Lectrue ILO’s

Question 1

Finger clubbing

Answer 1

Clubbing
• Loss of angle between the posterior nail fold and nail plate
• Loss of Schamroth’s window
• Always take note – can be a sign of serious disease
• Associated with lung malignancy, IBD, cirrhosis, cardiac problems, supparative lung problems, interstitial lung disease, Grave’s disease - lung disease which causes depleted blood oxygen levels

Question 2

Nail pitting

Answer 2

Pitting
• Punctuate depressions of the nail plate
• Usually psoriasis (also eczema/alopecia)

Question 3

Koilonychia

Answer 3

Koilonychia
• Spoon-shaped depression of the nail plate
• Iron deficiency anaemia

Question 4

Onycholysis

Answer 4

• Loosening or separation of the nail plate from the nail bed
• Causes include repetitive trauma, nail infections, manicures, drugs, hereditary, psoriasis, myeloma, diabetes, thyroid disease, leprosy

Question 5

General Terminology

Pruritis
Lesion
Rash
Naevus
Comedones

Answer 5

• Pruritis - Itching

• Lesion - An area of altered skin

• Rash - An eruption

• Naevus - Localised malformation (ie. moles)

• Comedones - Spots – open are blackheads/closed are whiteheads

Question 6

Erythema

Answer 6

Redness (due to inflammation and vasodilation) that blanches with pressure

Question 7

Purpura

Answer 7

• Purpura
• Red or purple discolouration (caused by bleeding into the skin) that does NOT blanch with pressure

Question 8

Hypopigmentation

Answer 8

• Hypopigmentation
Areas of pale or paler skin

Question 9

Dipigmentation

Answer 9

• Depigmentation
Areas of skin with no pigement, due to a lack of melanin

Question 10

Hyperpigmentation

Answer 10

Hyperpigementation Areas of skin with darker colouration

Question 11

Macule

Answer 11

Macule
Flat area of altered colour
Ie a freckle

Question 12

Plaque

Answer 12

• Plaque
Scaling lesion, raised and palpable

Question 13

Papule

Answer 13

• Papule
Solid raised lesion <0.5cm

Question 14

Vesicle

Answer 14

• Vesicle
Fluid-filled raised lesion <0.5cm

Question 15

Nodule

Answer 15

• Nodule
Solid raised lesion >0.5cm

Question 16

Bulla

Answer 16

• Bulla
Fluid-filled raised lesion >0.5cm

Question 17

Pustule

Answer 17

• Pustule
Pus-filled, <0.5cm

Question 18

Boil or furnacle

Answer 18

• Boil or Furuncle
Staph infection of hair follicle

• Carbuncle
Several furuncles

Question 19

Abscess

Answer 19

• Abcess
Localised collection of pus

Question 20

Cherry angionoma

Answer 20

Asymptomatic, bright red to violet macules and papules ranging from pinhead size to larger
⚫ AKA Campbell de Morgan spots
⚫ Acquired vascular proliferation, unknown cause
⚫ More common with age (third decade onwards)
⚫ Benign – no treatment necessary

Question 21

DERMATOFIBROMA

Answer 21

⚫ Benign skin tumour - ?trauma
⚫ Women > men, young adulthood,
immunosuppresed
⚫ Single nodules on an extremity (usually lower leg) – freely moving, firm, usually asymptomatic
⚫ Reassure but refer if uncertain of diagnosis or bothersome
Sarcoma is a differential

Question 22

SEBACEOUS HYPERPLASIA

Answer 22

Benign hair follicle tumour

Enlarged sebaceous glands (oil producing glands) on forehead or cheeks of middle- aged or elderly patients
⚫ Small yellow bumps up to 3mm diameter with central dimple (from hair)
⚫ Easily confused with BCCs
⚫ Prominent vascularisation on dermascopy

More common in immunosuppressed pts
No need for treatment – consider referral if unsure

Question 23

SEBORRHOEIC KERATOSIS

Answer 23

⚫ 90% of people aged 60+ have at least one
⚫ Warty growth with ‘stuck on’ appearance – very variable appearances
⚫ Flat or raised papule or plaque
⚫ Variety of colours and sizes
⚫ Smooth, waxy or warty surface

