MRCP2 Flashcards
Causes of acanthosis nagricans?
type 2 diabetes mellitus
gastrointestinal cancer
obesity
polycystic ovarian syndrome
acromegaly
Cushing’s disease
hypothyroidism
familial
Prader-Willi syndrome
Drugs that cause acanthosis nagricans?
combined oral contraceptive pill
nicotinic acid
Pathophysiology of acanthosis nagricans?
insulin resistance → hyperinsulinemia → stimulation of keratinocytes and dermal fibroblast proliferation via interaction with insulin-like growth factor receptor-1 (IGFR1)
Comodone + top closed
Whitehead
Comodone + top open
Black head
What lesions form when follicles burst and cause inflammation?
Papules
Pustules
excessive inflammation in acne sees what?
nodules
cysts
Acne vulgaris: what skin lesiosn are seen?
White head + blackheads
Papules + Pustules
Nodules and cysts
How to differeniate between acne and drug induced acne?
Drug induced acne typically is monomorphic
Acne + Fever ?
Acne fulminans
Treatment of acne fulminans ?
Hospital
Steroids
Features of mild acne?
mild: open and closed comedones with or without sparse inflammatory lesions
Features of moderate acne?
moderate acne: widespread non-inflammatory lesions and numerous papules and pustules
Features of severe acne?
severe acne: extensive inflammatory lesions, which may include nodules, pitting, and scarring
Management of acne?
- Single topical treatment (topical retinoids, benzoyl peroxide)
- Topical combination treatment (topical antibiotic, benzoyl peroxide, topical retinoid)
- Oral antibiotics + (Topical treatments)
tetracyclines: lymecycline, oxytetracycline, doxycycline - OCP + (Topical treatments)
- Isotretanoin
Choice of antibitoic in acne + pregnant ?
Erythromycin
Why is minocycline no longer used ?
Irreversible pigmentation
Management of gram negative folliculitis?
high-dose oral trimethoprim is effective if this occurs
How long should antibitoics be prescribed in acne - and why?
3 months
Risk of gram negative folliculitis
Management of actinic keratosis?
fluorouracil cream: typically a 2 to 3 week course.
topical diclofenac: may be used for mild AKs.
topical imiquimod: trials have shown good efficacy
cryotherapy
curettage and cautery
Exclamation mark hairs
Alopecia arreta
Is alopecia arrest reversible
Yes
Treatment of alopecia arreta?
topical or intralesional corticosteroids
topical minoxidil
phototherapy
dithranol
contact immunotherapy
wigs
What is bowens disease?
precursor to squamous cell carcinoma
red, scaly patches
often 10-15 mm in size
slow-growing
often occur on sun-exposed areas
Management of bowens disease?
topical 5-fluorouracil - BD for 4 weeks
Cryotherapy
Excision
Does pemphigoid have mucosal involvement?
No
Skin biopsy in pemphigoid?
immunofluorescence shows IgG and C3 at the dermoepidermal junction
Management of pemphigoid?
oral corticosteroids
oral corticosteroids
What are campbell de morgan spots?
erythematous, papular lesions
typically 1-3 mm in size
non-blanching
not found on the mucous membranes
What is Chondrodermatitis nodularis helicis?
Painful nodule on ear cartilage
Benign
Caused by pressure
Management of chondrodermatitis nodularis helicis?
‘ear protectors’ may be used during sleep
include cryotherapy, steroid injection, collagen injection
Features of chronic plaque psoriasis?
erythematous plaques covered with a silvery-white scale
typically on the extensor surfaces such as the elbows and knees. Also common on the scalp, trunk, buttocks and periumbilical area
clear delineation between normal and affected skin
plaques typically range from 1 to 10 cm in size
if the scale is removed, a red membrane with pinpoint bleeding points may be seen (Auspitz’s sign)
Pathophysiology of dermatitis herpetiformis?
Associated with coeliac disease
IgA deposition into skin
Causes blistering rash
Skin biopsy finding of dermatitis herpetiformis?
deposition of IgA in a granular pattern in the upper dermis
Management of dermatitis hepertiformis?
gluten-free diet
dapsone
What is a dermatofibroma?
Growth of dermal dendritic histiocyte cells, often following a precipitating injury
Benign
Features of discoid eczema?
round or oval plaques on the extremities
the lesions are extremely itchy
central clearing may occur giving a similar appearance to tinea corporis
What is the other name for discoid eczema?
Nummular eczema
What is eczema herpeticum?
severe primary infection of the skin by herpes simplex virus 1 or 2.
