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MSRA Content > Ophthalmology & Skin - Level 1/2 > Flashcards

Ophthalmology & Skin - Level 1/2 Flashcards

1
Q

Definition of glaucoma?

A
  • Glaucoma is group of eye diseases that cause progressive optic neuropathy, associated with raised IOP and characterised by visual field defects and changes to optic nerve (pathological cupping, pallor of disc)
  • Raised IOP = >21mmHg
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2
Q

Anatomy of eye - anterior chamber?

A

o Anterior chamber – fluid-filled space between iris and cornea
 Angle is between iris and cornea where they join sclera towards outside of the eye
 Trabecular network situated in apex of anterior chamber angle and is main aqueous outflow route

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3
Q

Anatomy of eye - aqueous humour?

A

o Aqueous Humour – fluid produced from plasma by ciliary epithelium of ciliary body
 Secreted into posterior chamber which is space between iris and lens, flows through pupil into anterior chamber and out of trabecular meshwork
 Secretion increased by stimulation of beta-2 receptors and decreased by stimulation of alpha-2 receptors on ciliary body

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4
Q

Normal IOP of eye?

A

 Pressure between 11-21mmHg is normal

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5
Q

Classifications of glaucoma?

A

o Age of onset – congenital, infantile, juvenile, adult
o Cause – primary, secondary
o Rate of onset – acute, subacute, chronic
o Anterior chamber open or closed

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6
Q

Definition and types of open angle glaucoma?

A

o Primary open angle glaucoma
 Most common, >40 years, insidious onset, both eyes usually, raised IOP

o Normal tension glaucoma
 POAG in normal IOP

o Secondary OA glaucoma

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7
Q

Definition and types of angle closure glaucoma?

A

o Primary angle closure glaucoma
 Onset may be acute, subacute or chronic
 Acute is medical emergency

o Secondary angle closure glaucoma

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8
Q

How common is ocular hypertension, POAG, PACG?

A
  • Ocular hypertension – 3-5% of over 40 year olds
  • POAG – 2% of over 40s – increases with age
  • PACG – women 3x more, increases with age
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9
Q

Risk factors of open angle glaucoma?

A 
	Raised IOP
	Older age
	FHx
	Black people
	Corticosteroid treatment
	Myopia
	T2DM
	Hypertension
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10
Q

Risk factors of angle-closure glaucoma?

A

 Older age
 Women 2-3x
 Asian people
 Short, hyperopic eyes

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11
Q

Aetiology of primary open angle glaucoma?

A

 Visual loss due to damage to retinal ganglion cells due to raised IOP causing mechanical pressure damage to axons of cells

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12
Q

Aetiology of secondary open angle glaucoma?

A

 Pseudoexfoliative – organelles deposited on trabecular meshwork
 Pigmentary – pigment from iris deposited in trabecular meshwork
 Neovascular – diabetic retinopathy, central retinal vein occlusion
 Uveitic – uveitis
 Steroid-induced
 Angle-recession – trauma

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13
Q

Aetiology of primary angle-closure glaucoma?

A

 Peripheral iris comes into contact with trabecular meshwork that restricts drainage of aqueous humour from eye

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14
Q

Symptoms of acute angle closure glaucoma?

A

o Eye pain – severe
 Spreads around orbit with generalied headache
o Headache, nausea and vomiting
o Red eye
o Impaired visual acuity, blurred vision and lights seen surrounded by halos (hazy oedematous cornea)
o Semi-dilated and fixed pupil (fixed in vertically oval shape)
o Tender, hard eye

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15
Q

Symptoms of ocular hypertension and POAG?

A

o Usually by optometrists in routine eye exams

o Increased IOP, visual field defects and cupped optic disc

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16
Q

When should people get examined for glaucoma?

A
  • Advise people with the follow risk factors to get eyes examined:
    o Older age
    o FHx of glaucoma
    o Black African
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17
Q

Management of acute angle closure glaucoma - primary care?

A

 Admit immediately for specialist ophthalmology assessment and treatment

 If immediate admission not possible – start emergency treatment
• Person lie flat with face up and head not supported by pillows
• Drugs – pilocarpine eye drops (1 drop of 2% in blue eyes, 4% in brown eyes), acetazolamide 500mg oral, analgesia and anti-emetic PRN

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18
Q

Management of acute angle closure glaucoma - secondary care initial treatment?

A

• Topical and IV drugs to reduce IOP
o Pilocarpine
o Acetazolamide
• Analgesia

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19
Q

Management of acute angle closure glaucoma - secondary care definitive treatment?

A
  • Laser iridotomy (creates holes in iris to allow aqueous humour to flow into anterior chamber)
  • Iridoplasty or cataract removal
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20
Q

Management of POAG or ocular hypertension - drug treatment?

A

o Under direction of ophthalmologist

o Drug treatment
 Topical prostaglandin analogue or prostamide
• Latanoprost, travoprost
 Topical beta-blocker

o Lifetime monitoring

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21
Q

Management of POAG or ocular hypertension - other treatments?

A

 Add other drug or carbonic anhydrase inhibitor

 Laser procedures
• Selective laser trabeculoplasty
• Argon laser trabeculoplasty
• Micro-pulse laser trabeculoplasty

 Surgical procedures
• Trabeculectomy
• Insertion of drainage shunt

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22
Q

Prognosis of POAG?

A

o Progresses slowly without treatment over years, most people asymptomatic until severe disease
o Visual loss is peripheral at first

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23
Q

Prognosis of PACG?

A

o Half of glaucoma related blindness

o Needs prompt treatment

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24
Q

Definition of cataracts?

A
  • Opacity forming within lens of the eye which reduces transparency
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25
Q

Classification of cataracts?

A

o Nuclear – central part of lens, most common
o Cortical – outer layer of lens
o Subcapsular – directly under lens capsule

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26
Q

Types of cataracts?

A

o Congenital – present at birth or within 1st year of life
o Developmental – develop after infancy
o Traumatic

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27
Q

Epidemiology of cataracts?

A
  • Older age increases incidence

- Most common elective surgical procedure

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28
Q

Causes of cataracts?

A 
o	Ageing
o	Secondary – chronic anterior uveitis, acute angle-closure glaucoma, high myopia
o	Trauma – blunt or penetrating injury
o	DM
o	Myotonic dystrophy
o	Neurofibromatosis Type 2
o	Atopic dermatitis
o	Congenital – hereditary, rubella, CMV, HSV, toxoplasmosis, Down’s, Edward’s, galactossaemia
o	FHx
o	Steroid treatment
o	Smoking
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29
Q

Symptoms of cataracts?

A

o Gradual, painless reduction in visual acuity
 Difficulty reading, recognising faces, watching television
o Glaring
o Reduced colour intensity
o Double vision in one eye

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30
Q

Signs of cataracts?