Question 24

SKIN TAGS

Answer 24

⚫ Skin-coloured or darker, pedunculated lesions (on a stalk) most commonly around neck, groin and armpits
⚫ More common in obese people and those with T2DM
⚫ Cause unknown- benign
⚫ Can be removed with elecsurgery, cryotherapy or ligation

Question 25

Naevi

Answer 25

⚫ Moles – well defined, congenital lesions
⚫ Appear and develop between age of 2 and 60, very rare to undergo malignant changes
⚫ Can be hairy, raised, skin coloured or pink/red to black/blue
⚫ If it looks suspicious or behaves differently Ie irregular, colour changing– REFER for expert assessment

Question 26

Lipomas

Answer 26

⚫ Slow-growing, benign tumour of adipose tissue
⚫ Fairly common (approx 1 in 1000 people) usually appear between 40-60yrs
⚫ Soft nodule, skin coloured, smooth surface
⚫ If >5cm, fast growing and near thigh/groin – refer to exclude liposarcoma
⚫ Removal for cosmetic reasons if needed
Refer for U/S to check for vascularity is concerned for Ca

Question 27

ACTINIC KERATOSIS

Answer 27

Red, scaly patchiness which is usually on old peoples scalp, cheeks and hand
Caused by UV damage to the skin
Most affected are fair people with blonde hair and blue eyes – almost entirely confined to type I and II
Increases with age (UV is cumulative)
More common in men (& Australians!)

Begin as small rough spots in sun exposed areas, and enlarge over several years to become red and scaly
If continued exposure – can progress to SCC (10% chance of one/7.7 becoming malignant within 10 years)
Don’t always need managing – refer to derm non-urgently

Question 28

BASAL CELL CARCINOMA

Answer 28

Accounts for 80% of skin cancers
Slow growing, locally invasive tumours
⚫ Very uncommon in dark-skinned races
⚫ Most common in sun-exposed areas ie: head and neck and in males
⚫ Increases with age – and likely to get more if have one
Small, translucent, pearly lesions with raised edges. Can then progress into’‘rodent ulcer’’

Referral should be on a routine basis if needed
Only consider 2ww if area is problematic or exceptionally large
Can be managed in GP with minor surgery if available
If not – refer to derm routinely

Question 29

Basal cell carcinoma treatment

Answer 29

Can be managed in GP with minor surgery if available
If not – refer to derm routinely
Treatment is either surgical excision, or imiquimod or flourouracil creams
Low risk of mets or spread – however, sun exposure and previous malignancy increases risk of other cancers such as SCCs and melanoma
Important to remind pts to stay out of the sun!

Question 30

Squamous cell carcinoma

Answer 30

⚫ Malignant tumour that arises from keratinising cells of the epidermis – locally invasive but CAN metastasise
⚫ About 10,000 cases diagnosed in England and Wales every year
⚫ More common in caucasion people, men, and older people
⚫ Linked to UV exposure

Typically presents as a non-healing ulcer in sun exposed area (ie head or neck)
Can vary considerably
Nodule with induration and keratisation, or can just be an ulcerated lesion
Can bleed
USUALLY ulcerated lesion with hard raised edges

Question 31

Malignant melanoma

Answer 31

Cancerous growth of melanocytes
Much less common than BCC or SCC
More common in women (legs) than men (trunk)
⚫ Affecting younger age groups (50% under 60)
⚫ Fifth most common cancer in UK (3rd inAus/NZ)
⚫ Lifetime risk UK 1 in 55/56

Usually irregular and has 2 colours
Superficial spreading melanoma most common subtype.Also have lentigo maligna, acral lentiginous and nodular (most aggressive)

Question 32

Malignant melanoma risk factors

Answer 32

⚫ Risk factors:
⚫ Naevi- >100 common naevi or >2
atypical, 5-20x chance
⚫ Sun exposure, especially sunbeds before 30y
⚫ Skin type 1 or 2 (black people 20x less)
⚫ Family history
⚫ Higher socio-econominc group

