MED: Dermatology Flashcards

Question

Intertrigo?

Answer 1

Dermatitis that affects a skin fold, for example underneath a breast. It may be non-infective but is commonly complicated by a secondary fungal infection.

Answer 2

- Erythematous rash on a skin fold - Skin may become moist and macerated - Typical sites include underneath the breast fold, in the groin, axilla, between the buttocks

Answer 3

- General measures - zinc oxide ointment - Fungal infection - clotrimazole, miconazole - Erythrasma infection - erythromycin

Answer 4

Rapidly growing, self-resolving, low-grade cutaneous tumour

Answer 5

- Rrapidly-growing, dome-shaped cutaneous lesion with a central keratin plug - Usually solitary - Evolves over weeks to months, eventually stabilising and sometimes regressing spontaneously - Hallmark = rapid growth, followed by a plateau phase, and potentially a resolution phase. - Most commonly found on sun-exposed areas - face, neck, and extremities (may also occur on mucous membranes) - Sometimes local trauma or scarring is implicated in the lesion's onset - Symmetry generally well maintained - ie benign appearance - Nodule or papule often flesh-coloured to erythematous, surrounded by a wall of inflamed tissue, with a central, keratin-filled crater - Surface of lesion often smooth, although crust or scale may be present - May be tender or painful depending on size and location - Some KAs may present with a superficial ulcerated surface. - Multiple lesions may be present in syndromic forms such as Ferguson-Smith syndrome or Muir-Torre syndrome.

Answer 6

- Spontaneous regression within 3 months common, often resulting in a scar - Such lesions should however be urgently excised as it is difficult clinically to exclude SCC - Removal also may prevent scarring

Answer 7

- Characteristic pinkish or pearly white papules with a central umbilication, which are up to 5 mm in diameter - Lesions appear in clusters in areas anywhere on the body (except the palms of the hands and the soles of the feet) - Children - commonly seen on trunk and in flexures, but anogenital lesions may also occur - Adults - sexual contact may lead to lesions developing on the genitalia, pubis, thighs, and lower abdomen - Rarely, lesions can occur on the oral mucosa and on the eyelids

Answer 8

**Self-care advice:** - Self-limiting condition // spontaneous resolution usually occurs <18 months - Avoid sharing towels, clothing, and baths with uninfected people - Avoid scratching lesions - if problematic, consider treatment to alleviate the itch **If lesions are troublesome or considered unsightly, use simple trauma or cryotherapy:** - Squeezing (with fingernails) or piercing (orange stick) lesions may be tried, following a bath (limited to a few lesions at one time) - Cryotherapy may be used in older children or adults **Treatment may be required if:** - Itching is problematic - prescribe an emollient and mild topical corticosteroid (e.g. hydrocortisone 1%) - Skin looks infected (e.g. oedema, crusting) - prescribe a topical antibiotic (e.g. fusidic acid 2%) **Referral may be necessary in some circumstances:** - HIV-positive + extensive lesions = urgent referral to a HIV specialist - Eyelid-margin or ocular lesions + associated red eye = urgent referral to an ophthalmologist - Adults with anogenital lesions = referral to genito-urinary medicine, for screening for other STIs

Answer 9

Inflammatory disorder of the skin which is characterised by the eruption of multiple erythematous papules and pustules around the eyes, nose and mouth

Answer 10

>>Most commonly seen in young females **Classical type:** - Clusters of follicular papules and pustules overlying an erythematous base, with or without scaling - The inflammation is limited only to the skin surrounding the mouth, nose and eyes. - Around the mouth, the skin of the vermilion border is often spared, this is characteristic of cPOD - Burning or stinging in the area of the lesions. Itching is rare, but can occur. - Patients may have noticed rash after using a new medication (e.g. corticosteroids), skincare or cosmetic product **Granulomatous type:** - Rarer variant - typically occurs in prepubescent children, most common of Afro-Caribbean ethnicity - Flesh coloured or yellow-brown coloured papules or plaques around the mouth, nose and lower eyelids - Erythema and scaling is less prominent, helping to differentiate this from classical POD - Biopsy of these lesions will reveal perifollicular granulomatous infiltration

