Major presentations and management Flashcards
Derm Features of malignant melanoma
- A- asymmetry
- B- ireg ireg
- C - variation
- D - >6mm
- E - Elevated
- Morphology -plaque
Risk factors for developing malignant melanoma
- Sun exposure
- Age
- Outdoor occupation
- FHx
- PMHx moles
- Immunosuppressants
- Red hair, blue eyes, pale skin
What are the prognostic factors for malignant melanoma
- TNM stage
- Breslow thickness
Breslow thickness –> stage
- Stage 1 <0.75mm
- Stage 2 0.76-1.5mm
- Stage 3 1.51-2.25mm
- Stage 4 2.26-3 mm
- Stage 5 >3.1mm
Management of malignant melanoma
- Excise w/ 2mm margin
- histology
- assess Breslow thickness
- WLE (wide local excision)
- Chemo
- Body scans for mets
- radiotherapy
- Sun advice
- Full skin check
- Skin cancer nurse referal
- MDT discusssion
Standard sun advice
- Avoid direct sunlight March-Oct, 11am-3pm
- SpF 50+ idealy minimum 30+ reapply every 2 hrs + 30 mins before going out
- Cover up
- No sunbeds
What subtype of malignant melanoma is more prevalent in darker areas?
acral lentiginous melanoma
What type of biopsy is required for acral lentiginous melanoma
incisional
derm features of benign melanocytic compound hair naevus
- A -symm
- B - reg reg
- C - uniform
- D - <6mm
- E - elevated
- Morph - nodule w/ or w/out hair
Management of benign melanocytic compound hair naevus
NHS can’t remove unless symptomatic
Derm features of SCC
- A - asym
- B - ireg ireg
- C - erythem varied
- D - >2cm
- E - Elevated
- Morph nodule/plaque with keratotic (dead skin), ulceration and crusting
Can present as ulcer on lower limbs esp if edges are raised and it doesn’t respond to simple ulcer measures
History features of SCC
PC: SC derm features
HPC: short (weeks)
Risk factors
- Sun exposure
- Age
- Outdoor occupation
- FHx
- PMHx
- Immunosuppressants
- Red hair, blue eyes, pale skin
Management of SCC
Topical
- Efudix
Surgical
- Cryo
- Excision 4-6mm margin
Other
- Full skin check
- LNs check
- Radio therapy for large non resectables
- MDT approach
- Skin cancer nurse referal
Derm features of actinic keratosis aka solar keratosis
A-asym
B-ireg ireg
C-red, pink, brown or skin-coloured
D-few mm-few cm
E-flat or elevated
Morph - scaly (keratotic) patches
**itchy and sore**
Why do we treat AK
Samll chance of developing into SCC
Management of AK (actinic keratosis)
Topical
- E-fudix
Surgical
- Freeze/cryotherapy if single
- Curettage and Cautery (C&C) if SCC suspected
Other
- Full skin check
Risk factors for AK
(same as SCC)
- Sun exposure
- Age
- Outdoor occupation
- FHx
- PMHx
- Immunosuppressants
- Red hair, blue eyes, pale skin
BCC derm features
A - asym
B - ireg
C - Shiny/pearly erythem non-uniform
D - Dunno
E - Elevated, depression in the center
Morph - Papule or nodule with central dimple and talengectasia
Which is more common BCC or SCC
BCC
Management of BCC
Topical
- Efudix
Surgery
- Cryo
- Excision 4mm margin
- Mohs excision (involves sending to histology to check all remoived)
Other
- Full skin check
- LNs check
- MDT approach
- Skin cancer nurse referal
Derm features of viral warts
A - fairly sym
B - reg
C - grey fairly uniform
D - 2mm-2cm
E - Elevated
Morph - Papules with cribiform appearance (numerous small hole)
Derm features in pyogenic granuloma
A - sym
B - reg
C - erythem some yellowness (tissue sloughing off)
D - <1cm
E - Elevated
Morph - Papule
Derm features cherry angioma aka strawberry naevus aka Strawberry hemangiomas and their prognosis
A asym
B reg
C cherry red
D up to 1.5 cm
E yes
Morph papule/nodule
Birth mark that can grow will reach peak at 1 year of age and then will slowly dimish may leave yellowish mark
What is important to rule out when presenting with cherry angioma or Pyogenic granuloma
SCC
if risk factors are present esp age SCC until peroved otherwise
Derm features of chronic plaque psoriasis aka discoid
D wide spread
C none
M discoid erythem well defined patches with scaling
Name the objective tool that can be used to decribed the area and severity of skin involvement in psoriasis
Psoriasis area severity index (PASI)
NAme the most common sites affected in chronic plaque psoriasis
Extensor surfaces, scalp, nails, flexor surfaces
What are the nail signs of psoriasis
