Genital Derm Dan Flashcards
1
Q
Causes of phimosis?
A
Non-specific balanoposthitis (esp diabetics) Lichen sclerosus Lichen planus Hidradenitis suppurativa Crohn’s disease Cicatricial pemphigoid Chronic penile lymphoedema Cutaneous lymphoma Kaposi’s sarcoma Other tumour/warts under prepuce
2
Q
Causes of paraphimosis?
A
Allergic contact dermatitis
Lichen sclerosus
Acute contact urticaria
3
Q
Causes of (DDs) balanoposthitis?
A
Eczema (atopic, seborrhoeic, ACD, ICD) Psoriasis Reiter’s disease Zoon’s plasma cell balanitis Lichen sclerosus Gonorrhoea HPV HSV Candidiasis Rarer causes - Crohn’s - Other infections (strep, staph, gonorrheoea, syphilis, mycoplasma, tichomonas, LGV, tinea, amoebiasis) - Scabies - Erythroplasia of queyrat - kaposi’s sarcoma - chronic lymphatic leukemia - fixed drug eruption
4
Q
What are Pearly penile papules?
A
tiny angiofibromas in rows on corona
Normal variant in 50% men
vestibular papillomatosis is female equivalent
5
Q
What are Tyson’s glands?
A
Free sebaceous glnds on ventral penis/prepuce just below glans
6
Q
What is Zoon’s balanitis/vulvitis?
what is Rx?
A
M>F esp uncircumcised uncertain cause - may be irritant dermatitis In women often complicates vulval LP 'Kissing lesions' - bright red or autumn brown patches on glans and visceral prepuce with sparing of keratinised penile shaft and outer foreskin cayenne pepper spots Rx hygeine measures Treat underlying dermatosis if present TCS laser circumcision
7
Q
what is Histo of Zoons?
A
Epidermal atrophy, absent granular and horny layers
Epi has lozenge-shaped keratinocytes (pathognomonic) with wide intercellular spaces
Polyclonal dense papillary dermal infiltrate esp plasma cells w/ haemosiderin and RBCs
May be Russell bodies in plasma cells (large eosinophilic cytoplasmic inclusions)
8
Q
T/F
LS is 10x more common in women then men
A
True
9
Q
What are the disease associations of LS?
A
thyroid, vitiligo, morphoea in females
Rarely any assoc in males
should do FBC, ELFT, ANA, TFTs and thyroid Abs esp in women
10
Q
T/F
5% of LS pts have extragenital disease
A
False
15-20%
11
Q
T/F
Perianal LS is very rare in men
A
True
affects 30% of women
12
Q
What is the risk of SCC in pts with genital LS?
A
2-6%
13
Q
T/F
prepubertal LS resolves at puberty
A
False
Used to be thought this was true
14
Q
T/F
LS does not affect the vagina
A
True
15
Q
T/F
Hyperkeratosis is only clinical marker of LS pts most at risk of SCC development
A
True
epidermal hyperplasis may be a clue to ensuing differentiated VIN
16
Q
T/F
LS is associated w/
HLA DQ7 or DRB1*12
A
True
17
Q
What are
Balanitis xerotica obliterans and
posthitis xerotica obliterans
A
Complications of LS in men
although BXO often used interchangeably with male LS
means scarring/destruction of glans or prepuce
18
Q
Where does extragenital LS occur?
A
submammary, shoulders, neck, wrists
asymptomatic, hypopigmented, wrinkeled patches with follicular plugging
19
Q
T/F
Good control of LS reduces the risk of SCC
A
True
2015 Gayle Fischer paper asserted this
Textbooks say is not known
20
Q
T/F
LS is a rare cause of secondary phimosis in school-age boys
A
False
most common cause
21
Q
Management of LS?
