Passmed Flashcards
What is ‘acne’ Rosacea?
Chronic skin rash involving the central face which most often presents at 30-60 years old
What is the cause of rosacea?
Environmental Genetic- celtic origin Vascular Inflammatory chronic exposure to UV radiation
What are the features of rosacea?
Affects nose, cheek, forehead flushing is often the first symptom Telangiectasia Flushing is often the first symptom Rhinophyma (large red bulbous nose) Can cause ocular involvement- blepharitis Sunlight exposure can make it worse
What is the management of rosacea?
topical metronidazole may be used for mild symptoms
Ie: when there is limited papules or patches but no plaques
topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia
more severe disease is treated with systemic antibiotics e.g. Oxytetracycline
recommend daily application of a high-factor sunscreen
camouflage creams may help conceal redness
laser therapy may be appropriate for patients with prominent telangiectasia
patients with a rhinophyma should be referred to dermatology
What is the management of chronic plaque psoriasis?
regular emollients may help to reduce scale loss and reduce pruritus
first-line: NICE recommend:
a potent corticosteroid applied once daily plus vitamin D analogue applied once daily
should be applied separately, one in the morning and the other in the evening)
for up to 4 weeks as initial treatment
second-line: if no improvement after 8 weeks then offer:
a vitamin D analogue twice daily
third-line: if no improvement after 8-12 weeks then offer either:
a potent corticosteroid applied twice daily for up to 4 weeks, or
a coal tar preparation applied once or twice daily
short-acting dithranol can also be used
What is the secondary care management of psoriasis?
Phototherapy
narrowband ultraviolet B light is now the treatment of choice. If possible this should be given 3 times a week
photochemotherapy is also used - psoralen + ultraviolet A light (PUVA)
adverse effects: skin ageing, squamous cell cancer (not melanoma)
Systemic therapy
oral methotrexate is used first-line. It is particularly useful if there is associated joint disease
ciclosporin
systemic retinoids
biological agents: infliximab, etanercept and adalimumab
ustekinumab (IL-12 and IL-23 blocker) is showing promise in early trials
What is erythema multiforme?
Hypersensitivity reaction, most commonly triggered by infections
It can be minor of major
The more severe form is major which is associated with mucosal involvement
Causes=
. Viruses- HSV, orf (disease of sheep and goats caused by parapox)
. Idiopathic
. Bacteria- mycoplasma, streptococcus
. Malignancy
. Sarcoidosis
. Drugs- penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDS, oral contraceptives, nevirapine
What is a keratocanthoma?
A benign epithelial tumour Common in advancing age Rare in young peoppe Festures- initially a smooth dome shaped papule Rapidly grows to become a crater Spontaneous regression within 3 months
What is lichen sclerosis?
An inflammatory condition which usually affects the genitalia and is more common in elderly females
Lichen sclerosus leads to atrophy of the epidermis with white plaques forming
Treat with topical steroids (clobetasol propionate) and emollients
What is the management of lichen sclerosus?
Topical steroids (clobetasol propionate) and emollient
What is alopecia acreata?
A presumed autoimmune condition causing localised, well dermacated patches of hair loas, their may be small broken ‘exlamation mark’ hairs
What is it important to test for in alopecia acreata?
It is important to screen for other auto-immune conditions
Such as: thyroid disease, diabetes, pernicious anaemia
useful tests- FBC, HbA1C, TFTs, B12 level
What are the treatment options for alopecia acreata?
Topical or intralesional corticosteroids Topical minoxidil Photopherapy Dithranol Contact immunotherapy Wigs
What are cafe au lait spots?
Macular and light brown birthmarks
They do not fade with age
Can increase in size with weight gain
What is infantile haemangioma?
Benign condition due to proliferating endothelial cells
They can keep growing up to 18 months and begin involute over the next 3-10 years
What are mangolian blue spots?
A type of birthmark which are benign and macular, the discolouration with resolve by four years of age
What are port wine stains?