Pitting, onycholysis, subungal keratosis
Name the non cutaneous manifestations of psoriasis
- psoriatic arthritis
- Psyhcological impact
Possible causes chicken egg sitch
- CV issues
- Metabolic syndrome
Name the tool used to assess the impact of dermatology conditions on the patients life
Dermatology life quality index (DLQI)
Describe the step wise approach to psoriasis treatment
**No Oral Steriods**
Lifestyle
- Dec smoking
- Dec wgt
- Dec stress
- Sunlight does improve psoriasis caution skin cancer
Step 1
- Topical
- Steriods mild/moderate
- Emollients
- Coal tar preparation
- Vit D analogue - calcipitol
- Dovobet/Dovenex (vit D and steriods)
Step 2
- Phototherapy
Step 3
- Immunosuppression (meds)
- Methotrexate
- Cyclosporin
- Acitretin
Step 4
- Biologics (strong immunosuppresants)
Define Erythrodema
Intense wide spread red rash affecting ≥90% of the body
Derm features of erythrodermic psoriasis
D - Widespread
C - none
M - Erythem plaques
+/- shedding scin, scaling, pustules, blisters
List 4 complications of erythroderma
- Sepsis
- Hypothermia
- Dehydration
- Inc cardiac output
Why don’t we perscribe oral steriods in psoriasis
When they come off the steriods they may get rebound erythrodermic psoriasis
Causes of erythroderma
- Eczema
- Psoriasis
- Lymphoma cutaneous t-cell
- Sezary syndrome
- Adverse drug reaction
- Idiopathic
Management of erythroderma
- IV fluids
- Stop any drugs that could be causative
- Punch biopsy
- Emollient (50/50)
- Topical steriods
- Consider immunosuppresants and non-drousy anti-histamines
Derm features flexural inverse psoriasis
D - Flex surfaces (folds)
C - None
M - Erythem plaque
What is the top DD for flexural inverse psoriasis and therefore what is a good drug to perscribe
DD: Fungal and bacterial infections
Trimovate b/c contains anti bacterial anti fungal and moderate steriod
Derm features of guttate psoriasis
D widespread
C Non
Morph erythem papules/nodules
DDs for guttate psoriais and investigations that need to be done to confirm psoriasis and why
Meningococcal septicaema
- check for systemic illness
- Illness onset (psoriais will be weeks menigitis will be days)
Investigations
- Throat swab
- ASO titre
Guttate is usually cased by a throat strep infection
Treatment of guttate psoriasis
- Emollient
- Topical steriod
- Phototherapy
- Consider system treatment e.g. anti biotics
Prognosis of guttate psoriasis
Usually resolves w/in weeks very likely w/in 6 months
Not infectious
Derm features Acne vulgaris
D Face chest and back
C non
M asymp erythem papules, pustules, open and shut comedone pitting
Main bacteria that causes acne vulgaris
Propionibacterium acnes (P. acnes)
Topical treatments of acne vulgaris
- Retiniods
- Antibiotics (erythromycin)
- Bensyl peroxide
Systemic treatments of acne vulgaris
- Oral antibiotics - doxycycline, erythromycin, trimethoprim
- Combined pill
Failing that
- Isotretinoin aka acutane
Side effects of Isotretinoin aka acutane
- Depression suicide
- Teratogenic (not in pregnancy)
- Dry lips, skin and eyes (mucous membrane)
- Can worsen acne initially
- Arthalgia
- Deranged LFTs ergo no alcohol and risk of pancreatitis
Secondary causes of acne vulgaris
- PCOS
- Cushings
- Anabolic steriods
- Lithium
- Phenytoin
- isoniazid (anti biotic)
- POP
- Steriods
- Congenital adrenal hyperplasia
Derm features of Rosacea
D Face
C None
M asymp erythem large patch w/ open and shut comedomes, pustules, papules, rhinophyma (large red bulbous nose), flushing
what are the complications of rosacae
Ocular rosacea - blepharitis, keratitis
Derm features of eczema
D Widespread but can affect flex surfaces
C none
Morph pruritic erythem plaques +/- excoriations, thickenings, Xerosis, fissures
Social effects of eczema
Puritis can lead to poor sleep and concentration having a nock on effect in school/work
What can exacerbate atopic eczema
- Infection
- Irritants e.g. soap
- Stress
- Allergens e.g. pollen, pets
- Environment e.g. winter low humidity
Emollient and steriod regime in eczema
Emollient
- Min 2x daily everywhere ideally 4x
Steriod
- 1% hydrocortisone (mild) on face
- Anywhere up to Eumovate (moderate to potent steriod) for body
- Maintanence 2x weekly