Appearance of eczema herpeticum?
monomorphic punched-out erosions (circular, depressed, ulcerated lesions) usually 1–3 mm in diameter are typically seen.
Management of eczema herpeticum?
Can be life threatening in children
IV aciclovir
Prognostic markers for severe eczema?
onset at age 3-6 months
severe disease in childhood
associated asthma or hay fever
small family size
high IgE serum levels
Management of eczema?
emollients
topical steroids
UV radiation
immunosuppressants: e.g. ciclosporin, antihistamines and azathioprine
Mild topical steroid?
Hydrocortisone 0.5-2.5%
Moderate topical steroid?
Betamethasone valerate 0.025% (Betnovate RD)
Clobetasone butyrate 0.05% (Eumovate)
Potent topical steroid?
Fluticasone propionate 0.05% (Cutivate)
Betamethasone valerate 0.1% (Betnovate)
Very potent topical steroid?
Clobetasol propionate 0.05% (Dermovate)
What is erythema multiforme?
Hypersenitivity reaction
Divided into:
- Erythema multiforme minor
- Erythema multiforme major
How to differentiate between erythema major and minor?
Major: Mucosal involvement
How to differentiate between seborrheic keratosis and malignant melanoma?
Pseudo-comedones and pale spots help distinguish seborrhoeic lesions from malignant melanomas
presence of dark pigmented pin-prick spots, sometimes described as pseudo-commodones
Management of dermatitis herpetiformis ?
Topical dapsone
What is dermatitis herpetiformsi associated with?
IDA –> coaeliac
Fixed drug erruption vs discoid eczema?
Fixed drug eruptions however tend to occur within 24 hours of starting the drug and disappear after 10 days.
Features of erythema multiforme?
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
What is erythema nodsum?
inflammation of subcutaneous fat
typically causes tender, erythematous, nodular lesions
Causes of erythema nodosum?
infection:
streptococci
tuberculosis
brucellosis
systemic disease:
sarcoidosis
inflammatory bowel disease
Behcet’s
malignancy/lymphoma
drugs:
penicillins
sulphonamides
combined oral contraceptive pill
pregnancy
Cause of erythroderma?
eczema
psoriasis
drugs e.g. gold
lymphomas, leukaemias
idiopathic
Erythroderma psoriasis
What can trigger an erythroderma psoriasis ?
Withdrawl of steroids
Causative organism of fungal nail onychomycosis?
dermatophytes
account for around 90% of cases
mainly Trichophyton rubrum
yeasts
account for around 5-10% of cases
e.g. Candida
Investigation of fungal nail onychomycosis?
nail clippings +/- scrapings of the affected nail
Management of fungal nail onychomycosis?
if 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
oral terbinafine is currently recommended first-line; 6 weeks - 3 months therapy is needed for fingernail infections whilst toenails should be treated for 3 - 6 months
Treatment of candida onychomycosis?
Candida infection: oral itraconazole is recommended first-line; ‘pulsed’ weekly therapy is recommended
papular lesions that are often slightly hyperpigmented and depressed centrally + Dorsum of hands / feet?
Grannuloma annular
Associations of granuloma annular?
Diabetes mellitus
What precipitates a guttate psoriasis flare?
streptococcal infection 2-4 weeks prior to the lesions appearing.
Management of guttate psoriasis?
topical agents as per psoriasis
UVB phototherapy
tonsillectomy may be necessary with recurrent episodes
‘Tear drop’, scaly papules on the trunk and limbs
Guttate psoriasis
Herald patch?
Pityriasis rosea
raised oval lesions with a fine scale confined to the outer aspects of the lesions.
oval lesions running parallel to the line of Langer.
Pityriasis rosea
Fir tree
Pityriasis rosea
Inheritance of HHT?
Autosomal dominant
Features of HHT?
epistaxis : spontaneous, recurrent nosebleeds
telangiectases: multiple at characteristic sites (lips, oral cavity, fingers, nose)
visceral lesions: for example gastrointestinal telangiectasia (with or without bleeding), pulmonary arteriovenous malformations (AVM), hepatic AVM, cerebral AVM, spinal AVM
Management of keratocanthoam?
Urgent excision - looks like squamous cell carcinoma
Causes of koebner phenomena?
psoriasis
vitiligo
warts
lichen planus
lichen sclerosus
molluscum contagiosum
What is lentigo maligna?
Lentigo maligna is a type of melanoma in-situ.
Can become lentigo maligna melanoma.
