Patient sem 1 SKIN

Question 1

Describe the structure of skin?

Answer 1

3 major layers:
epidermis, dermis and hypodermis/subcutis
epidermis made of 4 layers

Question 2

What is the function of the epidermis? Describe the structure

Answer 2

The epidermis’ main function is to replace damaged cells to maintain protective properties

4 layers: stratum basal, stratum spinous, stratum granulosum, stratum cornea

Question 3

Describe the form and function of the stratum basal

Answer 3

the stratum basal is the lowest layer, comprising of a single row of keratinocytes. constant cell division pushes older cells up . melanocytes are found here and produce melanin when skin is exposed to UV lighr

Question 4

Describe the form and function of the stratum spinosum

Answer 4

this layer anchors cells cells together by interlocking cytoplasmic processes. these cells are called prickle cells

Question 5

Describe the form and function of the stratum granulosum

Answer 5

cells undergo enzyme induced destruction, loosing nuclei and cytoplasmic organelle. lipid rich secretion acts a water sealant for skin, keratin is laid down meshing structures together

Question 6

Describe the form and function of the stratum cornea

Answer 6

layer of dead flattened cells, with densely packed keratin (corneocytes). corneocytes then shed from skin

Question 7

Describe the form and function of the dermis

Answer 7

Provides strength to skin (by providing collagen and fibroblasts) and elasticity by providing elastin.

Question 8

what are the impacts of skin conditions on patients and society?

Answer 8

Can be associated with severe psychological impact

Emerging evidence: increased risk of cardiovascular disease

Development issues in children

Many suffers experience low quality of life, bullying

Huge burden in society and impact on health services

Question 9

what are the different types of eczema?

Answer 9

Atopic, (main focus)
asteatotic, lichen(thick hardned skin brought by scratching), gravitationa (linked to venous pressure, fluid leaks and shiny red l, herpeticum, discoid, seborrhoea, pomphoylx
IgE antibody link

Question 10

what other conditions are commonly associated with eczema?

Answer 10

asthma and hay fever

IgE antibody link

Question 11

eczema epidemiology

Answer 11

affects all ages, mainly children
Most cases before age 5
More in urban areas, higher socioeconomic groups
Many cases clear in late childhood/adolescence, but not all

Question 12

eczema pathophysiology

Answer 12

Dysfunctional skin barrier (altered conversion of keratinocytes to protein lipid scales)
causes :
water loss from skin
hyper- reactivity (inflammation, itch)
infection (staphylococcus aureus )
Thelper cell dysregulation thought to involved (IgE and mast cells)

Question 13

risk factors for eczema?

Answer 13

stress, genetics, pollen and pets, rough clothes, contact allergens, soap, extreme temperatures , skin infection, hormones, certain foods

Question 14

how does eczema present?

Answer 14

v young - face ,cheeks, scalp and skin

growing kids - fletchers, wrists and ankles

Question 15

how is eczema diagnosed?

Answer 15

itch, early onset, involvement of the fletchers, asthma if older,

Question 16

why is it not advised to scratch eczema

Answer 16

lichenifies skin over time

Question 17

treatment of mild eczema

Answer 17

Emollients

Mild topical steroid if inflamed skin, spread thinly using fingertip u

Question 18

treatment of moderate eczema

Answer 18

Increase use of emollients
Use emollients quickly if you spot a flare coming on
Increase potency of steroid
Neck, face, genitals – may use mild steroid i. e. hydrocortisone
Loratidine, Ranitidine – non-sedating antihistamine – evidence is low which is why it is only on trial
*You can only use mild steroids on patients who are really young
Under 12 months old only use mild steroids

Question 19

treatment of severe eczema

Answer 19

Emollients. Increase use
Potent topical steroid. Start with moderate potency on sensitive areas. Aim for maximum 7-14 days (5 if sensitive areas)
Consider trial of non-sedating antihistamine if itch present, review 3/12

If itch affecting sleep, consider sedating antihistamine
Consider oral corticosteroid if severe symptoms and distress.

bandages, oral steroids,photherapy
between flares:
lower potency steroid (intermittently) ,topical cacinuirn inhibitors (tacrolimus) review 3/6 months

Question 20

describe what different severities of eczema will present like

Answer 20

Mild:Some dry skin, some itching, a little redness

Moderate
Dry skin, itching, redness, some thickening

Severe
Widespread as above, skin thickening, bleeding, oozing, etc.

