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PHAM 1128 > Responding To Symptoms: Skin > Flashcards

Responding To Symptoms: Skin Flashcards

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1
Q

What are the three functions of the skin?

A

1: Protection
Barrier between external environment
Mechanical impacts and pressure
Variations in temperature
Microorganisms
Radiation (UV light)
Chemicals

2: Regulation
Body temperature is regulated by sweat glands, hair and subcutaneous fat
Changes in peripheral circulations an fluid balance via sweat
Vitamin D synthesis

3: Sensation
Receptors for: Pressure, touch, temperature and pain

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2
Q

What are the three layers of the skin?

A

1: Epidermis
Outer protective layer
Keratinocytes = Synthesis the protein keratin
Cells are replaced around every 35 days

2: Dermis
Collagen for strength
Elastic fibres to allow stretch
Blood and nerve supply
Hair follicle
Sebaceous and sweat glands

3: Subcutaneous layer
Hypodermis
Layer of adipose tissue

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3
Q

Discuss the types of cells found in the epidermis:

A

Keratinocytes - produce keratin

Melanocytes - Produce melanin pigment

Langerhans cells - from bone marrow = provide immunity

Merkel cells - form the touch receptor with the sensory neuron

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4
Q

Describe the layers of the epidermis:

A

1: Stratum corneum: Horny layer
10 to 30 layers of dead keratinocytes
Creates a barrier to protect

2: stratum lucidum
Thin, translucent layer
Clear, flat, dead keratinocytes

3: Stratum Grandulosum
3 to 5 layers of flattened cells with deteriorating organelles
Lamellar granules = release lipids
Keratohyaline granules = help make keratin

4: Stratum spinosum
Layers of keratinocytes unified by desmosomes

5: Stratum basale
Deepest layer of the epidermis
One row of actively mitotic stem cells
As cells divide and differentiate they move to the surface

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5
Q

Describe the barrier functions of the epidermis

A

Keratinocytes: Produce keratin = mechanical strength

Langerhans cells = immune protection

Lipids and enzymes = chemical protection

Acid pH = 4-4.5

Skin flora: microorganisms on the skins surface repel other microorganisms

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6
Q

Describe the layers of the dermis and discuss the types of tissue and glands found in this layer

A

Layers:

1: Papillary layer: Loose connective tissue
2: Reticular layer: dense and irregular connective tissue

Types of tissue:
1: Collagen = strength
2: elastin = elasticity
3: reticular fibres = protein fibres

Glands:
1: sweat glands - produce sweat and used for temperature regulation
2: sebaceous glands - produce sebum and lubricates the skin

Hair follicles= protection and temperature regulation

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7
Q

Describe what happens to the dermis during hot and cold temperatures

A

Blood vessels = excretion and temperature control

Hot = sweating, vasodilation, insensible perspiration

Cold = reduced sweating, vasoconstriction, shivering and increased metabolism

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8
Q

Discuss skin pathologies

A

Physical disruption of the skin - cuts, grazes, burns, wounds and pressure sores

Infection
Bacterial - cellulitis, impetigo and boils
Fungal - athletes foot, ringworm
Viral - chickenpox, shingles

Infestation - head lice, scabies

Systemic pathology - measles, tumours, neuropathy

Allergies - eczema

Auto-immune disease- systemic lupus erythematous

Adverse drug reactions - Steven Johnson syndrome

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9
Q

What questions should patients with skin conditions be asked during history taking?

A

Examine the area if appropriate

WWHAM

When/where did it start?

Any other symptoms?

Any potential triggered?

Is anyone else affected?

Occupational history

Take a general medical history

Ask the patient what they think it could be

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10
Q

How to use differential diagnosis for skin conditions

A

Appearance: Red all over? Defined regions?

Distribution - is it all over the body, in certain places, random distribution?

What does it feel like? Rough, smooth, lumpy

Symmetry - diagnostic of some conditions

Broken skin

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11
Q

Discuss the red flags in skin conditions

A

A changing mole

Widespread lesions

Recurrent infections

Systemically unwell

Sudden/severe loss of hair

Uncontrollable itching

Herpetiform lesions

Other symptoms e.g. joint pain or night sweats

Recently returned from travels

Affecting mucus membranes

Suspected meningitis

Non accidental injury/ bruising

Suspected link with medication

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12
Q

What groups of patients are at risk?