A

o Reduced acuity
o Opacity seen in lens
o Red reflex reduced

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31
Q

When are babies screened for cataracts?

A

o All babies screened at birth and 6 weeks for cataracts

o May have nystagmus, squint, sensitivity to light, lighter pupil

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32
Q

Investigations of cataracts?

A
  • Document last visual acuity if referring

- Slit lamp at optometrists

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33
Q

Management of cataracts - surgical treatment - when to refer for cataracts surgery?

A
  • Visual impairment and affecting lifestyle (driving, reading)
  • Comorbidity that may benefit from surgery – elderly falls risk
  • Another eye condition where treatment will help
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34
Q

Management of cataracts - surgical treatment - benefits?

A

• Improve acuity, clarity and colour vision

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35
Q

Management of cataracts - surgical treatment - risks?

A
  • Posterior capsular opacity – needs laser treatment
  • Bruising to eye
  • Raised intraocular pressure
  • Macular oedema
  • Need for glasses
  • Detached retina
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36
Q

Management of cataracts - surgical treatment - biometry techniques before surgery?

A
  • Optical biometry to measure axial length of eye
  • Keratometry to measure curvature of cornea
  • Used to calculate lens power
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37
Q

Management of cataracts - surgical treatment - surgical technique and drug managements?

A
  • Small incision surgery with phacoemulsion + intraocular lens implant
  • Offer bilateral if both affected and low risk of complications
  • Antibiotic and antinflammatory drops for 3-6 weeks after
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38
Q

Management of cataracts - fitness to drive?

A

 Contact DVLA and not drive if either apply:
• Group 1 – cannot read number plate at 20 metres, visual acuity >6/12 corrected
• Group 2 – Visual acuity of >6/7.5 in better eye and at least 6/60 in other eye

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39
Q

Management of cataracts - in children?

A

o Urgent referral to ophthalmologist on same-day if red reflex shows:
 Opacity, absences, white pupil

o Urgent referral if:
 Inequality in colour, intensity or clarity of reflection

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40
Q

Prognosis of cataracts?

A

o Without treatment – progresses without any chance of recovery
o With surgery – 95% have 6/12 best correct vision if no pathology
o In children – no treatment can lead to amblyopia

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41
Q

Definitions of corneal abrasions, ulcers and dendritic ulcers?

A
  • Corneal abrasions – defects in epithelial surface
  • Corneal ulcer – epithelial defect with corneal infiltrate
  • Dendritic ulcer – branching staining pattern characteristic of herpetic infection
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42
Q

Causes of corneal ulcers?

A 
o	Bacterial (pseudomonas progresses rapidly)
o	Herpetic (HSV, HZV)
o	Fungal (candida, aspergillus)
o	Protozoal (acanthamoeba)
o	Vasculitis (RA)
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43
Q

Risk factors of corneal ulcers?

A 
o	Contact lens wearer
o	Corneal trauma
o	Corneal abrasion
o	Immunocompromised
o	Trichiasis
o	Herpes infection
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44
Q

Symptoms of corneal ulcers?

A

o Severe eye pain
o Lacrimation
o Inability to open eye
o Red Eye

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45
Q

Signs of corneal ulcers?

A

o Reduced visual acuity
o Photophobia
o High IOP

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46
Q

Management of corneal ulcers in primary care?

A
  • Refer to emergency eye service if:

o Corneal ulcer

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47
Q

Investigations of corneal ulcers in eye casualty?

A

Slit Lamp & Fluorescein staining
 Ulcer
 Dendritic Ulcer - HSV

Corneal scraping
 Microscopy
 Cultures and Sensitivity
• Blood agar, chocolate agar (haemophilus, neisseria), thioglycolate broth (anaerobic), non-nutrient agar, Lowenstein-Jensen’s medium (Mycobacteria, Nocardia)

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48
Q

Management of dendritic ulcers?

A

o Aciclovir 3% eye drops – 5x daily (can be oral if severe)
o Atropine 1% drops for photophobia
o PRN analgesia (paracetamol & ibuprofen)

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49
Q

Management of corneal ulcers?

A

o Chloramphenicol + Ofloxacin drops
o Atropine 1% drops for photophobia
o PRN analgesia (paracetamol & ibuprofen)
o Topical steroid drops (prednisolone)

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50
Q

Management of fungal ulcers?

A

o Natamycin drops
o Atropine 1% drops for photophobia
o PRN analgesia (paracetamol & ibuprofen)

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51
Q

Management of acanthamoeba ulcers?

A

o Chlorhexadine drops
o Oral Itraconazole
o Atropine 1% drops for photophobia
o PRN analgesia (paracetamol & ibuprofen)

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52
Q

Description of stye?

A
  • Also known as a hordeolum

- Acute localised infection or inflammation of eyelid margin

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53
Q

Types of stye?

A

o External stye (common)
 Eyelid margin
 Caused by infection of eyelash follicle or associated sebaceous or apocrine gland

o Internal Stye (meibomian stye)
 On conjunctival surface
 Caused by infection of meibomian gland (within tarsal plate) and usually more painful

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54
Q

Risk factors of stye?

A 
o	Chronic blepharitis
o	Acne rosacea
o	Ingrown eyelashes (trichiasis)
o	Ectropion
o	DM
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55
Q

Causes of stye?

A

o Staphylococcal infection – most common

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56
Q

Symptoms of stye?

A
  • Acute, painful, localised eyelid swelling developing over several days
    o Generally, only one eye – can be bilateral
    o Water excessively
  • No changes in visual acuity
  • External – located on eyelid margin, around follicle, points anteriorly through the skin, may have us-filled spot
  • Internal – tender on internal eyelid, on everting of eye welling of tarsal plate
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57
Q

Management of stye - in primary care?

A

o Apply warm compress (clean flannel with warm water) to eye for 5-10 minutes and repeat several times a day
o Do not attempt to puncture stye
o Avoid eye makeup or contact lenses until healed
o Plucking eyelash from infected follicle can facilitate drainage
o Incision and drainage if appropriate

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58
Q

Management of stye - when to refer and what management in ophthalmology?

A

Admit if signs of periorbital or orbital cellulitis

2-week-wait if signs of skin cancer

Refer to ophthalmologist for incision and drainage if:
 Stye is persistent and has not discharged following conservative
 treatment
 Internal stye if large or very painful

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59
Q

Prognosis of stye?

A

o Self-limiting

o Resolution within 5-7 days

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60
Q

Complications of stye?

A
  • Conjunctivitis
  • Perioribital or orbital cellulitis
  • Meibomian cyst (chalazion)
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61
Q

Description of Meibomian cyst (chalazion)?

