Huid Flashcards

Question

How do you grade the severity of acne?

Answer 1

Leeds grading system, grades 1 to 12

Answer 2

Reduce plugging • Topical retinoid • Topical benzoyl peroxide Reduce bacteria • Topical antibiotics (erythromycin, clindamycin) • Oral antibiotics (tetracyclines, erythromycin) • Benzoyl peroxide reduces bacterial resistance Reduce sebum production • Hormones – anti-androgen i.e. Dianette / OCP • Changes the viscosity of the oil produced and also leads to less sebum production

Answer 3

Roaccutane * Oral retinoid for severe acne vulgaris * Concentrated vitamin A * Reduces sebum, plugging and bacteria * Remission of acne in around 80% teenagers * Standard course for 16 weeks ``` Multiple side effects – most are trivial • Dry lips • nose bleeds • dry skin • myalgia ``` ``` Serious side effects • Deranged LFTs • Raised lipids • Mood disturbance • Teratogenicity - pregnancy prevention programme ```

Answer 4

• Overgrown scar tissue Causes: • Physical trauma • Burns • Hugely exaggerated scars as a result of acne Cannot be reversed

Answer 5

Direct action of UV on target cells (keratinocytes) for neoplastic transformation via DNA damage Effects of UV on the host's immune system

Answer 6

basal cell carcinoma

Answer 7

PTCH gene mutation may predispose to BCC (pronounced ‘patch gene’)

Answer 8

* Nodular * Superficial * Pigmented * Morphoeic

Answer 9

* Nodule i.e. raised lesion ( > 0.5cm) * Rolled shiny margin * Shiny “pearly” * Telangectasia (broken blood vessels) * Often ulcerated centrally

Answer 10

* No raised nodular appearance * Rolled shiny margin * Broken blood vessels * Usually doesn’t ulcerate * Indolent superficial spread

Answer 11

* Rolled shiny margin * Telangiectasia * Ulceration

Answer 12

Gold standard – Surgical excision with an adequate margin 3-4mm margin of normal looking skin

Answer 13

* Originates from keratinocytes * 2nd commonest skin cancer Appearance: • keratin – crusty • no rolled shiny margin • inflamed, but no specific blood vessels • no area of skin ulceration unless very aggressive

Answer 14

* actinic keratoses | * Bowens disease = SSC in situ

Answer 15

* Gold standard - Surgical excision * 4-5mm margin due to risk of metastasis * Curettage and cautery in elderly patients * Symptomatically debulk the tumour

Answer 16

• Topical imiquimod / 5-fluorouracil cream

Answer 17

* Malignant tumour of melanocytes * Most common in skin (but can be bowel/eye) * Accounts for 75% of deaths from skin cancer * Often affects young, fit people – hard to diagnose Depth of tumour penetration into skin at presentation determines prognosis

Answer 18

Metastatic spread is via lymphatics, but rarely can spread haematogenously or along the skin