Question 33

abcde of malignant melanoma

Answer 33

⚫ A Asymmetry
⚫ B Border irregularity
⚫ C Colour variation
⚫ D Diameter over 6 mm
⚫ E Evolving (enlarging, changing - inflammation, itching, oozing

Question 34

Eczema

Answer 34

 Also known as dermatitis (although dermatitis is a broader term)
 Characterised by dry, itchy and inflamed skin
 Not contagious
 Very common and increasing incidence – 20% of children and 1 in 12 adults have some form
 Types include atopic eczema,contact dermatitis, seborrhoeic dermatitis, discoid eczema, pompholyx, varicose eczema and asteatotic eczema

Question 35

Atopic eczema

Answer 35

 Presentation usually at a young age – itching, red,dry skin
 Genetic link – especially in those with family history of atopy – filaggrin
 Triggers include stress, diet, contact allergens, irritants, skin infections, animals, abrasive fabrics, temperature changes and inhaled allergens ie: dust mites

Question 36

Diagnostic criteria of eczema

Answer 36

 Must have an itchy skin condition (or report of scratching or rubbing in a child) plus three or more of the following:

 History of itchiness in skin creases such as folds of the elbows,behind the knees, fronts of ankles,or around the neck (or the cheeks in children aged 18 months or under).
 History of asthma or hay fever (or history of atopic disease in a first-degree relative in children aged under 4 years).
 General dry skin in the preceding year.
 Visible flexural eczema (or eczema affecting the cheeks or forehead and outer limbs
in children aged under 4 years).
 Onset in the first two years of life (not always diagnostic in children aged under 4 years).
 IF IT DOESN’T ITCH,IT’S VERY UNLIKELY TO BE ECZEMA!!!

Question 37

Potential eczema investigations

Answer 37

 No investigations usually required
 IgE and RAST testing simply confirms atopy

Question 38

Emollient - eczema treatment

Answer 38

 These are best applied when the skin is moist but they should also be applied at other times.
 They should be applied as liberally and frequently as possible and continual treatment with complete emollient therapy (combinations of cream, ointment, bath oil and emollient soap substitute) will help to provide maximal effect.
 Ideally the frequency of application of emollients should be every 4 hours or at least 3-4 times per day.
 They should be prescribed in large quantities, with the recommended quantities used in generalised eczema being 500 g/week for an adult and 250 g/week for a child.
 Intensive use of emollients will reduce the need for topical steroids.
 Education on how to use emollients is essential to ensure maximal rehydration of the
skin.
 Most patients use far too little emollient!

Question 39

Topical steroid for atopic eczema

Answer 39

TOPICAL STEROIDS ie hydrocortisone
 It is recommended that topical corticosteroids for atopic eczema should be prescribed for application only once or twice daily.
 Use mild potency for mild atopic eczema, moderate potency for moderate atopic eczema and potent for severe atopic eczema.
 Use mild potency for the face and neck, except for short-term (3-5 days) use of moderate potency for severe flares.
 Use moderate or potent preparations for short periods only (7-14 days) for flares in vulnerable sites such as the axillae and groin.
 Do not use very potent preparations in children, without specialist dermatological advice.
 Patients using moderate and potent steroids must be kept under review for both local and
systemic side-effects.
 Chronic eczema in adults: this often requires a potent steroid together with emollients and allergen avoidance.

Question 40

Topical steroid side effects

Answer 40

 Local side effects may arise when a potent topical steroid is applied daily for long periods of time (months).
 Skin thinning (atrophy)
 Stretch marks (striae) in armpits or groin
 Easy bruising (senile/solar purpura) and tearing of the skin
 Enlargedbloodvessels(telangiectasia)
 Localisedincreasedhairthicknessandlength(hypertrichosis)
 Potent topical steroid applied for weeks to months or longer can lead to:
 Periorificial dermatitis (common)
 Steroidrosacea
 Symptoms due to topical corticosteroid withdrawal
 Pustular psoriasis.
 Stinging frequently occurs when a topical steroid is first applied, due to underlying inflammation and
broken skin.
 Veryrarely:Cushing’s