A

o Sterile, inflammatory granuloma caused by obstruction of sebaceous gland
o Often indistinguishable from stye (chalazion usually less painful and acute)

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62
Q

Symptoms of Meibomian cysts?

A

Firm, painless, localised eyelid swelling developed over several weeks

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63
Q

Treatments of Meibomian cysts?

A

Apply warm compress, massage cyst after application in direction of eyelashes, refer if chronic

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64
Q

Definition of infective conjunctivitis?

A
  • Redness and inflammation of conjunctiva (thin layer that covers front of eye)
  • Hyperaemic vessels may be moved to sclera by pressure on globe

o Hyper-acute conjunctivitis is a rapidly developing severe conjunctivitis typically caused by infection with Neisseria gonorrhoeae.

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65
Q

What is Ophthalmia neonatorum?

A

o Ophthalmia neonatorum (ON) is conjunctivitis occurring within the first four weeks of life
 Can be infectious or non-infectious
 Can be caused by Neisseria gonorrhoeae or Chlamydia trachomatis

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66
Q

Causative organisms of infective conjunctivitis?

A

o Viral
 Most common 80% adenoviruses
 HSV, VZV, EBV, enterovirus

o Bacterial
 Streptococcus pneumoniae, Staphylococcus aureus and Haemophilus influenzae
 Moraxella catarrhalis, Chlamydia trachomatis, and Neisseria gonorrhoea

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67
Q

Causative organisms of Ophthalmia neonatorum?

A

o Purulent or mucopurulent discharge with crusting of lids, may be stuck together on waking
o If copious – consider Neisseria gonorrhoea
o Pre-auricular lymph nodes

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68
Q

Symptoms of viral infective conjunctivitis?

A 
o	Mild to moderate erythema
o	Subconjunctival haemorrhages
o	Watery discharge
o	Mild pruritus
o	URTI and pre-auricular lymph nodes
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69
Q

Symptoms of bacterial infective conjunctivitis?

A

o Purulent or mucopurulent discharge with crusting of lids, may be stuck together on waking
o If copious – consider Neisseria gonorrhoea
o Pre-auricular lymph nodes

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70
Q

STI causes of conjunctivitis?

A

o Chlamydia
 Chronic low-grade irritation and mucous discharge, mostly unilateral

o Gonorrhoea
 Rapid development of copious mucopurulent discharge, eyelide swelling, tender lymph nodes

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71
Q

Symptoms in Ophthalmia neonatorum?

A

o Discharge in first few weeks of life

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72
Q

Investigations if gonococcal infection suspected?

A
  • Gram staining and culture if gonococcal suspected
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73
Q

Management of infective conjunctivitis - when to refer to ophthalmology?

A 
o	Red flag for serious red eye disease
o	Ophthalmia neonatorum
o	Suspected gonococcal or chlamydial conjunctivitis
o	Herpes infection
o	Cellulitis
o	Recent intraocular surgery
o	Systemic conditions
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74
Q

Management of infective conjunctivitis - viral?

A

o Self-limiting – resolve in 1-2 weeks
o Bathe eyelids with cotton wool soaked in sterile water
o Cold compresses around eyes
o Artificial tears

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75
Q

Management of infective conjunctivitis - bacterial?

A

o Chloramphenicol 0.5%/1% topical drops
 Apply 1 drop 2-hourly for 2 days then QDS for 5 days

o Chloramphenicol 1%
 Apply 1 drop QDS for 2 days then, 1 drop BDS for 5 days

o Fusidic acid 1% drops
 Apply BDS for 7 days

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76
Q

Management of infective conjunctivitis - neonates?

A

o Treat with neomycin

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77
Q

Management of infective conjunctivitis - ophthalmia neonatorum?

A

o Gonococcal infection should be cultured and treated with 3rd generation cephalosporin given

o If chlamydia infection then treated with oral erythromycin

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78
Q

Prognosis of infective conjunctivitis?

A
  • Viral – most cases resolve in 7 days

- Bacterial – resolves within 10 days

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79
Q

Definition of allergic conjunctivitis?

A
  • Redness and inflammation of conjunctiva (thin layer that covers front of eye)
  • Hyperaemic vessels may be moved to sclera by pressure on globe

o Associated with IgE antibodies bind to mast cells in conjunctiva causing degranulation and inflammation with histamine:
 Itching due to activation of H1 receptors and redness, swelling

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80
Q

Types of allergic conjunctivitis?

A

 Seasonal allergic (hayfever)
 Perennial allergic – non-seasonal environmental allergences (houst dust mites, mould spores, animal dander)
 Vernal keratoconjunctivitis – hot, arid environments
 Atopic

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81
Q

Causes of allergic conjunctivitis?

A

o 15-40% of population

o Mostly in spring and summer

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82
Q

Epidemiology of allergic conjunctivitis?`

A

o Allergic, mechanical/irritative/toxic, immune-mediated and neoplastic

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83
Q

Symptoms of seasonal allergic conjunctivitis?

A

o Eyes itch, burn, ‘gritty feeling’ and lacrimate
o Watery discharge, tearing
o Conjunctival redness, swelling
o Eyelid oedema
o May have rhinitis, sinusitis, asthma, eczema

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84
Q

Symptoms of vernal keratoconjunctivitis?

A

o Typically resolves after puberty
o Worse in spring
o Giant papillae on superior tarsal conjunctiva, Horner’s points (yellow white points)

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85
Q

Symptoms of atopic allergic conjunctivitis?

A

o Chronic itching, tearing, swelling, corneal scarring

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86
Q

Management of allergic conjunctivitis - urgent referral to ophthalmology?

A

 Atopic, vernal or giant papillary conjunctivitis

 Severe or resistant conjunctivitis

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87
Q

Management of allergic conjunctivitis - routine referral to ophthalmology?

A

 Atopic, vernal or giant papillary conjunctivitis

 Severe or resistant conjunctivitis

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88
Q

Management of allergic conjunctivitis - sticky eyes in 1st few days of life?

A

o Clean with saline
o Eye drops lubricating
o Usually self-limiting and rarely causes loss of vision (resolves within 5-10 days)

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89
Q

Management of allergic conjunctivitis -general advice?

A

 Avoid allergens, ventilate home, washing hair before bed
 Avoid eye rubbing
 Cold compress on eyes
 Artificial tears help lubricate eye

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90
Q

Management of allergic conjunctivitis - drug treatment?

A

 Topical antihistamines

 Cromoglycate eye drops

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91
Q

Causes of eye trauma?

A 
o	Mechanical trauma (fingernail, twig, paper edge, mascara brush, trichiasis)
o	Foreign bodies (dust, rust, glass)
o	Chemical burns
o	Exposure to UV light
o	Contact lenses on insertion or removal
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92
Q

Symptoms of eye trauma?

