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Med Derm Flashcards > Perineal/perianal Skin > Flashcards

Perineal/perianal Skin Flashcards

1
Q

History

A

History of topical treatments including OTC remedies
Wet wipes
Toiletries

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2
Q

Examination

A

Local exam
Woods lamp helpful for erythrasma, vitiligo
Extragenital skin

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3
Q

Investigations

A 
Bacterial swab
Viral swab
Fungal scrapings 
Urine for glucose
Pelvic MRI, endoanal USS useful in anal fistula, anal malignancy
Allergy patch testing if suspect ACD
Sellotape test if suspect threadworms
Stool exam
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4
Q

Signs of spinal dysgraphism I.e. Spina bifida

A

Congenital hypertrichosis over the midline in lumbosacral area (faun tail)
Congenital naevi
Hamartomas

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5
Q

Idiopathic (primary) pruritus ani predisposing factors

A

Faecal contamination and it’s causes -
Difficulty cleaning - obesity, anatomical factors (deep funnel anus, hirsutism)
Anal leakage - haemorrhoids, perianal tags, fissures, primary anal sphincter dysfunction, caffeine lowers anal resting pressure
Loose frequent stools I.e. IBS
Food and drink (role uncertain) - coffee, tea, cola, beer, chocolate, tomatoes, spices, citrus
Psychological - stress, anxiety

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6
Q

Secondary pruritus ani causes

A 
Inflammatory - 
Endogenous eczema I.e. seb derm, atopic eczema
ICD
ACD
Psoriasis
Lichen planus
Urticaria
Lichen sclerosis (females only)
HS
Infectious - 
Candida (exclude diabetes in severe and persistent infection)
Dermatophyte
Erythrasma (corynebacterium)
Staph aureus
Beta-haemolytic strep
Gonorrhoea
Syphilis
HPV
HSV
HIV

Infestations -
Threadworms (enterobius vermicularis)
Pubic lice (phthiriasis pubis)

Premalignant/malignant -
EMPD
Anal intraepithelial neoplasia
Anal carcinoma

Ano-rectal disease -
Haemorrhoids
Anal fissure 
Perianal fistula 
Perianal abscess
IBD
Systemic disease -
Iron deficiency anaemia
Diabetes
Renal, thyroid, liver disease 
Leukaemia, lymphoma
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7
Q

Common allergens in perineal/perianal ACD

A 
Neomycin
Fragrance mix
Balsam of Peru 
Methylisothiazolinone
Condom allergy
Spermicide allergy
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8
Q

Management of pruritus ani

A

General measures -
Address secondary causes
Attention to washing habits
Maintain cleanliness
Ensure area dried after washing
Soap substitutes
Wash off shampoo residue
Apply emollient after each wash
Pre-apply barrier cream before bowels open
Washing in a bidet preferable to wiping with toilet paper
If using toilet paper, dab and not rub
Avoid wet wipes/pre-moistened toilet paper
Loose cotton underwear
Avoid topical anaesthetic preparations (causes sensitisation)
Keep fingernails short
Reduce coffee consumption
Eliminate implicated food and drinks
If history of haemorrhoids, encourage high fibre diet

Referral - colorectal if suspect ano-rectal disease

First line -
BD liquid cleanser
BD 1% hydrocortisone ointment (caution with TCS due to risk of atrophy infection in occluded skin) +/- antibacterial/anti fungal

Second line - 
Zinc paste + 1-2% phenol
0.006% capsaicin ointment
0.1% tacrolimus ointment
Oral antihistamines
ILCS
Corticosteroid suppositories

Third line -
Intradermal 1-2% methylene blue +/- 0.5% lignocaine
Cryotherapy

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9
Q

Inflammatory Dermatoses in the perineal/perianal skin

A

Seb derm - brownish red with large greasy scales towards the edge extending beyond natal cleft
Psoriasis - dull red hue, smooth glazed surface, fissured
Lichen simplex - unilateral
Fungal infection - suspect if prior TCS use
ACD - ill-defined spreading border, very inflamed, blisters
ICD - urine, faeces, laxatives containing danthon
Lichen sclerosus - figure of 8 distribution (Vulval to perianal skin), perianal only in women (assoc with urinary incontinence and contact of perianal skin with urine),
Lichen planus - very itchy (excoriated, hypertrophic), may be solitary involvement, Wickham’s striae
Harley-Hailey disease (biopsy helpful to confirm) - exacerbated by heat, friction, infection, contact dermatitis
Acrodermatitis enteropathica - malnutrition, malabsorption
Cicatricial pemphigoid - inflammation, ulceration, scarring leading to anal stenosis
SJS - inflammation, ulceration, scarring leading to anal stenosis
Behcet disease - shallow ulcers/fissures of the anal margin
Radiodermatitis - following treatment for anal CA