Answer 19

``` family history UV irradiation sunburns during childhood high SE status intermittent burning in fair unacclimatised skin skin type I/II ```

Answer 20

Breslow depth score

Answer 21

under the nail (nailbed is skin)

Answer 22

* Affects hands and feet * Tend to present late * Poor prognosis * More common in darker skin types

Answer 23

• melanoma in situ lesion on sun-damaged skin

Answer 24

Surgical excision: • (Breslow < 1mm) – 1cm margin • (Breslow > 1mm) – 2cm margin If metastatic: • Chemotherapy • isolated limb perfusion

Answer 25

* Immunotherapy (ipilimumab) * Immune checkpoint/MEK inhibitors * antibodies to BRAF genetic defects (vemurafenib)

Answer 26

Gardner Syndrome – soft tissue tumours, polyps, bowel ca Cowden’s Syndrome – multiple hamartomas thyroid, breast ca

Answer 27

= Dermatitis - inflammation of the skin Inflammation in eczema is primarily due to inherited abnormalities in skin “barrier defect”, causing increased permeability and reduces its antimicrobial function An inherited abnormality in filaggrin expression is considered a primary cause of disordered barrier function. The gene for filaggrin is on Chromosome 1

Answer 28

Filaggrins are filament-associated proteins which bind to keratin fibres in the epidermal cells.

Answer 29

Endogenous • Atopic eczema – classical type • Seborrhoeic eczema • Varicose eczema Exogenous (external irritants to the skin) • Contact (allergic, irritant) • Photoreaction (allergic, drug)

Answer 30

* Itchy inflammatory skin condition * Yellow crusting suggests a secondary bacterial infection ``` Associated with atopic conditions: • Asthma • allergic rhinitis • conjunctivitis • hay fever ``` * high IgE levels * Genetic and immune aetiology * 10% of infants affected * Remission occurs in majority by 15 years * 2/3 have a family history of atopy

Answer 31

* Itchy * occasionally vesicular (small blisters) * often facial component * secondary infection (yellow crusting) * < 50% still have eczema by 18 months occasionally aggravated by food (i.e. milk, eggs, wheat) unlike in adult eczema Symmetrical distribution

Answer 32

* Growth reduction * Psychological impact * Bacterial infection due to broken skin * Viral infection

Answer 33

Emollients – ‘reseal’ the skin with a protective film Topical steroids – targets the inflammatory component Bandages, antihistamines (sedative) – to prevent scratching Antibiotics / antivirals (if prone to HSV/eczema herpeticum) Education for parents and child – specialised eczema nurses Avoidance of exacerbating factors Systemic drugs – immune modifications. Very potent drugs • Ciclosporin • Methotrexate Newer biological agents • Dupilumab – IL-4/IL-13 blocker

Answer 34

Precipitated by an exogenous agent Two types: • Irritant - direct noxious effect on skin barrier • Allergic - Type IV hypersensitivity reaction. Immune system is sensitised and reaction occurs on repeated exposure

Answer 35

Nickel - Jewellery, zips, scissors, coins, door handles Fragrance - Cosmetics, creams, soaps Chromate - Cement, tanned leather Cobalt - Pigment

Answer 36

* Chronic, scaly inflammatory condition * Often thought to be “dandruff” * Face, scalp, and eyebrows * Overgrowth of Pityrosporum Ovale yeast. Natural commensal organism. Thrives on oily parts of the skin * Can be worse in teenagers * Identifying illness for HIV

Answer 37

Scalp - medicated anti yeast shampoo Face - anti-microbial, mild steroid Simple moisturizer Often improves with UV/sunlight

Answer 38

Underlying venous disease causing incompetence of deep perforating veins This leads to increased hydrostatic pressure Skin gradually starts to stretch out, and ultimately this causes inflammation and external dermatitis Symmetrical Usually in the area with the most gravitational pressure - affects lower legs Brown discolouration due to haemosiderin deposition Can cause areas of superficial ulceration

Answer 39

Emollient Mild/moderate topical steroid to target inflammation Compression bandaging / stockings – to target the valve issues/gravitational effects Consider venous surgical intervention

Answer 40

a chronic relapsing and remitting scaling skin disease may appear at any age and affect any part of the skin common on the lower back Age onset often two peaks: • Early onset 20-30y • Late onset 50-60y

Answer 41

T cell mediated autoimmune disease Abnormal infiltration of T Cells causes release of inflammatory cytokines Inflammation causes increased keratinocyte proliferation This is what causes the skin to become scaly and build up (turnover is too fast) - Inflammation is what causes the redness Environmental and genetic factors

