Ophthalmology & Skin - Level 1/2 Flashcards
Definition of glaucoma?
- 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
Anatomy of eye - anterior chamber?
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
Anatomy of eye - aqueous humour?
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
Normal IOP of eye?
Pressure between 11-21mmHg is normal
Classifications of glaucoma?
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
Definition and types of open angle glaucoma?
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
Definition and types of angle closure glaucoma?
o Primary angle closure glaucoma
Onset may be acute, subacute or chronic
Acute is medical emergency
o Secondary angle closure glaucoma
How common is ocular hypertension, POAG, PACG?
- Ocular hypertension – 3-5% of over 40 year olds
- POAG – 2% of over 40s – increases with age
- PACG – women 3x more, increases with age
Risk factors of open angle glaucoma?
Raised IOP Older age FHx Black people Corticosteroid treatment Myopia T2DM Hypertension
Risk factors of angle-closure glaucoma?
Older age
Women 2-3x
Asian people
Short, hyperopic eyes
Aetiology of primary open angle glaucoma?
Visual loss due to damage to retinal ganglion cells due to raised IOP causing mechanical pressure damage to axons of cells
Aetiology of secondary open angle glaucoma?
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
Aetiology of primary angle-closure glaucoma?
Peripheral iris comes into contact with trabecular meshwork that restricts drainage of aqueous humour from eye
Symptoms of acute angle closure glaucoma?
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
Symptoms of ocular hypertension and POAG?
o Usually by optometrists in routine eye exams
o Increased IOP, visual field defects and cupped optic disc
When should people get examined for glaucoma?
- Advise people with the follow risk factors to get eyes examined:
o Older age
o FHx of glaucoma
o Black African
Management of acute angle closure glaucoma - primary care?
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
Management of acute angle closure glaucoma - secondary care initial treatment?
• Topical and IV drugs to reduce IOP
o Pilocarpine
o Acetazolamide
• Analgesia
Management of acute angle closure glaucoma - secondary care definitive treatment?
- Laser iridotomy (creates holes in iris to allow aqueous humour to flow into anterior chamber)
- Iridoplasty or cataract removal
Management of POAG or ocular hypertension - drug treatment?
o Under direction of ophthalmologist
o Drug treatment
Topical prostaglandin analogue or prostamide
• Latanoprost, travoprost
Topical beta-blocker
o Lifetime monitoring
Management of POAG or ocular hypertension - other treatments?
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
Prognosis of POAG?
o Progresses slowly without treatment over years, most people asymptomatic until severe disease
o Visual loss is peripheral at first
Prognosis of PACG?
o Half of glaucoma related blindness
o Needs prompt treatment
Definition of cataracts?
- Opacity forming within lens of the eye which reduces transparency
Classification of cataracts?
o Nuclear – central part of lens, most common
o Cortical – outer layer of lens
o Subcapsular – directly under lens capsule
Types of cataracts?
o Congenital – present at birth or within 1st year of life
o Developmental – develop after infancy
o Traumatic
Epidemiology of cataracts?
- Older age increases incidence
- Most common elective surgical procedure
Causes of cataracts?
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
Symptoms of cataracts?
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
Signs of cataracts?
o Reduced acuity
o Opacity seen in lens
o Red reflex reduced
When are babies screened for cataracts?
o All babies screened at birth and 6 weeks for cataracts
o May have nystagmus, squint, sensitivity to light, lighter pupil
Investigations of cataracts?
- Document last visual acuity if referring
- Slit lamp at optometrists
Management of cataracts - surgical treatment - when to refer for cataracts surgery?
- Visual impairment and affecting lifestyle (driving, reading)
- Comorbidity that may benefit from surgery – elderly falls risk
- Another eye condition where treatment will help
Management of cataracts - surgical treatment - benefits?
• Improve acuity, clarity and colour vision
Management of cataracts - surgical treatment - risks?
- Posterior capsular opacity – needs laser treatment
- Bruising to eye
- Raised intraocular pressure
- Macular oedema
- Need for glasses
- Detached retina
Management of cataracts - surgical treatment - biometry techniques before surgery?
- Optical biometry to measure axial length of eye
- Keratometry to measure curvature of cornea
- Used to calculate lens power
Management of cataracts - surgical treatment - surgical technique and drug managements?
- 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
Management of cataracts - fitness to drive?
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
Management of cataracts - in children?
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
Prognosis of cataracts?