A 
o	Precipitating event of injury
o	Unilateral sudden onset eye pain on blinking
o	Gritty or scratchy sensation
o	Lacrimation
o	Photophobia
o	Blurred vision
o	Conjunctival redness
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93
Q

Signs of penetrating injury eye trauma?

A

o Distorted globe
o Conjunctival laceration
o Distorted iris or pupil
o Air bubbles under cornea

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94
Q

Signs of abrasion in eye trauma?

A

o Ciliary injection

o Epithelial defect with fluorescein

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95
Q

Signs of foreign body in eye trauma?

A

o Visible FB

o Rust ring, if ferrous FB embedded

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96
Q

Management of eye trauma - when to refer?

A 
o	Suspected penetrating eye injury or foreign body suspected
o	Orbital trauma
o	Chemical Injury
o	Retained foreign body
o	Corneal ulcer
o	Metallic rust ring
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97
Q

Management of eye trauma - corneal abrasion?

A

 Refer large abrasions
 Topical chloramphenicol ointment for 7 days
• Fusidic acid 2nd line
 Oral paracetamol
 Avoid wearing contact lenses for two weeks
 Re-evaluate in 24 hours to check resolving
 Follow up in 24 hours
• Refer is vision worsening, symptoms not improving, abrasion increased in size, rust ring

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98
Q

Management of eye trauma - corneal foreign body?

A

 Refer if cannot removed/not competent
 Remove loose superficial foreign body
 Irrigate with saline
• If fails, apply topical ocular anaesthetic (amethocaine) and sweep sterile cotton-tipped over cornea
 Oral paracetamol
 Refer is not able to remove foreign body
 After removal examine and treat for corneal abrasion accordingly
 Follow up in 24 hours
• Refer is vision worsening, symptoms not improving, abrasion increased in size, rust ring

99
Q

Management of eye trauma - rust rings?

A

 Develop within hours of metallic FB, removed using rotating sterile burr using slit lamp

100
Q

Management of eye trauma - orbital trauma?

A

o CT scan to detect fractures
• Do not touch, manipulate or pad the eye
• Do not check IOP
• Rigid eye shield
• Refer immediately – will need antibiotic cover and surgery
• NBM

101
Q

Management of eye trauma - chemical injury?

A

o Irrigate with saline, lactate ringer solution or water for 20-30 minutes
o Topical anaesthetic to keep eye open, every 5 minutes
o pH testing
o Broad-spectrum topical antibiotic, cycloplegic and anti-glaucoma
o If corneal scarring – surgical debridement

102
Q

Prognosis of eye trauma?

A
  • Good – mostly heal within 1-2 days without visual impairment but can take up to 5 days
  • Chemical injuries depend on:
    o pH of chemical
    o Duration of contact with ocular surface
    o How quickly eye is irrigated
103
Q

Complications of eye trauma?

A
  • Corneal ulceration
  • Infective keratitis
  • Iritis
  • Recurrent erosion syndrome
104
Q

Description of diabetic retinopathy?

A
  • Retinal consequence of chronic progressive diabetic microvascular leakage and occlusion
  • Occurs to some degree in all DM patients
  • Other eye problems in diabetics:
    o Cataracts, glaucoma, ocular motor nerve palsies
105
Q

Pathogenesis of diabetic retinopathy?

A

o Vascular occlusion – ischaemia and new vessel formation which bleed
o Vascular leakage – microaneurysms, oedema and hard exudates (lipoproteins), blot haemorrhages

106
Q

Risk factors of diabetic retinopathy?

A 
o	Younger onset of diagnosis
o	Long duration of diabetes
o	Poorly controlled
o	Hypertension
o	Renal disease
107
Q

Symptoms of diabetic retinopathy?

A

o Painless, gradual visual loss

o Dark, painless floaters

108
Q

4 stages of diabetic retinopathy?

A

o Background (non-proliferative) – capillary microaneurysms, blot haemorrhages, hard exudates (yellow/white irregular outline)

o Pre-proliferative – cotton wool spots (greyish with dull surface)

o Proliferative – New blood vessels

o Maculopathy – Bleeds/Exudates encroach on macula and cause decreased visual acuity

109
Q

Investigations of diabetic retinopathy?

A
  • Retinal photography with ophthalmoscopy
110
Q

Prevention of diabetic retinopathy?

A

o Improve glycaemic control
o Correct hypertension
o Lipid control
o Smoking cessation

111
Q

Management of diabetic retinopathy in diabetes?

A
  • On diagnosis, refer to local eye screening service, within 3 months and repeat annually
  • Annual retinal screening programme
    o Visual acuity
    o Digital fundus photography
112
Q

Management of diabetic retinopathy - when to refer for emergency review by ophthalmologist?

A

o Sudden loss of vision
o Rubeosis iridis
o Pre-retinal or vitreous haemorrhage
o Retinal detachment

113
Q

Management of diabetic retinopathy - when to refer for routine review by ophthalmologist?

A

o Maculopathy
o Pre-proliferative retinopathy
o Sudden drop in visual acuity

114
Q

Management of diabetic retinopathy - treatment of maculopathy?

A

o Macular and panretinal laser photocoagulation
o Intravitrial injection of anti-VEGF
o Severe - Vitrectomy surgery
o Refractory disease - Intravitrial corticosteroids

115
Q

Complications of diabetic retinopathy?

A

o Cataracts
o Postvitrectomy – cataract, haemorrhage
o Visual loss

116
Q

Description of hypertensive retinopathy?

A
  • Microvascular abnormalities associated with persistently raised BP
117
Q

Grades of hypertensive retinopathy?

A

o Grade 1 – Tortuous arteries, narrowing of vessels

o Grade 2 – AV nipping, silver-copper wiring

o Grade 3 – Flame and splinter haemorrhages, soft ‘cotton wool’ exudates, hard exudates

o Grade 4 – Papilloedema

118
Q

Risk factors of hypertensive retinopathy?

A
  • Uncontrolled hypertension

- Malignant hypertension

119
Q

Symptoms of hypertensive retinopathy?

A

o Usually asymptomatic
o May have decreased visual acuity
o Malignant hypertension – headaches, low visual acuity

120
Q

Fundoscopt findings of hypertensive retinopathy?

A

o Grade 1 – Tortuous arteries, narrowing of vessels

o Grade 2 – AV nipping, silver-copper wiring

o Grade 3 – Flame and splinter haemorrhages, soft ‘cotton wool’ exudates, hard exudates

o Grade 4 – Papilloedema

121
Q

Management of hypertensive retinopathy?

A
  • Correct BP

- If malignant hypertension – emergency admission and urgent reduction in BP

122
Q

Complications of hypertensive retinopathy?