Question 41

Contact dermatitis

Answer 41

 Two types – irritant (common substances) and allergic (uncommon substances) . Irritant occurs when skin contacts known irritants ie solvents, and also frequent hand washing. Allergic is a reaction to ‘normal’ stimulus ie: nickel, rubber etc.
 Irritant more common in those with atopy.
 Differentiate with careful history taking

 Hands most commonly affected, then arms, neck and face.
 Not contagious
 Symptoms – itching, sore, red skin,
blisters and fissures
 Diagnosis – clinical, allergic can be confirmed with skin patch testing

Question 42

Contact dermatitis treatment

Answer 42

 Avoid contact with irritants and substances that trigger
 Emollient use
 Steroid cream
 Can use oral steroids if very severe
 Antibiotics if secondary infection

Question 43

SEBORRHOEIC DERMATITIS

Answer 43

 Very common – affects up to 50% of population but most don’t know they have it.
 Slightly more common in men.
 Affects greasy areas ie:scalp,sternal area,face,groin.
 Dandruff (v. mild on scalp), cradle cap (babies)
 Thought to be triggered by overgrowth of yeast or an over-reaction to it.
 Tiredness and stress can trigger; more common in cold weather
 Not linked to any underlying disease, although can be more severe in HIV patients and more common in Parkinson’s
 Affected areas are red with greasy looking flakes – commonly scalp, eyebrows, ears, chest.
 Itching and painful if rashes start weeping – can be very embarrassing.

Question 44

SEBORRHOEIC DERMATITIS treatment

Answer 44

 Treatment is usually needed on a long-term basis
 On the scalp: medicated, anti-dandruff shampoos containing agents such as zinc pyrithione, selenium sulphide or ketoconazole can be used regularly.Thick scales can be removed with coconut oil and salicyclic acid overnight.
 Elsewhere: anti-yeast creams or ointments are usually effective and can be used safely as long-term treatment.Examples include clotrimazole, miconazole and nystatin.They are sometimes combined with a mild steroid for a few weeks to settle inflammation.

Question 45

POMPHOLYX

Answer 45

 Also known as dishydrotic eczema
 Characterised by burning sesnsation followed by small vesicles and blisters on hands and feet – intensely itchy. Then subsquent peeling leaving dry, hard skin.
 Unknown causes although stress and heat can play a part. More common in females.
 Affectspalms,soles,sidesoffingers, tops of toes. Can cause nail problems (paronychia).

Question 46

POMPHOLYX treatment

Answer 46

 Difficult to treat due to extra horny layer of skin on hands & feet.
 Wet dressings – can try dilute potassium permangenate (stains!!)
 Cold packs
 Emollients +++
 Some cases are helped by mild steroids (hydrocortisone 1%) but usually need potent
 Specialist advice: ultrapotent topical steroids applied to new blisters under occlusion, and ointments applied during the inflamed dry phase.
 Short courses of prednisolone if needed for severe flares

Question 47

DISCOID (NUMMULAR) ECZEMA

Answer 47

 Characteristic round/oval patches. More common in men than women. Rare in children.
 Usually worse on arms and legs
 Starts as tiny red spots which cluster together and form red, swollen, sometimes moist round patch which then becomes dry and scaly (red target like lesions)
 Diagnosis – often take skin scrapings to r/o other pathology

Question 48

DISCOID (NUMMULAR) ECZEMA treatment

Answer 48

 Emollients +++ (even when not dry)
 Mild topical steroids no use – must use potent or very potent.
 Tacrolimus/pimecrolimus (specialist)
 UV light therapy
 Oral steroids
 Rarely – immunosuppression like azathioprine

Question 49

ASTEATOTIC ECZEMA

Answer 49

 Almost always in over 60s
 Cause unknown – could be linked to loss of skin oils, low humidity, hot baths
 Appears on shins initially – crazy paving, red scaly dry skin in old people
 Clinical diagnosis