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
Definitions of corneal abrasions, ulcers and dendritic ulcers?
- Corneal abrasions – defects in epithelial surface
- Corneal ulcer – epithelial defect with corneal infiltrate
- Dendritic ulcer – branching staining pattern characteristic of herpetic infection
Causes of corneal ulcers?
o Bacterial (pseudomonas progresses rapidly) o Herpetic (HSV, HZV) o Fungal (candida, aspergillus) o Protozoal (acanthamoeba) o Vasculitis (RA)
Risk factors of corneal ulcers?
o Contact lens wearer o Corneal trauma o Corneal abrasion o Immunocompromised o Trichiasis o Herpes infection
Symptoms of corneal ulcers?
o Severe eye pain
o Lacrimation
o Inability to open eye
o Red Eye
Signs of corneal ulcers?
o Reduced visual acuity
o Photophobia
o High IOP
Management of corneal ulcers in primary care?
- Refer to emergency eye service if:
o Corneal ulcer
Investigations of corneal ulcers in eye casualty?
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)
Management of dendritic ulcers?
o Aciclovir 3% eye drops – 5x daily (can be oral if severe)
o Atropine 1% drops for photophobia
o PRN analgesia (paracetamol & ibuprofen)
Management of corneal ulcers?
o Chloramphenicol + Ofloxacin drops
o Atropine 1% drops for photophobia
o PRN analgesia (paracetamol & ibuprofen)
o Topical steroid drops (prednisolone)
Management of fungal ulcers?
o Natamycin drops
o Atropine 1% drops for photophobia
o PRN analgesia (paracetamol & ibuprofen)
Management of acanthamoeba ulcers?
o Chlorhexadine drops
o Oral Itraconazole
o Atropine 1% drops for photophobia
o PRN analgesia (paracetamol & ibuprofen)
Description of stye?
- Also known as a hordeolum
- Acute localised infection or inflammation of eyelid margin
Types of stye?
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
Risk factors of stye?
o Chronic blepharitis o Acne rosacea o Ingrown eyelashes (trichiasis) o Ectropion o DM
Causes of stye?
o Staphylococcal infection – most common
Symptoms of stye?
- 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
Management of stye - in primary care?
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
Management of stye - when to refer and what management in ophthalmology?
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
Prognosis of stye?
o Self-limiting
o Resolution within 5-7 days
Complications of stye?
- Conjunctivitis
- Perioribital or orbital cellulitis
- Meibomian cyst (chalazion)
Description of Meibomian cyst (chalazion)?
o Sterile, inflammatory granuloma caused by obstruction of sebaceous gland
o Often indistinguishable from stye (chalazion usually less painful and acute)
Symptoms of Meibomian cysts?
Firm, painless, localised eyelid swelling developed over several weeks
Treatments of Meibomian cysts?
Apply warm compress, massage cyst after application in direction of eyelashes, refer if chronic
Definition of infective conjunctivitis?
- 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.
What is Ophthalmia neonatorum?
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
Causative organisms of infective conjunctivitis?
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
Causative organisms of Ophthalmia neonatorum?
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
Symptoms of viral infective conjunctivitis?
o Mild to moderate erythema o Subconjunctival haemorrhages o Watery discharge o Mild pruritus o URTI and pre-auricular lymph nodes
Symptoms of bacterial infective conjunctivitis?
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
STI causes of conjunctivitis?
o Chlamydia
Chronic low-grade irritation and mucous discharge, mostly unilateral
o Gonorrhoea
Rapid development of copious mucopurulent discharge, eyelide swelling, tender lymph nodes
Symptoms in Ophthalmia neonatorum?
o Discharge in first few weeks of life
Investigations if gonococcal infection suspected?
- Gram staining and culture if gonococcal suspected
Management of infective conjunctivitis - when to refer to ophthalmology?
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
Management of infective conjunctivitis - viral?
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
Management of infective conjunctivitis - bacterial?
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
Management of infective conjunctivitis - neonates?
o Treat with neomycin
Management of infective conjunctivitis - ophthalmia neonatorum?
o Gonococcal infection should be cultured and treated with 3rd generation cephalosporin given
o If chlamydia infection then treated with oral erythromycin
Prognosis of infective conjunctivitis?
- Viral – most cases resolve in 7 days
- Bacterial – resolves within 10 days
Definition of allergic conjunctivitis?
- 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
Types of allergic conjunctivitis?