- 1x daily on affected areas for 2 wks
Do not apply emollient and steriod on same area within 30 mins one won’t be absorbed
Side effects of topical steriods and how to avoid
- Skin atrophy
- Stretch marks
- Easy bruising
- Telangiectasia
- Inc suscptability of infection
- Hair growth
Rare
- Glaucoma
- Cataract
Avoid all of these by using sparingly or steriod sparing agents e.g. tacrolimus/protopic ointment
Derm features of eczema herpeticum
D Usually Perioral or on the face
C none
M Monomorphic (sometimes vesicular) punched out erythem lesions
Investigations and management of eczema herpeticum
Investigations
- VIral swabs
Management
- Aciclovir oral
- Stop topical steriods
- Treat any 2ary bacterial infection
- Opthalm review if eye involved
Derm features of impetigo
D Usually on face (perioral)
C none
M orange/yellow/gold crusted plaques
causes of impetigo and treatment
Staph
Strep
Flucloxacillin (oral)
Derm features of allergic contact dermaitis
D area touching allergen
C clustered
M Erythem plaques
Cutaneous manifestation of rheumatoid disease
Granulomatous nodules on the elbows
Investigations in allergic contact dermatitis
Patch test
Derm features of non allergic irritant dermatitis
D Area affects (usually hands form hand washing)
C none
M generalised erythm w/ scales
Derm features of scabies
D Wrists, axilla, groin, finger webs, flexural folds
C slightly linear to begin with
M starts with small line of silver dots (papules) –> erythem papules, nodules and patches. Also puritic ergo excoriation
Treatment of scabies
- permethrin cream 5% (insectiside)
- Use on whole body
- Treat all contact simulanteously
- Repeat after 7 days
- Wash all bedding
Derm features tinea pedis (athletes foot)
D Gaps in toes esp
C none
M White patches with skin degredation
Risk factors for tinea pedis
- Long hours in thick boots and socks
- Sport esp swimming public pools and showers
- Diabetic
Investigations for tinea pedis
Skin scrapings
Nail clippings
Treatment of tinea pedis
Eliminate risk factors
Terbinafine or griseofulvin (anti fungal pill)
Derm features tinea capitis
D scalp
C none
M erythem plaques w/ scaling and GRADUAL alopecia
Important questions to ask in Hx of tinea capitis tp exclusde other causes and spread
- Pets
- Known allergies
- Contacts +/- Sx
- Siblings +/- Sx
- Other symptoms
Major difference between scalp psorisis and tinea capitis
no hair loss in psoriasis
Investigations to confirm tinea capitis
Skin scraping
Hair sample
Treatment of tinae capitis
griseofulvin - oral anti fungal
AND
Terbinafine - topical anti fungal
Derm features of shingles
D anywhere of body usually doesn’t cross midline
C dermatomic
M Uniform erythema, haemoragic blisters, pustules crusting
What causes shingles
Varicella zoster virus
Treatment of shingles
Oral or IV aciclover depending on severity
Analgesia
Consider opthalm review if eye involved
Complication of shingles
2ary bacterial infection
Reactiviation
Facial palsy
Post herpetic neuralgia
Risk factors for venous ulcer
- Obesity
- DVT
- Mobility issues
- Varicose veins
- Age
- Previous leg trauma
classical features of a venous ulcer
- Odeoma
- Stasis dermatitis rash around ulcer from haemosiderin deposition (red brown)
- Located on legs, ankle or gaiter area ( above ankle where long sock would cover)
- Minimal pain
- Shallow
- Lots of exudate
Risk factors for arterial ulcer
- DM
- HTN
- Atherosclerosis
- Age
- Trauma to leg
- Decreased mobility
- Foot deformity causing high pressure on certain areas
- Weak pulses
classic features of an arterial ulcer
- Raised edges (punched out)
- Deep (down to tendons)
- Not bleeding
- shiny, tight, dry, and hairless skin surrounding
- Leg goes red on de-elevation and white on elevation
- Leg pain at night resolved by dangling leg off bed
Risk factors for neuropathic ulcer
- DM
- Peripheral neuropathy
- B12 insufficiency
- Foot deformity
Features of neuropathic ulcer
- On toes or under metatarsal heads (pressure areas)
- No pain (usually no feeling either)
- Also have quite punched out appearance
What is the test used to help differentiate ulcer type and describe it
Ankle Brachial Pressure Index (ABPI)
Difference in BP between ankle and leg.