Treatment same: alleviate factors, emollients, steroid creams

Question 50

Varicose eczema

Answer 50

 Also known as stasis eczema,gravitational dermatitis
 Valves in legs don’t work properly, reducing venous drainage & increasing
pressure causing damage to overlying skin.
 Being overweight, immobility, leg swelling, varicose veins,VTE and previous cellulitis are possible contributory factors.
 Appears on lower legs – appearance from dry skin through to thickening, ulcers, and classic eczema appearance

Treatment
 Emollients! +++
 Bandaging and compression stockings
 Address underlying issue
 No steroids

Question 51

Psoriasis

Answer 51

 Psoriasis is an immune-mediated disease that causes raised, red, scaly patches to appear on the skin.
 Skin cells grow at an abnormally fast rate, causing characteristic lesions and scaling of psoriasis
 Five types: chronic plaque psoriasis, guttate psoriasis, pustular, erythrodermic, inverse

Question 52

CHRONIC PLAQUE PSORIASIS

Answer 52

 Psoriasis affects approx 1.3-2.2% of people, mostly white people.
 Plaque psoriasis accounts for 90% of patients
 Men and women equally effected
 Can occur at any age, usually before 35, uncommon in children
 30% have family history
 Environmental factors – drugs, trauma, sunlight
 Associated with IBD, metabolic syndrome, increased risk of CVD and lymphoma – unsure why

PRESENTATION
 Chronic plaque psoriasis is typified by itchy, well-demarcated circular-to-oval bright red/pink elevated lesions (plaques) with overlying white or silvery scale, distributed symmetrically over extensor body surfaces and the scalp.
 Fissuring within plaques can occur when lesions are present over joint lines or on the palms and soles.
 Gentle scraping accentuates the scale (vigorous scraping causes pinpoint bleeding - Auspitz’ sign - pitting of the nails).
 The psoriatic lesions are a very distinctive rich, full, red colour.When present on the legs, lesions sometimes carry a blue or violaceous tint.
 Remember nail changes!

Question 53

Management of chronic plaque psoriasis

Answer 53

 First-line therapy which includes traditional topical therapies - eg, corticosteroids, vitamin D analogues, dithranol and tar preparations.

 Second-line therapy which includes phototherapy, broad-band or narrow-band ultraviolet B light, with or without supervised application of complex topical therapies such as dithranol in Lassar’s paste or crude coal tar and photochemotherapy,psoralens in combination with UVA irradiation (PUVA), and non-biological systemic agents such as ciclosporin, methotrexate and acitretin.

 Third-line therapy which refers to systemic biological therapies that use molecules designed to block specific molecular steps important in the development of psoriasis, such as the TNF antagonists adalimumab, etanercept and infliximab, and ustekinumab, anti-IL12-23 monoclonal antibody.

TOPICAL THERAPIES
 Emollients ++++!!
 Short term use of potent or very potent topical corticosteroids  Vitamin D analogues (calciprotel/Dovonex) for maintenance
 Coal tar
 Tarozatene gel (vit A analogue)

Question 54

GUTTATE PSORIASIS

Answer 54

 Small, scattered, round/oval lesions that appear over about a week
 Trunk and proximal limbs most affected
 Classically appears as first presentation and after an illness eg usually a viral infection
 If widespread (>10%) urgent ref to derm for phototherapy
 Self-resolves within 3-4/12, but can use topical rx to help interim

Question 55

Inverse psoriasis

Answer 55

 Inverse psoriasis (aka intertrigous or flexural)
 Found in skin folds, armpits, breasts etc
 Often mistaken for fungal – can coincide
 Lacks scale due to moistness
 Rx much the same

Question 56

Pustular psoriasis

Answer 56

 Pustular psoriasis
 White bumps on plaques, can
coalesce to form “lakes” of pus
Blister like rash
 MEDICAL EMERGENCY

Question 57

ERYTHRODERMIC PSORIASIS

Answer 57

 Diffuse,widespread,severe
Blister like red scaly rash all over body
 Affects >90% of body
 Can be systemically unwell
 MEDICAL EMERGENCY

Question 58

URTICARIA

Answer 58

Allergic reaction ie nettle sting reaction
⚫ Commonly known as hives
⚫ Characterised by raised pale or skin-coloured patches surrounded by erythema - “wheals”
⚫ Itchy +++, swelling of the superficial skin layers
⚫ Typically transient so will come and go within minutes to hours
⚫ Can be subdivided into acute or chronic (>6/52).Acute (1 in 6 people) much more common than chronic (1 in 1000).