A
Careful and thorough work up
check for extragenital disease
check if affecting urinating, sex, menstrual periods
sensitive examination with chaperone
Must biopsy to confrim
exclude SCC at presentation
Detailed information and support - refer if required to gynae, urology, counselling etc
Provdie deatils teratment plan and ensure correct expectations of treatment
general measures - hygeine, soap-free wash
avoid irritants
Potent TCS to gain control - dip ung nocte for 3 months and longer if skin colour and texture not normalised
Maintain w/ dip or AFO regularly NOT PRN eg twice a week and HCT on other days
consider risk of candida or reactivation of warts/HSV
Can used Top Tacro if unresponsive to TCS
Acitretin and CsA have been used
UVA1 and CO2 laser have also been used
Curcumcision for men if not responding/severe/phimosis/malignancy
women may need serial introital dilators or vulval surgery
22
Q
T/F
Genital LP affects 50% of men and 25% of women with LP
A
False
other way around
23
Q
What are the types of genital LP?
A
Classical LP - mons, lab maj, often annular on penis
Pigmented flexural LP - mons, inguinal and genitocrural folds; also affects axillae and inframammary areas
Erosive LP - vulvovaginal, often gingivitis too F only
Hypertrophic LP - hyperkeratotic white plaques
LPP - mons, lab maj
24
Q
T/F
Genital LP does not increase risk of SCC
A
False
small increased risk
25
T/F
| Differentiated VIN is most dangerous in terms of risk of an invsice SCC w/ potential to invade and metastasize
True
This type is not HPV associated
Can arise from LS
epidermis is hyperplastic + atypia in basal layer
Be suspicious for a micorinvasive carcinoma nearby
26
What is Treatment of genital LP?
```
Largely similar to LS esp if eroded
Must examine for LP elsewhere
General measures
Potent TCS
Top Tacro
Topical retinoids for hypertrophic/hyperkeratotic LP
Pred, MTX, MMF, CsA, AZA
PDT has been used for LP on penis
Surgery
```
27
T/F
| Vulval LP affects prebubescent girls
False
| unlike LS
28
T/F
| Non-specific Balanoposthitis is a diagnosis of exclusion
True
irritation and inflammation, can be erosive
Need to exclude all other causes inc STIs, other infections, dermatoses and malignancy
General measures may help
circumcision curative
29
T/F
| Peyronie’s disease is treated with ILCS
True
30
T/F
| Penis is a site of predilection for fixed drug eruption
True
31
What are the causes of fixed drug eruptions?
```
BARBwire PANTS (helps remember penis is comon site and it can be painful)
Barbituates
Phenolphthalein laxatives
Aspirin
NSAIDs inc ibuprofen
Tetracyclines
Sulphonamides esp TMP-SMX
```
32
What are risk factors for Fournier's gangrene?
```
DM
alcoholism
anogenital infection
chemotherapy
HIV
post-instrumentation/postoperative/trauma
```
33
What are the clinical variants of PIN?
Erythroplasia of Queyrat
- Red shiny patches or plaques of the ‘mucosal’ penis (glans and prepuce of the uncircumcised)
Bowen’s disease of the penis
- Red, sometime slightly pigmented, scaly patches and plaques of the keratinized penis
Bowenoid papulosis
- Multiple warty lesions, which are often pigmented in keratinised sites and more nubmerous and more inflamed at ‘mucosal’ sites
- Associated with a lesser risk of SCC than EQ and BDP
- Associated with HPV infection (esp HPV16) and HIV
34
What are the treatment options for genital warts?
```
Podophyllotoxin (not if preg)
Imiquimod
Cryotherapy
Trichloroacetic acid
Electrocautery
Curettage
Scalpel excision
Laser ablation
5-FU (not if preg)
Interferon (not if preg)
Cidofovir
Gardisil vaccine (HPV 6, 11, 16, 18)
```
35
T/F
| smoking is a risk factor for scrotal carcinoma
False
| is for penile Ca but not scrotal
36
T/F
| coal tar use is a risk factor for penile carcinoma
False
| is for scrotal Ca but not penile
37
T/F
| HPV is a risk factor for penile carcinoma
True
| 16, 18, 31, 33
38
What are risk factors for penile Ca?