What is leukoplakia?
premalignant condition which presents as white, hard spots on the mucous membranes of the mouth
More common in smokers
How hsould leukoplakia be managed?
Regular follow
Biopsies normally preformed to exclude malignancy
Features of lichen planus?
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
oral involvement in around 50% of patients: “White lace”
nails: thinning of nail plate, longitudinal ridging
Drugs that cause lichenoid drug rash?
gold
quinine
thiazides
What is lichen sclerosis?
On genitals
white patches that may scar
itch is prominent
may result in pain during intercourse or urination
increased risk of vulval cancer
How to manage lichen scleorsis?
Emolients
Steroids
If lichen sclerosis does not respond to steroids what is the next management
Biopsy
What is the most aggressive malignant melanoma?
Nodular
Most common form of malignant melanoma?
Superficial spreading
What is hutchinson signs (melanoma)?
Subungual pigmentation
Seen in acral malignant melanoma
What are major diagnostic factors of malignant melanoma?
Major:
Change in size
Change in shape
Change in colour
Minor :
Diameter >= 7mm
Inflammation
Oozing or bleeding
Altered sensation
What is melasma?
development of hyperpigmented macules in sun-exposed
Cause of melasma?
pregnancy
combined oral contraceptive pill, hormone replacement therapy
Management of molloscum contagious?
Reassure people that molluscum contagiosum is a self-limiting condition.
Spontaneous resolution usually occurs within 18 months
Explain are contagious - do not share towels
Encourage not to itch
What virus causes molloscum contagious?
molluscum contagiosum virus (MCV)
HIV + significant cropping of molloscum?
Urgent referral to HIV specialist
Molloscum + at eye margin?
Urgent referral to ophthalmology
What rash is caused by T cell lymphoma?
Mycosis fungoides i
Feature of mycosis fungoides?
itchy, red patches which are
lesions tend to be of different colours in contrast to eczema/psoriasis where there is greater homogenicity
What is palmar plantar erythrodysesthesia ?
Side effect of chemotherapy
tingling or numbness first in the fingers and palms and then toes and soles of the feet
erythematous rash which can desquamate, blister and ulcerate which can be associated with onycholysis
What are the features of pellagra?
dermatitis (brown scaly rash on sun-exposed sites - termed Casal’s necklace if around neck)
diarrhoea
dementia, depression
death if not treated
What drug may cause pellagra?
Isoniazid
inhibits the conversion of tryptophan to niacin
Pellagra is deficiency in what?
Niacin
Pemphigus is caused by antibodies to what?
Desmoglyin 3
Nilosky positive + mucosal lesions + flaccid blisters?
Pemphigus
Management of pemphigus ?
Steroids
Immunosuppression
Causes of Pityriasis versicolor
Malassezia furfur
Management of Pityriasis versicolor
topical antifungal.
- ketoconazole shampoo as this is more cost effective for large areas
- If not fixed: send scrapping
- oral itraconazole
What is a polymorphic light eruption?
primary photosensitivity that mainly occurs in young adult women in temperate climates during spring and summer.
provoked by several hours outside on a sunny day. If further sun exposure is avoided, the rash settles in a few days.
Management of pompholyx eczema?
cool compresses
emollients
topical steroids
HLA association of psoriasis?
HLA-B13, -B17, and -Cw6.
Types of psoriasis ?
plaque psoriasis: the most common sub-type resulting in the typical well-demarcated red, scaly patches affecting the extensor surfaces, sacrum and scalp
flexural psoriasis: in contrast to plaque psoriasis the skin is smooth
guttate psoriasis: transient psoriatic rash frequently triggered by a streptococcal infection. Multiple red, teardrop lesions appear on the body
pustular psoriasis: commonly occurs on the palms and soles
Exacerbating factors of psoriasis?
trauma
alcohol
drugs: beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab
withdrawal of systemic steroids
Management of psoriasis?
- Potent topical steroid OD + Vitamin D topical analogue OD
If no improvement by 8 weeks
2. Potent topical steroid OD + Vitamin D topical analogue BD
If no improvement 8-12 weeks:
a potent corticosteroid applied twice daily for up to 4 weeks, or
a coal tar preparation applied once or twice daily
- Methotrexate or cyclosporin
(provided criteria met)
Flare:
How is phototherapy delivered?
narrowband ultraviolet B light is now the treatment of choice - three times per week
photochemotherapy is also used - psoralen + ultraviolet A light (PUVA)
Adverse effects of phototherapy?
Skin ageing
Squamous cell carcinoma
Systemic treatment for psoriasis - when is it indicated?