Answer 11

>>Benign and self-limiting (many patients reach symptom resolution without intervention) >>If symptoms are troublesome / persistent, pharmacological therapy should be initiated **Zero therapy:** - Discontinuing the use of all topical facial products which may have triggered or could have exacerbated POD symptoms: - Discontinue the use of corticosteroids on the face and encourage patients using them elsewhere on the body to wash their hands thoroughly after application to prevent transfer to the face - Avoidance of topical skincare/cosmetic products which may irritate the skin - Once POD has resolved patients can restart topical products slowly and individually to allow the skin to respond to each product and allow the discontinuation of any known POD triggering product **Pharmacological therapies:** *Mild POD (lesions covering only a small area):* - Initial therapy: Topical antibiotic cream, such as erythromycin or metronidazole - Second line therapy: Topical tacrolimus ointment or pimecrolimus cream *Moderate or severe POD (lesions covering large areas of the face) or whose symptoms have not resolved with topical therapy:* - Initial therapy: oral antibiotic therapy, typically with tetracycline, is recommended. This is typically used for 4-8 weeks - Erythromycin can be substituted for one of the tetracycline's if they are not well tolerated or contraindicated

Answer 12

- Usually no prodrome, but minority recent viral infection - Acute onset of a solitary, oval-shaped herald patch (usually on trunk) - Followed by smaller, erythematous, oval, scaly patches in a characteristic 'Christmas tree' distribution along the Langer's lines - Pruritus may be present and can range from mild to severe in intensity

Answer 13

>>Self-limiting (not contagious and recurrences are rare) **Symptomatic relief:** - Topical corticosteroids - mild-to-moderate potency (e.g., hydrocortisone or clobetasone butyrate) for short-term use (<2 weeks) - Emollients - regular application - Oral antihistamines - cetirizine or loratadine **Ultraviolet (UV) therapy:** - In severe or persistent cases - Narrowband UVB phototherapy may be considered as an adjunct treatment - Expedites resolution of the rash and provides symptomatic relief

Answer 14

Superficial cutaneous fungal infection caused by Malassezia furfur

Answer 15

- Most commonly affects trunk - Patches may be hypopigmented, pink or brown (hence versicolor). May be more noticeable following a suntan - Scale is common - Mild pruritus

Answer 16

- Topical antifungal - ketoconazole shampoo - If failure to respond to topical treatment then consider alternative diagnoses (e.g. send scrapings to confirm the diagnosis) + oral itraconazole

Answer 17

- Usually starts quite suddenly - Typically on the lower limb - Soften at the site of a minor injury (pathergy) - Small pustule, red bump or blood-blister - Skin then breaks down resulting in an ulcer which is often painful - Edge of the ulcer is often described as purple, violaceous and undermined - Ulcer itself may be deep and necrotic - May be accompanied by systemic symptoms - fever, myalgia

Answer 18

>>Potential for rapid progression is high in most patients - First line = oral steroids - Other immunosuppressive therapy, e.g., ciclosporin and infliximab, in difficult cases - Any surgery should be postponed until the disease process is controlled on immunosuppression to risk worsening of the disease (pathergy)

Answer 19

Benign vascular proliferation that commonly manifests as a rapidly growing, friable, erythematous papule or nodule, frequently observed on the skin and mucous membranes

Answer 20

- Most common sites are head/neck, upper trunk and hands - Lesions in the oral mucosa are common in pregnancy - Initially small red/brown spot - Rapidly progress within days to weeks forming raised, red/brown lesions which are often spherical in shape - Lesions may bleed profusely or ulcerate

Answer 21

- Lesions associated with pregnancy often resolve spontaneously post-partum - Other lesions usually persist - Removal methods include curettage and cauterisation, cryotherapy, excision

Answer 22

Chronic, inflammatory skin condition that primarily affects the face, causing redness, flushing, and visible blood vessels

Answer 23

- **Erythematotelangiectatic rosacea (ETR):** Characterized by facial redness, flushing, and visible blood vessels (telangiectasias). - **Papulopustular rosacea:** Presents with acne-like breakouts, including papules and pustules, along with facial redness and swelling. - **Phymatous rosacea:** Associated with skin thickening, especially around the nose (rhinophyma), and can also affect the chin, forehead, cheeks, and ears. - **Ocular rosacea:** Involves the eyes, causing redness, burning, itching, and the sensation of a foreign body. It can lead to complications such as blepharitis, conjunctivitis, and keratitis if not treated promptly.