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10
Q

Drug reactions in perineal/perianal skin

A

Fixed drug eruption - pigmentation
Atrophy - from prolonged TCS - dusky erythema, telengiectasia, atrophy, induration, acneform lesions/comedones
Contact dermatitis - topical imiquimod (ICD or ACD)
Perianal ulceration - from Nicorandil

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11
Q

Bacterial folliculitis/furunculosis in perineal/perianal skin predisposing factors

A

High temperature, Humidity, Pressure, Friction encourage colonisation with staph aureus
Poor personal hygiene
Hyperhidrosis
Obesity
Anaemia
Personal/family Hx atopic eczema
Nasal carriage of staph aureus
Immunodeficiency I.e. HIV, diabetes, malnutrition (recurrent furunculosis)
EGFR inhibitors I.e. cetuximab (folliculitis)

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12
Q

Bacterial folliculitis/furunculosis in perineal/perianal skin causative organisms

A

Staph aureus (commonest)
MRSA
Pseudomonas (hot tub/wet suit folliculitis)
Malassezia furfur (pityrosporum folliculitis)
Klebsiella (gram neg folliculitis)
HSV

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13
Q

DDx of folliculitis/furunculosis in perineal/perianal skin

A

HS
Pilonidal sinus
Crohn disease

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14
Q

Investigations for folliculitis/furunculosis in perineal/perianal skin

A

Bacterial swab
Viral swab
Fungal scrapings
Nasal swab +/- other carrier sites (patient, consider for close contacts)

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15
Q

Treatment ladder folliculitis/furunculosis in perineal/perianal skin

A

General measures -
Antibacterial soap
Good personal, interpersonal, environmental hygiene

First line -
Topical antibiotics (superficial folliculitis)
Systemic antibiotics as guided by MCS (furunculosis)

Other -
I&D
Topical decolonisation regimen in recurrent furunculosis, MRSA

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16
Q

Streptococcal dermatitis (perianal cellulitis) features

A 
Group A beta-haemolytic strep
Boys 6 -10 months, sometimes adults
Itch, perianal pain, painful,defaecation
Sharply demarcated boggy erythema
Satellite pustulosis on buttocks
May trigger guttate psoriasis
Treat with systemic antibiotics
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17
Q

Ano-genital cellulitis features

A

Cysts, sinuses, fistulae
Abscess

DDx - 
Staph cellulitis
Strep cellulitis
Gonococcal cellulitis
Necrotising soft tissue infections i.e. necrotising fascitis (strep, clostridium)
HS
Crohn disease
EMPD
Carcinoma erysipeloides
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18
Q

Necrotising fasciitis features

A

Often middle aged/elderly
Risk factors - diabetes, IVDU, trauma, haem malignancy
Extreme pain, out of proportion to physical signs
Fever, cellulitis, then distinct dusky red to black spot with extreme rapidity
Crepitus
Dark brown turbid fluid without pus
Rapid deterioration and septicaemia
Surgical debridement

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19
Q

Ecthyma gangrenosum features

A 
Pseudomonas aeruginosa septicaemia
Immunosuppressive/critically ill
Predilection for ano-genital region
Severe, painful, necrotising ulcers
High mortality
20
Q

Perianal TB features

A

Indolent irregular ulcers, fistulae, abscesses
Fumigating, vegetative appearance (lupus vulgaris)
painful

21
Q

Fungal infections in perineal/perianal skin

A

Consider this for unusual perianal dermatitis and perform MCS

Candidiasis (bright red glazed with outlying small pustules)
Dermatophyte I.e. T rubrum (well defined scaly patch with circinate edge)
Histoplasmosis
Blastomycosis

22
Q

Viral infections in perineal/perianal skin

A

HSV (ulcerated inflamed skin on buttocks, perianal skin)
HPV
CMV (perianal ulcers) - setting of HIV
Kawasaki disease (red desquamating perineal eruption in 1st week of disease)

23
Q

Helminth infections in perineal/perianal skin

A

Strongyloides stercoralis chronic infection (filariform larvae passed in the stool attach to perianal skin and lead to autoinfection by migrating through skin) - larva currens (very itchy red papules and serpiginous tracts on perianal, buttock, upper thigh)

Cutaneous larva migrans (infective larvae from dog/cat hookworms)

Schistosomiasis (perineal itchy granulomatous papules in endemic countries)