A

Babies and young children

Elderly patients

Pregnant women

Immunocompromised patients

Patients taking other medications

Patients with pre-existing skin conditions

Patients with neuropathy (nerve damage)

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13
Q

Treatment principles when dealing with skin conditions

A

Treat the underlying cause

Preventative measures e.g. emollients

Topical or systemic therapy

Consider the formulation

Consider allergies and sensitivity to excipients

High concentrations of paraffin = fire risk

Application of multiple products

Steroids dose - finger tip units

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14
Q

Discuss what is dry skin, the symptoms and who dry skin is more common in

A

Moisture content of the skin is reduced

Causes small fine flakes and dry patches

Itching is one of the most common symptoms of dry skin

Dry skin is more common in:
Cold winter months
Elderly patients
Hypothyroidism
Patients with a history of eczema

Dry skin may be a side effect of some medications

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15
Q

What is eczema and dermatitis? What are the different types?

A

Dermatitis = inflammation of skin

Eczema = acute/chronic, allergy/genetic

Types of dermatitis:
Irritant contact dermatitis: direct damage caused by a provoking agent e.g. handling water, detergents, solvents or harsh chemicals. Also friction.

Allergic contact dermatitis: hypersensitivity of skin when in contact with substances that most people don’t react to e.g. nickel, perfume, rubber, hair dye or preservatives

Atopic eczema: chronic itchy skin condition - commonly prevalent in children

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16
Q

Causes of dermatitis and eczema

A

Irritants
E.g. detergent, soap, acid and alkalis (cement) and oils

Allergens
e.g. nickel, topical corticosteroids, cosmetics, rubber, latex and dyes

Genetics
E.g. a family history

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17
Q

Signs and symptoms of dermatitis:

A

Red, sore, itchy skin

Populous ever and vesicles may appear

Blistering

Crusting

Fissures

Weeping

Can be chronic or acute

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18
Q

Differential diagnosis of dermatitis:

A

Psoriasis

Fungal skin infections

Pompholyx

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19
Q

When to refer somebody for dermatitis:

A

Widespread, severe or broken skin

Lesions on the face not responding to emollients

OTC treatment failure

Children under 10 years old who need steroids

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20
Q

Discuss the treatment of dermatitis:

A

Emollients:
Moisturisers
Helps soothe the skin and provide relief from itching and dryness
Emollients trap moisture in the skin and form a protective oily layer on the outer skin surface which helps skin repair and improves skin hydration

Steroids:
Reduce inflammation in the skin

Humectant:
Penetrate skin layers and attract and retain water
Water from the dermis is moved to the epidermis to hydrate the stratum corneum
At higher concentrations urea and lactic acid acts as keratolytics to help remove hard skin

Antiseptics:
Slows or stops the growth of microorganisms on external surfaces of the body and helps to prevent infection help prevent infection when you itch as it damages the skin barrier function and microbes can get into the skin and cause infections
Often in combination with emollients

Antipruritic:
Relieves itching

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21
Q

Give an example of emollients, steroids, humectants, antiseptics, antipruritics

A

Emollients:
White soft paraffin
Liquid paraffin
Soya oil

Steroids:
Hydrocortisone 1%
Clobetasone 0.5%

Humectant:
Urea 10%

Antiseptics:
Benzalkonium chloride 0.1%
Chlorhexidine hydrochloride 0.1%

Antipruritic:
Crotamiton

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22
Q

What are the formulations of dermatitis treatments

A

Bath oil

Cream

Gel

Lotion

Oil

Ointment

Pastels

Shower gel

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23
Q

Describe the formulations of ointments, creams and lotions

A

Ointments:
Greasy in nature
They are usually made of white soft paraffin or liquid paraffin
Ideal for very dry or thickened skin and night time application
They do not usually contain preservatives (ingredients that help to protect the product from bacteria/germs and increase its shelf life) and are therefore less likely to cause skin reactions