Answer 42

formation of psoriatic skin lesions on parts of the body that aren't typically where a person with psoriasis experiences lesions Can appear at the sites of trauma/scars

Answer 43

the appearance of punctate bleeding spots when psoriasis scales are scraped off

Answer 44

Most common type of psoriasis ``` Appearance:  salmon pink  well-demarcated  scaly on top  symmetrical ``` Changes seen in the nails:  Onycholysis - nail end lifts off due to plaques underneath the nail  Nail pitting  Dystrophic nails psoriatic arthritis

Answer 45

* Teardrop/raindrop shape * Comes on very quickly, often in unwell patients * Can be triggered by infection (e.g. streptococcal throat infection)

Answer 46

* Very inflammatory * Acute presentation * Pustules are not infective, but markers of acute inflammation

Answer 47

In order of increasing effectiveness (and toxicity) • Topical therapies - moisturisers, steroids • Phototherapy light treatment • Acitretin • Methotrexate • Ciclosporin • Biologic therapies

Answer 48

Non-specific immunosuppressant therapy to the skin • Eczema • Acne • Seborrhoeic dermatitis * Can reduce T cell proliferations * Decreases release of inflammatory cytokines • Encourages Vitamin D (reduces skin turnover) UV-B light most commonly used – less damaging

Answer 49

* Coagulase negative staphylococci * Corynebacterium sp. In areas of skin with less acidic pH: • Staphylococcus aureus • Streptococcus pyogenes Usually not Gram negative bacteria or anaerobic organisms NB: Anaerobe P. acnes dwells in sweat and sebacious glands

Answer 50

* Staphylococcus aureus | * Group A streptococcus

Answer 51

Golden encrusted skin lesions with inflammation localised to the dermis. Most common in children Highly contagious and may occur in small outbreaks Caused by S. aureus; usually mild and self limiting Can treat with topical fusidic acid or topical mupiricin Usually not severe enough to require oral or systemic antibiotics NB: Staphylococcus aureus classically crusts

Answer 52

bacterial infections cause much more inflammation than fungal infections • Redder • Hotter • Erythematous Fungal infections tend to be less red and not too painful to touch

Answer 53

Superficial fungal infection of the skin or nails Very common, particularly on the feet Demarcated appearance, but appears to be spreading

Answer 54

Diagnosis can be made on skin scrapings Treatment with topical therapy in non-severe cases involving skin alone: terbinafine cream Systemic therapy in severe cases and those involving hair/nails: • Terbinafine or itraconazole Fungal nail infections may require an extended period of oral antifungal therapy

Answer 55

Infection within the dermis or fat layers with development of walled off infection and pooled pus Best treatment for abscess is always surgical drainage because antibiotics cannot penetrate abscesses very well Antibiotics not usually required if abscess fully drained and no surrounding cellulitis Same causative organisms as cellulitis • Staph aureus • Group A strep

Answer 56

Virulence factor (cytotoxin) carried by some Staphylococcus aureus Association with recurrent soft tissue boils and abscesses Transmissible – outbreaks occur in families and others living closely together

Answer 57

Infection involving dermis Usually caused by β-haemolytic streptococci (Gp A Strep most common) and S. aureus Most commonly begins on the lower limbs Often tracks through the lymphatic system and may involve localised lymph nodes May be associated with systemic upset although bacteraemia is relatively uncommon

Answer 58

Enron Classification: I. Patient not systemically unwell and no significant co-morbidites (i.e. diabetes) a) <48h antibiotic therapy b) failure to respond to >48h antibiotic therapy II. Patient systemically unwell or has significant co-morbidities which may delay resolution of infection III. Patient has significant systemic upset or unstable co-morbitidies that will interfere with response to treatment IV. sepsis or life threatening complications

Answer 59

Caused by toxin producing Group A Streptococcus Primary infection is typically within the throat or skin/soft tissue Patients present with localised infection (not necessarily severe), fever and shock Exotoxins cause massive immune stimulation and cytokine cascade causes blood vessel dilation --> patients often present with a diffuse, faint rash over body/limbs

Answer 60

