FFP Specialty Skills Flashcards
Tonsillitis - Cause and presentation, management
Most commonly viral, but Strep pyogenes if bacterial
Viral insidious onset with URTI sx, bacterial sudden with fever, lymph nodes, headache, no cough
Simple analgesia + maintain fluid intake
Abx if high risk/bacterial; CENTOR criteria:
38oC, tender lymph, NO cough, exudate on tonsils
=> Oral phenoxymethylpenicillin (Penicillin V)
Criteria for giving Abx in tonsillitis
CENTOR criteria: if 3/4
38oC, tender lymph, NO cough, exudate on tonsils
=> Oral phenoxymethylpenicillin (Penicillin V)
Glandular fever - Cause, investigations, management
EBV
Tonsillitis sx + prodromal illness, organomegaly, abdo pain, rash, cervical lymphadenopathy
FBC, LFT, Monospot test
Simple analgesia + maintain fluid intake
avoid contact sport and alcohol
Do not give amoxicillin/ampicillin => macular rash
Peritonsillar abscess (Quinsy) - Cause, investigations, management
From infection e.g. tonsillitis
Unilateral swelling above and lateral to tonsil; tonsil and uvula shift
Fever, systemic illness, trismus (locked jaw) => URT obstruction
CT neck if ? spread
Abx: benzylpenicillin +- surgical or needle drainage
Signs of deep neck space infection
complications
Septic
Poor head/neck motility
Airway compromise
Lemierres syndrome - IVJ thrombosis + oropharynx inf.
Carotid artery erosion - sentinel bleeds
Parotitis - Cause, management
Mumps in children
Bacterial in elderly, poor hygeine
Treat with abx
Supra/epiglottis - Cause, investigations, management
Swelling of larynx
Fever, stridor/stertor, hot potato voice, resp. distress, drooling
Haem influenza
Do not directly visualise or irritate pt (if child)
Secure the airway, high flow O2
i.v. cephalosporins + MRSA coverage +- dexamethasone
Salivary gland tumours
pleomorphic adenoma - most common, benign
Warthins tumour - bilateral, benign
US + FNA
Fractured nose management
Acute: Check for other injuries
Septal haematoma -> drainage on the day
Clinic: 5-7 days later (maximum 3 weeks)
manipulate nose into correct position (only if its the bone)
cartilage requires surgical intervention
Epistaxis - causes/location, management
Littles area; ethmoidal, sphenopalatine and facial anastomosis
Woodruff’s area if posterior; SPA
Tumour
Hereditary haemorrhagic Telangiectasia
First aid; lean forward, pinch soft nose for 10 minutes +- fluid resus
Silver nitrate cautery - LA spray, then stick to bleeding point, then antiseptic
Anterior packing; refer to ENT for removal 24/48 hr after insertion
If still bleeding, admit for posterior packing
Then SPA ligation
Prescribe Naseptin (antiseptic) to prevent crusting/vestibulitis (contains nuts)
Rhinitis - causes and sx
Infective, allergic, gustatory, medicamentosa (decongestant overuse)
Discharge, blockage, sneezing etc.
Acute Rhinosinusitis - causes, sx, management, complications
Haem influ, S pneumoniae
Discharge, blockage, sneezing, facial pain, loss of taste/smell, (cough in children)
Defined as URTI symptoms that persist for >10 days, or worsen after 5 days
(common cold by definition lasts <10 days; chronic rhinosinusitis >3 months)
Mostly self limiting
Decongestants (head forwards, no sniff)
Co-amoxiclav after 7 further days
orbital cellulitis, intracranial inf., septic cavernous sinus thrombosis.
Chronic Rhinosinusitis - types, sx, investigations, management
3 months
Without polyps - post bacterial inf.
With polyps - high inflammatory cytokines -> inflamm
nasal discharge, blockage bilaterally ,pain, decreased smell/taste for 3 months
Anterior rhinoscopy, CT sinuses, endoscopy, allergy testing
Saline irrigation with corticosteroids for 3 months,
refer to ENT if still sx;
With polyps: oral steroids then ?surgery
Without polyps: co-amoxiclav + oral steroids then ?surgery
Obstructive sleep apnoea - sx, investigations/questionnaires, management
Interrupted and repeated collapse of the upper airway during REM sleep with hypopnea and hypoxia
wakes pt up, daytime sleepiness, snoring, gasping + in children; poor growth, hyperactivity, impulsivity.