Creams:
Contain a mixture of oil and water
Less greasy
Easier to spread on the skin than ointments
Should be used frequently and applied liberally to prevent the skin from drying out
Creams usually come in a container with a pup dispenser
Good for day-time application

Lotions:
Contain the least oil and most water
Least effective in moisturising skin
They normally contain preservatives so may cause skin irritation
Lotions are useful for hairy areas such as scalp

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24
Q

What are the causes of seborrhoeic dermatitis:

A

Causes are unknown

Increased cell turnover - could be linked to immunological, hormonal, nutritional factors

Malassezia ovale (which is a yeast) involved

May be related to medication e.g. haloperidol, methyldopa, lithium, phenothiazines

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25
What are the signs and symptoms of seborrhoeic dermatitis
In infants it is known as cradle cap = large yellow, greasy sales which crust over Can sometimes affect other areas too e.g. face, ears and skin folds Adults ranges from dandruff (not inflamed) to more severe inflamed condition More common in men than women No changes in sebum production
26
Differential diagnosis of seborrhoeic dermatitis
Atopic dermatitis Psoriasis
27
When to refer seborrhoeic dermatitis:
OTC treatment failure Lesions are weeping, broken skin or widespread
28
Seborrhoeic dermatitis treatments:
Cradle cap: Dentinox cradle cap shampoo (sodium lauryl ether sulphate) Olive oil Adults seborrhoeic dermatitis: medication shampoos (can cause local irritation) Ketoconazole (Nizoral) Anti-fungal and anti-dandruff Selenium sulphide (selsun) Anti-fungal and anti-dandruff Coal tar (polytar or T-gel) Antiseptic and anti-inflammatory action Salicylic acid (capasal therapeutic shampoo) Keratolytic, reduces itchiness and dandruff Corticosteroids may need to be prescribed if no response to OTC treatments
29
Discuss some infections which causes systemic illnesses and affects the skin
Meningitis: Stiff neck, headache, fever, drowsy Blotchy, red rash that doesn’t fade when a glass is rolled over it Measles: Cold like symptoms for 7 to 10 days before rash appears Sore, red eyes that may be sensitive to light Mumps: Painful swelling of the parathyroid glands (hamster face) Rubella: Swollen glands and fever
30
What are the causes of erythema multiform
Adverse drug reaction e.g. antibiotics such as tetracyclines, NSAIDs Triggered by infection (viral infection)
31
What are the symptoms of erythema multiform
Rash- suddenly develops in a few days (starts on the hands and feet and spreads to limbs, upper body and the face). Starts as small red spots which can become raised. Patches look like a target (bulls eye). Fades after two to four weeks High temperature Headache Generally feeling unwell Achy joints Sores inside of the mouth (make it hard to eat and drink) Sore eyes, sensitivity to light and blurred vision Sores on the genitals (makes urination painful)
32
What is the treatment of erythema multiform
Stop the medication which may be triggering the reaction Antiviral tablets (if caused by viral infection) Antihistamines (to reduce itching) Emollients (to reduce itching) Steroid cream to reduce redness and swelling (inflammation) Pain relief Aesthetic mouthwash to ease the discomfort of any mouth sores Antibiotics if a bacterial infection develops
33
What is Stevens-Johnson syndrome (SJS)
Causes flu like symptoms Red purple rash that spreads quickly and forms blisters Skin dies and peels off Medical emergency
34
What medications can causes Stevens-Johnson syndrome (SJS)
Allopurinol Fluconaozle Paracetamol Phenytoin Carbamazepine NSAIDs (e.g. ibuprofen) Phenobarbital Sertraline
35
What is toxic epidermal necrolysis (TEN)
Prodromal symptoms (fever, sore throat, conjunctivitis) Red, burning/ painful rash Spreads across the body Hair and nails may be shed Epidermis layer peels off
36
What medicines cause toxic epidermal necrolysis (TEN)
Allopurinol Ampicillin Anti-convulsants (carbamazepine, phenytoin) Corticosteroids NSAIDs
37
What is the epidemiology of acne vulgaris