Capillary malformations seen at birth
They persist throughout life
What are salmon patches?
Congenital capillary malformations seen at birth
They are often flat, small patches of pink or red skin with poorly defined borders
They tend to resolve by 18 months
They can be seen in around half of newborn babies
They are also known as stork bites/marks
Pink and blotchy
Commonly found on forehead, eyelids, nape of neck
What is erythroderma?
A term used when more than 95% of skin is involved in a rash of any kind
What are the causes of erythroderma?
Eczema Psoriasis Drugs- gold Lymphomas Leukaemias Idiopathic
What do dermatologists need to look out for in erythroderma?
Signs of dehydration (note that dry mucous membranes would be expected and nausea)
High output heart failure (SOB is an emergency)
Infection
What is erythrodermic psoriasis?
This may result from progression of chronic disease to an exfoliative phase with plaques covering most of the body, associated with mild systemic upset
More serious form= acute deterioration, which may be triggered by a variety of factors like withdrawal of systemic steroids patients need to be admitted ti hospital.
What is the koebner phenomenon? What does it occur in?
Skin lesions which appear at the site of injury Occurs in... - psoriasis - vitiligo - warts - lichen planus - lichen sclerosus - mollascum contagiosum
What are the drugs known to cause toxic epidermal necrolysis?
Phenytoin Sulphonamides Allopurinol Penicillins Carbamazepine NSAIDS
How do you treat toxic epidermal necrolysis?
Stop the precipitating factor
Supportive care
- often in ICU
- volume loss and electrolyte derangements are possible complications
- intravenous immunoglobulins have been shown to be effective and are commonly used first line
Other treatments= Immunosuppresive agents (ciclosporin and cyclophosphamide) Plasmapheresis
What is pyoderma gangrenosum?
Rare inflammatory skin disease where painful pustules or nodules become ulcers that progressively grow
It isn’t infectious
What are the causes of pyoderma gangrenosum?
Idiopathic in 50% IBD RA, SLE Myeloproliferative disorders Lymphoma, myeloid leukaemias Monoclonal gammopathy (IgA) Primary billiary cirrhosis
What is the management of pyoderma gangrenosum?
The potential for rapid progression is high in most patients and therefore most patients advocate oral steroids as first line treatment
Other immunosuppresive therapy- ciclosporin and infliximab have a role in difficult cases
What are the features of acne rosacea?
Typically affects the nose, cheeks and forehead
Flushing is often the first symptom
Telangiectasia is common
Later develops into persistent erythema with papules and pustules
Rhinophyma
Ocular involvement- blepharitis
Sunlight may exacerbate symptoms
What is the management of acne rosacea?
Topical metronidazole may be used for mild symptoms- limited no. Of papules and pustules, but no plaques
Topical brumonidine for predominant flushing
More severe disease is treated with systemic abx
Recommend daily suncream
Camouflage cream
Laser therapy (not on nhs) for prominent telangiectasia
What is pityriasis rosea.
An acute self limiting rash which tends to affect young adukts
The aetiology is not fully understood thought that the herpes hominis virus 7 plays a role
What are the features of pityriasis rosea?
In the majority there is no prodome, however in a minority there may be a hx of a recent viral infection
Herald patch (usually on the trunk) Followed by erythematous, slightly raised oval lesions with a fine scale confined to the outer aspects of the lesions May produce a fir tree appearance
How do you differentiate between guttate psoriasis and pityriasis rosea?
In guttate psoriasis there is a classical prodome of a streptococcal sore throat for 2-4 weeks
Whereas in pityriasis rosea only some patients report resp tract infections
Tear drop appearance in guttate psoriasis, herald patch in pityriasis rosea
Most cases of guttate psoriasis will resolve within 2-3 months, UVB, photopherapy
Pityriasis rosea is self limiting and resolves after around 6 weeks
What is pemphigoid gestationis?