Seasonal allergic (hayfever)
Perennial allergic – non-seasonal environmental allergences (houst dust mites, mould spores, animal dander)
Vernal keratoconjunctivitis – hot, arid environments
Atopic
Causes of allergic conjunctivitis?
o 15-40% of population
o Mostly in spring and summer
Epidemiology of allergic conjunctivitis?`
o Allergic, mechanical/irritative/toxic, immune-mediated and neoplastic
Symptoms of seasonal allergic conjunctivitis?
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
Symptoms of vernal keratoconjunctivitis?
o Typically resolves after puberty
o Worse in spring
o Giant papillae on superior tarsal conjunctiva, Horner’s points (yellow white points)
Symptoms of atopic allergic conjunctivitis?
o Chronic itching, tearing, swelling, corneal scarring
Management of allergic conjunctivitis - urgent referral to ophthalmology?
Atopic, vernal or giant papillary conjunctivitis
Severe or resistant conjunctivitis
Management of allergic conjunctivitis - routine referral to ophthalmology?
Atopic, vernal or giant papillary conjunctivitis
Severe or resistant conjunctivitis
Management of allergic conjunctivitis - sticky eyes in 1st few days of life?
o Clean with saline
o Eye drops lubricating
o Usually self-limiting and rarely causes loss of vision (resolves within 5-10 days)
Management of allergic conjunctivitis -general advice?
Avoid allergens, ventilate home, washing hair before bed
Avoid eye rubbing
Cold compress on eyes
Artificial tears help lubricate eye
Management of allergic conjunctivitis - drug treatment?
Topical antihistamines
Cromoglycate eye drops
Causes of eye trauma?
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
Symptoms of eye trauma?
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
Signs of penetrating injury eye trauma?
o Distorted globe
o Conjunctival laceration
o Distorted iris or pupil
o Air bubbles under cornea
Signs of abrasion in eye trauma?
o Ciliary injection
o Epithelial defect with fluorescein
Signs of foreign body in eye trauma?
o Visible FB
o Rust ring, if ferrous FB embedded
Management of eye trauma - when to refer?
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
Management of eye trauma - corneal abrasion?
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
Management of eye trauma - corneal foreign body?
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
Management of eye trauma - rust rings?
Develop within hours of metallic FB, removed using rotating sterile burr using slit lamp
Management of eye trauma - orbital trauma?
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
Management of eye trauma - chemical injury?
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
Prognosis of eye trauma?
- 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
Complications of eye trauma?
- Corneal ulceration
- Infective keratitis
- Iritis
- Recurrent erosion syndrome
Description of diabetic retinopathy?
- 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
Pathogenesis of diabetic retinopathy?
o Vascular occlusion – ischaemia and new vessel formation which bleed
o Vascular leakage – microaneurysms, oedema and hard exudates (lipoproteins), blot haemorrhages
Risk factors of diabetic retinopathy?
o Younger onset of diagnosis o Long duration of diabetes o Poorly controlled o Hypertension o Renal disease
Symptoms of diabetic retinopathy?
o Painless, gradual visual loss
o Dark, painless floaters
4 stages of diabetic retinopathy?
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
Investigations of diabetic retinopathy?
- Retinal photography with ophthalmoscopy
Prevention of diabetic retinopathy?
o Improve glycaemic control
o Correct hypertension
o Lipid control
o Smoking cessation
Management of diabetic retinopathy in diabetes?
- 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
Management of diabetic retinopathy - when to refer for emergency review by ophthalmologist?
o Sudden loss of vision
o Rubeosis iridis
o Pre-retinal or vitreous haemorrhage
o Retinal detachment
Management of diabetic retinopathy - when to refer for routine review by ophthalmologist?
o Maculopathy
o Pre-proliferative retinopathy
o Sudden drop in visual acuity
Management of diabetic retinopathy - treatment of maculopathy?
o Macular and panretinal laser photocoagulation
o Intravitrial injection of anti-VEGF
o Severe - Vitrectomy surgery
o Refractory disease - Intravitrial corticosteroids
Complications of diabetic retinopathy?
o Cataracts
o Postvitrectomy – cataract, haemorrhage
o Visual loss
Description of hypertensive retinopathy?
- Microvascular abnormalities associated with persistently raised BP
Grades of hypertensive retinopathy?
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
Risk factors of hypertensive retinopathy?