24
Q

Other parasitic infections in perineal/perianal skin

A

Scabies (sarcoptes scabiei var hominis) - nodules buttock, perineum

Amoebiasis (antamoeba histolytica) - perianal abscess, ulcer

25
Q

STDs in the perineal/perianal skin

A

Particularly MSM, HIV positive men
Ulcers

Syphilis (treponema pallidum) - primary chancre (primary syphilis), condylomata lata (secondary syphilis), granulomatous gumma (tertiary syphilis)

Gonorrhoea (neisseria gonorrhoea) - oedema, discharge, fissures, erosions

Lymphogranuloma venereum (chlamydia trachomatis) - ulcerative haemorrhagic proctitis mimicking Crohn’s colitis

Granuloma inguinale, Donovanosis (klebsiella granulomatis) - PAINLESS papules/nodules that ulcerate, risk SCC

Chancroid (haemophilus ducreyi) - PAINFUL ulcers, inguinal lymphadenopathy

HPV - anal warts (not always STD)

HSV 2 - ACUTE PAINFUL ulcers, proctitis without perianal ulcers

Pubic lice (phthiriasis pubis)

26
Q

Causes of anal/perianal ulcers in setting of HIV positive men/women

A

Infective -
HSV
CMV
Syphilis I.e. primary chancre (treponema pallidum)
Lymphogranuloma venereum (chlamydia trachomatis)
Amoebiasis
Anal sepsis (perianal abscess, fistula)

Malignancy -
Kaposi sarcoma
Non-Hodgkin lymphoma
SCC

Idiopathic I.e. aphthous ulcer

Structural -
Anal fissure
Haemorrhoids

Other -
Trauma
Pruritus ani

27
Q

HPV infection in the ano-genital region (ano-genital warts/condyloma acuminata)

A

Commonest viral STD in this region
HPV types 6, 11 - benign warts
HPV types 16, 18 - anal intraepithelial neoplasia, anal CA
Higher in men, especially MSM

28
Q

HPV infection predisposing factors

A

Ano-receptive sex
Increase lifetime sexual partners
Immunosuppression

29
Q

Ano-genital wart pathology

A 
Hyperkeratosis
Parakeratosis 
Papillomatosis
Acanthosis 
Coarse keratohyaline granules in the granular layer
Koi located in the granular layer
30
Q

DDx of ano-genital warts

A 
Molluscum contagiosum 
Condyloma lata (secondary syphilis)
Lichen planus
Anal intraepithelial neoplasia
Anal CA
31
Q

Complications of ano-genital warts

A

Risk of ano-genital neoplasia, oropharyngeal CA
If immunosuppressed, higher risk of progression to anal intraepithelial neoplasia and anal CA
If MSM, higher risk of HIV

32
Q

Management of ano-genital warts

A

REFERRALS -
Genito-urinary medicine specialist needs full sexual health screen
Colorectal if intra-anal disease suspected

INVESTIGATIONS -
Biopsy of diagnosis in doubt or dysplasia suspected

TREATMENT - 
First line
- 5% imiquimod cream
- Podophylin
- Podophylotoxin
- TCA

Second line

  • cryotherapy
  • electrocautery
  • excision
  • ablative laser

Third line -
- topical, intralesional, systemic interferon (not recommended as routine)

33
Q

Anal intraepithelial neoplasia (carcinoma in situ, Bowen disease, Bowenoid papulosis)

A

HPV 16, 18
Older women
MSM
Can affect anal, perianal, vulva, cervix, penis

34
Q

Anal intraepithelial neoplasia risk factors

A 
MSM (esp with HIV)
Receptive anal sex 
Hx ano-genital warts
Lifetime number of sexual partners
Smoking
Immunosuppression I.e. renal transplant
35
Q

Anal intraepithelial neoplasia path

A 
Epidermal Cytological atypia 
Dyskeratosis
Nuclear pleomorphism
Nuclear hyperchromatism
Mitoses 
Koilocytes may be present
p16 (proliferative biomarker) can be useful for grading of severity
36
Q

Anal intraepithelial neoplasia clinical features

A 
Often asymptomatic
Can be itchy, bleeding
Solitary vs multifocal 
Intra-anal lesions may be papillomatous, red, white, pigmented, fissured 
Induration/ulceration (sign of invasion)

Variants -
- Perianal Bowen disease - asymptomatic red shiny scaly plaque, may be continuous with dysplastic lesions in anal canal, Risk of progression to invasive SCC

  • Bowenoid papulosis - solitary/multiple reddish brown/pigmented/flesh-coloured flat/verrucous papules, unknown risk of progression to invasive CA
37
Q