This is pruritic blistering lesions found in pregnant women
Often develop in the peri-umbilical region and later spread to the trunk, back, buttocks and arms
Usually presents in 2nd/3rd trimester and is rarely seen in the first pregnancy
Oral corticosteroids are required
What would you give to someone with acne rosacea with ocular involvement (blepharitis, conjunctivitis, keratitis)?
Oral tetracycline
What eye problems can acne rosacea cause
Blepharitis, keratitis, conjunctivitis
What is hereditary haemorrhagic telangiectasia?
Also know as osler weber rendu sydrome
It is an autosomal dominant condition characterised by multiple telangiectasia over the skin and mucous membranes. 20% of cases occur spontaneously without prior FH
There are 4 main diagnostic criteria, if the patient has 2 then they are said to have a possible diagnosis of HHT
- Epistaxis
- telangiectasia
- visceral lesions
- FH
What type of patients are at particular risk of SCC?
Immunosuppressed patients- renal transplant patients
What are keloid scars?
Tumour like lesions that arise from the connective tissue of a scar and extend beyond the dimensions of the original wound
What are the precipitating factors for keloid scars?
Ethnicity- more common in people with darker skin
Occurs more in young adults, rare in the ekdely
Common sites- sternum, shoulder, neck, face, extensor surface of limbs, trunk
How do you treat keloid scars?
Early keloid scars may be treated with intra lesional steroids eg: triamcinolone
Excision is sometimes required
What is erythrasma and how do you treat it?
Erythrasma is a superficial skin infection that causes brown, scaly skin patches. It is caused by Corynebacterium minutissimum bacteria, a normal part of skin flora (the microorganisms that are normally present on the skin).
Treated with erythromycin
What are the causes of pruritis?
Liver disease Iron deficiency anaemia Polycythaemia (ruddy coplexion, gout, peptic ulcer disease) Chronic kidney disease Lymphoma
Other causes..
- hyper and hypothyroidism
- diabetes
- pregnancy
- senile pruritis
- urticaria
- skin disorders; eczema, scabies, psoriasis, pityriasis rosea
What are the types of skin?
Fitzpatrick Type 1= never tans, always burns Type 2= usually tans, always burns Type 3= always tans, sometimes burns 4= always tans, rarely burns 5= sunburn and tanning after extreme UV exposure 6= black skin never tans and never burns
What is acanthosis nigricans and what are the causes?
Symmetrical, brown, velvety plaques that are often found on the neck, axilla and groin
Causes.
- type 2 diabetes mellitus
- GI cancer
- obesity
- PCOS
- acromegaly
- cushing’s
- hypothyroidism
- familial
- prader willi syndrome
- drugs; COCP, nicotinic acid
What are the skin disorders associated with SLE?
Photosensitive butterfly rash
Discoid lupus
Alopecia
Livedo reticularis (net like rash)
What is hidradenitis suppurativa?
A chronic, painful, inflammatory skin condition which is characterised by nodules, pustules, sinus tracts and scars in intertriginous areas
Who is hidradenitis suppurativa most likely to affect?
Women are more likely to develop it
Most commonly affects adult under 40
Risk factors- FH Smoking Obesity, diabetes, PCOS Mechanical stretching of skin
What bacteria contributes to acne?
Propionibacterium acnes is the bacteria that contributes to the development of acne
What is seborrhoeic dermatitis?
Seborrhoeic dermatitis in adults is a chronic dermatitis thought to be caused by an inflammatory reaction related to a proliferation of a normal skin inhabitant, a fungus called Malassezia furfur (formerly known as Pityrosporum ovale). It is common, affecting around 2% of the general population.
What are the features of seborrhoeic keratitis?
eczematous lesions on the sebum-rich areas: scalp (may cause dandruff), periorbital, auricular and nasolabial folds
otitis externa and blepharitis may develop
What are the associated conditions of seborrhoeic dermatitis?
HIV
Parkinsons
What is the management of seborrhoeic dermatitis?