- Uncontrolled hypertension
- Malignant hypertension
Symptoms of hypertensive retinopathy?
o Usually asymptomatic
o May have decreased visual acuity
o Malignant hypertension – headaches, low visual acuity
Fundoscopt findings of hypertensive retinopathy?
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
Management of hypertensive retinopathy?
- Correct BP
- If malignant hypertension – emergency admission and urgent reduction in BP
Complications of hypertensive retinopathy?
o Retinal vein or artery occlusion
o Ischaemic optic neuropathy
Definition of acne?
- Chronic inflammation of pilosebaceous units producing comedones, papules, pustules, cysts and scars
Pathology of acne?
o Increased sebum production – seborrhoea
o Pilosebaceous gland hyperkeratosis and comedone formation
o Colonisation with proprionibacterium acnes (P.acnes)
o Releases inflammatory mediators
Epidemiology of acne?
- 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
Risk factors of acne?
o Family history o High fat diets o Hormonal changes – steroid containing pills o PCOS o Cosmetic skin products
Symptoms and signs of acne?
- Comedomes are either open (blackheads) or closed (whiteheads) or pus-filled (pustules)
- Scars may be ice pick or keloid
Severity assessment of acne?
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
Diagnosis of acne?
- Clinical diagnosis
Management of acne - general advice?
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
Management of acne - mild-to-moderate acne?
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
Management of acne - acne not responding?
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
Management of acne - follow up?
o Every 8-12 weeks
If responded at 12 weeks – maintenance topical retinoid or azelaic acid
Management of acne - referral to dermatologist?
o Severe acne
o Visible scarring
o Multiple treatments have failed
Management of acne - specialist management of severe acne?
o Isotretinoin oral
Complications of acne?
o Skin changes – scarring, post-inflammatory pigmentation changes
o Psychological effects
Prognosis of acne?
o Usually resolves after end of growth
o Can persist for years
o Females more likely to persist
Definition of eczema?
- Chronic, itchy, inflammatory skin condition affect people of all ages, most frequently in childhood
- Typically, episodic flares and remission
Pathology of eczema?
o Skin barrier dysfunction causes water loss leading to dryness and itching, skin susceptible to allergens leading to IgE hypersensitivity and predisposes to infections
Associated diseases with eczema?
- Atopic describes eczema, asthma, hay-fever and food allergy linked to increase allergic immune system
Epidemiology of eczema?
- Prevalence increasing
- Around 20% of children and 5% of adults
- Mostly <5 years old
Risk factors of eczema?
- Smaller families
- Urban areas
- Higher socio-economic classes
Aetiology of eczema?
- Genetic
o Mutations of filaggrin - Environmental
o Soap, animal dander, house-dust mites, extreme temperatures, clothing, pollen, foods and stress - Family History in 70%
Symptoms of eczema?
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
Triggers of eczema?
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
Severity assessment of eczema?
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
Management of eczema - general advice?
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
Management of eczema - mild eczema?
o Emollients – liberal use (E45, Aveeno)
o Mild topical corticosteroid (Hydrocortisone 1%)
Management of eczema - moderate eczema?
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)
Management of eczema - severe eczema?
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)
Management of eczema - infected eczema?
Flucloxacillin (erythromycin if pen allergic)
Creams/ointments containing antibiotics if localised
Management of eczema - follow up?
- 3-6 months to review regular maintenance therapy
- Annual if emollients being used
Management of eczema - when to refer to dermatology?
o Management not controlled, facial eczema especially
o Severe or recurrent secondary infection
Prognosis of eczema?
- Episodic flares
- Tends to improve through adulthood
- Children may go on to develop asthma and/or hay-fever
Definition of psoriasis?
- Systemic, immune-mediated, inflammatory skin disease
- Typically, chronic relapsing-remitting course
Pathology of psoriasis?
o Epidermal hyperproliferation
o Abnormal keratinocyte differentiation
o Lymphocyte infiltration
Classification of psoriasis?
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
Epidemiology of psoriasis?
- 2% of world population
- Peak incidence between 20-30 and 50-60 years of age
- Men and women equally
- More common in white people
Trigger for episode of psoriasis?
- Streptococcal infection
- Drugs – Lithium, chloroquine, beta-blockers, NSAIDs, ACEi, tetracycline
- UV light exposure
- Trauma
- Hormonal changes
- HIV
- Stress
- Alcohol and Smoking
Symptoms of psoriasis?
- Itch
- Irritation
- Burning
- Pain
- Bleeding
- Scaling
- Systemic symptoms – fever, malaise, hypothermia, hypotension (in GPP and EP)
Typical rash of psoriasis?