Answer 24

- Typically affects nose, cheeks and forehead - Flushing is often first symptom - Telangiectasia are common - Later develops into persistent erythema with papules and pustules - Rhinophyma - Ocular involvement: blepharitis - Sunlight may exacerbate symptoms

Answer 25

- Daily application of a high-factor sunscreen - Predominant erythema/flushing but limited telangiectasia - topical brimonidine gel (used on an 'as required basis' to temporarily reduce redness) - Mild-to-moderate papules and/or pustules - topical ivermectin - Alternatives include: topical metronidazole or topical azelaic acid - Moderate-to-severe papules and/or pustules - combination of topical ivermectin + oral doxycycline *Referral should be considered if:* - Symptoms have not improved with optimal management in primary care - Laser therapy may be appropriate for patients with prominent telangiectasia - Patients with a rhinophyma

Answer 26

Caused by the mite Sarcoptes scabiei

Answer 27

- widespread pruritus - linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist - 'silver lines' - in infants, the face and scalp may also be affected - secondary features are seen due to scratching: excoriation, infection

Answer 28

- permethrin 5% is first-line - 2 applications, 1 week apart - malathion 0.5% is second-line **Guidance:** - avoid close physical contact with others until treatment is complete - all household and close physical contacts should be treated at the same time, even if asymptomatic - launder, iron or tumble dry clothing, bedding, towels, etc., on the first day of treatment to kill off mites.

Answer 29

- Eczematous lesions on the sebum-rich areas - scalp (may cause dandruff), periorbital, auricular and nasolabial folds - Otitis externa and blepharitis may develop

Answer 30

**Scalp disease management:** - First-line = ketoconazole 2% shampoo - OTC preparations containing zinc pyrithione ('Head & Shoulders') and tar ('Neutrogena T/Gel') if ketoconazole not appropriate or acceptable to the person - Selenium sulphide and topical corticosteroid may also be useful **Face and body management:** - topical antifungals: e.g. ketoconazole - topical steroids: best used for short periods - difficult to treat - recurrences are common

Answer 31

- Erythematous patches with greasy scales predominantly on sebum-rich areas - Typically affects the scalp ('Cradle cap'), nappy area, face and limb flexures. - Cradle cap is an early sign which may develop in the first few weeks of life - characterised by an erythematous rash with coarse yellow scales

Answer 32

- Reassurance that it doesn't affect the baby and usually resolves within a few weeks - Massage a topical emollient onto the scalp to loosen scales, brush gently with a soft brush and wash off with shampoo. - If severe/persistent a topical imidazole cream may be tried

Answer 33

**Prodrome:** - Acute neuralgia - tingling, burning, itching or occasionally stabbing in nature - Non-specific symptoms such as malaise, fatigue, headache - Enlarged lymph nodes in region of affected area - Typically 2-3 days long, may last up to a week **Infectious phase:** - Rash usually affecting a single dermatome in a band-like distribution - Unilateral, rarely crossing the midline - Initially is erythematous and macular in nature - Progression to erythematous papules, and eventually vesicles or bullae by day 7 - Vesicles become pustular or haemorrhagic near the end of this phase, right before crusting over - Pain located around the region where the rash is located - Very rarely, the rash is painless (typically this occurs in children) - Lasts approximately 7-10 days **Resolution phase:** - The vesicular rash crusts over within 10-12 days of rash onset - The crusted lesions can take up to one month to completely disappear

Answer 34

**Supportive management:** - Common mild analgesics, such as paracetamol alone or in combination with codeine or NSAIDs such as ibuprofen - In cases of moderate-severe pain, add either amitriptyline, duloxetine, gabapentin or pregabalin - Calamine lotion application to affected skin can provide relief to both pain and pruritis, if present - Topical capsaicin can be considered and can provide some pain relief - Cool compresses on affected area a few times a day **Anti-viral therapy:** *Oral antiviral within 72 hours of rash onset if:* - Immunocompromised patients - Non-truncal rash involvement (e.g. affecting face, neck, limbs, perineum) - Moderate-severe pain or rash - Consider prescribing anti-viral therapy if aged >50-years-old (to reduce incidence of post-herpetic neuralgia) *Oral aciclovir, famciclovir, or valaciclovir* - Can still be considered up to one week after onset of the rash - IV considered, only if oral therapy is not tolerated **Corticosteroids:** - If a patient is on anti-viral treatment, consider course of oral corticosteroids - Used in the first 2 weeks following the onset of the rash - This should only be used in conjunction with anti-viral treatment, and in immunocompetent adults with localised shingles if the pain is severe

