Eczema, psoriasis & acne

Question 1

Atopic Eczema (also called infantile eczema)

Answer 1

Chronic (usually) inflammatory itchy (pruritic) skin condition which develops in early childhood (<2yrs)
20% of school children - diffuse with limb and face involvement
FH of atopy or food allergies

Question 2

Atopic facial signs

Answer 2

Morgan-Dennie folds (extra skin fold in upper eyelid)
Eczema on cheeks but sparing the tip of the nose
Mouth breathing. ‘Allergic shiners’ - dark shiny circles under both eyes

Question 3

Skin signs of atopic Eczema

Answer 3

Dryness (xerosis) and erythema

Poorly defined macules with signs of excoriation (scratching) – can lead to lichenification

Question 4

Pompholyx

Answer 4

A type of eczema affecting the hands and feet with itchy blisters followed by inflammation and dry skin

Question 5

Childhood eczema

Answer 5

Atopic eczema but in older children

More commonly flexural and if chronic may become lichenified

Question 6

Impact of infantile and childhood eczema

Answer 6

15-20% of school children

Impacts sleep, school performance, relationships, confidence and mood, etc

Question 7

Treatment for Eczema

Answer 7

Mild - Emollient therapy + mild steroids
Moderate - Emollient therapy + moderate steroids + topical calcineurin inhibitors + Bandages
Severe - Emollient therapy + potent steroids + topical calcineurin inhibitors + Bandages + Phototherapy + systemic treatment

Question 8

Emollients

Answer 8

Can be bath additives, soap substitutes or topical therapy
Work by providing a barrier & prevent water loss
May require multiple applications

Question 9

Infected Eczema

Answer 9

Normal skin pathogens are more virulent in eczema (staph aureus, HSV or VZV, impetigo)

Question 10

Topical Steroids (how much and side effects)

Answer 10

Use fingertip measures (1 per two hand surfaces) - prolonged use thins skin

Question 11

Contact allergic Dermatitis

Answer 11

Type IV delayed hypersensitivity due to hapten/compound allergy
Nickel particularly. Check with patch testing.

Question 12

Venous Eczema

Answer 12

Skin changes due to venous stasis in the lower legs

Can lead to lipodermatosclerosis

Question 13

Seborrhoeic dermatitis (or eczema)

Answer 13

Usually on scalp (dandruff) or milder on face and presternal area (symmetrical) –> Type IV reaction to pityrosporum yeast Often recurrent. Worse in males and immunosuppressed (HIV or parkinsons). Associated with Blepharitis and otitis externa.

Question 14

Psoriasis (AKA psoriasis vulgaris)

Answer 14

Scaly salmon pink plaques, particularly on extensor surfaces with are sharply demarcated - 2% prevalence
40% heritability - abnormal, reactive epidermal differentiation and hyperproliferation with a T-cell infiltrate

Question 15

Triggers for psoriasis

Answer 15

Infections or antibiotics for infection
Smoking
Stress

Question 16

Koebner phenomenon

Answer 16

Skin trauma elicits lesions

Question 17

Types of psoriasis

Answer 17

Guttate – look like rain drops
Palmo-plantar - pustular, discrete lesions
Severe unstable (pustular or erythrodermic)

Question 18

Treatment of psoriasis

Answer 18

Local treatment is generally effective and avoids SEs but is messy and long.
Can use topical therapy, systemic or phototherapy

Question 19

Tacrolimus

Answer 19

Calcineurin inhibitor

Question 20

Phototherapy

Answer 20

UVB (narrow or broad band) is gentler or UVA (stronger) with/without psoralen (sensitising agent)
Risks include photoaging and skin cancer risk (max 200 sessions)

Question 21

Local treatments of psoriasis

Answer 21

Emollients, corticosteroids, Tacrolimus, topical Vit D (analogues), Coal tar (to stop itching), Dithranol

Question 22

Dithranol

Answer 22

accumulates in mitochondria leading to free radical release and so inhibits cell proliferation

Question 23

Systemic therapy for psoriasis

Answer 23

Retinoids – Vit A analogues
Immunosuppressants – methotrexate or cyclosporin
Biologics – anti-TNF or anti-IL-2

Question 24

Eczema Herpeticum (HSV)

Answer 24

Disruption of normal skin barrier can lead to widespread and aggressive HSV spread. Can be life threatening so should children should be admitted for IV aciclovir

Question 25

Pathophysiology of Acne

Answer 25

Increased sebum secretion –> narrowing of pilosebaceous duct –> bacterium P. Acnes activity in blocked duct –> secondary inflammation
White head>Blackhead>Pustules>cysts

Question 26

Treatment of Acne

Answer 26

Topical –> benzoyl peroxide, Vit A (isotretinoin) and Abx
Systemic –> hormones (dianette, yasmin), Abx (tetracycline, erythromycin), Roaccutane (isotretinoin) (risk of sucicidality)

Question 27

Side effects of Roccutane (Isotretinoin)

Answer 27

Teratogenic - women should use two forms of contraception ideally
Most common SE is dry eyes, skin and lips. Can also cause low mood/depression, hair thinning, photosensitivity, raised triglycerides

Question 28

Distribution of Eczema

Answer 28

In older children the classic pattern of flexor surfaces and face/neck creases. In young children it may be more on the extensor surfaces and in infants the face and trunk are often more affected

Question 29

Acne Rosacea

Answer 29

a chronic skin condition of unknown cause typically affecting the nose, cheeks and forehead. starts with flushing, then telangiectasia and later persistent erythema, papules and pustules.

Question 30

Management of Acne rosacea

Answer 30

Topical metronidazole if mild. More severe –> oral oxytetracycline. Also sun protection and laser therapy can be used.

Question 31

First line treatment for chronic plaque psoriasis

Answer 31

Emollients with potent steroids OD and Vit D (calcipotriol) OD as first line. If no improvement Vit D BD, then steroid BD or coal tar OD/BD. can also add Dithranol

Question 32

Acne Fulminans

Answer 32

a very severe form of acne associated with systemic upset (fever) and hospital admission is often required and the condition usually responds to oral steroids

Question 33

Classification of acne

Answer 33

Mild - open and closed comedones with or without sparse inflammatory lesions
Moderate - widespread non-inflammatory lesions with numerous papules and pustules
Severe - extensive inflammatory lesions with nodules, pitting and scarring

Question 34

Role of Dietary modification in acne treatment

Answer 34

None, from this i am taking that there is no significant role of dietary fat in acne.

Question 35

Management of Seborrhoeic dermatitis

Answer 35

Face/Body – topical Ketoconazole or steroids.
Scalp - zinc pyrithione (head and shoulders) or tar (Neutrogena T). 2nd line is ketoconazole. Selenium sulphide or topical corticosteroids can also help.

Question 36

Melasma

Answer 36

Hyperpigmented macules in sun-exposed areas (face). chloasma is used for melasma during pregnancy. More common in women and people with darker skin. Linked to pregnancy or COC/HRT

Question 37

Things which will make psoriasis worse

Answer 37

Trauma
Alcohol
Drugs - B-blockers, Lithium, antimalarials (chloroquine & hydroxychloroquine), NSAIDs and ACEis
Withdrawal of systemic steroids.