Immediately life threatening soft tissue infection with deep tissue involvement Rapidly progressive (within hours) with extensive tissue damage requiring extensive surgical debridement

Answer 61

* Rapidly progressive * Pain out of proportion to clinical signs * Severe systemic upset * Presence of visible necrotic tissue

Answer 62

* Flucloxacillin * Benzylpenicillin * Gentamicin * Metronidazole * Clindamycin Remember: Fight Back GMC NB: Antibiotics are no substitute for surgical intervention

Answer 63

* DVT * Thrombophlebitis * Lyme disease

Answer 64

Often present late with neglected soft tissue infection Staphylococcus aureus predominates but infections often polymicrobial High rates of bacteraemia and disseminated infection Triad of: • S. aureus bacteraemia • DVT • multiple pulmonary abscesses Often have endocarditis Must offer BBV testing

Answer 65

* Itchy, wheals (hives) - red, raised, itchy bumps * Lesions last <24 hours * Non-scarring Immune-mediated – type 1 allergic IgE response Non-immune-mediated – direct mast cell degranulation – e.g. opiates, antibiotics, contrast media, NSAIDs

Answer 66

measles-like rash (red macular rash)

Answer 67

causes a rash in a specific place every time you take a drug can be caused by paracetamol

Answer 68

• Affects areas exposed to UV light Systemic reaction between absorbed drug that has leaked into the skin and UV light – Tetracyclines – Isotretinoin (roaccutane) – Quinine – bendroflumethiazide

Answer 69

antibiotics

Answer 70

* Purply itchy rash * Looks similar to the rash “Lichen planus” * Can be drug-induced * Tends to have a white network pattern on top

Answer 71

Lithium, Beta blockers rash that resembles the plaquelike erythematous lesions of psoriasis (Psoriasis–like) Well demarcated pink erythema with scale Sudden onset, no FHx

Answer 72

– Steven Johnson Syndrome | – Toxic epidermal necrolysis

Answer 73

– Bullous pemphigoid – Pemphigus immunobullous conditions are characterised by pathogenic autoantibodies directed at target antigens whose function is either cell-to-cell adhesion within the epidermis or adhesion of stratified squamous epithelium to the dermis target antigens are components of desmosomes or the functional unit of the basement membrane screen for underlying malignancy – immunobullous diseases can be associated with malignancy

Answer 74

* Blistering condition * Often affects mucosal areas * Some blistering on skin possible * Can have haemorrhagic crusting on the lips NB: If < 10% skin involvement, it is SJS not Toxic epidermal necrolysis

Answer 75

Much more extensive than SJS Looks like a 3rd degree burn, skin becomes necrotic and essentially falls off Dermatological emergency Majority of cases are drug induced If < 10% skin involvement, it is SJS not TEN >10% of skin involvement = TEN Common cause of mortality is secondary sepsis

Answer 76

Characterised by red blistering skin that looks like a burn or scald caused by the release of exotoxins from S. aureus Not very systemically unwell No mucosal involvement Generalized redness and some peeling

Answer 77

hypersensitivity reaction usually triggered by infections, most commonly HSV presents with a skin eruption characterised by typical Target lesions acute and self-limiting

Answer 78

Erythema multiforme

Answer 79

Autoimmune pruritic skin disease preferentially affects elderly people formation of blisters (bullae) at the space between the epidermis and dermis skin layers. classified as a type II hypersensitivity reaction, with the formation of anti-hemidesmosome antibodies

Answer 80

More severe than bullous pemphigoid Pemphigus is unique from pemphigoid in that the blistering can involve the mucous membranes as well as skin. causes blisters that slough off and turn into sores – Sheared pattern – Superficial split (pemphigus) Autoantibodies to various skin components – i.e. basement membrane proteins in BP

Answer 81

(coeliac disease) Tiny blisters on elbows, knees and buttocks (extensor surfaces) Topical steroids to treat autoimmune component Gluten free diet Oral dapsone

Answer 82

* Unknown * Viral infections * Medication * Foods * Physical stimulants

Answer 83

* Descriptive term * erythema with >80-90% involvement ``` Causes: – Psoriasis – Eczema – Drug reaction – Cutaneous lymphoma (unusual) – others ``` Treat underlying skin disorder

Answer 84

also known as pustular drug eruption / toxic pustuloderma rare skin reaction related to medication administration in 90% of cases characterized by sudden skin eruptions (numerous sterile pustules) appear on average five days after medication is started

Answer 85