A

o Retinal vein or artery occlusion

o Ischaemic optic neuropathy

123
Q

Definition of acne?

A
  • Chronic inflammation of pilosebaceous units producing comedones, papules, pustules, cysts and scars
124
Q

Pathology of acne?

A

o Increased sebum production – seborrhoea
o Pilosebaceous gland hyperkeratosis and comedone formation
o Colonisation with proprionibacterium acnes (P.acnes)
o Releases inflammatory mediators

125
Q

Epidemiology of acne?

A
  • Affects nearly every adolescent to some degree
    o 20-30% have moderate or severe
  • Peak age 18, peaks around puberty
  • Males during adolescence but females in adulthood
  • Mostly on face, back and chest
126
Q

Risk factors of acne?

A 
o	Family history
o	High fat diets
o	Hormonal changes – steroid containing pills
o	PCOS
o	Cosmetic skin products
127
Q

Symptoms and signs of acne?

A
  • Comedomes are either open (blackheads) or closed (whiteheads) or pus-filled (pustules)
  • Scars may be ice pick or keloid
128
Q

Severity assessment of acne?

A

o Mild – predominately non-inflamed lesions with few inflammatory lesions
o Moderate – more widespread with increased number of inflammatory papules and pustules
o Severe – widespread inflammatory papules, pustules or cysts

129
Q

Diagnosis of acne?

A
  • Clinical diagnosis
130
Q

Management of acne - general advice?

A

o Avoid over cleaning skin (causes dryness and irritation)
o It is not caused by poor hygiene
o Avoid picking or squeezing spots – risk of scarring
o Treatments take time to work (weeks) and may irritate skin initially
o Maintain healthy diet

131
Q

Management of acne - mild-to-moderate acne?

A

12 week course of OD evening:
Topical adapalene with topical benzoyl peroxide
Topical tretinoin with topical Clindamycin
Topical benzoyl peroxide with topical clindamycin
Topical benzoyl peroxide (if tretonoin/Abx CI or not wanted)

Cream or lotions less greasy

132
Q

Management of acne - acne not responding?

A

12week course of:
Topical adapalene with topical Benzoyl peroxide
Topical tretinoin with topical clindamycin
Topical adapalene with topical benzoyl peroxide with oral doxycycline/lymecycline
Topical azelaic acid with lymecycline/doxycycline

Add Oral doxycycline (100mg OD)/lymecycline for 3 months
 Use with topical retinoid and benzoyl peroxidase

In women, COCP for 3 months

133
Q

Management of acne - follow up?

A

o Every 8-12 weeks

 If responded at 12 weeks – maintenance topical retinoid or azelaic acid

134
Q

Management of acne - referral to dermatologist?

A

o Severe acne
o Visible scarring
o Multiple treatments have failed

135
Q

Management of acne - specialist management of severe acne?

A

o Isotretinoin oral

136
Q

Complications of acne?

A

o Skin changes – scarring, post-inflammatory pigmentation changes
o Psychological effects

137
Q

Prognosis of acne?

A

o Usually resolves after end of growth
o Can persist for years
o Females more likely to persist

138
Q

Definition of eczema?

A
  • Chronic, itchy, inflammatory skin condition affect people of all ages, most frequently in childhood
  • Typically, episodic flares and remission
139
Q

Pathology of eczema?

A

o Skin barrier dysfunction causes water loss leading to dryness and itching, skin susceptible to allergens leading to IgE hypersensitivity and predisposes to infections

140
Q

Associated diseases with eczema?

A
  • Atopic describes eczema, asthma, hay-fever and food allergy linked to increase allergic immune system
141
Q

Epidemiology of eczema?

A
  • Prevalence increasing
  • Around 20% of children and 5% of adults
  • Mostly <5 years old
142
Q

Risk factors of eczema?

A
  • Smaller families
  • Urban areas
  • Higher socio-economic classes
143
Q

Aetiology of eczema?

A
  • Genetic
    o Mutations of filaggrin
  • Environmental
    o Soap, animal dander, house-dust mites, extreme temperatures, clothing, pollen, foods and stress
  • Family History in 70%
144
Q

Symptoms of eczema?

A 
o	Itch
o	Rash
o	Dryness, itching
o	Redness, scaling and crusting of skin
o	Lichenified if chronic
o	Usually flexures of limbs
o	Can be on hands, scalp, face
o	Starts in infancy, episodic
o	Family history of atopy
145
Q

Triggers of eczema?

A 
o	Allergens – soaps, detergents, pollen
o	Irritants – synthetics, silk, cotton
o	Infections
o	Contact – perfume, metals, latex
o	Climate
o	Diet – foods, diarrhoea, weight loss
146
Q

Severity assessment of eczema?

A

o Clear
o Mild – dry skin, infrequent itching
o Moderate – dry skin, frequent itching redness (with/without excoriation and lichenification)
o Severe – widespread dry skin, incessant itching, redness, bleeding, oozing
o Infected – weeping, crusted, pustules

147
Q

Management of eczema - general advice?

A 
o	Instruct on emollients and creams
o	Avoid triggers known to exascerbate
o	Don’t scratch – keep nails short
o	Do not alter diet
o	BAD leaflet
148
Q

Management of eczema - mild eczema?

A

o Emollients – liberal use (E45, Aveeno)

o Mild topical corticosteroid (Hydrocortisone 1%)

149
Q

Management of eczema - moderate eczema?

A

o Admit if eczema herpeticum
o Emollients – liberal use (E45, Aveeno)
o Moderately potent corticosteroid (betamethasone valerate 0.025% or clobetasone butyrate 0.05%)
o Occlusive bandages
o Antihistamine if itchy
o Prevention with – corticosteroids, or topical calcineurin inhibitors (tacrolimus)

150
Q

Management of eczema - severe eczema?

A

o Admit if eczema herpeticum
o Emollient – liberal use (E45, Aveeno)
o Potent topical corticosteroid (betamethasone valerate 0.1%)
o Antihistamine if itchy
o Oral corticosteroid if severe psychological distressing eczema
o Prevention with – corticosteroids, or topical calcineurin inhibitors (tacrolimus)

151
Q

Management of eczema - infected eczema?

A

Flucloxacillin (erythromycin if pen allergic)

Creams/ointments containing antibiotics if localised

152
Q

Management of eczema - follow up?

A
  • 3-6 months to review regular maintenance therapy

- Annual if emollients being used

153
Q

Management of eczema - when to refer to dermatology?

A

o Management not controlled, facial eczema especially

o Severe or recurrent secondary infection

154
Q

Prognosis of eczema?

A
  • Episodic flares
  • Tends to improve through adulthood
  • Children may go on to develop asthma and/or hay-fever
155
Q

Definition of psoriasis?