STOP-Bang score/Epworth sleep score
Examine
Polysomnography gold standard or resp polygraphy at home
If +VE, ENT examination and pressure studies
Wt loss, decrease alcohol
CPAP, intraoral devices, surgery
adenotonsillectomy in children if identified cause
Hearing loss classification audiometry
<20dB normal
20-30 mild
30-60 moderate
60-90 severe
90 profound
Tympanometry findings
Type A - normal - curve with apex at 0
Type B - TM perf or effusion - flat
Type C - Poor eustachian tube function or early OM - curve with apex at -200
Pinna haematoma treatement
Drainage to prevent necrosis and cauliflower ear
Temporal bone fracture signs, tests and management
Bleeding, CSF leak (test it for beta 2 transferrin), battles sign, racoon eyes, facial palsy(give steroids), balance
ENT manage conservatively
pneumococcal vaccine given
Otitis externa sx, cause, rf, management and complications
Pain, discharge, itching, hearing loss, pinna tenderness, TM obscured
water exposure, hearing aids, trauma, skin conditions
Keep ear dry
topical acetic drops
topical Abx +- steroids
Faruncle OE - infection of hair follicles; treat as per OE
Malignant/Necrotising OE - seen in immunocompromised
infection spreads to the skull base
Severe pain +- palsy, granulomatous tissue on ear canal floor
CT + ENT for I.v. cipro/taz
Acute otitis media sx, cause, rf, management and complications
Most commonly bacterial: S. pneumoniae, H. influ, moraxella
pain, fever, discharge if perf., conductive hearing loss
White bulging TM
Recurrent if 3< in 6 months, 4< in a year
Conservative + safety netting +- back up amoxicillin
(If perforation; give oral amoxicillin)
Otitis media with effusion
Choleastoma
Hearing loss
CNVII palsy
Chronic suppurative OM
Mastoiditis
TM perf
Malignant/Necrotising OE
seen in immunocompromised
infection spreads to the skull base
Severe pain +- palsy, granulomatous tissue on ear canal floor
CT + ENT for I.v. cipro/taz for 6 weeks
Gallium scan for ?resolution
Otitis media with effusion
Glue ear
Hearing loss, aural fullness, balance
Leads to social/developmental issues if untreated
Mostly self limiting
If 3 months+ and bilateral/causing issues - grommets
Choleastoma
Keratinized, desquamated epithelial collection in the middle ear
Foul smelling discharge, deep retraction pockets in TM, white mass behind TM, granulation in the attic
CT temporal bone
Surgical excision
Chronic suppurative otitis media
Hypertrophic and hypersecretory mucosa leading to micro abscesses
Purelent drainage for 6 weeks<, hearing loss, with perforation
Topical Abx with cleaning
Temporal CT if persistent for ?Choleastoma
Tympanoplasty if resistant
Acute bacterial mastoiditis signs, management, complications
AOM -> mastoid air cells —-> intracranial inf.
AOM does not settle; otalgia, otorrhoea, hearing loss,
Post auricular swelling with sulcus hidden, tender, auricular protrusion
i.v. abx
Surgical if complications or sx after 48 hours; Do a CT
Extradural abscess, subdural abscess (Lower GCS)
Sigmoid venous thrombosis
Meningitis
Post auricular swelling with sulcus hidden
Acute bacterial mastoiditis
Otosclerosis
?inheritable
Stapes becomes sclerosed -> conductive hearing loss (cohorts notch on audiometry)
Conservative management
hearing aids
stapedotomy
TM perforation treatment
Most heal within 6 weeks
Abx if inf.