Scalp disease management
over the counter preparations containing zinc pyrithione (‘Head & Shoulders’) and tar (‘Neutrogena T/Gel’) are first-line
the preferred second-line agent is ketoconazole
selenium sulphide and topical corticosteroid may also be useful
Face and body management
topical antifungals: e.g. ketoconazole
topical steroids: best used for short periods
difficult to treat - recurrences are common
A 28-year-old man undergoes an ileocaecal resection and end ileostomy for Crohn’s disease. One year later he presents with a deep painful ulcer at his stoma site. What is the most likely diagnosis?
Pyoderma gangrenosum is associated with inflammatory bowel disease (this patient had a stoma for Crohn’s). It is commonly found on lower limbs and described as being painful, the size of an insect bite and growing. It looks like a Margherita pizza (with a red base and yellow topping) Treatment involves steroids.
It would be rare for a poorly fitting appliance to cause a deep painful ulcer.
What are the exacerbating factors of psoriasis?
Trauma
Alcohol
Drugs- beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDS and ACE-I, infliximab
Withdrawal of systemic steroids
Streptococcal infection may triggee guttate psoriasis
What is pityriasis versicolor?
Pityriasis versicolor, also called tinea versicolor, is a superficial cutaneous fungal infection caused by Malassezia furfur (formerly termed Pityrosporum ovale)
What are the features of pityriasis versicolor?
Pityriasis versicolor, also called tinea versicolor, is a superficial cutaneous fungal infection caused by Malassezia furfur (formerly termed Pityrosporum ovale)
What are the features of pityriasis versicolor?
most commonly affects trunk
patches may be hypopigmented, pink or brown (hence versicolor). May be more noticeable following a suntan
scale is common
mild pruritus
What are the predisposing factors of pityriasis versicolor?
Occurs in healthy individuals
Immunosuppression
Malnutrition
Cushings
What is the management of pityriasis versicolor?
topical antifungal. NICE Clinical Knowledge Summaries advise ketoconazole shampoo as this is more cost effective for large areas
if failure to respond to topical treatment then consider alternative diagnoses (e.g. send scrapings to confirm the diagnosis) + oral itraconazole
What are the features of acne rosacea?
nose, cheeks and forehead
flushing, erythema, telangiectasia → papules and pustules
What is the treatment of SCC?
Surgical excision with 4mm margins if lesion <20mm in diameter. If tumour >20mm then margins should be 6mm. Mohs micrographic surgery may be used in high-risk patients and in cosmetically important sites.
What are the risk factors for scc?
excessive exposure to sunlight / psoralen UVA therapy
actinic keratoses and Bowen’s disease
immunosuppression e.g. following renal transplant, HIV
smoking
long-standing leg ulcers (Marjolin’s ulcer)
genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism
How can you differentiate spider naevi and telangiectasia?
Spider naevi can be differentiated from telangiectasia by pressing on them and watching them fill. Spider naevi fill from the centre, telangiectasia from the edge .
What are the associations with spider naevi?
Around 10-15% of people will have one or more spider naevi and they are more common in childhood. Other associations
liver disease
pregnancy
combined oral contraceptive pill
What is molloscum contagiosum?
A common skin infection caused by molloscum contagiosum virus
How does molluscum contagious present?
Typically, molluscum contagiosum presents with characteristic pinkish or pearly white papules with a central umbilication, which are up to 5 mm in diameter. Lesions appear in clusters in areas anywhere on the body (except the palms of the hands and the soles of the feet). In children, lesions are commonly seen on the trunk and in flexures, but anogenital lesions may also occur. In adults, sexual contact may lead to lesions developing on the genitalia, pubis, thighs, and lower abdomen. Rarely, lesions can occur on the oral mucosa and on the eyelids.
How do you treat molloscum contagiosum?
Self care advice…
Reassure people that molluscum contagiosum is a self-limiting condition.