A
  • Systemic, immune-mediated, inflammatory skin disease

- Typically, chronic relapsing-remitting course

156
Q

Pathology of psoriasis?

A

o Epidermal hyperproliferation
o Abnormal keratinocyte differentiation
o Lymphocyte infiltration

157
Q

Classification of psoriasis?

A

o Chronic plaque psoriasis (including scalp and facial) – most common 80%
o Localised pustular psoriasis of palms and soles
o Flexural psoriasis – inverse pattern
o Guttae psoriasis – droplet psoriasis
o Rarer, erythrodermic psoriasis and generalised pustular psoriasis

158
Q

Epidemiology of psoriasis?

A
  • 2% of world population
  • Peak incidence between 20-30 and 50-60 years of age
  • Men and women equally
  • More common in white people
159
Q

Trigger for episode of psoriasis?

A
  • Streptococcal infection
  • Drugs – Lithium, chloroquine, beta-blockers, NSAIDs, ACEi, tetracycline
  • UV light exposure
  • Trauma
  • Hormonal changes
  • HIV
  • Stress
  • Alcohol and Smoking
160
Q

Symptoms of psoriasis?

A
  • Itch
  • Irritation
  • Burning
  • Pain
  • Bleeding
  • Scaling
  • Systemic symptoms – fever, malaise, hypothermia, hypotension (in GPP and EP)
161
Q

Typical rash of psoriasis?

A
  • Extensor surfaces (elbows and knees), trunk, flexures, sacral, scalp and behind ears
  • Large plaques, clear delineation between normal and diseased skin (guttate more small droplet lesions)
  • Severity classed using 7-point PGA score
  • Scaly and may be pink/red – typically silvery scale
  • Pin-point bleeding (Auspitz’s sign)
162
Q

Associated condition in psoriasis?

A
  • Psoriatic Arthritis
    o Seronegative arthritis usually developing after skin lesions
    o Inflammation, pain, swelling especially knees, ankles, hands (dactylitis) and feet
  • Nail changes
    o Pitting, discoloration to nail bed, subungual hyperkeratosis, onycholysis
  • Metabolic Syndrome
    o Obesity, hyperlipidemia, hypertension, type 2 DM, IHD, IBD
  • Anxiety and Depression
163
Q

Management of psoriasis - GPP and EP?

A

GPP and EP are life-threatening and medical emergency

o Same day dermatology assessment

164
Q

Management of psoriasis - general advice?

A

o Explain treatment is aimed to control symptoms and not cure
o Leaflet

165
Q

Management of psoriasis - lifestyle advice?