True vertigo
Sensation of moving/spinning
Benign paroxysmal positional vertigo - diagnosis and treatment
Calcium debris in the semicircular canals
Short <60s episodes of vertigo provoked by head movements
Dix-hallpike manoeuvre - turn pt head 45 degrees whilst sat then move to supine with head extended over the bed
+ve if nystagmus and vertigo
Epley manoeuvre - from last step of Dix-hallpike turn head 90 degrees to other side and hold for 30 seconds. Ask pt to roll body onto side then rotate head to look at the floor for 30 seconds. Maintains head position, sit pt up and return head to midline
Acute labyrinthitis sx and management
2o to vital inf. or OM
Vertigo, tinnitus and hearing loss
Vestibular sedatives e,g prochlorperazine, in the very acute phase
Vestibular neuronitis sx and management
Often 2o to viral inf. or herpes zoster
Sudden onset severe vertigo
Vestibular sedatives may help e.g. prochlorperazine in the acute phase only
Ménière’s disease
Increase pressure in the endolymphatic system
Episodic vertigo, tinnitus, hearing loss
With aural dullness
Audiometry: low frequency loss
MRI to exclude acoustic neuroma, MS, TIA
Education
Low salt and caffeine intake
Betahistine to decrease attacks
Prochlorperazine in attacks
Vestibular rehab
Facial Nerve Palsy - House Brackman score
I normal
II mild weakness
III obvious weakness; eye can close
IV eye cannot close
V flickers
VI no movement
Facial nerve palsy causes and management
Bell’s palsy
Ramsay Hunt Syndrome
OM
Tumour
Moebius syndrome - congenital absence
Oral pred 50mg 10 days +-ppi
Sudden sensorineural hearing loss management
Oral steroids ASAP
Urgent ENT referral
Acoustic neuroma/vestibular schwannoma - sx, test, management
Benign tumour on CNVIII
Unilateral SNHL, tinnitus, vertigo
MRI; if bilateral cerebellarpontine angle lesion ?neurofibromatosis
Watch and wait
Surgery
Radiation
Congenital causes of nasal obstruction
Worse when, better when
Neonatal rhinitis
Pyriform aperture stenosis (front of nasal cavity)
Choanal atresia (rear of nasal cavity) -worse on feeding, better on crying
Choanal atresia
(rear of nasal cavity) -worse on feeding, better on crying
Laryngomalacia - sx and management
Collapse of supraglottic structures
Inspiratory stridor
Self resolving 18 months
Tracheomalacia
Collapse of trachea
In expiratory stridor
Self resolving 1 year
Cpap can be used
Blepharitis sx, examination findings and management
Two types - posterior; inner portion of the eyelid at dysfunctional meibomian glands
Anterior - Base of eyelashes; staphylococcus or seborrheic dermatitis
Red, itchy, swollen eyelids. Crusting of the eyelashes, gritty, burning, Mild conjunctival injection.
Lid hygiene: warm compress, lid wash and massage
Topical lubricants
Abx if severe
Hordoleum (Stye) sx, examination findings and management
Internum: Infection of Meibomian glands
Externum: Sebum producing glands of zies or sweat producing of moll
Swollen lump in eyelid
Lid hygiene: warm compress, lid wash and massage
Abx if severe
Chalazion sx, examination findings and management
Meibomian cyst - Chronic inflamm; painless lump
hot compress or drainage
Entropion
Extropion
Entropion - eyelid turns inwards
Extropion - eyelid turns outwards
Both caused by ageing
=> discomfort, corneal ulceration
Lubricants or surgery
Conjunctivitis sx, examination findings and management
Infectious - bacterial; S.Aureus. viral;Adenovirus, HSV, Molluscum
Non-infectious - Allergic; type I hypersensitivity. Toxic
Red eye; diffuse injection, painless, discharge, itchy (allergic), lid follicles (viral).
Prevent contagion
If bacterial; topical chloramphenicol / erythromycin; arrange follow up.
Viral; self limiting
Allergic; anti-histamines, mast cell stabilisers e.g. cromoglicate.
If hyperacute bacterial conjunctivitis
Profuse discharge, erythema and chemosis due to nesseria infection
immediate gram stain/PCR
ceftriaxone + azithromycin
If newborn, ?chlamydial
topical chloramphenicol + IM benzylpenicillin
Infective Keratitis sx, examination findings and management + common viral types.
Inflammation of the cornea; pseudomonas infection most common.
Strong association with contact lenses
Rapidly progressive painful eye, decreased visual acuity, photophobia. tearing, discharge, oedema.
Slit lamp: corneal epithelial deficit with underlying stromal infiltrate +- Hypopyon (pus)
Urgent ophthalmology referral
Remove contact lenses
Emperical broad spectrum topical Abx; every hour for 24
Avoid steroids
If untreated => enophthalmos, corneal ulcers, scars.
HSV keratitis - pain, blurriness, watery discharge, red eye, On slit lamp: conjunctivitis, decreased corneal sensation, dendritic ulcer
Aciclovir
HZV ophthalmicus
Shingles in CNV1
Hutchinson’s sign = rash on tip of nose = increased chance of ocular complications.