Spontaneous resolution usually occurs within 18 months
Explain that lesions are contagious, and it is sensible to avoid sharing towels, clothing, and baths with uninfected people (e.g. siblings)
Encourage people not to scratch the lesions. If it is problematic, consider treatment to alleviate the itch
Exclusion from school, gym, or swimming is not necessary
Treatment is not usually recommended
- squeezing with fingernails or piercing lesions may be tried
Treatment should be limited to a few lesions at a time
What is dermatitis herpetiformis and how is it diagnosed?
Dermatitis herpetiformis is an autoimmune blistering skin disorder associated with coeliac disease. It is caused by deposition of IgA in the dermis.
Diagnosis
skin biopsy: direct immunofluorescence shows deposition of IgA in a granular pattern in the upper dermis
Management
gluten-free diet
dapsone
What are the features of lichen planus?
itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms
rash often polygonal in shape, with a ‘white-lines’ pattern on the surface (Wickham’s striae)
Koebner phenomenon may be seen (new skin lesions appearing at the site of trauma)
oral involvement in around 50% of patients: typically a white-lace pattern on the buccal mucosa
nails: thinning of nail plate, longitudinal ridging
What is the treatment of lichen planus?
potent topical steroids are the mainstay of treatment
benzydamine mouthwash or spray is recommended for oral lichen planus
extensive lichen planus may require oral steroids or immunosuppression
How to remember features of lichen planus vs lichen sclerosus?
Lichen
planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham’s striae over surface. Oral involvement common
sclerosus: itchy white spots typically seen on the vulva of elderly women
What are the causes of hirsutism?
Polycystic ovarian syndrome is the most common causes of hirsutism. Other causes include: Cushing's syndrome congenital adrenal hyperplasia androgen therapy obesity: thought to be due to insulin resistance adrenal tumour androgen secreting ovarian tumour drugs: phenytoin, corticosteroids
What is the management of hirsutism?
advise weight loss if overweight
cosmetic techniques such as waxing/bleaching - not available on the NHS
consider using combined oral contraceptive pills such as co-cyprindiol (Dianette) or ethinylestradiol and drospirenone (Yasmin). Co-cyprindiol should not be used long-term due to the increased risk of venous thromboembolism
facial hirsutism: topical eflornithine - contraindicated in pregnancy and breast-feeding
What are the causes of hypertrichosis?
drugs: minoxidil, ciclosporin, diazoxide
congenital hypertrichosis lanuginosa, congenital hypertrichosis terminalis
porphyria cutanea tarda
anorexia nervosa
What is acitinic keratoses?
Actinic, or solar, keratoses (AK) is a common premalignant skin lesion that develops as a consequence of chronic sun exposure
What are the features of actinic keratosis?
small, crusty or scaly, lesions
may be pink, red, brown or the same colour as the skin
typically on sun-exposed areas e.g. temples of head
multiple lesions may be present
What are the management options of actinic keratoses?
prevention of further risk: e.g. sun avoidance, sun cream
fluorouracil cream: typically a 2 to 3 week course. The skin will become red and inflamed - sometimes topical hydrocortisone is given following fluorouracil to help settle the inflammation
topical diclofenac: may be used for mild AKs. Moderate efficacy but much fewer side-effects
topical imiquimod: trials have shown good efficacy
cryotherapy
curettage and cautery
What is a lipoma?
A common benign tumour of adipocytes
What is the features, diagnosis and management of lipomas?
Features- lump will be smooth, mobile, painless
Diagnosis is clinical
If diagnosis is uncertain or compressing on surrounding structures then it may be removed
What are the features of liposarcoma?
Pain
Increasing size
>5cm
Deep anatomical location
What does eczema herpeticum present like?
It is more commonly seen in children with atopic eczema and often presents as a rapidly progressing painful rash
On examination, monomorphic punched out erosions (1-3mm in diameter are typically seen)
It is potentially life threatening and therefore children should be admitted for IV aciclovir
What is eczema herpeticum?
Eczema herpeticum describes a severe primary infection of the skin by herpes simplex virus 1 or 2.