Question 59

Urticaria treatment

Answer 59

⚫ Consider drugs that can cause reactions specifically NSAIDs/ACEIs
⚫ Management is to soothe itch (calamine lotion) and principally with anti- histamines
⚫ Cetirizine,loratadine and fexofenadine are preferred.Can use up to 4x standard dose.
⚫ Refer if not controlled on max dose or causing significant distress

Question 60

ANGIOEDEMA

Answer 60

⚫ Often co-exists with urticaria
⚫ Characterised by swelling of the deeper subcutaneous tissues, frequently around the mucus membranes of eyelids and lips
⚫ Tends to be more painful than itchy
⚫ Can be chronic or acute

Question 61

Angioedema types and causes

Answer 61

Types/Causes

Allergic (1-2hrs after exposure): commonly food, latex, drugs, insect venom

Drug reaction (days to months after exposure): most commonly seen with ACE-Is in black people

Idiopathic: most cases, cause unknown. ?autoimmune

Hereditary: very rare

Question 62

Angioedema treatment

Answer 62

Treatment
Treatment is much the same as urticaria with antihistamines
Sometimes oral corticosteroids are used and in some specialist cases, anabolics!
Severe cases should be referred on – tx can then include immunosuppressants and monoclonal antibodies but under specialist care only

Question 63

Anaphylaxis

Answer 63

⚫ A severe and rapidly developing systemic hypersensitivity reaction
⚫ Often associated with urticaria in reaction to stimulus. Commonly foods (peanuts/shellfish), drugs (penicillin most freq), insect stings (bees/wasps) but can react to a wide range
⚫ Characterised by urticaria, angiodema, hypotension and bronchospasm that is sudden onset and life threatening
⚫ ANAPHYLAXIS IS A MEDICAL EMERGENCY AND REQUIRES IMMEDIATE RECOGNITION AND TREATMENT

⚫ Initially, patients usually develop skin symptoms, including generalised itching, urticaria and erythema, rhinitis, conjunctivitis and angioedema.
⚫ Signs that the airway is becoming involved include itching of the palate or external auditory meatus, dyspnoea, laryngeal oedema (stridor) and wheezing (bronchospasm).
⚫ General symptoms include palpitations and tachycardia (as opposed to bradycardia in a simple vasovagal episode), nausea, vomiting and abdominal pain, feeling faint - with a sense of impending doom; and, ultimately, collapse and loss of consciousness.
⚫ Airway swelling, stridor, breathing difficulty, wheeze, cyanosis, hypotension, tachycardia and reduced capillary filling suggest impending severe reaction.

Question 64

Anaphylaxis management

Answer 64

⚫ Assess as emergency with ABCDEs
⚫ Give high-flow oxygen
⚫ Give adrenaline IM (500mcg for adults and children >12yrs, 300mcg 6- 12yrs, 150mcg <6yrs) into thigh – can repeat doses if no response after 5m
⚫ Get patient flat, call for help, likely to need airway mgmt/intubation
⚫ Cannulate and fluid challenge, warmed NS/Hartmann’s 500ml-1L
⚫ Antihistamines such as chlorphenamine (IM or IV)
⚫ Hydrocortisone (IM or IV) after initial resuscitation
⚫ Any out-of-hospital anaphylaxis should be sent to hospital due to the risk of rebound reactions

Question 65

ERYTHEMA NODOSUM

Answer 65

⚫ Likely to be a hypersensitivity reaction and/or a dermatological manifestation of underlying disease
⚫ Characterised by red, tender nodules frequently on the shins. These tend to last 2-6 weeks and can change in consistency to feel fluctuant or tense, and may be associated with joint pains, fever or general malaise
⚫ Most common in younger women aged 20-30,but can affect all ages/sexes