Answer 35

- Most common complication of shingles - Persistent pain in region of rash, even after rash and acute illness is resolved (lasting >1 month) - Burning, shooting or tingling pain - Hyperalgesia or allodynia over region affected

Answer 36

- Begin with mild analgesics (NSAIDs +/- paracetamol) - Opioid analgesics can be added if mild pain relief is not sufficient - As the pain is neuropathic in nature, it may respond to a tricyclic anti-depressant or anti-convulsant

Answer 37

- excessive exposure to sunlight / psoralen UVA therapy - actinic keratoses and Bowen's disease - immunosuppression e.g. following renal transplant, HIV - smoking - long-standing leg ulcers (Marjolin's ulcer) - genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism

Answer 38

- Rough, reddish scaly area. - Open sore (often with a raised border) - Brown spot that looks like an age spot. - Firm, dome-shaped growth. - Wart-like growth. - Tiny, rhinoceros-shaped horn growing from your skin. - Sore developing in an old scar.

Answer 39

- Surgical excision with 4mm margins if lesion <20mm in diameter - If tumour >20mm then margins should be 6mm - Mohs micrographic surgery may be used in high-risk patients and in cosmetically important sites

Answer 40

- fever: temperature > 38.9ºC - hypotension: systolic blood pressure < 90 mmHg - diffuse erythematous rash - desquamation of rash, especially of the palms and soles - involvement of three or more organ systems: e.g. GI (diarrhoea and vomiting), mucous membrane erythema, renal failure, hepatitis, thrombocytopenia, CNS involvement (e.g. confusion)

Answer 41

Superficial fungal infection of the skin, often referred to as ringworm, due to the characteristic circular, ring-like rash it produces

Answer 42

- Erythematous, scaly plaques with an active, advancing, and often pruritic border - The centre of the lesion may clear up as it expands, resulting in a characteristic ring-like appearance, hence the name ringworm - The size, shape, and number of lesions can vary significantly between individuals.

Answer 43

*If diagnostic uncertainty:* Potassium hydroxide (KOH) preparation of skin scrapings can be used to confirm the presence of fungal elements under microscopy

Answer 44

- Topical antifungal medication such as clotrimazole or terbinafine for uncomplicated cases (at least 2 weeks) - In extensive, severe, or refractory cases, systemic antifungal therapy with agents such as terbinafine, itraconazole, or fluconazole may be necessary

Answer 45

- Typically occur in the gaiter area of the leg (from the ankle to the mid-calf), above the medial malleolus - They present as irregular, shallow wounds with a granulating base and are often accompanied by substantial exudate - The surrounding skin may show signs of chronic venous insufficiency, including oedema, pigmentation, lipodermatosclerosis (hardening and discolouration of the skin), and atrophie blanche (small, white scars surrounded by dilated capillaries) - Can be painful, but the degree of pain is usually less severe than that associated with arterial ulcers

Answer 46

**Ankle-brachial pressure index:** - Important in non-healing ulcers to assess for poor arterial flow which could impair healing - A 'normal' ABPI is between 0.9 - 1.2 - Values below 0.9 indicate arterial disease - Values above 1.3 may also indicate arterial disease, in the form of false-negative results secondary to arterial calcification (e.g. In diabetics) **Doppler ultrasound examination:** - Often used to assess the venous system's competence and exclude arterial disease, particularly if the patient is to be considered for compression therapy. >>If the ulcer does not respond to standard treatment, or if malignancy is suspected, a biopsy may be performed.

Answer 47

- Compression therapy (improves venous return and reduces oedema) - multilayer bandages or compression stockings. - Wound care - regular cleaning and dressing - Topical agents may be used to control bacterial overgrowth and promote wound healing. In some cases, debridement may be required. - Systemic treatment can include analgesics for pain control and, if indicated, antibiotics for cellulitis - In patients with recurrent or non-healing ulcers, surgical interventions such as endovenous ablation, sclerotherapy, or venous valve repair may be considered.

