Inflammatory skin disease

Question 1

What is dermatitis?

Answer 1

Inflammation of the skin

Question 2

What is the aetiology of eczema?

Answer 2

• Combination of genetic, immune and reactivity to a variety of stimuli
• Inflammation primarily due to inherited abnormalities (abnormal filaggrin) in the skin called ‘barrier defect’
• This leads to increased permeability and reduces its antimicrobial function

Question 3

What is the role of filaggrin?

Answer 3

Proteins that bind to keratin fibres in the epidermal cells

Question 4

What are the types of endogenous eczemas?

Answer 4

• Atopic
• Seborrhoeic
• Discoid
• Varicose
• Pompholyx

Question 5

What are the types of exogenous eczemas?

Answer 5

• Contact (allergic, irritant)

* Photoreaction (allergic, drug)

Question 6

What is atopic eczema?

Answer 6

• Itchy inflammatory skin condition

* Genetic and immune aetiology

Question 7

What is atopic eczema associated with?

Answer 7

• Asthma
• Allergic rhinitis
• Conjunctivitis
• Hayfever
• High IgE immunoglobulin antibody levels

Question 8

Describe the appearance of atopic eczema

Answer 8

• Occasionally vascular
• Erythema
• Itchy so scratch marks/damage/secondary infection
• Often a facial component

Question 9

What is the appearance of atopic eczema on darker skin colours?

Answer 9

Baseline darkening/hyperpigmentation in background with white keratinisation/crust

Question 10

What are the complications of atopic eczema?

Answer 10

• Bacterial infection, most commonly staph aureus
• Viral infection: molluscum, viral warts, eczema herpeticum
• Tiredness due to interrupted sleep due to itch
• Growth reduction
• Psychological impact

Question 11

What are the managements of atopic eczema?

Answer 11

• Emollient
• Topical steroid
• Bandages
• Antihistamines
• Antibiotics/anti-virals
• Avoidance of exacerbating factors
• Systemic drugs e.g. cyclosporin, methotrexate
• IL4/13 blocker: Dupilumab

Question 12

What is contact dermatitis?

Answer 12

Inflammation precipitated by an exogenous agent

• irritant: direct noxious effect on skin barrier
• allergic: type 4 hypersensitivity reaction

Question 13

What immune reaction is Type 1?

Answer 13

• Anaphylaxis
• IgE
• Mast cell

Question 14

What immune reaction is type 2?

Answer 14

• Transfusion reaction
• IgG
• Cytotoxic

Question 15

What immune reaction is type 3?

Answer 15

• IgG
• Immune complex
• Serum sickness

Question 16

What immune reaction is type 4?

Answer 16

• Delayed T cell

* Contact dermatitis

Question 17

What are the common allergies causing a contact dermatitis?

Answer 17

• Nickel
• Chromate
• Cobalt
• Colophony
• Fragrance

Question 18

What is seborrhoea dermatitis?

Answer 18

• Chronic, scaly inflammatory condition
• Often thought to be dandruff
• Face, scalp, and eyebrows, occasionally upper chest
• Overgrowth of pityrosporum ovale yeast
• Can be severe in HIV

Question 19

What is the management of seborrhoea dermatitis?

Answer 19

• Scalp: medicated anti-yeast shampoo
• Face: anti-microbial, mild steroid, simple moisturiser
• Rarely systemic anti fungals
• Often improves with UV/sun

Question 20

What is venous dermatitis?

Answer 20

• Underlying venous disease
• Affects lower leg
• Incompetence of deep perforating veins
• Increased by hydrostatic pressure

Question 21

What is the management of venous dermatitis?

Answer 21

• Emollients
• Mild/moderate topical steroid
• Compression bandaging/stockings
• Consider early venous surgical intervention

Question 22

What is the definition of psoriasis?

Answer 22

Chronic relapsing and remitting scaling skin disease which may appear at any age and affect any part of the skin

Question 23

What are the age onset peaks of psoriasis?

Answer 23

• 20-30

* 50-60

Question 24

What causes psoriasis?

Answer 24

•T cell mediated autoimmune disease
•Abnormal infiltration of T cells
- release of inflammatory cytokines including interferon, interleukins and TNF
- increased keratinocyte proliferation

Question 25

What is psoriasis linked to?

Answer 25

• Psoriatic arthritis
• Metabolic syndrome
• Liver disease/alcohol misuse
• Depression

Question 26

What genes are associated with psoriasis?

Answer 26

• PSORS genes

* HLA-Cw0602

Question 27

What are the types of psoriasis?

Answer 27

• Plaque
• Guttate
• Pustular
• Erythrodermic
• Flexural/inverse

Question 28

What is the koebner phenomenon?

Answer 28

Psoriasis at the sites of trauma/scars

Question 29

What signs on the nail are suggestive of psoriasis?

Answer 29

• Onycholysis

* Nail pitting (could just be down to trauma, especially if only one)

Question 30

What are the scoring systems for psoriasis?

Answer 30

• DLQI
• PASI
• PEST

Question 31

What are the treatments for psoriasis?

Answer 31

In order of increasing effectiveness (and toxicities):
•Topical creams and ointments
•Phototherapy light treatments
•Systemic drugs/ immunosuppressants 
•Biological therapies

Question 32

What are the topical therapies for psoriasis?

Answer 32

•Moisturisers 
•Steroids 
•Salicylic acid 
•Slow down keratinocyte proliferation: 
 - vitamin D analogues 
 - Coal tar 
 - Dithranol

Question 33

What is ultraviolet phototherapy?

Answer 33

• Non specific immunosuppressant therapy
• Can reduce T cell proliferation
• Encourages vitamin D and reduces skin turnover

Question 34

What are the UV options for phototherapy?

Answer 34

• UV-B light most commonly used

* UV-A with psoralen photosensitiser

Question 35

What are the risks of UV phototherapy?

Answer 35

• Short term burning

* Longer term skin cancer

Question 36

What are the systemic therapies available for psoriasis?

Answer 36

• Immunosuppressants: methotrexate and ciclosporin
• Acitretin (oral retinoid/vitamin A)
• Dimethyl fumarate
• Biologics: Adalimumab (anti TNF), ustekinumab (anti IL 12/23)

Question 37

What is a potent side effect of methotrexate?

Answer 37

Liver dysfunction

Question 38

What is a potent side effect of ciclosporin?

Answer 38

Hypertension