``` o Endocrine disease o Internal malignancy o Nutritional deficiency o Systemic infection o Systemic inflammatory disease ```

Answer 86

= pretibial myxoedema Seen in Grave’s disease an infiltrative dermopathy most commonly seen on the shins (pretibial areas) characterised by swelling and lumpiness of lower legs.

Answer 87

Seen in Grave’s disease extreme manifestation of autoimmune thyroid disease. presents with finger clubbing, swelling of digits and toes, and periosteal reaction of extremity bones. almost always associated with ophthalmopathy and thyroid dermopathy

Answer 88

Seen in diabetes waxy appearance yellow discolouration often localized to bilateral shins occasionally ulcerates and scars (“shopping trolley distribution” – the area where a shopping trolley would hit) if chronic or with trauma

Answer 89

The lesions are asymptomatic red crusted papules occur on the shins of patients with diabetes.

Answer 90

Scleredema (NB: not scleroderma) associated with diabetes

Answer 91

Granuloma annulare

Answer 92

Acne – disproportionate aggressive acne, particularly on the trunk Striae Erythema – generalized redness Gynaecomastia Global skin atrophy --> easy bruising

Answer 93

Hyperpigmentation – distinctive bronze discoloration o Seen in palmar creases and old scars o Areas of increased skin markings e.g. over extensor surfaces of knees Acanthosis nigricans

Answer 94

* Acne * Hirsutism – male pattern e.g. Polycystic Ovarian Syndrome Testicular tumours Testosterone drug therapy – e.g. topical androgen gels

Answer 95

* Acne * Dermatitis E.g. o Congenital adrenal hyperplasia o Contraceptive treatment

Answer 96

* Necrolytic migratory erythema * Erythema gyratum repens * Acanthosis nigricans

Answer 97

Necrolytic Migratory Erythema Red, blistering rash that spreads across the skin. Haphazard, irregular plaques particularly affects the skin around the mouth and distal extremities o Erythematous o scaly plaques on acral (peripheral body parts), intertriginous (where two skin areas may touch or rub together), and periorificial areas

Answer 98

Erythema Gyratum Repens Significant disproportionate itch and peripheral eosinophilia Strong association with solid organ malignancy, especially lung cancer

Answer 99

Sister Mary Joseph Nodule originates from the umbilicus

Answer 100

B6 - pyridoxine • Dermatitis (disproportionate) B12 - cobalamin • Angular chelitis B3 - niacin • Pellagra (dementia, dermatitis, diarrhoea)

Answer 101

Acrodermatitis Enteropathica autosomal recessive caused by mutations in the gene that encodes a membrane protein that binds zinc In infants, deficiency can follow breast-feeding, when breast milk contains low levels of zinc ``` In adults, disease can occur with: o total parenteral nutrition without zinc supplements o alcoholism o malabsorption states o inflammatory bowel disease o bowel surgery ```

Answer 102

``` Scurvy • Punctate purpura / bruising • “Corkscrew” spiral curly hairs • Patchy hyperpimentation • Dry skin • Dry hair • Non-healing wounds • Inflamed gums ```

Answer 103

inflammatory condition characterized by inflammation of the fat cells under the skin, resulting in tender red nodules or lumps usually seen on both shins causes severe pain ``` Underlying causes: • Streptococcal infection • Pregnancy • Sarcoidosis • Drug induced • Bacterial / Viral infection ```

Answer 104

condition that causes tissue to become necrotic, causing deep ulcers that usually occur on the legs. Ulcers usually initially look like small bug bites or papules, and they progress to larger ulcers. Often affects the shins • Central area of ulceration with purple rim • “Overhanging” edge Associated with: • Inflammatory Bowel Disease • Rheumatoid arthritis • Myeloma

Answer 105

* Inflammatory Bowel Disease * Rheumatoid arthritis * Myeloma

Answer 106

o B12 deficiency o Iron deficiency o lupus o hypothyroidism

Answer 107

``` Connective tissue diseases  RA  SLE  scleroderma  dermatomyositis ```

Answer 108

eczema psoriasis Seborrheoic dermatitis

Answer 109

Condition caused by the abnormal release of histamine within the skin Not normally the result of allergy

Answer 110

characterized by blanching, raised, palpable wheals (hives) can vary in shape occur on any skin area; usually transient and migratory. lesions are often separated by normal skin, but may coalesce rapidly to form large areas of erythematous, raised lesions that blanch with pressure. Dermographism may occur (urticarial lesions resulting from light scratching)