Infected
Weeping, crusted, pustules, +/- systemic symptoms

Question 21

treatment for infected eczema

Answer 21

Weeping, crusted, pustules, +/- systemic symptoms

Oral antibiotics may be required, if localised infection use topical

Question 22

give an example of a low potency topical steroid

Answer 22

Hydrocortisone 0.1, 0.5, 1, 2.5%

Question 23

give an example of a moderate potency topical steroid

Answer 23

Clobetasone butyrate 0.05%

Betamethasone valerate 0.025%

Question 24

give an example of a potent potency topical steroid

Answer 24

Betamethasone Valerate 0.1%

Betamethasone dipropionate 0.05%

Question 25

what counselling is given to patients with eczema?

Answer 25

use emollients liberally and frequently continue steroids for 48hr after reduced inflammation scratch mittens, cut nails discard old products after infective episode ointments less well tolerated - use at night (v good at managing dry hard thickened skin Creams and lotions – better if not wanting occlusive barrier e.g. weeping

Question 26

what are important things to remember about emollients

Answer 26

fire hazard - paraffin based steroid sparing urea and lanolin reactions aq cream avoided due to sodium laurel sulphate irritation pump tub to decrease cross contamination after wash, gently dry skin and stroke in following hair growth

Question 27

what is psoriasis

Answer 27

Chronic, inflammatory disorder of skin and joints | Relapsing remitting in nature

Question 28

what is the main type of psoriasis?

Answer 28

vulgaris ( chronic plaque )

Question 29

where does vulgarisms affect mainly ?

Answer 29

scalp, knees, elbows,

Question 30

what is the prevalence of psoriasis in the UK? | what age demographic are affected ?

Answer 30

1-2% | 15-25 (75% of cases)

Question 31

pathophysiology of psoriasis

Answer 31

Inflammatory cells present in all layers of psoriatic skin leading to epidermal hyper proliferation and vascular changes. Particularly important role for T cells, TNF alpha and interleukins

Question 32

risk factors for psoriasis

Answer 32

Healthy diet and exercise improves symptoms Stopping smoking can improve disease status Alcohol excess is a trigger Genetics – family history 70% Pregnancy can be a protective factor Puberty and menopause is a risk factor – hormonal changes Skin injuries e.g. Burns, cuts  psoriasis

Question 33

what are some complications of psoriasis?

Answer 33

Psoriatic arthritis – screening for symptoms and use of PEST tool Depression/anxiety – screening at appointments for symptoms Metabolic syndrome and CVD – lifestyle modification, screening

Question 34

how do you treat psoriasis of the trunk and limb?

Answer 34

adults: potent corticosteroid and vitamin D analogue (calcipitrol) coal tar if above not effective

Question 35

how do vitamin d analogues work

Answer 35

reduce cell proliferation

Question 36

how do you treat psoriasis of the scalp

Answer 36

Potent corticosteroid. If not effective try a different formulation and/or salicylic acid/emollients. Combine steroid with calcipotriol or use vitamin D analogue alone if not effective/tolerated

Question 37

how to treat psoriasis of face, flexures or genitals

Answer 37

Mild-moderate steroid Short term treatment If not effective/long term treatment needed, use calcineurin inhibitor (tacrolimus)

Question 38

how does salicylic acid help treat psoriasis?

Answer 38

removes scales which prevent treatment from properly penetrating

Question 39

how is mild psoriasis treated :

Answer 39

emollients, topical corticosteroid alone or with vitamin D analogue calcinurin inhibitor coal tar

Question 40

how is moderate psoriasis treated?

Answer 40

Phototherapy plus topical treatments oral methotrexate or cyclosporin plus topical oral acitretin plus topical

Question 41

how is severe psoriasis treated?

Answer 41

add biological agent

Question 42

how is severity measured?