Anterior uveitis rf, sx, examination findings and management
Associated with systemic disease: inflamm arthritis, IBD, sarcoidosis, SLE, vasculitis
HSV, HZV, TB, Syphillis
Ache pain, redness at limbus, miosis or irregular pupil. photophobia, decreased visual acuity,
Leukocytes in the anterior chamber cells or keratic precipitates
+- hypopyon
Topical steroids if not infection
Topical mydriatic agent e.g cyclopentolate (relieves spasms)
Intermediate/posterior uveitis - sx, examination findings and management
Painless, decreased visual acuity, floaters, photophobia
active chorioretinal inflamm and/or leukocytes in VH
Refer to ophthalmology
May require periocular steroid injection
Scleritis - rf, sx, examination findings and management
Associated with systemic disease: RA, GPa, HZV
gradual, severe, worsening pain with very red eye(not if posterior); worse on eye movement. Tender globe, violaceous erythema
Slit lamp: scleral oedema with deep episcleral plexus oedema
Autoimmune screen done if no previous diagnoses
Diffuse and nodular subtypes - Oral NSAIDS e.g. indomethacin
Necrotising or posterior - high dose oral steroids
Episcleritis sx, examination findings and management
Milder version of scleritis (gradual, severe, worsening pain with very red eye(not if posterior); worse on eye movement. Tender globe, violaceous erythema); less red eye, less pain.
Self limiting or NSAIDs
Primary Open Angle Glaucoma - RF, sx, examination findings and management, primary prevention
Optic nerve damage: bilateral progresssive loss of retinal ganglion axons; caused by unequal aqueous production and drainage.
RF: Increased IOP, myopia, age, FH, black, HTN, DM
Asymptomatic, until almost blind.
Dx: optic nerve structural abnormalities i.e. cupping.
+ typical visual field loss e.g. tunnel vision
IOP measurement
360 selective laser trabeculoplasty 1st line
Then topical:
Prostaglandin analogues e.g. latanoprost - increase outflow
B blockers e.g. timolol - decrease production
A agonists e.g. brimnidine - decrease production and increase outflow
Carbonic anhydrase inhibitors e.g. dorzolamide - decrease secretion
cholinergics e.g. pilocarpine - increase outflow
Screened for by opticians when over 40yo
If IOP >25 refer, if >30 urgent
Open angle glaucoma treatments, MoA and side effects
360 selective laser trabeculoplasty 1st line
Then topical:
Prostaglandin analogues e.g. latanoprost - increase outflow; hyperaemia, eyelash growth , avoid in pregnancy/uveitis
B blockers e.g. timolol - decrease production
A agonists e.g. brimnidine - decrease production and increase outflow; increase in allergic conjunctivitis.
Carbonic anhydrase inhibitors e.g. dorzolamide - decrease secretion; taste and acidosis
cholinergics e.g. pilocarpine - increase outflow
Acute angle closure Glaucoma - RF, sx, examination findings and management
Lens is too far forward against the iris, blocking outflow.
RF: FH, age, female, hyperopia, Asian.
Headache, severe eye pain, N+V, decreased visual acuity. conjunctival erythema, mild dilation with decrease reaction to light, cloudy cornea.
Initial, pilocarpine eyedrops, 500mg acetazolamide i.v., analgesia and anti-emetics.
Then laser peripheral iridotomy.
Periorbital cellulitis - sx and management
Infection of anterior portion of the eyelid
Often 2o to sinusitis; S.Aureus.
Unilateral ocular pain, eyelid swelling, erythema; no conjunctival involvement.
Oral co-amoxiclav TDS 7 days
Orbital cellulitis - sx and management
infection of extraocular muscles and fat
Often 2o to sinusitis; S.Aureus.
Unilateral ocular pain, eyelid swelling, erythema.
Ophthalmoplegia, pain on eye movement, proptosis
Chemosis and fever
CT orbit and sinuses with contrast
i.v. vancomycin + ceftriaxone
Corneal foreign body sx and management
sudden onset irritation +- decreased visual acuity
Removal under slit lamp guidance
fluorescein used to look for epithelial defects
Topical abx on discharge +- daily reassessment
Blow out fracture - investigations and management
orbital floor fracture into maxillary sinus
Severe oedema, ocular injury, pain on vertical eye movement + diplopia
CT
Conservative management
If “trap door” fracture, medial rectus is strapped -> ischaemia = surgical intervention.
Hyphema - complication and management
Blood in anterior chamber
Can lead to acute angle closure glaucoma
Topical steroids and mydriatics.