Answer 48

Presumed autoimmune condition causing localised, well demarcated patches of hair loss. At the edge of the hair loss, there may be small, broken 'exclamation mark' hairs

Answer 49

Hair will regrow in 50% of patients by 1 year, and in 80-90% eventually. Careful explanation is therefore sufficient in many patients. *Other treatment options include:* - topical or intralesional corticosteroids - topical minoxidil - phototherapy - dithranol - contact immunotherapy - wigs

Answer 50

Typically scaling, flaking, and itching between the toes

Answer 51

topical imidazole, undecenoate, or terbinafine first-line

Answer 52

A type of precancerous dermatosis that is a precursor to squamous cell carcinoma

Answer 53

- red, scaly patches - often 10-15 mm in size - slow-growing - often occur on sun-exposed areas such as the head (e.g. temples) and neck, lower limbs

Answer 54

- topical 5-fluorouracil - typically used twice daily for 4 weeks - often results in significant inflammation/erythema. Topical steroids are often given to control this - cryotherapy - excision

Answer 55

Autoimmune condition causing sub-epidermal blistering of the skin. This is secondary to the development of antibodies against hemidesmosomal proteins BP180 and BP230

Answer 56

- more common in the elderly - itchy, tense blisters typically around flexures - the blisters usually heal without scarring - there is stereotypically no mucosal involvement (i.e. the mouth is spared)

Answer 57

immunofluorescence shows IgG and C3 at the dermoepidermal junction

Answer 58

- Referral to a dermatologist for biopsy and confirmation of diagnosis - Oral corticosteroids are the mainstay of treatment - Topical corticosteroids, immunosuppressants and antibiotics are also used

Answer 59

In psoriasis, if the scale is removed, a red membrane with pinpoint bleeding points may be seen

Answer 60

- **Irritant contact dermatitis:** common - non-allergic reaction due to weak acids or alkalis (e.g. detergents). Often seen on the hands. Erythema is typical, crusting and vesicles are rare - **Allergic contact dermatitis:** type IV hypersensitivity reaction. Uncommon - often seen on the head following hair dyes. Presents as an acute weeping eczema which predominately affects the margins of the hairline rather than the hairy scalp itself. Topical treatment with a potent steroid is indicated

Answer 61

Cement *Both irritant contact dermatitis and allergic contact dermatitis*

Answer 62

// Histiocytomas Common benign fibrous skin lesions. They are caused by the abnormal growth of dermal dendritic histiocyte cells, often following a precipitating injury

Answer 63

- solitary firm papule or nodule, typically on a limb - typically around 5-10mm in size - overlying skin dimples on pinching the lesion

Answer 64

Localised skin infection caused by Streptococcus pyogenes. In simple terms, it is a more superficial, limited version of cellulitis. The treatment of choice is flucloxacillin.

Answer 65

Skin disorder caused by over exposure to infrared radiation. Characteristic features include reticulated, erythematous patches with hyperpigmentation and telangiectasia. A typical history would be an elderly women who always sits next to an open fire. If the cause is not treated then patients may go on to develop squamous cell skin cancer.

Answer 66

Hypersensitivity reaction that is most commonly triggered by infections

Answer 67

- target lesions - initially seen on the back of the hands / feet before spreading to the torso - upper limbs are more commonly affected than the lower limbs - pruritus is occasionally seen and is usually mild

Answer 68

- viruses: HSV (most common cause), Orf - idiopathic - bacteria: Mycoplasma, Streptococcus - drugs: penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill, nevirapine - connective tissue disease e.g. SLE - sarcoidosis - malignancy

Answer 69

The more severe form, erythema multiforme major is associated with mucosal involvement.

Answer 70

asymptomatic, flat, slightly scaly, pink or brown rash usually found in the groin or axillae

Answer 71

Examination with Wood's light reveals a coral-red fluorescence

Answer 72

Topical miconazole or antibacterial are usually effective. Oral erythromycin may be used for more extensive infection

Answer 73

Term used when more than 95% of the skin is involved in a rash of any kind.