Anal intraepithelial neoplasia DDx

A

Anal CA
HPV infection
Psoriasis
Lichen planus

38
Q

Anal intraepithelial neoplasia course/prognosis

A

Risk of progression to anal/perianal SCC poorly understood

39
Q

Anal epithelial neoplasia investigations

A

Biopsy - confirm Dx, evidence of invasive disease

High resolution anoscopy with mapping biopsies of suspicious areas

40
Q

Anal intraepithelial neoplasia management

A

Aims -
Alleviate symptoms
Prevent progression to anal CA
Close follow up

General measures -
MDT approach
Examine genital skin for associated diseases I.e. warts
Colorectal - Digital rectal exam, anoscopy (determine if any intra-anal disease)
Gynae for females - exclude concomitant CIN

First line - 
Top 5% imiquimod
Top 5-FU
Electrocautery
CO2 Laser ablation
Excision (small solitary perianal lesions) —> risk of anal stenosis, faecal incontinence

Second line -
PDT

Screening/prevention -
HPV vaccine in MSM
No national screening program
Controversial use of anal cytology, high resolution anoscopy due to cost-effectiveness
Recommended in high risk population I.e. MSM, HIV

41
Q

Extramammary Paget disease (EMPD)

A

Primary - intraepithelial adenoCA from apocrine gland ducts intraepidermal cells/pluripotent keratinocyte stem cells (neoplastic cells showing glandular differentiation), CA in situ but can become invasive, metastatic

Secondary - epidermal involvement from an internal neoplasm, either by direct extension or metastasis

Secondary EMPD Associations -
Ano-rectal adenoCA (especially with perianal EMPD)
Bladder/urethra adenoCA
Other adenoCA

Pruritus
Burning
Perianal bleeding

Red plaques/erosions, moist, hyperkeratotic “strawberries and cream”
Sharp border
Solitary vs multifocal
Variable hyperpigmentation
Thickened/ulcerate (sign of invasion)
Sites rich in apocrine glands I.e. vulva, Anogenital skin, scrotum, penis, axilla
Perianal lesions can extend into anal canal
Vulval lesions can extend to introitus

DDx - 
Psoriasis 
Eczema
Vulval/anal intraepithelial neoplasia
Bowen disease

Histo -
Epidermal hyperplasia
Paget cells (large vacuolated cells with circular nuclei, foamy pale cytoplasm) infiltrate epidermis

IHC primary + secondary EMPD -
PAS +
CAM5.2 + (LMW keratin)
CK7 + (LMW keratin)
CEA +
Pankeratin - (excludes carcinoma)
CK5/6 - (excludes carcinoma)
S100 - (exclude melanoma)
Melan A - (exclude melanoma)

Differentiating IHC for primary vs secondary EMPD = CK20, GCDFP-15
Primary EMPD CK20 - GCDFP-15 + (marker of apocrine epithelium)
Secondary EMPD CK20 + GCDFP-15 -

Investigations -
Full exam for extent and an underlying adenoCA esp cervix, rectum
Skin Biopsy
Ensure cervical cytology/mammogram UTD (female)
Consider bowel/urological investigation

Primary EMPD Treatment (combo often needed) -
Excision with large margins (first line)
MOHS
Top 5-FU
Top 5% imiquimod (widespread disease, for post-surgery recurrence)
Top bleomycin
Oral retinoids
Cryotherapy
PDT
CO2 ablative laser
RTX (adjunct to surgery or if surgery not possible)
TCS if itchy 
Regular monitoring

Secondary EMPD Treatment -
Treat underlying CA

Course/prognosis -
Indolent, but spreads by local extension and mets
Recurrence common
Excellent prognosis for primary intraepithelial disease, less so for invasive disease

42
Q

Other malignancies

A

EMPD

BCC - predisposed from radiation, trauma, burns

Melanoma

LCH

Carcinoma erysipeloides

43
Q

Carcinoma erysipeloides

A

Infiltration of the skin with neoplastic cells
Infiltrated papules

Associated malignancies -
Bladder, prostate CA (perineum, thigh)
Colon adenoCA (genito-crural region)

44
Q

Anal/perianal cancer

A

Anal canal or anal margin or both

Subtypes of anal cancer - 
SCC (usually preceded by anal intraepithelial neoplasia)
AdenoCA
Melanoma
Lymphoma
Kaposi sarcoma (HIV related)
45
Q

Anal SCC (a subtype of anal cancer)

A

HPV-16, 18

Ano-receptive sex

Med Derm Flashcards (35 decks)

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