Retinal detachment - rf, sx, management
Neurosensory layer separates from retinal pigment epithelium
RF: myopia, FH, previous cataract surgery, age
Floaters, flashing lights from posterior vitreous detachment]Then, painless vision loss
Red reflex loss, RAPD, decreased visual acuity, corrugated retina
Urgent ophthalmology assessment
Surgical correction; pneumatic retinopexy
Central retinal artery occlusion - sx, signs, investigations, management
Supply to inner retina and optic nerve surface occluded
Acute, profound loss of vision
RAPD, Cherry red spot on macula, retinal whitening
Echo for source of emboli
Fluoroscein angiography if ?dx
CRP/ESR to exclude GCA
Emergency thrombolysis or anterior chamber paracentesis (IOP decreased => emboli dislodged)
Whilst awaiting above, massage, nitrates, i.v. acetozolamide, hyperbaric 02
Discuss lifestyle and Coag
Types of cataracts and signs/sx
Opacity within the lens
RF: age, smoking, alcohol, UV, diabetes, metabolic syndrome, uveitis.
Age related:
Nuclear sclerotic - myopic shift (second sight), brown/yellow
Subcapsular - associated with steroids, renal failure and diabetes. Younger patients and faster.
Cortical - often not in visual axis. spoke like.
Metabolic:
Diabetes - snowflake opacities
myotonic dystrophy - christmas tree
Stages of cataracts
Immature - slightly opaque
mature - opaque with loss of red reflex
hypermature - lens shrinks
morgagnian - cortex liquid, lens sinks.
Management of cataracts
phacoemulsification
Dry Age related macular degeneration - sx, signs, rf, management
Most common; gradual blurry vision loss
Death of macula photoreceptors due to:
Drusens
Geographic atrophy
RF: smoking, age, genetics, CVD, hyperopia, HTN
Antioxidant/mineral supplementation AREDS2:
Vitamin C, E, betacarotene (not in smokers as increases risk of cancer), Zinc, Iron
Wet Age Related Macular Degeneration - sx, signs, rf, management
Increased risk of blindness, but less common
Death of macula photoreceptors due to:
Drusens
Geographic atrophy
+ neovascularisation due to VEGF
Rapid loss of central vision
OCT or fluoroscein angiography
Intravitreal anti-VEGF therapy
Diabetic retinopathy - types, sx/signs, management
Increased permeability and occlusion -> neovascularisation
Investigations: fundoscopy, slit lamp, fluoroscein angiography, OCT
Non proliferative - often asymptomatic:
Microaneurysms, dot/blot haemorrhages, exudates, cotton wool spots
Management: Good glucose control for all, annual photography
Pre-proliferative:
haemorrhages in all 4 quadrants or venous beading in more than 2 or microvascular abnormalities
Management: Pan-retinal photocoagulation
Proliferative:
neovascularisation
=> vitreous haemorrhages, retinal detachment, retinal fibrosis
Management: Pan-retinal photocoagulation or anti-VEGF
Diabetic maculopathy
Focal - leakage from microaneurysms -> focal retinal thickening and exudates
Diffuse - oedema of the macula
ischaemic - perifoveal occlusion
Management: focal photocoagulation and anti-VEGF
Diabetic maculopathy types
Diabetic maculopathy
Focal - leakage from microaneurysms -> focal retinal thickening and exudates
Diffuse - oedema of the macula
ischaemic - perifoveal occlusion
Management: focal photocoagulation and anti-VEGF
Management of proliferative diabetic retinopathy
Management: panretinal photocoagulation or anti-VEGF
Signs of malignant hypertension in eyes
optic disc swelling, macular oedema, occlusions
+- headache, eye pain, visual disturbances
Giant cell arteritis - sx, investigations, management
Granulomatous vasculitis
Initial fever, fatigue, wt loss
Headache over temples, jaw claudication, visual loss; Arteritic anterior ischaemic optic neuropathy
Pale disc, with obliterated margin and no cup. Fundal pallor.
Raised CRP/ESR
Temporal artery biopsy
High dose oral steroids; 60mg daily tapered down over years
Fundoscopy - retinal vein occlusions
multiple haemorrhages, dilated tortuous veins, optic disc swelling
Strabismus types and management
manifest: - tropias
Latent: -phorias
If convergent squint - convex lens
If divergent - concave lens
DVLA vision requirements
6/12 (0.5) required with visual fields for type I driving
HGVs need 7.5/12 (0.8)
Malignant melanoma - types, features, investigation, management
Melanocyte prolif.