Risk factors for penis
- Uncircumcised
- Smoking
- Poor hygiene
- Chronic irritation and inflammation (phimosis and balanitis)
- Lichen sclerosus
- Lichen planus
- HPV (16, 18, 31, 33)
- HIV
- Intraepitherlial carcinoma (BDP, EQ, BP)
- Photochemotherapy (PUVA)
- Iatrogenic immunosuppression (renal transplant, SLE, IBD, radiotherapy)
39
What are risk factors for scrotal Ca?
Risk factors for scrotum
- Psoriasis treated with arsenic, coal tar, UVB and PUVA
- Radiotherapy
- scrotal HPV infection
- hidradenitis suppurativa
- Bowen’s disease
- Multiple cutaneous keratoses and epitheliomas
40
T/F
| scrotal Ca has a good prognosis
False
| poor prognosis 5yr mortality 50-60%
41
T/F In Extramammary Paget's disease;
| Internal malignancy is 5x more likely when perianal as opposed to vulvar or penoscrotal involvement
True
| Up to 50% of men can have malignancies
42
T/F In Extramammary Paget's disease;
| In men, perianal disease is most common site
True
43
What is Pagetoid VIN?
Rare variant resembling EMPD or pagetoid Bowens disease
| Abnormal cells are CK7 positive but negative for mucin stains and cam5.2
44
How is VIN graded?
No longer graded I-III
Now just called undifferentiated VIN if less aggressive, HPV-associated type
differentiated VIN is not HPV-associated and is more aggressive
45
T/F
| Almost all women with VIN are smokers
True
46
T/F
| VIN is usually multifocal and may be multicentric
True
multifocal = several distinct sites of vulva involved
multicentric = intraepithelial neoplasia also in the cervix, vagina and perianal skin
47
T/F
| 15% of VIN pts also have CIN of cervix
False
| 2/3 have CIN - must get smear/colposcopy
48
T/F
| VIN can cause wart like overgrowths
True
49
T/F
| VIN commonly extends into vagina
False
| v rare
50
T/F
| 10% of VIN progress to invasive malignancy
```
True
higher risk if;
Immunocompromised
perianal disease
older women with solitary plaque
```
51
What is the Rx of VIN?
Depends on pt age, circumstances, preference etc
Must examine other sites regularly – cervix, vagina, perianal area – refer to gynae
If perianal area involved need proctoscopy to look inside – send to colorectal
Excision is treatment of choice for amenable solitary VIN
Efudix can be used on lab min, vestibule and clit but not on hair-bearing areas
Immiquimod useful for multifocal undiff VIN
In extensive undiff disease can follow up regularly and excise thick or polypid areas and biopsy suspicious areas
NB Cryo and laser not effective
52
T/F
| younger women are more likely to get SCC arising from differentiated VIN
False
Of all vulval SCCs;
60% in elderly women with LP or LS (no HPV link – diff VIN)
40% in younger women with undiff VIN
53
What is the treatment of PIN?
```
topical 5FU
Immiquimod
cryosurgery
curettage
excision/Mohs
PDT
laser
XRT
Should screen for HPV, HIV, other STIs
stop smoking
advise sexual partners to be checked for HPV and STIs
Nb circumcision removes major risk factors for cancer;
```
54
What are the histological types of vulval SCC?
Keratinizing – older women non HPV type
Basaloid – younger, HPV type
Warty – also younger HPV type
55
What is the staging of vulval SCC?
Stage T1: 1mm deep
Stage T2: Any size tumour invading lower vagina, urethra or anus
Stage T3: Any size tumour invading upper vagina, urethra, rectum or pubic bone
56
What is the Rx and prognosis of vulval SCC?