Joint involvement –> Methotrexate
ciclosporin
systemic retinoids
biological agents: infliximab, etanercept and adalimumab
ustekinumab (IL-12 and IL-23 blocker) is showing promise in early trials
Can vitamin D analogous be used in pregnancy ?
No
presence of multiple bullae and papules on the extensor surface of his knees and buttocks, with excoriation.
Dermatitis herpetiformis
Criteria for systemic treatment in psoriasis?
psoriasis is extensive (for example, more than 10% of body surface area affected or a PASI score of more than 10)
psoriasis is localised and associated with significant functional impairment and/or high levels of distress (for example severe nail disease or involvement at high-impact sites)
phototherapy has been ineffective, cannot be used or has resulted in rapid relapse (rapid relapse is defined as greater than 50% of baseline disease severity within 3 months).
nose, cheeks and forehead
flushing, erythema, telangiectasia → papules and pustules
Acne rosacea
Pemphigoid gestinatus?
pruritic blistering lesions
often develop in peri-umbilical region, later spreading to the trunk, back, buttocks and arms
usually presents 2nd or 3rd trimester and is rarely seen in the first pregnancy
Management of pemphigoid gestinates?
Oral corticosteroid
Features of Polymorphic eruption of pregnancy?
pruritic condition associated with last trimester
lesions often first appear in abdominal striae
Management of polymorhic eruption of pregnancy?
management depends on severity: emollients, mild potency topical steroids and oral steroids may be used
Conditions associated with vitiligo?
type 1 diabetes mellitus
Addison’s disease
autoimmune thyroid disorders
pernicious anaemia
alopecia areata
Management of vitiligo?
topical corticosteroids if caught early enough
ole for topical tacrolimus and phototherapy
Eczema management?
- emollients and topical steroids
- oral prednisolone
- topical tacrolimus
pemphigus cause mouth lesions?
yes
Drugs that exacerbate psoriasis?
lithium
beta blockers
antimalarials
non-steroidal anti-inflammatory drugs
ACE-inhibitors
antibiotics such as tetracycline and penicillin
Complications of psoriasis ?
psoriatic arthropathy (around 10%)
increased incidence of metabolic syndrome
increased incidence of cardiovascular disease
increased incidence of venous thromboembolism
psychological distress
Features of scabies?
widespread pruritus
linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist
in infants, the face and scalp may also be affected
secondary features are seen due to scratching: excoriation, infection
Management of scabies?
permethrin 5% is first-line
malathion 0.5% is second-line
give appropriate guidance on use (see below)
pruritus persists for up to 4-6 weeks post eradication
How should household contacts be managed in scabies?
Everyone should be treated
Custed scabies?
HIV
What is sezary syndrome ?
pruritus
erythroderma typically affecting the palms, soles and face
atypical T cells
lymphadenopathy
hepatosplenomegaly
Neutrophil dermatosis ?
skin conditions characterised by dense infiltration of neutrophils in the affected tissue and this is often seen on biopsy
Pyoderma gangrensum
Causes of pyoderma gangrenosum?
idiopathic in 50%
inflammatory bowel disease in 10-15%
ulcerative colitis
Crohn’s
rheumatological
rheumatoid arthritis
SLE
haematological
myeloproliferative disorders
lymphoma
myeloid leukaemias
monoclonal gammopathy (IgA)
granulomatosis with polyangiitis
primary biliary cirrhosis
Features of pyoderma gangrenosum?
Sudden formation
Forms blood blister
Breaks down
resulting in an ulcer which is often painful
the edge of the ulcer is often described as purple, violaceous and undermined.
the ulcer itself may be deep and necrotic
Management of pyoderma gangrenosum?
advocate oral steroids as first-line treatment
immunosuppressive therapy, for example, ciclosporin and infliximab, have a role in difficult cases
Pyoderma gangrenosum + surgery ?
any surgery should be postponed until the disease process is controlled on immunosuppression to risk worsening of the disease (pathergy)
Drugs that cause erythema multiforme?
drugs: penicillin,
sulphonamides,
carbamazepine,
allopurinol,
NSAIDs
oral contraceptive pill
nevirapine
What viruses causes pityriasis rosea?
Human herpes 7
What are the nail changes in psoriaiss?
pitting
onycholysis (separation of the nail from the nail bed)
subungual hyperkeratosis
loss of the nail
Systemic therapy used in psoriasis?
oral methotrexate is used first-line. It is particularly useful if there is 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
Cause of pyogenic granulooma?
trauma
pregnancy
more common in women and young adults
Features of rosacea?