Answer 111

```  Heat/cold  pressure  exercise  sunlight  emotional stress  chronic medical conditions (hyperthyroidism, RA, SLE) ```

Answer 112

Mainstay – antihistamines. Higher dose than hayfever ```  Cetirizine  Fexofenadine  Loratidine  Chlorpheniramine  Hydroxyzine ```

Answer 113

* Allergic Contact Dermatitis * Atopic Dermatitis * Erythema Multiforme

Answer 114

o obesity o smoking o hypertension o history of deep vein thrombosis

Answer 115

usually in gaiter area caused by sustained venous HTN due to venous insufficiency (e.g. varicose veins, pregnancy, trauma) RBC pushed out of capillaries due to HTN -> haemosiderin deposition from RBC breakdown can develop venous eczema due to irritation of the skin by waste products leaking from the blood Tends to be less painful than arterial, usual more superficial and diffuse with more surrounding skin changes

Answer 116

result of reduced arterial blood flow/tissue perfusion. Atherosclerosis or peripheral vascular disease is the most common cause if left untreated, can cause death of tissue Ulcer development is often rapid with deep destruction of tissue. limb looks pale and there is a noticeable lack of hair. Capillary refill is reduced; pedal pulses weak or absent. classically look punched out and deep

Answer 117

Ankle Brachial Pressure Index ABPI (blood pressure comparison between upper and lower limbs) should be roughly equal 0.8 ratio might suggest occlusion and need vascular arterial assessment NB: Compression bandages are used for venous ulcers If a patient has arterial disease with occlusion, compression bandages will worsen the supply to the distal limbs, which will cause ischaemic disease

Answer 118

compression bandages emollient, topical steroid, avoidance of irritant soaps Topical steroid

Answer 119

```  Arterial disease  Connective Tissue Disease ie Lupus  Diabetic  Pressure sores  Skin cancer – eg basal cell ca  Infection, deep fungal  Trauma  Necrobiosis lipoidica  Drug induced  Pyoderma gangrenosum ```

Answer 120

full excision of the whole lesion for diagnostic biopsy and histology

Answer 121

distance in mm of the furthest tumour cell from the basal layer of the epidermis prognostic tool for malignant melanoma

Answer 122

 Size of presenting lesion  depth of clinical pigmentation (Blue / grey colours)  Anatomical location (e.g. poor prognosis for late presentation acral melanoma e.g. sole foot  Evidence of clinical ulceration  Evidence of resorption e.g. regression  Obvious local metastases / satellites (eg in transit)

Answer 123

``` A - asymmetry B - border C - colour D - diameter E - evolution ```

Answer 124

Surgical excision with wide local excision - margin based on Breslow thickness 1cm margin Breslow <1mm Lymph node dissection if LN involved Chemotherapeutic agents e.g. BRAF inhibitors o Vemurafenib Immunotherapy e.g. nivolumab, ipilimumab

Answer 125

 alopecia areata  telogen effluvium (hair cycle disorder)  Drug induced, e.g. Chemotherapy  anorexia / vitamin deficiency

Answer 126

 discoid cutaneous lupus  fibrosing alopecia  lichen planus  fungal infection

Answer 127

 alopecia areata |  fungal infection

Answer 128

autoimmune disease that causes hair to fall out in round patches Immune phenomenon against hair follicles and follicular melanocytes (regrowth will be white)  Alopecia Totalis (whole scalp hair loss)  Alopecia Universalis (whole body hair loss)

Answer 129

Super potent topical corticosteroid Intralesional corticosteroid injections High dose oral corticosteroids (in very rapid onset progressive AA) Allergic contact immunotherapy o Induces contact dermatitis o This makes the immune system distracted from the hair follicle, and allows the hair to grow biologic agents eg Jak2 Inhibitors

Answer 130

Alopecia Areata psoriasis eczema Fungal infection/ringworm Syphilis ``` Secondary medical causes  Thyroid disease  systemic lupus  vitamin deficiencies eg iron, B12, zinc  Hormonal ```

Answer 131

Dermoscopy Associated autoimmune bloods o Thyroid o Glucose - diabetic o B12 Fungal mycology check ANA antibodies Syphilis serology (multi patch moth eaten hair loss) Diagnostic skin biopsy including hair follicles