Calculated: systolic BP in leg/systolic BP in arm
Normal = 0.9-1
Changes in ABPI in different ulcers
Arterial uler ABPI <0.9 usually 0.5
Else it should be fairly normal
Management of venous ulcers
- Compression and leg elevation
- If venous eczema present –> emollient + moderate steriod
- Potassium permangonate soaks
- Refer to vascular surgeon for varicose vv
Toxic epidermal necrolysis derm featres
D Wide spread
C Non
M erythema, necrosis, and bullous detachment of the epidermis and mucous membranes. Sheering
Complications of TEN
- Hypothermia
- Inc cardiac output
- Sepsis
- Fluid loss
Management of TEN
- Pour on emollients, don’t rub
- Analgesia
- Fluid
- Stop medications (may have caused it)
- IV immunogloblins
- Propholactic anti biotics
- Nutritional support
- Opthalm review
Derm features of vasculitis
D Anywhere usually legs
C symmetrical
M Pupuric papules with central necrosis
Causes of vasculitis
- Meningococal sepsis
- HIV
- TB
- HSP
- SLE (lupus)
- Malignancy
- Hep C
- Idiopathic
Derm features of lupus
D Face
C Butterly
M Erythema
Associations of pyoderma gangrenosum
Crohns/IBD (bowel disease)
List a derm feature of DM1
DM1 -> necrobiosis lipoidica
List a derm feature of DM (usually type 2)
Acanthosis nigricans
Name a derm feature of Graves and Hyperthyroidism
Pretibial myxoedema
urticaria aka hives derm features and causes
D-can affect anywhere
C-none
M-Erythem plaque itchy bumps. They may also burn or sting.
Usually caused by insect sting or allergies to food
Derm features seborrhoeic warts aka keratosis
A asym
B reg reg well defined
C brown yellow uniformish
D small
E elevated
Morph Scaly papules, look warty
Benign but exclude malignant melanoma
Types of eczema and how they differ
Atopic
- History of past flexural involvement
- Onset under the age of 2
- Current visible flexural dermatitis
- Personal or family history of atopic disease
- A generally dry skin
Contact eczema/dermatitis
- Localised reaction to allergen
Nummular/discoid
- Circular discoid
- In children is usually atopic
- In adults that don’t meet criteria set off by stress, infections and excessive drying of skin
Features of lichen planus
- itchy violaceous rash around the ankles, fronts of the wrists, lower sacrum
- white patches in the mouth.
what is Dermographism and how is it diagnosed
enhanced ability to realise histamine from the skin on minimal trauma
Itchyness w/out obvious cause but small trauma will produce disproportional marks
Drug that causes eruptive acne
anabolic steriod/testosterone
What is perioral dermatitis and how is it treated
mix between acne and dermatitis
Steriod will reduce redness but will cause rebound worsening
Treat with oral tetracyclines e.g. doxycycline
What causes Mollusca, derm features and treatment
Pox virus
D anywwhere
C clustered
M shiny itchy papules may be red and inflammed due to excoriation
Will naturally resolve
vitiligo features and possible cause
D sym
C non
M well defined macules of hypopigmentation
can be caused by exposure to hydroquinone products (skin lightening products)
Treatment of rosacea
Metronidazole cream
Bowen’s disease (intra-epithelial carcinoma) derm features and treatment
A asym
B ireg
C erythem
D small
E elevated
Morph red, scaly plaque
Risk of becoming SCC
Topical
- Efudix
Surgical
- Cryo
- Excision 4-6mm margin
Other
- Full skin check
- LNs check
- Radio therapy for large non resectables
- MDT approach
- Skin cancer nurse referal
Derm feature of sarciodosis
Erythema Nodosum
Derm feature of herpes
Erythema multiforme
derm features of IBD
Pyoderma gangrenosum
Erythema Nodosum