Wide excision/vulvectomy
Lymph node dissection is mandatory if stage 1b or above
Central lesions have bilateral drainage and need bilateral LN dissection
Adjuvent DXT if positive nodes
Palliative DXT if inoperable
Prognosis – 75% 5-year survival or 90% if No nodes involved
57
T/F
| XRT is contraindicated for Rx of Verrucous carcinoma (Giant condylomata of Buschke-Lowenstein)
True
| can induce anaplastic transformation with worse prognosis
58
```
T/F
Verrucous carcinoma (Giant condylomata of Buschke-Lowenstein) has a worse prognosis that other genital SCC
```
```
False
large but well circumscribed
rarely metastasises
treat with excision
oral retinoids have been used
```
59
```
T/F
Verrucous carcinoma (Giant condylomata of Buschke-Lowenstein) is strongly associated w/ HPV
```
True
60
T/F
| melanoma accounts for 5% of vulval malignancies but is exceptionally rare on the penis
True
61
T/F
| Langerhans cell histiocytosis mostly presents with perianal ulceration
True
| can also be be plaques, nodules, erosions, ulcers or pustules
62
T/F
| Langerhans cell histiocytosis affecting the genital region can be primary or secondary (disseminated)
True
63
T/F
| Langerhans cell histiocytosis of the genital region is more common in men than women
False
| F>M
64
Which rare tumours can affect the genitals?
DFSP, liposarcoma, epitheloid sarcoma, Merkel cell carcinoma, Kaposi's sarcoma(in HIV), Bartholin’s gland carcinoma, Langerhan's cell histiocytosis, lymphoma (NHL>Hodgkins)
Benign - trichoepithelioma (esp in Bazex), hidradenoma papilliferum (mostly on vulva)
Mets;
Cervix>endometrium>vagin>ovary
>urethra>kidney>breast>lung
endometriosis can affect the vulva
65
T/F
| Necrolytic migratory erythema can affect the anogenital region
True
| anogenital skin and buttocks, legs and lower abdomen as well as mouth, tongue and perioral skin
66
T/F
localised genital papular acantholytic dyskeratosis is thought to be an attenuated form (forme fruste) of one either Dariers or Hailey-hailey
True
67
T/F
| Hypertrophy of labia minora seen in neurofibromatosis
True
68
T/F
| clitoral pseudocyst is a feature of vulval LS
True
| debris accumulates under clitoral hood adhesions
69
T/F
| sexual abuse should be considered if supposed LS does not improve with Rx
True
70
T/F
| It is illegal to perform FGM on an Australian citizen overseas
True
| and illegal in all states of Australia
71
T/F
| FGM is allowed if consent has been given
```
False
consent (from the woman herself or parents of girl) is not a defence
```
72
T/F
| Reporting FGM is mandatory for healthcare professionals
True
73
Which inflam dermatoses can cause vaginal discharge?
Lichen planus
Pemphigus
Mucous membrane pemphigoid
SJS
74
Which 3 common inflam dermatoses may involve the vulva without involving other sites?
Seb derm
Irritant contact dermatitis
Allergic contact dermatitis
75
T/F
| allergic contact dermatitis of the vulva is more common than irritant
False
| irritant much more common
76
Which iritants are implicated in vulval ICD?
```
urine
vaginal discharge
Topical medications
soaps, bath additives
lubricants, contraceptives
disinfectants
perfumes, deodorants
```
77
Which allergens are implicated in vulval ACD?
vaginal medicaments, IUD, condoms, sanitary wear
| NB not semen - causes type 1 hypersens (urticaria)
78
Which allergens are implicated in vulval contact urticaria?
2 common causes – latex and semen
| • Can use immunotherapy for semen allergy
79
What condition causes circinate balanitis (circiante ulcerative vulvitis)
Reactive arthritis (Reiter's)
80
What is Chronic vulval purpura?
quite common condition
Purpuric patches often at vestibule
haemosiderin, plasma cells, non-specific features
may be assoc w/ PPD
81
T/F
| 5-10% of Crohn's pts get anogenital invovlement
False
30%
direct extension or metastatic
Deep linear fissures along skin creases = knife cut sign
82
What are causes of genital (mainly vulval) ulcers?