A

o Stop smoking, restrict alcohol, weight loss

o Keep nails short – if nail problems then dermatology review

166
Q

Management of psoriasis
- chronic plaque psoriasis

A

Emollients (E45, Aveeno)
 Creams, lotions or gels for widespread
 Ointments for thick scale

~~~
Potent Topical corticosteroids (localised areas) + topical vitamin D analogue
 Used short-term if specific areas
 Not long-term as risk of deterioration into unstable EP and GPP form

Vitamin D preparation
 Calcipotriol

If poor response after 4 weeks:
-Continue for another 4 weeks or try stopping steroid and continuing vitamin d for 12 weeks
- vitamin D + Coal tar preparation
- Salicylic acid if scaly problematic

167
Q

Management of psoriasis - specialist treatments?

A

o Tacrolimus for difficult-to-treat sites
o UVB Phototherapy (2-3x a week)
o Methotrexate, ciclosporin
o Adalimumab, eternacept or infliximab if other treatments not tolerated/working

168
Q

Management of psoriasis - follow up?

A
  • 4 weeks after treatment initiation
    o Do not apply corticosteroid for more than 8 weeks at any one site
    o May need to move to potent corticosteroid
  • Annually if using short-courses of potent corticosteroids
  • Assess cardiovascular risk every 5 years
169
Q

Management of psoriasis - when to refer?

A
  • Extensive psoriasis or moderately severe using PGA
  • Medications not improving symptoms
  • Impact to psychosocial well-being
170
Q

Prognosis of psoriasis?

A
  • Remission occurs spontaneously in 25% of people and can last months
  • Guttate psoriasis usually lasts 3-4 months and is self-limiting – 1/3 develop classical disease
  • Early onset, being female and having FHx give worse prognosis
171
Q

Description of warts?

A
  • Small, rough growths caused by infection of keratinocytes with strains of Human Papilloma Virus (HPV)
  • Spread by direct skin-to-skin contact or via contaminated floors or surfaces
172
Q

Causes of warts?

A

strains of HPV

173
Q

Types of warts?

A

o Common Wart
 Papules and nodules with keratotic and papillomatous surface
o Flat wart
o Plantar Wart (verruca)
o Filiform Wart
 Small finger-like warts of hyperkeratotic projections
 Usually on face

174
Q

Symptoms and signs of warts?

A
  • Commonly on hands and feet
    o Verruca = wart on sole of foot
  • Lesion
    o Firm, raised with rough surface that resembles a cauliflower
    o Paring down the wart will lead to bleeding
175
Q

Management of warts - when to consider treatment?

A

o Painful
o Cosmetically unsightly
o Person requests treatment

176
Q

Management of warts - when to refer to dermatologist?

A 
o	Facial wart
o	Diagnosis uncertain
o	Immunocompromised
o	Extensive
o	Persists beyond primary care treatment
177
Q

Management of warts - general advice?

A

o Contagious but risk of transmission low
o To reduce risk:
 Cover wart with water proof plaster when swimming
 Wear flip flops in communal showers
 Avoid sharing socks, shoes, towels
 Avoid scratching, biting nails

178
Q

Management of warts - primary care treatments?
When and what?

A

Consider treatment if painful, cosmetically unsightly, person requests

Facial - refer to dermatology

Non Facial
o Topical salicylic acid applied daily for up to 12 weeks
| o Cryotherapy with liquid nitrogen (every 2 weeks for 3-4 months until gone)

Or combination
Younger children topical salicylic acid

179
Q

Management of warts - secondary care treatments?

A 
o	Physical removal – surgery, curettage, laser
o	Podophyllotoxin – topical
o	Retinoids
o	Bleomycin
o	Imiquimod
o	5-FU
180
Q

Definition of basal cell carcinoma?

A
  • Slow growing, locally invasive malignant epidermal skin tumours
181
Q

Epidemiology of basal cell carcinoma?

A
  • Very common - 75,000 diagnosed by year
  • Caucasians predominantly
  • Incidence increases with age
182
Q

Risk factors of basal cell carcinoma?

A

o Exposure to UV radiation
o Age
o Male
o People who burn easily

183
Q

Types of basal cell carcinoma?

A 
Nodular
	Solitary, shiny red nodule with large vessels
	Common on face
	Cystic, pearly, telangectasia
	May be ulcerated

Superficial
 Multiple, usually upper trunk
 Erythematous well-demarcated scaly plaques

Morphoeic
 Mid-facial sites and more aggressive
 Thickened yellow plaque

Pigmented

184
Q

Areas affected by basal cell carcinoma?

A

o Head and neck most commonly

185
Q

Lesion in basal cell carcinoma?

A

o Ulcer with raised pearly-coloured rolled edge
o Prominent fine blood vessels around lesion (telangiectasia)
o Nodule on skin

186
Q

Diagnosis of basal cell carcinoma?

A
  • Clinical suspicion

- Excisional biopsy – histology

187
Q

Management of basal cell carcinoma - referral?

A

o Routine referral if skin lesion raises suspicion of BCC

o 2-week referral if concern that delay may have significant impact (site, size)

188
Q

Management of basal cell carcinoma - low risk BCCs?

A

o Primary care – if located below clavicle and is <1cm and not recurrent
o Excision then performed by GP

189
Q

Management of basal cell carcinoma - types of management?

A

Surgery
Radiotherapy
Medical treatment

190
Q

Management of basal cell carcinoma - surgery?

A

 Excised with primary closure, flaps and grafts
• Incompletely excised BCCs must be re-excised

 Mohs micrographic surgery
• Excision of skin and examination under microscope to see margins
• Used in difficult anatomical sites or recurrent BCCs

 Curettage and Cautery
• Only for small tumour not on the face
• Used in low risk BCC

 Cryotherapy
• Low-risk BCCs

191
Q

Management of basal cell carcinoma - non-surgical?

A 
o	Radiotherapy
o	Medical
	Imiquimod 5% cream
	Fluorouracil 5% cream
	Photodynamic therapy
192
Q

Management of basal cell carcinoma - prevention?

A

o Avoid UV exposure in susceptible individual
o Stay out of the sun between 10am and 4pm
o High-factor sunscreens
o Hats, long sleeved shirts and trousers

193
Q

Prognosis of BCC?

A

o Very rare to die from BCC

o Early diagnosis leads to less extensive treatment

194
Q

Definition of squamous cell carcinoma?

A
  • Malignant tumour arising from keratinising cells of the epidermis or its appendages
  • Locally invasive and potential to metastasise to other organs
195
Q

Epidemiology of squamous cell carcinoma?

A
  • 2nd most common skin cancer

- Incidence rising and rises with age

196
Q

Risk factors of squamous cell carcinoma?

A 
o	UV radiation exposure
o	Fair skin, blonde hair
o	Chemical carcinogens
o	Immunodeficiency
o	Pre-malignant conditions – Bowen’s disease, actinic keratoses, keratoacanthomas
197
Q

Lesion of squamous cell carcinoma?

A
  • Indurated nodular keratinizing or crusted tumour that may ulcerate
    o Non-healing ulcer
    o Small nodule enlarges and centre becomes necrotic
    o Hard, raised edges
    o Bleeding may occur
  • Usually on head and neck
198
Q

Diagnosis of squamous cell carcinoma?

A
  • Clinical inspection
  • Skin biopsy
    o Excisional – small lesions, not cosmetically sensitive areas, wide margins
    o Incisional – large lesions
  • CT if extensive
199
Q

Management of squamous cell carcinoma - referral?

A

o 2-week pathway for suspect cancer

200
Q

Management of squamous cell carcinoma - treatment?

A

o Surgical excision and sent for histology
o Other option:
 Curettage and cautery
 Cryotherapy
 Topical Imiquimod 5% or 5-Fluorouracil 5%
 Photodynamic therapy
 Radiotherapy

201
Q

Management of squamous cell carcinoma - prevention?

A

o Avoid UV exposure in susceptible individual
o Stay out of the sun between 10am and 4pm
o High-factor sunscreens
o Hats, long sleeved shirts and trousers

202
Q

Factors affecting metastatic potential of SCCs?

A 
o	Site – sun-exposed areas
o	Diameter >2cm
o	Depth >4mm
o	Poorly differentiated
o	Host immunosuppression
203
Q

Prognosis of SCCs?

A

o Death is rare

o Early diagnosis leads to less extensive treatment

204
Q

Definition of melanoma?

A
  • Abnormal proliferation of melanocytes
205
Q

Risk factors of melanoma?

A 
o	Personal history of skin cancer
o	Family history of skin cancer
o	Pale skin
o	Blonde/red hair