- 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)
Associated condition in psoriasis?
- 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
Management of psoriasis - GPP and EP?
GPP and EP are life-threatening and medical emergency
o Same day dermatology assessment
Management of psoriasis - general advice?
o Explain treatment is aimed to control symptoms and not cure
o Leaflet
Management of psoriasis - lifestyle advice?
o Stop smoking, restrict alcohol, weight loss
o Keep nails short – if nail problems then dermatology review
Management of psoriasis
- chronic plaque psoriasis
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
Management of psoriasis - specialist treatments?
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
Management of psoriasis - follow up?
- 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
Management of psoriasis - when to refer?
- Extensive psoriasis or moderately severe using PGA
- Medications not improving symptoms
- Impact to psychosocial well-being
Prognosis of psoriasis?
- 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
Description of warts?
- 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
Causes of warts?
strains of HPV
Types of warts?
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
Symptoms and signs of warts?
- 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
Management of warts - when to consider treatment?
o Painful
o Cosmetically unsightly
o Person requests treatment
Management of warts - when to refer to dermatologist?
o Facial wart o Diagnosis uncertain o Immunocompromised o Extensive o Persists beyond primary care treatment
Management of warts - general advice?
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
Management of warts - primary care treatments?
When and what?
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
Management of warts - secondary care treatments?
o Physical removal – surgery, curettage, laser o Podophyllotoxin – topical o Retinoids o Bleomycin o Imiquimod o 5-FU
Definition of basal cell carcinoma?
- Slow growing, locally invasive malignant epidermal skin tumours
Epidemiology of basal cell carcinoma?
- Very common - 75,000 diagnosed by year
- Caucasians predominantly
- Incidence increases with age
Risk factors of basal cell carcinoma?
o Exposure to UV radiation
o Age
o Male
o People who burn easily
Types of basal cell carcinoma?
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
Areas affected by basal cell carcinoma?
o Head and neck most commonly
Lesion in basal cell carcinoma?
o Ulcer with raised pearly-coloured rolled edge
o Prominent fine blood vessels around lesion (telangiectasia)
o Nodule on skin
Diagnosis of basal cell carcinoma?
- Clinical suspicion
- Excisional biopsy – histology
Management of basal cell carcinoma - referral?
o Routine referral if skin lesion raises suspicion of BCC
o 2-week referral if concern that delay may have significant impact (site, size)
Management of basal cell carcinoma - low risk BCCs?
o Primary care – if located below clavicle and is <1cm and not recurrent
o Excision then performed by GP
Management of basal cell carcinoma - types of management?
Surgery
Radiotherapy
Medical treatment
Management of basal cell carcinoma - surgery?
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
Management of basal cell carcinoma - non-surgical?
o Radiotherapy o Medical Imiquimod 5% cream Fluorouracil 5% cream Photodynamic therapy
Management of basal cell carcinoma - prevention?
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
Prognosis of BCC?
o Very rare to die from BCC
o Early diagnosis leads to less extensive treatment
Definition of squamous cell carcinoma?
- Malignant tumour arising from keratinising cells of the epidermis or its appendages
- Locally invasive and potential to metastasise to other organs
Epidemiology of squamous cell carcinoma?
- 2nd most common skin cancer
- Incidence rising and rises with age
Risk factors of squamous cell carcinoma?
o UV radiation exposure o Fair skin, blonde hair o Chemical carcinogens o Immunodeficiency o Pre-malignant conditions – Bowen’s disease, actinic keratoses, keratoacanthomas
Lesion of squamous cell carcinoma?
- 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
Diagnosis of squamous cell carcinoma?
- Clinical inspection
- Skin biopsy
o Excisional – small lesions, not cosmetically sensitive areas, wide margins
o Incisional – large lesions - CT if extensive
Management of squamous cell carcinoma - referral?
o 2-week pathway for suspect cancer
Management of squamous cell carcinoma - treatment?
o Surgical excision and sent for histology
o Other option:
Curettage and cautery
Cryotherapy
Topical Imiquimod 5% or 5-Fluorouracil 5%
Photodynamic therapy
Radiotherapy
Management of squamous cell carcinoma - prevention?
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
Factors affecting metastatic potential of SCCs?
o Site – sun-exposed areas o Diameter >2cm o Depth >4mm o Poorly differentiated o Host immunosuppression
Prognosis of SCCs?
o Death is rare
o Early diagnosis leads to less extensive treatment
Definition of melanoma?