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
Management of flushing in rosea?
topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia
- topical alpha agonist
Management of mild / moderate papules / pustules in rosacea?
topical ivermectin is first-line
topical metronidazole or topical azelaic acid
Management of moderate / severe papules / pustules in rosacea?
combination of topical ivermectin + oral doxycycline
Causative organism of seborrheic dermatitis?
Malassezia furfur
Associated conditions of seborrheic dermatitis?
Parkinsons
HIV
Management of seborrheic dermatitis?
Scalp disease:
over the counter preparations containing zinc pyrithione (‘Head & Shoulders’) and tar (‘Neutrogena T/Gel’) are first-line
the preferred second-line agent is ketoconazole
Face and body management:
topical antifungals: e.g. ketoconazole
topical steroids: best used for short periods
difficult to treat - recurrences are common
Necrobiosis lipoidica diabeticorum?
shiny, painless areas of yellow/red skin typically on the shin of diabetics
often associated with telangiectasia
Pretibial myxoedema?
symmetrical, erythematous lesions seen in Graves’ disease
shiny, orange peel skin
Features of shingles?
prodromal period
burning pain over the affected dermatome for 2-3 days
pain may be severe and interfere with sleep
around 20% of patients will experience fever, headache, lethargy
rash
initially erythematous, macular rash over the affected dermatome
quickly becomes vesicular
characteristically is well demarcated by the dermatome and does not cross the midline. However, some ‘bleeding’ into adjacent areas may be seen
Skin manifestations in SLE?
photosensitive ‘butterfly’ rash
discoid lupus
alopecia
livedo reticularis: net-like rash
Good prognosis of SCC?
Well differeniated
< 20 mm diameter
< 2 mm deep
No associated dsease
Poor prognosis of SCC?
Poorly differentiated tumours
> 20 mm diameter
> 4 mm deep
Immunosupression for whatever reason
Causes of stevens johnson syndrome?
penicillin
sulphonamides
lamotrigine, carbamazepine, phenytoin
allopurinol
NSAIDs
oral contraceptive pill
Rash in steven johnson?
the 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
Features of systemic mastocytosis?
urticaria pigmentosa - produces a wheal on rubbing (Darier’s sign)
flushing
abdominal pain
monocytosis on the blood film
Management of systemic mastocytosis?
raised serum tryptase levels
urinary histamine
If ring worm is untreated what can it form?
Kerion - a boggy mass
Most common cause of scalp tinea ?
Trichophyton tonsurans in the UK and the USA
Microsporum canis acquired from cats or dogs
Tinea capitus+ glows with woods lamp?
Microsporum canis
Best investigation for tinea capitus ?
Skin scrapings
Management of tinea capituts?
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
Cause of tinea corpus?
Trichophyton rubrum and Trichophyton verrucosum
Treatment of tinea corpus?
oral fluconazole
Drugs that cause toxic epidermal necrolysis?
phenytoin
sulphonamides
allopurinol
penicillins
carbamazepine
NSAIDs
Management of toxic epidermal necrolysis
intravenous immunoglobulin has been shown to be effective and is now commonly used first-line
treatment options include: immunosuppressive agents (ciclosporin and cyclophosphamide), plasmapheresis
Features of toxic epidermal necrolysis?
systemically unwell e.g. pyrexia, tachycardic
positive Nikolsky’s sign: the epidermis separates with mild lateral pressure
Features of yellow nail syndrome?
congenital lymphoedema
pleural effusions
bronchiectasis
chronic sinus infections
Slowing of the nail growth leads to the characteristic thickened and discoloured nails seen in yellow nail syndrome
Features of zinc deficiency?
acrodermatitis: red, crusted lesions
acral distribution
peri-orificial
perianal
alopecia
short stature
hypogonadism
hepatosplenomegaly
geophagia (ingesting clay/soil)
cognitive impairment
BCC vs SCC?
SCC –> erythematous base
linear burrows ?
scabies
How should oral steroids be prescribed ?
30 mg for one week
Then to wean - in case of rebound
intertriginous and perioral areas rash + aploecia + taste impairment, glucose intolerance, and diarrhoea
Magnesium deficiency
How long is shingles infectious for ?
Until lesions rust over
What cancer are you at risk of with Vemurafenib ?
squamous cell carcinoma
Bacterial cause of erythema multiform?
Mycoplasma pneumonia
Management of erythroderma?
Systemic steroids
Ciclosporin