Question 66

ERYTHEMA NODOSUM underlying differential diseases

Answer 66

Bacterial - TB, claymidia, salmonella
Viral - EBV, HSV, HIV
Fungal infections
Sarcoidosis
Drug reactions
Pregnancy
IBD

Question 67

ERYTHEMA MULTIFORME

Answer 67

⚫ Hypersensitivity reaction, caused by an infection in 90% of cases, most commonly HSV.Young men most affected, some familial links.
⚫ Usually begins with lesions on hands and feet, then spread along limbs towards trunk within 24hrs.
⚫ Classic lesions are target lesions, although can take many forms. Target lesions have three colour zones: a central crusted dusky/dark red area, a raised pale pink oedamatous area, and a bright red outermost ring
⚫ Mucous membranes are very rarely affected and if they are, only very mild involvement
⚫ Clinical diagnosis, and treatment usually not required as is self-limiting

Question 68

Stevens-Johnson syndrome and TOXIC EPIDERMAL NECROLYSIS

Answer 68

Life threatening medical emergency
SJS is a less severe version of TEN

⚫ Rare skin reactions that cause sheet-like skin and mucosal loss – severe and can be life-threatening dermatological emergencies
⚫ Caused by medication in 75% of cases, infection in the remaining.Antibiotics are the most common (40%) and drugs with longer half-lives seem to be more likely to cause issues
⚫ Unpredictable,anyoneonanymedicationcandevelop,howeveritis100xmore common in HIV patients
⚫ Some genetic risk with certain HLA genotypes
⚫ Very rare – in Europe,approx 2-3 cases per million people per year but serious
so needs to be recognised
⚫ Mechanism is not understood

⚫ Usually within 2 weeks of abx therapy (2/12 of anticonvulsant) a prodromal flu-like illness/URTI develops which is followed by:
⚫ Rapid onset of painful skin rash that starts on trunk and extends rapidly onto face and limbs, reaching maximal extent ~4 days. Can be macules, papules, blisters, target lesions. Blisters then merge to form sheets of skin detachment and leave exposed erythematous oozing dermis.
⚫ Mucus membranes and eyes are affected with ulcers – GI problems are common
⚫ The patient will be unwell, in a lot of pain, and likely to be dehydrated
⚫ Mortality is 10% in SJS and at least 30% in TEN (diagnosed by amount of skin loss)

Question 69

WHAT ARE BLISTERS AND LICHEN?

Answer 69

Blisters (or bullae) are accumulations of fluid under, or within, the epidermis
Commonly caused by trauma (dodgy shoes!) and burns.

Lichen is a symbiotic algae/fungus that commonly grows on trees and gravestones
Lichenoid disorders are named because of their flat, scaly appearance – look similar to lichen!

Question 70

LICHEN PLANUS
PRESENTATION AND AETIOLOGY

Answer 70

Affects approx 1% of people worldwide
More common in 40yrs+ and in women
50% of cases are oral lichen planus
T-cell mediated autoimmune disease – unknown which protein they attack

Often appears at sites of trauma (Koebners)
Shiny, flat, firm plaques with white lines (Wickham striae) – can be intensely itchy
Fade over time to leave brown-grey macules.
In the mouth – lacy, white pattern across tongue and mucosa
Similar looking to psoriasis but wouldn’t flake off when scratched

Question 71

Lichen planus management

Answer 71

Treatment is with steroid cream – often potent to control the itch
Tacrolimus can also be used especially where skin-thinning could be a problem (e.g face)
Severe cases need derm assessment – can have phototherapy, methotrexate etc

Question 72

LICHEN SCLEROSUS PRESENTATION AND AETIOLOGY

Answer 72

10x more common in women
Can present at any age but frequently over 50 (post- menopausal)
Common in genital areas but can be elsewhere on body – typically under breasts, wrists, inner thigh, buttocks and armpits
5% of people can develop SCC of vulva/skin/penis