```
Acute;
Benign apthae - can be small or large
Sutton's ulcer - solitary, recurrent, painful vulval ulcer
Lipschutz’s ulcer – adolescent girls, often with EBV
CMV can rarely cause ulcer
Behcets diseas
MAGIC syndrome
HSV
syphylitic chancre (painless)
chancroid (haemophilus ducreyi) (painful 'Do Cry')
EM Major
SJS/TEN
```
```
Chronic;
fixed chronic genital ulcer is cancer until proven otherwise; SCC>BCC>MM>rare tumours or mets
Langerhans cell histiocytosis
Bartholins gland abscess
LGV - late stage
Pemphigus vulgaris or vegetans
MMP
severe contact dermatitis
LP
LS
Crohns
HS
PG
Drugs
XRT
DA
Malakoplakia - ulcerating soft plaque due to granuloamtous response to staph, pseudamonas, E.coli etc
atypical infection - Fournier gangrene/nec fasc, TB, actinomycosis, deep mycobacteria
```
83
What are the anogenital complications of Crohns?
```
Anal and perianal conditions
o Maceration
o Erosion
o Pruritis ani
o Sin tags
o Secondary infection
o ‘metastatic’ granulomatous plaques
o Perianal abscess
o Fissure in ano
o Fistula in ano
Spreading ulceration of perineum and buttocks post colectomy
• Skin changes around stoma sites
• Genital lesions
Men
- Balanitis
- Posthitis
- Chronic penile lymphoedema and granulomatous lymphangiitis
Women
- Vulval lesions
```
84
what are the DDs of genital LS?
LP
morphoea
mucous membrane pemphigoid
lichen simplex chronicus
These are all DDs for each other
Clinical and histo overlap between morphoea, LP and LS (may be a spectrum)
85
what is the most common organism to cause vulval cellulitis?
Beta haemolytic group A strep
| most commonly occurs after surgery
86
what is the most common organism to cause infection of anogenital hidradenitis suppuritiva?
Staph and strep esp Strep Milleri
87
T/F
| Genital Diphtheria causes ulcers with greyish membrane
True
Corynebacteria diphtheriae
rare in developed countries due to vaccination
88
T/F
| Pubic hair loss can be a feature of leprosy
True
89
What are triggers/predisposing factors for candidal vulvovaginitis?
```
pregnancy
high dose Oe OCP
diabetes
immunosuppression
antibiotics course
```
90
Which species of dermatophyte are most common in the perianal/ inguinal region?
T. Rubrum and Epidermophyton floccosum
91
What is the presentation of Trichomonas vaginalis (TV)?
Protozoan infection (most common type in vulva, STI)
asymptomatic in 50%
causes cervicitis
grey-green thin/thick malodorous discharge
Other rarer protozoa which can infect vulva;
• Leishmania tropica
• Entamoeba histolytica
• Schistosoma haematobium (schistosomiasis)
92
What is Bacterial vaginosis (BV)?
Infection caused by Gardnerella+ another bacteria together eg bacteroides, mycoplasma
grey, watery, fishy smelling d/c
Increased vaginal pH (less acidic)
Test
Whiff test - add 10% KOH to sample of discharge - +ve if strong fishy odour produced
Wet mount - smear of discharge on microscope slide with salt - Clue cells often seen if BV present
Not an STI
treat w/ metronidazole
93
T/F
| Vulval molluscum is extremely rare
False
Not that rare
Lesions on mons and lab maj
Common in children and usually not a sign of abuse
More likely to be sexually transmitted in adults
Can be solitary or several
if many large mollusca think of immunosuppression/ deficiency including HIV
94
T/F
| Cowpox is most commonly acquired from cows?
False
| From domestic cats
95
Which viruses cause sexually transmitted and non- sexually transmitted genital infections/ulcers?
Herpes viruses
HSV - STI - type 2 in 50-80%
VZV (S3 dermatome shingles), non-STI
EBV (HHV8) – Sometimes causes genital ulcers during infectious mononucleosis, non-STI
CMV (HHV5) – very rare, immunosuppressed pts, perineal ulcers, non-STI
Papillomaviruses
genital warts and cancers
Pox viruses
Molluscum - can be STI esp in adults
Very rarely Orf or cowpox, non-STI
96
What is vulvodynia?
| what are the subtypes?