Answer 74

- eczema - psoriasis - drugs e.g. gold - lymphomas, leukaemias - idiopathic

Answer 75

- May result from progression of chronic disease to an exfoliative phase with plaques covering most of the body - Associated with mild systemic upset - More serious form is an acute deterioration. - This may be triggered by a variety of factors such as withdrawal of systemic steroids. - Patients need to be admitted to hospital for management

Answer 76

- 'unsightly' nails are a common reason for presentation - thickened, rough, opaque nails are the most common finding

Answer 77

**Nail clippings +/- scrapings of the affected nail:** - microscopy and culture - should be done for all patients if antifungal treatment is being considered - the false-negative rate for cultures are around 30%, so repeat samples may need to be sent if the clinical suspicion is high

Answer 78

>>Do not need to be treated if it is asymptomatic and the patient is not bothered by the appearance **Dermatophyte or Candida infection confirmed:** - Limited involvement (≤50% nail affected, ≤ 2 nails affected, more superficial white onychomycosis): topical treatment with amorolfine 5% nail lacquer; 6 months for fingernails and 9 - 12 months for toenails - More extensive involvement due to a dermatophyte infection: oral terbinafine first-line; 6 weeks - 3 months therapy is needed for fingernail infections whilst toenails should be treated for 3 - 6 months - More extensive involvement due to a Candida infection: oral itraconazole first-line; 'pulsed' weekly therapy is recommended

Answer 79

- Initial manifestation involves recurrent, painful, and inflamed nodules. - Most commonly on intertriginous skin - Axilla is the most common site - Other areas include inguinal, inner thighs, perineal and perianal, inframammary skin. - The nodules may rupture, discharging purulent, malodorous material. - Coalescence of nodules can result in plaques, sinus tracts and 'rope-like’ scarring.

Answer 80

- Encourage good hygiene and loose-fitting clothing - Smoking cessation - Weight loss in obese - Acute flares can be treated with steroids (intra-lesional or oral) or flucloxacillin. Surgical incision and drainage may be needed in some cases. - Long-term disease can be treated with topical (clindamycin) or oral (lymecycline or clindamycin and rifampicin) antibiotics. - Lumps that persist despite prolonged medical treatment are excised surgically.

Answer 81

- topical aluminium chloride preparations are first-line. Main side effect is skin irritation - iontophoresis: particularly useful for patients with palmar, plantar and axillary hyperhidrosis - botulinum toxin: currently licensed for axillary symptoms - surgery: e.g. Endoscopic transthoracic sympathectomy. Patients should be made aware of the risk of compensatory sweating

Answer 82

- itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms - rash often polygonal in shape, with a 'white-lines' pattern on the surface (Wickham's striae) - Koebner phenomenon may be seen (new skin lesions appearing at the site of trauma) - oral involvement in around 50% of patients: typically a white-lace pattern on the buccal mucosa - nails: thinning of nail plate, longitudinal ridging

Answer 83

- potent topical steroids are the mainstay of treatment - benzydamine mouthwash or spray is recommended for oral lichen planus - extensive lichen planus may require oral steroids or immunosuppression

Answer 84

- usually affects the genitalia - more common in elderly females - white patches / plaques that may scar - itch is prominent - may result in pain during intercourse or urination

Answer 85

topical steroids and emollients Follow-up - increased risk of vulval cancer

Answer 86

**Major criteria:** - Change in size - Change in shape - Change in colour **Secondary features (minor criteria):** - Diameter >= 7mm - Inflammation - Oozing or bleeding - Altered sensation

Answer 87

- Suspicious lesions should undergo excision biopsy. - The lesion should be removed completely as incision biopsy can make subsequent histopathological assessment difficult. - Once the diagnosis is confirmed the pathology report should be reviewed to determine whether further re-excision of margins is required Further treatments such as sentinel lymph node mapping, isolated limb perfusion and block dissection of regional lymph node groups should be selectively applied.

Answer 88

The invasion depth of a tumour (Breslow depth)

Answer 89

Rare form of T-cell lymphoma that affects the skin - itchy, red patches which are - lesions tend to be of different colours in contrast to eczema/psoriasis where there is greater homogenicity

Answer 90

3 D's - dermatitis, diarrhoea and dementia may occur as a consequence of isoniazid therapy (isoniazid inhibits the conversion of tryptophan to niacin) and it is more common in alcoholics.