Superficial spreading
Nodular
Lentigo maligna - pre-malignant
Acral - on palmar, plantars, nail surfaces
ABCDE
Glasgow 7 point checklist:
Changing colour (2), shape (2), or size (2), bleeding (1), inflamed (1), itching (1), diameter 7mm< (1) if more than 3 points 2WW
Biopsy 1-3mm margins:
TNM
T0 in situ, T1 <1mm breslow thickness, T2 1-2mm, T3 2-4mm, T4 4mm<
Sentinel node biopsy if >0.8mm
CT if 1.0mm<
Wide local excision with 1-2CM margins
MDT
Skin lesion with stuck on appearance
Seborrheic Keratosis
Basal cell carcinoma - types, features, investigation, management
Stratum basale carcinoma
Slow growing, no metastases
Pink or pigmented lesion with pearly white rolled edges
Nodular - “rodent ulcer”, central ulceration, telangiectasia
Superficial - irregular erythamatous patches
Pigmented
Morphoeic - resemble waxy scar tissue
Biopsy
If low risk;
excision with 4mm margins
Topical imiquimod cream (not for nodular)
Topical 5-FU (leaves a scar)
Cryotherapy
Photodynamic therapy
High risk:
excision
Moh’s micrographic surgery - repeated until margins are clear
Radiotherapy
Squamous cell carcinoma - types, features, investigation, management
Keratinocyte prolif.
Well differentiated; hyperkeratotic papules, plaques and nodules
Poorly; fleshy papules, ulceration, bleeding, necrosis
Biopsy
Excision
Bowens disease:
SCC in situ
Treat as per BCC
Actinic Keratosis:
Pre-malignant
Old people bald head
Cryotherapy if sole lesion - 5-FU if multiple
Marjolin’s ulcer - SCC at previous wound/scar
Skin signs in diabetes
Diabetic dermopathy - brown red macules on the shins
Necrobiosis lipoidica - granulomatous disorder, small red/brown papules that enlarge into yellow brown plaques with central atrophy and telangiectasia
Granuloma anulare - raised ring lesions
Acanthosis nigricans - sx, causes
Hyperpigmentation and hyperkeratosis
Axilla and groin
Linked to T2DM, obesity, COC, Pregnancy, GI adenocarcinomaP
Pyoderma gangrenosum - sx, causes
Benign inflamed nodules which then become rapidly enlarging painful ulcers +- fever
Associated with myeloma, leukaemia, IBD
Treat with oral immunosuppresion
Erythema nodosum - sx, causes
inflammation of the subcutis; red tender nodules on the shins
Associated with IBD, URTI, TB, Chlamydia, COC, NSAIDs, sulfonamides, amoxicillin, pregnancy
Urticaria - sx, causes, managment
Itchy wheals; dermal oedema. pruritic erythematous plaques.
Allergy, medication, infection, idiopathic
cetirizine/loratidine
oral steroids if severe or no response
Eczema (atopic dermatitis) - sx, distribution through ages, management and complications
Dry skin, severe itch
Poorly demarcated areas of erythema, weeping, crusting, scaling, vesicles.
Infants - face , extensors. Child - flexors. Adult - hands. Elderly - legs
Emollients
Topical corticosteroids for flares
(Mild potency for face e.g. 1% hydrocortisone)
Can be used for maintenance - tacrolimus 2nd line
Antihistamines PRN
Phototherapy or immunosuppressants if resistant
If infective; topical fusidic acid, widespread oral fluclox
Eczema herpeticum: HSV infection of eczematous skin; Fever, pain, systemic illness
Admit for i.v. aciclovir.
Eczema herpeticum cause, sx, management
HSV infection of eczematous skin; Fever, pain, systemic illness
Admit for i.v. aciclovir.