Pain or discomfort for 3 months or more without any visible abnormality or explanation
o Strictly a diagnosis of exclusion
Types;
Dysaesthetic vulvodynia = spontaneous diffuse vulval pain; may or may not be triggered by touch or other stimuli; older, post-menopausal women
Vestibulodynia = pain localized to vulval vestibule triggered by touch alone; young women
Triad of
- Erythema of epithelium of vestibule
- tenderness to light touch
- dyspareunia
97
T/F
| dermographism as this can mimic or exacerbate vulvodynia
True
| assess for this elswhere if vulval discomfot and no cause found
98
T/F
| Vestibulodynia can turn into dysaesthetic vulvodynia
True
99
What is management of of vulval pain syndromes?
First confirm and define diagnosis and exclude a physical cause of pain - full Hx and exam, psych Hx
Check for atrophic vaginitis in older women (and younger if early menopause)
Need lots of explanation/ hand holding
Avoid precipitants eg) excessive touching
General measures - soap free wash, avoid irritants
5% lidocaine ung useful and low risk of contact sensitivity. Avoid other amide anaesthetics as higher risk of sensitivity
Add oral antihistamine if pt ahs dermographism
Oral options – consider referral to pain clinic
Tricyclic antidepressant – amitryptaline
Pregabalin
Gabapentin
Carbamazepine
Involve psych if associated psych or psychosexual issues
Biofeedback useful esp if vaginismus
Self help group may be useful
100
T/F
| pruritus vulvae affects most women at some time
True
101
T/F
| pruritus vulvae/scroti is usually psychogenic
False
usually a cause
1 in 20 psychogenic
102
What is management of pruritus vulvae/scroti?
Need full work up similar to pruritus ani
In women most cases due to candida, BV or TV.
In acute cases consider infection or allergic or irritant contact derm
Chronic cases may be almost any dermatosis as most cause itch or malignancy or in women atrophic vaginitis
Rarely could be due to lumbosacral nerve damage/entrapment/radiculopathy
103
What is Dermatitis vegetans?
loose term for any vegetating looking inflamed lesion. This is a common occurrence of many conditions in the perianal area. The term is not a full diagnosis in itself
104
List some typical contact allergens in the perianal area
Neomycin
Caine mix (LA in haemorrhoid preparations)
Kathon CG (mix of MI + Methylchloroisothiazolinone)
Quinolones
Lanolin
Ethylenediamine
Nystatin
Latex (condoms)
Spermicides
Danthron – From laxatives not topical application
105
What is Danthron erythema?
Irritant contact dermatitis due to laxatives containing danthron
Danthron reduced in the bowel to chemical identical to dithranol
Pts with foecal incontinence get dermatitis that is essentially dithranol ‘burns’ – bizarre livid erythema in perianal area, groins, thighs and buttocks with sharp outlines
Seen in pts with Hirschsprungs disease or encopresis (foecal incontinence)
106
T/F
| Lichen sclerosus et atrophicus does not occur in perianal region in men
True
107
What are the DDs for the appearance of perineal HS?
```
HS
STIs eg) lymphogranuloma venereum
Non venereal infection (is there diabetes or immunosuppression?)