Answer 91

Autoimmune disease caused by antibodies directed against desmoglein 3

Answer 92

- mucosal ulceration is common and often the presenting symptom - skin blistering - flaccid, easily ruptured vesicles and bullae - Lesions are typically painful but not itchy. These may develop months after the initial mucosal symptoms. - Nikolsky's describes the spread of bullae following application of horizontal, tangential pressure to the skin - acantholysis on biopsy

Answer 93

steroids are first-line immunosuppressants

Answer 94

Type of eczema which affects both the hands (cheiropompholyx) and the feet (pedopompholyx). It is also known as dyshidrotic eczema.

Answer 95

- may be precipitated by humidity (e.g. sweating) and high temperatures - small blisters on the palms and soles - pruritic - often intensely itchy - sometimes burning sensation - once blisters burst skin may become dry and crack

Answer 96

cool compresses emollients topical steroids

Answer 97

most common hepatic porphyria. It is due to an inherited defect in uroporphyrinogen decarboxylase or caused by hepatocyte damage e.g. alcohol, hepatitis C, oestrogen

Answer 98

- classically presents with photosensitive rash with blistering and skin fragility on the face and dorsal aspect of hands (most common feature) - hypertrichosis - hyperpigmentation

Answer 99

- urine: elevated uroporphyrinogen and pink fluorescence of urine under Wood's lamp - serum iron ferritin level is used to guide therapy

Answer 100

chloroquine venesection - preferred if iron ferritin is above 600 ng/ml

Answer 101

- pitting - onycholysis - subungual hyperkeratosis - loss of the nail - associated with psoriatic arthropathy

Answer 102

- trauma - alcohol - drugs: beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab - withdrawal of systemic steroids - Streptococcal infection may trigger guttate psoriasis.

Answer 103

- regular emollients may help to reduce scale loss and reduce pruritus - **first-line = potent corticosteroid applied once daily plus vitamin D analogue applied once daily** - should be applied separately, one in the morning and the other in the evening) - for up to 4 weeks as initial treatment - second-line (no improvement after 8 weeks) = vitamin D analogue twice daily - third-line (no improvement after 8-12 weeks) = potent corticosteroid applied twice daily for up to 4 weeks, or a coal tar preparation applied once or twice daily - short-acting dithranol can also be used

Answer 104

**Phototherapy:** - narrowband ultraviolet B light is now the treatment of choice - 3 times a week - photochemotherapy is also used - psoralen + ultraviolet A light (PUVA) - adverse effects: skin ageing, squamous cell cancer (not melanoma) **Systemic therapy:** - oral methotrexate first-line - particularly useful if associated joint disease - ciclosporin - systemic retinoids - biological agents: infliximab, etanercept and adalimumab ustekinumab (IL-12 and IL-23 blocker) is showing promise in early trials

Answer 105

- first line = potent topical corticosteroids used once daily for 4 weeks - second line (no improvement after 4 weeks) = either use a different formulation of the potent corticosteroid (for example, a shampoo or mousse) and/or a topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid

Answer 106

mild or moderate potency corticosteroid applied once or twice daily for a maximum of 2 weeks

Answer 107

Benign epidermal skin lesions seen in older people - large variation in colour from flesh to light-brown to black - have a 'stuck-on' appearance - keratotic plugs may be seen on the surface >> reassurance about the benign nature of the lesion is an option >>options for removal include curettage, cryosurgery and shave biopsy

Answer 108

photosensitive 'butterfly' rash discoid lupus alopecia livedo reticularis: net-like rash

Answer 109

Severe systemic reaction affecting the skin and mucosa that is almost always caused by a drug reaction. - penicillin - sulphonamides - lamotrigine, carbamazepine, phenytoin - allopurinol - NSAIDs - oral contraceptive pill

Answer 110

- rash is typically maculopapular with target lesions being characteristic - may develop into vesicles or bullae - Nikolsky sign is positive in erythematous areas - blisters and erosions appear when the skin is rubbed gently - mucosal involvement - systemic symptoms: fever, arthralgia