Allergic contact dermatitis - cause, sx, investigations, management
Type IV hypersensitivity to e.g. metals, preservatives, fragrances, topical abx
Well demarcated acute eczematous area of skin; itchy and dry
Patch testing
Avoid allergen and treat as per eczema:
Emollients
Topical corticosteroids for flares
(Mild potency for face e.g. 1% hydrocortisone)
Can be used for maintenance - tacrolimus 2nd line
Antihistamines PRN
Phototherapy or immunosuppressants if resistant
If infective; topical fusidic acid, widespread oral fluclox
Irritant contact dermatitis - cause, sx, investigations, management
Presents as per acute eczema
treat as per and avoid irritant:
Emollients
Topical corticosteroids for flares
(Mild potency for face e.g. 1% hydrocortisone)
Can be used for maintenance - tacrolimus 2nd line
Antihistamines PRN
Phototherapy or immunosuppressants if resistant
If infective; topical fusidic acid, widespread oral fluclox
Seborrhoeic dermatitis sx and management
Erythamatous, scaly patches in areas with increased sebaceous glands e.g. scalp, nose, auricular folds
Cradle cap in child
Antifungal treatment; ketonazole
Folliculitis sx and management
Inflammation of a hair follicle
S.aureus or ?pseudomonas if hot tub use
Inflamed pustules around hair follicle
Good hygiene + antimicrobial e.g. benzyl peroxide
If persistent, topical abx e.g. fusidic acid or mupirocin
Oral fluclox if extensive
Psuedofolliculitis
razer burn
Faruncle and carbuncle
Faruncle - necrotic infection of single hair follicle
Carbuncle - multiple follicles infected with deep abcess
Treat both with oral abx.
Impetigo - sx/signs, cause, types, treatment
Superficial skin infection; S.aureus most common
Often in children on face and extremities
Non bullous; erythematous papules, then vesciles, then pustules then break down leaving a honey coloured thick crust.
Treat with topical hydrogen peroxide/fusidic acid; oral fluclox if widespread
Bullous; flaccid, fluid filled vesicles and blisters, which burst to leave a thin crust
Treat with oral fluclox
Ecthyma
Rare ulcerative form of impetigo
Infection into dermis
Long oral abx course required
Cellulitis - sx/signs, cause, treatment, compilcations
Infection of the dermis and subcutaneous fat
Strep Pyogenes
Erythema, calor, oedema, fever, abscess
Oral flucloxacillin
admit for I.V. if systemic, reapid progression, extensive erythema, immunosuppressed.
Necrotising fasciitis, sepsis, endocarditis, joint infection
Erysipelas
Superficial form of cellulitis; inflamm of upper dermis and lymphatics
Necrotising fasciitis; sx, signs, types, diagnosis, management
Rapidly progressive infection of deep soft tissues; muscle fascia and fat
Systemically unwell, erythema, crepitus, anaesthesia; eventual skin breakdown with bullae and cutaneous gangrene
Type 1 - ploymicrobial; aerobes and anaerobes. DM is a risk factor
Type 2 - monomicrobial; streptococci
Clinical diagnosis; confirmed by surgical exploration
CT if lower suspicion
Surgical debridement and i.v. clindamycin
Cutaneous warts - cause, types, management
Hyperkeratotic lesions
HPV 1 - plantar
HPV 3 & 10 - Plane
HPV 6 & 11 - genital
Common - verruca vulgaris - cauliflower like papules
Verruca plantaris - tender, can grow inwards
filiform
periungal
Self limiting or cryotherapy/topical paints if painful, unsightly, persistent
Tinea - sx, cause, types, management
Fungal infection of keratinised skin
Dematophytes e.g. Trichophyton, Microsporum, Epidermophyton
Corporis (ringworm) - annular scaly plaques, red border with central clearing
Manuum - hands
Pedis - athletes foot
ungium - nails - discolouration, hyperkeratosis, loss of the nail plate
capitis - scalp
Azole or terbinafine for local skin infection
Oral terbinafine if systemic, scalp or nail; itraconazole 2nd line (more for candida)
Intertrigo
Fungal infection of skin folds
Candida albicans; erythema, pustules at advancing edge
Treat with topical azoles
Pityriasis versicolour - sx, investigations, management
Superficial yeast infection; Malassezia (after transforming to pathogenic mycelial form)
Asymptomatic macules, patches, plaques +- hypopigmentation
Skin scrapings
Ketonazole cream
oral if immunosuppressed
Scabies - sx, cause, management
Sarcoptes scabei mite; spread by direct contact
Itchy small erythematous papules
Can be crusted scabies in immunosuppressed; poorly defined plaques with crusting
2 doses of Topical permethrin 5% cream for pt and close contacts
Oral ivermectin if crusted + investigations for immunodeficiency
Molluscum contagiosum
Pearly papules with central umbilication
Self limiting
Head lice
Manage with wet combing, physical or traditional insecticides
Erythamsa
Erythrasma is a superficial skin infection that causes a pink/brown rash in groin/axilla
Corynebacterium minutissimum bacteria, a normal part of skin flora.