Crohn’s
Chloracne
Simple faruncle or perianal abscess or pilonidal sinus
Severe acne
Developmental fistulae
```
108
T/F
| Long term Hidradenitis suppuritiva in perianal region has signif risk of SCC
True
| + rarely verrucous carcinoma
109
T/F
| Perianal skin is affected in 75-90% of Crohn’s patients
```
True
Can be;
Maceration
Erosion
Pruritus ani
Sin tags
Secondary infection
‘metastatic’ granulomatous plaques
Perianal abscess
Fissure in ano
Fistula in ano
```
110
T/F
| anus involved in 25% of SJS
False
| 5%
111
T/F
| Pruritus ani is 4x more common in men
True
112
T/F
| Pts with colostomies dont get pruritus ani
True
113
T/F
| Pruritus ani affects 15% of population
False
| 1-5%
114
T/F
| Primary pruritus ani where no cause is found accounts for 50% of cases
True
| The other 50% are secondary where there is a cause - cutaneous, anorectal or colonic disorder
115
List causes of pruritus ani
Often multifactorial
Foecal contamination is a common aetiological factor in many cases - infection and/or contact dermatitis may complicate the primary cause
- Skin diseases – most common causal group; LP, LS, Pso, Seb derm, ACD
- Infection; candida, staph, folliculitis, erythrasma, tinea, genital warts, pinworms
- Local Malignancy; anal or colonic, Pagets, IEC
- Any cause of generalized pruritus; liver Dx, Renal Dx, Thyroid Dx, iron deficiency, lymphoma, polycythaemia, pregnancy, diabetes
- Deficiency; Pellagra, zinc, Vit A or D (fat malabsorption or low fat diet)
- Anal leakage/recurrent diarrhoea
- Drugs (opiates, laxatives), XRT
- Psych; habitual, delusions of parasitosis
116
T/F
| Excision of skin tags if present can help settle pruritus ani
False
| often no help
117
T/F
| Menthol cream is good for relieving the symptoms of pruritus ani
False
| menthol not effective
118
Management plan for pruritus ani
Need full work up - Hx and exam whole body, diet, exclude cancer, patch test if req, Blds for causes of itch
Treat underlying cause
Avoid irritants
Soap free wash
Stop topical medicaments unless contact allergy excluded
Moisturize after washing – ointment not cream; zinc or silicone preparations
Apply barrier cream before opening bowels
Must have meticulous hygiene
Sitz baths or bidet can help
Cool compresses
Avoid rubbing with toilet paper –dab or wash in bidet if possible
Avoid moist wipes as often cause irritation/ACD unless bland formulation
Loose cotton underwear
Diet – avoid laxatives
Can use topical steroid/antibiotic/antifungal if needed for acute episodes
Oral or intralesional steroids
antihistamines
Wick of bandage impregnated with 1% HCT and 10% silicone inserted in natal cleft
119
T/F
| perianal fissure is most commonly anterior
False
Mostly posterior
90% in men, 70% in women
120
T/F
| Topical GTN cream relaxes the sphincter allowing a perianal fissure to heal
True
| Botox also
121
What is a perianal fistula?
An abnormal epithelialized connection between anal canal and perianal skin
Caused by infection of anal glands resulting abscess and sinus that become a fistula
• Can be caused by Crohn’s, foreign body or TB
• Hidradenitis suppuritiva is differential
122
What is Goodsall’s law
Regarding perianal fistulae;
if the external opening is in the posterior perianal region it usually opens into the anus in the midline
If the external opening is anterior it opens directly into anus in a straight line
123
T/F
| Haemorrhoids occur at the 11, 3 and 7 o clock positions
True
124
T/F
| Pilonidal sinus derives from a perineal pilosebaceous unit which froms a cyst and then a deep sinus track
True
125
T/F
| SCC is a rare complication of both perianal fistula and pilonidal sinus
True
126
T/F
| Anogenital shingles is a relatively benign form
False
can be serious
Rare; S2-4 >L1-2 dermatomes
Can cause acute cystitis and urinary retention
Can cause foecal retention
Need to hospitalize and treat and fully work up with colorectal and urological examination
Check for HIV or other immunosuppression
127
T/F
| Women with AIN have increased risk of CIN and VIN
True
| – need full gynae exam
128
What are the risk factors for anal carcinoma?
```
smoking
CIN, anogenital warts
MSM
Crohn’s (10x increased risk)
STIs; including Chlamydia, gonorrhoea, HSV and HPV
Immunosuppression
LS, LP, HS
```
129
T/F
| anal carcinoma is most often adenocarcinoma
False
| >50% SCC
130
T/F
anal carcinoma is
o More common in women
o More aggressive in men
True
131
T/F
| 75% of perianal EMPD presents as pruritus ani
True
132
What are the treatments of EMPD?
surgery is mainstay
– may need margin control multistep procedure/Mohs
Plastic repair with grafting/flap
XRT is option for if surgery contraindicated or refused or recurrent
PDT and laser have been used
Others as per genital EMPD – efudix, aldara
133
What is Proctalgia fugax?