White, shiny, thin tissue- paper appearance of skin
Can be itchy and lead to skin breakdown
Can lead to vulvovaginal atrophy, clitoral phimosis, and constipation if anal area is affected

Question 73

LICHEN SCLEROSUS
DIAGNOSIS AND MANAGEMENT

Answer 73

Diagnosis usually clinical – fairly obvious pathology to see – however NICE recommends referring all cases to dermatology
Can be sent for biopsy and histopathology,especially if there is a suspicion of cancer

Management is with very potent steroid, usually clobetasol proponiate 0.05%
General lifestyle measures such as gentle washing, avoiding bikes/horseriding, avoid tight underwear, use emollients
Can be embaressing and difficult as effect on sex life etc

Question 74

BULLOUS PEMPHIGOID PRESENTATION AND AETIOLOGY

Answer 74

Blistering condition - red, sore, bulging blisters all over the body
Autoimmune, subepidermal blistering condition
Occurs later in life – usually in people 80+ (looks and presents like eczema but they’ve never had eczema before so tends to be this instead)
More prevalent in those with neurological disease ie dementia or Parkinson’s
A variation affects pregnant women

Initial presentation is variable but itch is common, followed by rash which can appear eczematous or urticarial
Large, tense, fluid-filled bullae then appear especially in folds and on abdomen
Can have oral involvement in 25% of cases

Question 75

BULLOUS PEMPHIGOID DIAGNOSIS AND TREATMENT

Answer 75

Diagnosis is clinical but should be referred to dermatology
Fluid from blisters can be tested and immunoflouresced
Disease often self-limiting within 1-5 years and leaves no scarring

Aims of tx – reduce current blisters, prevent new blisters, minimal meds as elderly pts
Very mild cases can use steroid creams
Oral steroid such as prednisolone often used initially alongside tetracycline abx and supplementation for vit D/calcium
Immunosuppressants if needed

Question 76

PEMPHIGUS
What is it?
Aetiology
Presentation

Answer 76

⚫ Autoimmune disease
Differentiated from pemphigoid due to where the blisters form – these are in the epidermal layer rather than subepidermal – have thinner roofs and burst easier
⚫ Subtypes
Permphigus vulgaris most common subset (70%) - affects mucosa
Pemphigus foliaceus is only in the skin and associated with antibodies to DSG1 (desmoglein)

Most common in ages 30-60yrs
Less common than BP in the UK
More common in Jewish populations and those of Indian descent
Could be triggered by environmental factors

Often appears in mouth first (in PV)
Thin walled, fluid-filled clear flaccid blisters burst easily to leave erosions/ulcers
Painful and slow to heal, but not normally itchy

Question 77

PEMPHIGUS
DIAGNOSIS & MANAGEMENT

Answer 77

⚫ Refer to dermatology and/or oral medicine
⚫ Biopsy taken, histopathologically analysed and direct immunoflourescence used
to confirm – can also use IDIF look for antibodies in blood
⚫ Oral corticosteroids mainstay of tx (their use has improved mortality from 99% to 5%!)
⚫ Immunosuppressants can be used to minimise steroid use
⚫ Plasmapheresis in very extreme cases

Question 78

STAPHYLOCOCCAL SCALDED SKIN SYNDROME

Answer 78

⚫ Red, wrinkled, blistered skin (looks like a burn) caused by exotoxins released by S. aureus
⚫ Usually occurs in children, especially neonates
⚫ Send to hospital – needs tx with IV flucloxacillin Also use simple analgesa
and skin care as is fragile

Question 79

What is a good antibiotics used to treat skin conditions

Answer 79

flucloxacillin

Question 80

DERMATITIS HERPETIFORMIS

Answer 80

⚫ Not due to viral infection–named because blisters appear in clusters.
Autoimmune.
⚫ Linked to coeliac disease(over90%)
⚫ Most common in Caucasian people, males 2:1
Symmetrical distribution, intensely itchy but often not much to see

⚫ Diagnosis is with skin biopsy showing IgA
Treatment is definitive with lifelong gluten-free diet however there is a medication called Dapsone which resolves rash whilst waiting for diet to take effect