Answer 111

hospital admission is required for supportive treatment

Answer 112

Potentially life-threatening skin disorder that is most commonly seen secondary to a drug reaction - phenytoin - sulphonamides - allopurinol - penicillins - carbamazepine - NSAIDs

Answer 113

- skin develops a scalded appearance over an extensive area - systemically unwell e.g. pyrexia, tachycardic - positive Nikolsky's sign: the epidermis separates with mild lateral pressure

Answer 114

- stop precipitating factor - supportive care, often in ICU - IV immunoglobulin first-line - other treatment options include: immunosuppressive agents (ciclosporin and cyclophosphamide), plasmapheresis

Answer 115

- well-demarcated patches of depigmented skin - the peripheries tend to be most affected - trauma may precipitate new lesions (Koebner phenomenon)

Answer 116

- sunblock for affected areas of skin - camouflage make-up - topical corticosteroids may reverse the changes if applied early - there may also be a role for topical tacrolimus and phototherapy, although caution needs to be exercised with light-skinned patients

Answer 117

Gastrointestinal adenocarcinoma

Answer 118

- **Wallace's Rule of Nines:** head + neck = 9%, each arm = 9%, each anterior part of leg = 9%, each posterior part of leg = 9%, anterior chest = 9%, posterior chest = 9%, anterior abdomen = 9%, posterior abdomen = 9% - **Lund and Browder chart:** most accurate method, the palmar surface is roughly equivalent to 1% of total body surface area (TBSA). Not accurate for burns > 15% TBSA

Answer 119

*Burns caused by heat:* - Remove the person from the source - Within 20 minutes of the injury irrigate the burn with cool (not iced) water for between 10 and 30 minutes - Cover the burn using cling film, layered, rather than wrapped around a limb *Electrical burns:* - switch off power supply, remove the person from the source *Chemical burns:* - Brush any powder off then irrigate with water - Attempts to neutralise the chemical are not recommended

Answer 120

- all deep dermal and full-thickness burns. - superficial dermal burns of more than 3% TBSA in adults, or more than 2% TBSA in children - superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso, or neck - any inhalation injury - any electrical or chemical burn injury - suspicion of non-accidental injury

Answer 121

**Immediate:** - Airway assessed first - early intubation considered e.g. if deep burns to face or neck, blisters or oedema of oropharynx, stridor etc - IV fluids for children with burns >10% TBSA / adults >15% TBSA - Fluids calculated using the Parkland formula - volume of fluid = TSBA of burn % x weight (Kg) x4. Half of the fluid is administered in the first 8 hours. - Urinary catheter inserted - Analgesia given - Complex burns, burns involving the hand, perineum and face and burns >10% in adults and >5% in children should be transferred to a burns unit. **More definitive:** - Conservative management appropriate for superficial burns and mixed superficial burns that will heal in 2 weeks. - More complex burns may require excision and skin grafting. **Escharotomies:** - Indicated in circumferential full thickness burns to the torso or limbs. - Careful division of the encasing band of burn tissue will potentially improve ventilation (if the burn involves the torso), or relieve compartment syndrome and oedema (where a limb is involved)

Answer 122

Acute gastric ulcers that develop in response to severe physiological stress, such as burns. Haematemesis, or vomiting blood, is a common presentation of these ulcers.

Answer 123

- a cause of scarring alopecia mainly seen in children - flaky skin, itch, and hair loss - if untreated a raised, pustular, spongy/boggy mass called a kerion may form

Answer 124

oral antifungals: terbinafine for Trichophyton tonsurans infections and griseofulvin for Microsporum infections. Topical ketoconazole shampoo should be given for the first two weeks to reduce transmission

Answer 125

- type 1 = caused by mixed anaerobes and aerobes (often occurs post-surgery in diabetics). This is the most common type - type 2 = caused by Streptococcus pyogenes

Answer 126

- acute onset - pain, swelling, erythema at the affected site - presence of bullae, purple discolouration - most commonly affected site is the perineum - often presents as rapidly worsening cellulitis with pain out of keeping with physical features - extremely tender over infected tissue with hypoaesthesia to light touch - skin necrosis and crepitus/gas gangrene are late signs - fever and tachycardia may be absent or occur late in the presentation

Answer 127

urgent surgical referral debridement intravenous antibiotics