treat with erythromycin. topical miconazole
Types of psoriasis
Chronic plaque
Guttate
Pustular
erythrodermic
Chronic plaque Psoriasis - cause, sx, management
Immune mediated inflamm disorder
erythematous plaques, well defined, silvery scale
Typically on scalp, extensors, gluteal cleft
Scratching can from new plaques - koebner phenomenon
Removal of plaques keaves pinpoint bleeding - Auspitz sign
Emollients
Corticosteroids e.g. betnovate, eumovate
Vitamin D analoues e.g. calcitriol
E + C used for face, E + C and Vit D for limbs/trunk
Coal tar, keratolytics e.g salicylic acid, antikeratinocytes e.g. dianthrol can also be used
Phototherapy - UV therapy 3 times a week
Systemic treatment
Methotrexate
Ciclosporin
Acitretin
Anti-TNFs
Psoriasis systemic treatment options and side effects/Facts
Methotrexate; Folic acid antagonist
Bone marrow and liver, GI, and Resp toxicity
Teratogen; take folic acid with it
Don’t prescribe sulfonamides
Ciclosporin; calcineurin inhibitor
Good short term response. Long term cause HTN, nephrotoxity, carcinogenesis
Acitretin
Vit A derivative
Chelitis, alopecia, hepatotixic
Anti-TNFs e.g. infliximab
Contraindicated in TB
Guttate Psoriasis - cause, sx, management
Abrupt appearance of small psoriatic papules and plaques
Strong association with recent infection (step throat) or new medications
Self resolving in 3-4 months; topicals abx if needed.
Phototherapy if 10%< skin involvement
Pustular Psoriasis -, sx, management
Acute onset widespread erythema, scaling, pustules
Systemic sx, hepatic failure, sepsis
Same day assessment in hospital
Erythrodermic Psoriasis - cause, sx, management
Whole body erythema and scaling
leading to skin failure
Same day assessment in hospital
Acne vulgaris - cause, sx, subtypes, management
Inflammation of the pilosebaceous units; increased sebum, abnormal hyperkeratinisation cutibacterium acnes.
Closed comedomes (whiteheads), open comedomes (black), papules, pustules, noudules, cysts
Severe; nodules and cysts present; scarring atrophic or hypertrophic.
Conglobata - nodular acne with sinus formation
Fulminans - severe inflammation; ulceration, bleeding, systemically unwell
Avoid over cleaning, mkeupp etc.
Mild/moderate- topical combination therapy
e.g. benzyl peroxide, topical abx, retinoids e.g. tretinoin (photosensitivity, teratogen)
Moderate/severe - monotherapy + 12 weeks doxycycline (hormonal therapy if female e.g. co-cyprindiol; oestrogen + anti-androgen)
Severe/resistant - roaccutane
Isotretinoin (roaccutane) facts/side effects
Used as monotherapy
Decreases sebum, gland size and follicular occlusion
Teratogen; females must be on double contraception
Dry skin, mood changes, initial flare of sx.
Hyperlipidaemia, hepatic transaminase derangement
Bloods done 1 month after initiation
Acne rosacea
Flushing then papules, pustules and telangiectasia
Can lead to blepharitis
Topical brimonidine if flushing only
Topical ivermectin if mild papules/pustules
Oral doxy if severe
Licehn planus
purple-ey lesions
Treat with potent steroids
Pityriasis rosea
Initial single large patch; then many smaller pathces
Resolves in 2 months
Erythroderma
Erythema of >90% of body surface
exacerbation of inflammatory conditions
Treat underlying cause
Toxic epidermal necrolysis
Cytotoxic cell-mediated reaction against skin cells
Induced by drugs e.g. NSAIDs, Abx, anti-convulsants
Fever + 30%< erythema
If only 10%> = stephen-johnson syndrome
Nikolsky sign - blisters expand with lateral ptessure
Within 72 hours; full thickness necrosis can occur.
Investigation required before starting terbinafine
LFTs need to be checked before commencing a patient on terbinafine (to treat a fungal nail infection)
Cystic Hygroma
Posterior triangle neck lump
Child
Branchial Cysts
Neck lump located in the anterior triangle. They characteristically appear in-front on sternocleidomastoid.
The fluid may contain cholesterol crystals which are also characteristic.
Typically early adulthood