- Abnormal proliferation of melanocytes
Risk factors of melanoma?
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
Types of melanoma?
o Superficial spreading – most common o Nodular o Lentigo Maligna o Acral Lentiginous o Amelanotic Melanoma
Types of melanoma - superficial spreading?
Stays within epidermis and spread horizontally
Flat pigmented lesion with asymmetrical or irregular borders
MOST COMMON
Types of melanoma - nodular?
Atypical nodule that ulcerates and bleeds
Common on legs or trunk
Can spread rapidly
Types of melanoma - lentigo maligna?
Slow growing patch of brown skin, often like a freckle
Irregular brown macule, which grows slowly
Types of melanoma - acral lentiginous?
Soles of feet and palms of hand
Flat pigmented area, increasing in size and irregularity
Types of melanoma - amelanotic melanoma?
Pink coloured nodule which lacks pigmentation
Assessment of melanoma? When to refer?
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
Other assessment used in melanoma?
ABCDE
Asymmetry Border Irregular Colour Irregular Diameter >7mm Evolving
Management of melanoma - referral?
- 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)
Management of melanoma - safety net?
o Seek advice if getting bigger, changing shape/colour, itchy, bleeding
Management of melanoma - secondary care investigations?
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
Management of melanoma - secondary care management - general measures?
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
Management of melanoma - secondary care management - Stage 0-2?
o Surgery - Wide Local Excision
o Topical Imiquimod if surgery not an option
Management of melanoma - secondary care management - Stage 3?
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
Management of melanoma - secondary care management - Stage 4?
o Surgery or ablative treatments to prevent and control symptoms
Follow up of melanomas?
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
Prognosis of melanomaS?
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
Definition of leg ulcer?
- Leg ulcer = Break in the skin below the knee, not healed within 2 weeks
What is most common type of leg ulcer and where?
- Venous leg ulcer is most common type of leg ulcer
o Typically occurs from ankle to mid-calf
Types of leg ulcer?
o Venous o Arterial o DM o RA o Neuropathic o Malignant o Drugs – nicorandil, corticosteroids, NSAIDs o Pyoderma gangrenosum
Risk factors of venous leg ulcers?
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
Pathology of venous leg ulcers?
o Sustained venous hypertension, results from chronic venous insufficiency due to valve incompetence or impaired calf muscle pump
Risk factors of arterial leg ulcers?
o CHD o Hx of stroke or TIA o DM o PAD o Obesity o Immobility
Symptoms of venous leg ulcers?
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
Symptoms of arterial leg ulcers?
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
Assessment in leg ulcers?
- 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
Management of leg ulcers - immediate referral?
o Vascular – ABPI <0.8
o Dermatology – deteriorating, malignancy, poor ankle mobility
Management of venous leg ulcers - lifestyle advice?
Paracetamol with or without codeine
Elevate legs for 30 minutes 3-4 times a day
Pillow under legs whilst sleeping
Regular walking
Management of venous leg ulcers - Medical treatment?
o Clean and dress ulcer – district nurse
o Compression Therapy
o Pentoxifylline 400mg TDS for up to 6 months
Management of venous leg ulcers - if signs of infection?
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
Management of venous leg ulcers - follow up?
o Follow up weekly for first 2 weeks
Below-knee graduated compression stockings, once healed to prevent recurrence
Complications of venous leg ulcers?
o Chronic pain o Impaired mobility o Infection o Allergic contact dermatitis o Marjolin’s ulcer
Prognosis of venous leg ulcers?
o 6-month heal rate around 50%
o Poor prognostic factors – wound >1 year, larger wounds, ABPI <0.8, lower socioeconomic group
Describe lesions in chronic plaque psoriasis
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)
Describe lesions in pustular psoriasis (generalised and localised)
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
Describe lesions in erythrodermjc psoriasis
Medical emergency
Diffuse widespread severe psoriasis affecting more than 90% of body
Precipitated by systemic infection, irritants, phototherapy,withdrawal of steroids
Systemically unwell
Describe lesions in guttate psoriasis
Small scattered round scaly papules pink or red
All over body, trunk and proximal limbs
Children or young adults
Usually after streptococcal infection
Nail changes in psoriasis
Nail pitting
Orange yellow discolouration (oil drop sign)
Subungual hyperkeratosis
Onycholysis (detachment of nail)
