangiomas are bright red birth marks that show up at first weeks of life - looks like RUBBERY RED BUMP (made up of extra BV in skin)
start of as blue /pink macules / patches then become elevated above surrounding skin (Prolifertative phase) (DIFFERENT COMPARED TO OTHER VASCULAR LESIONS) - stage usually ends at 5 months.
Infantile haemangiomas/ strawberry marks - (described in above paragraphs)
Congential haemangiomas - fully formed at birth
Haemangiomas - also used to describe acquired lesions in adults (cherry Haemgiomas /angioma) - DO NOT REALLY UNDERGO INVOLUTION.
Some of the angiomas will be INVOLUTING (skrink & lighten over time ) while others are NON - INVOLUTING.
SIGNS/ SYMPTOMS
- Red , pink blue colour (sign vascular lesion present)
(can also be dark red (look slightly purple ) - cause it to look like early melanoma) - Flat patches / macule or nodular character
- Rapid growth (infantile Haemangiomas - proliferate rapidly )
- can be ulceration & bleeding .
(ulceration can cause significant painful lesions , other haemangiomas not usually painful) - Lesions in lumbar sacral area - may signal underlying spinal dysraphism (baby’s spine / cord do not form properly - defects)
- Lesions in bread area / lower face / neck - may associated with laryngeal involvement - May present with Stidor.
RISK FACTORS
0 Hx of low birth weight 0 Premature birth 0 White 0 Female 0 Maternal multiple gestation (twins , triplets etc - highter risk of lower birth rate , premature )
0 Advanced maternal age - risk of LBW , premature.
What is multifocal infantile haemangiomas ?
More than Five Haemangiomas on the skin
increased risk of internal involvement (affect internal organs - extracutaneous involvement e.g LIVER , GI)
Diagnosis of Haemangiomas ?
0 Doppler ultrasound - Used to distinguish haemangiomas from vascular malformations e.g. ( Venous / arterial /lymphatic malformations )
CONSIDER -
0 MRI of angioma - to determine extent & assess relationship with other stuctures (e.g. organ involvement)
0 Biopsy of lesion (if maligant tumour with significant vascular component is suspected/is possible )
Treatment of Haemogiomas?
Corticosteriods - oral / topical (cream) / injectable
e.g.
0 Pred oral
0
Treatment of Haemogiomas?
1ST LINE
Corticosteriods - oral / topical (cream) / injectable
e.g.
0 Pred oral
0 Triamcinolone acetonide - intra lesional
type used depends on whether angioma is superfical or deep
if well localised without deep extension - (intralesional can be used)
oral / systemic are avoided if possible - more side effects.
0 Beta blockers -
- Timolol topical (can be considered if oral not warranted or contraindicated ( good for superficial lesions)
- Propranolol oral ( be careful in those with PHACES syndrome - propanolol induced hypotension)
2ND LINE
0 Surgery (excision ) - if other measure inadequate & lesions threatens functional & cosmetic intergrity.
- sometimes used for patients where involution is complete to improve cosmetic appearence if needed. (e.g. unsightly fibro - fatty tissue)
or
0 Laser treatment
ADJUNCTS
- Emollient creams
- Topical antibiotics (metronidazole - 1st, mupirocin topical)
- Analgesia (para , topical lidocaine (local anesthetic )
- Dressings