o	History of sunburn
o	Sunbed use
o	Large number of moles
o	Age
206
Q

Types of melanoma?

A 
o	Superficial spreading – most common
o	Nodular
o	Lentigo Maligna
o	Acral Lentiginous
o	Amelanotic Melanoma
207
Q

Types of melanoma - superficial spreading?

A

 Stays within epidermis and spread horizontally
 Flat pigmented lesion with asymmetrical or irregular borders

MOST COMMON

208
Q

Types of melanoma - nodular?

A

 Atypical nodule that ulcerates and bleeds
 Common on legs or trunk
 Can spread rapidly

209
Q

Types of melanoma - lentigo maligna?

A

 Slow growing patch of brown skin, often like a freckle

 Irregular brown macule, which grows slowly

210
Q

Types of melanoma - acral lentiginous?

A

 Soles of feet and palms of hand

 Flat pigmented area, increasing in size and irregularity

211
Q

Types of melanoma - amelanotic melanoma?

A

 Pink coloured nodule which lacks pigmentation

212
Q

Assessment of melanoma? When to refer?

A 
Weighted 7-point checklist
	Major Features (2 points)
•	Change in size
•	Irregular shape/border
•	Irregular colour
	Minor Features (1 point)
•	Largest diameter >7mm
•	Inflammation
•	Oozing or crusting of lesion
•	Itch/Change in sensation
	3 point of more (or suspicious) – prompt referral to 2-week appointment
213
Q

Other assessment used in melanoma?

A

ABCDE

	Asymmetry
	Border Irregular
	Colour Irregular
	Diameter >7mm
	Evolving
214
Q

Management of melanoma - referral?

A
  • Referral to dermatologist
    o 3 or more point on Weighted 7-point score – 2-week wait
  • Routine referral for risk estimation and follow-up if:
    o Giant congenital pigmented naevi
    o Family history of 3 or more cases of melanoma
    o >100 moles
    o Atypical mole (multiple)
215
Q

Management of melanoma - safety net?

A

o Seek advice if getting bigger, changing shape/colour, itchy, bleeding

216
Q

Management of melanoma - secondary care investigations?

A

o Dermatoscope
 If atypical lesions but no excision – review after 3 months

o Full-thickness excisional biopsy
 Histology and staging

o	Staging
	TNM
	Sentinel node biopsy – if Stage 1B-2C
	CT – Stage 2C and above
	Whole-body MRI in young patients
217
Q

Management of melanoma - secondary care management - general measures?

A

o Sun protection advice
 Avoid UV exposure in susceptible individual
 Stay out of the sun between 10am and 4pm
 High-factor sunscreens
 Hats, long sleeved shirts and trousers
o Measure Vitamin D levels – give supplements if needed
o Minimise immunosuppressant therapy for other conditions

218
Q

Management of melanoma - secondary care management - Stage 0-2?

A

o Surgery - Wide Local Excision

o Topical Imiquimod if surgery not an option

219
Q

Management of melanoma - secondary care management - Stage 3?

A 
o	Wide local excision
o	Completion lymphadenectomy (if sentinel nodes have micro-metastases)
o	Lymph node dissection (if needed)
o	Adjuvant radiotherapy
o	Palliative surgery/systemic therapy
220
Q

Management of melanoma - secondary care management - Stage 4?

A

o Surgery or ablative treatments to prevent and control symptoms

221
Q

Follow up of melanomas?

A

o Stage 1A – 2-4 times during first year and discharge

o Stage 1B-3 – Every 3 months for 3 years then every 6 months for 2 years

222
Q

Prognosis of melanomaS?

A

o Advance stages cause serious morbidity and mortality
o Depends on stage, level of ulceration and spread
o Highest incidence of mortality in any skin cancer
o 90% survive 10 years

223
Q

Definition of leg ulcer?

A
  • Leg ulcer = Break in the skin below the knee, not healed within 2 weeks
224
Q

What is most common type of leg ulcer and where?

A
  • Venous leg ulcer is most common type of leg ulcer

o Typically occurs from ankle to mid-calf

225
Q

Types of leg ulcer?

A 
o	Venous
o	Arterial
o	DM
o	RA
o	Neuropathic
o	Malignant
o	Drugs – nicorandil, corticosteroids, NSAIDs
o	Pyoderma gangrenosum
226
Q

Risk factors of venous leg ulcers?

A 
o	Increasing age
o	Obesity
o	Immobolity
o	Previous ulcer
o	Fhx or Hx of varicose veins
o	Female sex
o	Multiple pregnancies
o	Hx of leg fracture or trauma
o	Sedentary
227
Q

Pathology of venous leg ulcers?

A

o Sustained venous hypertension, results from chronic venous insufficiency due to valve incompetence or impaired calf muscle pump

228
Q

Risk factors of arterial leg ulcers?

A 
o	CHD
o	Hx of stroke or TIA
o	DM
o	PAD
o	Obesity
o	Immobility
229
Q

Symptoms of venous leg ulcers?

A

o Pain, heaviness, aching, swelling and itching of affected leg
 Worse at end of the day and relieved by leg elevation
o Ulcer
 Typically, gaiter area - ankle to mid-calf (above medial malleolus)
 Wound edge sloping, irregular edges
o Pitting oedema
o Skin Changes in venous ulcers:
 Hyperpigmentation
 Venous eczema
 Lipodermatosclerosis

230
Q

Symptoms of arterial leg ulcers?

A 
o	Distal and on dorsal foot or toes
o	Clearly defined ulcer
	Punched out ulcer
o	Nocturnal pain, worse when supine and relived when dangled over bed
o	Skin Changes
	Hairless
	Pale skin
	Absent pulses
	Wasted calves
231
Q

Assessment in leg ulcers?

A
  • ABPI
    o Determines arterial insufficiency
    o <0.5 – severe arterial disease, compression CI, refer to vascular specialist
    o 0.5-0.8 – arterial disease, avoid compression, refer to vascular specialist
    o 0.8-1.3 – no disease
    o >1.3 – arterial calcification in DM, RA, systemic vasculitis, atherosclerotic disease and CKD
  • Other tests:
    o FBC, CRP, ESR, U&E, albumin, HbA1c
  • Swabs if evidence of infection
232
Q

Management of leg ulcers - immediate referral?

A

o Vascular – ABPI <0.8

o Dermatology – deteriorating, malignancy, poor ankle mobility

233
Q

Management of venous leg ulcers - lifestyle advice?

A

 Paracetamol with or without codeine
 Elevate legs for 30 minutes 3-4 times a day
 Pillow under legs whilst sleeping
 Regular walking

234
Q

Management of venous leg ulcers - Medical treatment?

A

o Clean and dress ulcer – district nurse
o Compression Therapy
o Pentoxifylline 400mg TDS for up to 6 months

235
Q

Management of venous leg ulcers - if signs of infection?

A

 Swab
 Oral flucloxacillin 500mg QDS for 7 days (clarithromycin)
 If worsening, co-amoxiclav 500/125mg TDS for 7 days
 Refer if signs of sepsis, necrotising fasciitis, osteomyelitis

236
Q

Management of venous leg ulcers - follow up?

A

o Follow up weekly for first 2 weeks

 Below-knee graduated compression stockings, once healed to prevent recurrence

237
Q

Complications of venous leg ulcers?

A 
o	Chronic pain
o	Impaired mobility
o	Infection
o	Allergic contact dermatitis
o	Marjolin’s ulcer
238
Q

Prognosis of venous leg ulcers?

A

o 6-month heal rate around 50%

o Poor prognostic factors – wound >1 year, larger wounds, ABPI <0.8, lower socioeconomic group

239
Q

Describe lesions in chronic plaque psoriasis

A

Monomorphic, erythematous plaques covered with silvery scale

Scalp, behind ears, trunks, buttocks, extensor surfaces

Typically symmetrical

Clear demyelination from normal skin

If scale removed, glossy red membrane with pinpoint bleeeding (Auspitz sign)

240
Q

Describe lesions in pustular psoriasis (generalised and localised)

A

Generalised
- life threatening medical emergency
- rapidly developing erythema, eruption of white pustules which coalesce
- fever, malaise, tachycardia, weight loss

Localised
- palms and soles, yellow brown pustules within psoriatic plaques

241
Q

Describe lesions in erythrodermjc psoriasis

A

Medical emergency
Diffuse widespread severe psoriasis affecting more than 90% of body
Precipitated by systemic infection, irritants, phototherapy,withdrawal of steroids
Systemically unwell

242
Q

Describe lesions in guttate psoriasis

A

Small scattered round scaly papules pink or red
All over body, trunk and proximal limbs
Children or young adults
Usually after streptococcal infection

243
Q

Nail changes in psoriasis

A

Nail pitting
Orange yellow discolouration (oil drop sign)
Subungual hyperkeratosis
Onycholysis (detachment of nail)

MSRA Content (87 decks)

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