Mainly young adult males
Often occurs at night – may wake pt from sleep
Sudden onset cramp-like or stabbing pain in rectal area which resolves in few minutes or is relieved by digital dilatation of anal sphincter
134
What is Episodic burning perineal pain with itch?
Stressed individuals
Short lived intense symptoms
May be precipitated by full rectum
Skin is normal
135
What is a sister Mary-Joseph’s nodule?
```
Skin met from GIT tumour to umbilicus
mostly from stomach cancer
F>M
41% present before diagnosis of the primary tumour
DDs
EMPD
Pyogenic granuloma
talc granuloma
endometriosis
choristia - intestinal mucosa
```
136
T/F
| Gastroschisis usually protrudes to the left of the umbilicus
False
always to the right side of umbilicus
= extrusion of abdominal contents without a covering membrane
137
What is prune belly syndrome?
```
v rare conditon
named due to wrinkled abdominal skin
triad;
hypoplastic abdominal musculature
urinary tract abnormalities
cryptorchidism
```
138
T/F
| early surgery is recommended for congenital umbilical hernia
False
usually resolves by age 5
surgery only if complications (common)
139
What are associations of congenital umbilical hernia?
```
Low birth weight
afro-caribbean ethnicity
congenital hypothyroidism
Ehlers-Danlos (dermatospraxis type)
Beckwith-Wiedmann syndrome
mucopolysaccharidoses
cutis laxa
```
140
T/F
| Umbilical granuloma is most common cause of umbilical mass in neonates
```
True
glistening red
topical silver nitrate
scan +/- biopsy of non-resolving
DD is omphalomesenteric duct malformation
```
141
T/F
| delayed separation of the umbilical stump may be due to leukocyte adhesion defects
True
142
T/F
| Angiokeratomas in Fabrys disease can present as a perimumbilical rosette
True
143
Which 2 allergens commonly cause periumbilcal allergic contact dermatitis?
Nickel
| dibenzyldithlocarbamate - rubber chemical in elastic waist bands which reacts with bleach
144
What is clear cell papulosis?
Rrae disease of young children
may be related to EMPD
due to defect in melanogenesis
hypopigmented macules or flat papules on lower abdomen close to umbilicus or along milk lines
145
Which bullous diseases have a predilection for the region of the umbilicus?
pemphigoid gestationis
| Linear IgA/ chronic bullous disease of childhood
146
T/F
| periumbilical thumbprint purpura is a sign of hyperinfection syndrome caused by larva currens (strongyloides)
True
147
T/F
| perimumbilical Rose spots are a feature of measles
False
pale pink abdominal macules seen in enteric fever due to salmonella typhi or paratyphi
pt has fever, abdo pain, hepatosplenomegally, anorexia, constipation
148
What is an omphalith?
Omphalith is an accumulation of keratinous and
sebaceous material in the umbilicus, commonly
resulting from poor hygiene
149
T/F
| umbilical erythema affects 9% of pts with cows milk protein intolerance
True
150
T/F
| Primary systemic amyloidosis may present with umbilical petechiae, purpura, and ecchymoses
True
151
Which benign neoplasms affect the umbilicus?
```
acrochordon
keloid
lipoma
neurofibroma
dermatofibroma
seb k
pyogenic granuloma
umbilical polyp
syringoma
melanocytic naevi (special site)
epidermoid cyst
epidermal naevus
desmoid tumour
endometriosis
condylomata acuminata
granular cell tumour
```
152
Which malignant neoplasms affect the umbilicus?
```
BCC
SCC
Melanoma
EMPD
Adenocarcinoma of urachal elements
MF
```
153
Which genodermatoses may be associated with vulval melanosis?
```
JAAD paper 2015
Peutz-Jeghers
carney complex
LEOPARD
Bannayan-Riley-Ruvalcaba
Dowling-Degos
```
154
What percentage of pts with genital LS have extragenital disease?
15-20%
155
T/F
| most prepubertal girls with LS will grow out if by puberty
F
| used to think it resolved in most but latest data says it persists in 75%