Answer 42

covering 10% of body | patient very distressed

Question 43

name 3 vitamin d analogues?

Answer 43

calcipqotriol calcitriol tacalitol

Question 44

patient advice for psoriasis?

Answer 44

emollients use liberally care with prolonged steroid use continue steroids 48 hours after reduced inflammation Skin irritation and photosensitivity with vitamin D analogues Several weeks for effect to be seen, persevere Avoid scratching and picking Report joint symptoms immediately Importance of review after 4 weeks – toxicity, adherence, effectiveness Combination steroid and calcipotriol product better than each alone Emollients for daily use, other treatments for flares Treatment break in between steroid courses, in between could use Vit D

Question 45

what types of acne are there?

Answer 45

vulgaris rosacea conglobata fulminant

Question 46

where does acne affect most

Answer 46

face back chest

Question 47

pathophysiology of acne

Answer 47

pilosebaceous follicles involved increased hyperplasia of cells secreting hair sebum enlarge, turnover increase composition of substrate ideal for bacterial growth bacteria stimulates inflammation - production of fatty acids - stimulate keratincye proliferation and differentiation grow over follicle and block causing inflammation

Question 48

what is comodogensis?

Answer 48

blocked follicles

Question 49

presentation of acne?

Answer 49

Open follicle – blackheads (close to the skin, melanin in the skin interact with the atmosphere and turns black) Closed follicle – whiteheads (lower down and they can progress into acne lesions) Can also get hypercornification – hardening of the skin

Question 50

risk factors for acne

Answer 50

Family members with acne High glycaemic index foods - inc androgens Medications (not technically acne!) Polycystic ovary syndrome (PCOS) - 30% affected Smoking? Stress Cosmetics – look for those that are labelled non-comedogenic

Question 51

treating mild to moderate acne

Answer 51

``` Topical retinoid (adapaline 0.1% gel/cream, isotretinoin) Benzoyl peroxide (BPO - 4% cream or 5% gel/wash) Azelaic acid (20% cream, 15% gel) Topical antibiotic (clindamycin 1%) always with BPO ```

Question 52

treating moderate acne

Answer 52

Oral antibiotic and topical retinoid . doxycycline, linocycline with topical retinoid Can add BPO - reduces incidence of resistance to the antimicrobials Treat for 6-8 weeks can repeat course may need maintenance treatment i.e BPO and azaelic acid or retinoid

Question 53

treating severe acne

Answer 53

oral isotretinoin

Question 54

how does BPO / benzyl peroxide treat acne?

Answer 54

anti-bacterial and uses free radical oxidation

Question 55

why is azaelic acid preferable for mild - moderate acne

Answer 55

less skin irritation and for milder acne

Question 56

what are common drug combinations for treating mild to moderate acne?

Answer 56

Antibiotics + BPO | Retinoids + BPO

Question 57

patient advice for acne

Answer 57

Do not over clean the skin Do not pick/squeeze lesions – scarring risk Use non-comedogenic / no oil products (uncertain benefit for facial cleansers) Bleaching of hair and clothing – BPO Skin irritation, if severe reduce application frequency/switch – all Avoid contact with eyes and mucous membranes - all treatments Sunscreen and avoid sunbeds – retinoids/BPO/oral antibiotics Avoid in pregnancy – retinoids/oral antibiotics Apply to whole affected area, not just individual lesions For gels: apply after washing and then remove a few hours later to avoid irritation For washes: apply and leave on for a few minutes, then rinse off Apply pea sized amount to entire affected area, wash off after 30-60 mins (retinoids) Lifestyle advice important

Question 58

What are the 3 main functions of the skin

Answer 58

barrier to protect tissues and organs temperature control sensory organ for touch, pain,temperature production of vitamin D

Question 59

How does vitamin D production occur?

Answer 59

7-dehydrocholesterol in the skin produces vitamin D3 (cholecalciferol) in the presence of ultraviolet radiation in sunligh

Question 60

What can lack of vitamin D leas too?

Answer 60

nadequate calcium absorption and lack of deposition in bone, causing bone deformity in children (rickets) and bone pain and tenderness in adults (osteomalacia).