Affects up to 80% of people at some point Roughly 60% of people see treatment Can commonly occur between the ages of 11 to 30 years Common during puberty due to changes in hormones (crease in testosterone levels in both males and females)
38
What are the causes of acne vulgaris?
Hormone imbalance: High testosterone levels increase sebum secretion from the sebaceous gland = keratin cell become cohesive and form keratin plugs (common during puberty) Microorganisms: Propionobacterium acnes Bacterial proliferation in stagnant oil = stimulates cytokines production causing local inflammation. This leads to the formation of papules around follicular openings In severe cases, cysts can form in deeper layers of the skin Medication E.g. lithium, phenytoin, oral contraceptives and steroids
39
Signs and symptoms of acne vulgaris:
Seborrhoea Inflammation Comedones (open/closed blackhead or whiteheads) Papules, pustules, nodules Tenderness Scarring Social problems Can affect face, chest and back Classified as mild, moderate or severe
40
Describe the stages of acne
Normal follicle Blackhead (ope comedo) Whitehead (closed comedo) Papule Pustule Nodule/cyst
41
Differential diagnosis of acne vulgaris:
Rosacea: Acne like papules and pustules but redness and flushing of the central facial area and cheeks Usually affects middle aged adults
42
When to refer acne vulgaris symptoms:
Mild acne which has not improved within two months Moderate to severe acne Acne beginning later in life, not usual puberty age Suspected link with medication e.g. anti-epileptics (carbamazepine), anti-depressants (lithium) Occupational cause Suspected rosacea Psychologically affecting patient
43
Treatment for acne vulgaris:
OTC can treat mild to moderate acne Antibacterial: Chlorhexidine (cepton medicated cleansing lotion) Keratolytics: Benzoyl peroxide Salicylic acid Potassium hydroxyquinoline sulphate E.g. PanOxyl Aquagel, Acnisal wash, quinoderm Anti-inflammatory: Nicotinamide (freederm) For severe acne, doctors can prescribe oral antibiotics (lymcycline or oxytetracycline), hormonal therapy, isotretinoin
44
What is the first line treatment for acne vulgaris? And how does it work?
Benzoyl peroxide is the 1st line treatment for mild to moderate acne Mode of action: Keratolytic - promotes shedding of keratinised epithelial cells Anti-bacterial : bactericidal against propionibacterium acnes Anti-inflammatory Available as 2.5, 4, 5 and 10% strengths Start with the lowest strength and work up to minimise adverse effects Apply once daily at night to start, if tolerance builds, can increase to twice daily use Side effects: mildly irritant, can cause redness, peeling and thinning of skin ,
45
Treatment principles of acne vulgaris
Underlying cause Preventative measures Topical or systemic therapy Formulation Allergies/sensitivities to excipients
46
Key questions to ask patients with acne vulgaris:
Age of onset Mild, moderate or severe Long term problem? Refer OTC treatment failure - refer Medication? Oral contraceptives, lithium, phenytoin and steroids
47
Causes of rosacea:
Inflammatory disease of skin follicles The exact cause is uncertain but bacteria may have a role as it often responds to antibiotics
48
Epidemiology of rosacea
Common in patients over 40 years old
49
Signs and symptoms of rosacea;
Flushing and blushing of the skin around the nose and cheeks Crops of papules and pustules can appear Broken blood vessels Rhinophyma
50
When to refer rosacea:
Cannot treat OTC so must refer
51
What is the treatment for rosacea?
Oral or topical antibiotics (e.g. metronidazole) prescribed
52
What is rhinophyma?
Thickening of the skin around the nose Red Lumpy Sometimes associated with alcoholism
53
What is the epidemiology of impetigo?
Common in children
54
Causes of impetigo: Including primary and secondary impetigo
Bacterial skin infection commonly caused by staphylococcus aureus or streptococcus pyogenes Primary impetigo: Break in skin e.g. cut, insect bite or injury Secondary impetigo: underlying condition becomes infected e.g. eczema
55
Signs and symptoms of impetigo:
Symptoms commonly present on the face around the nose and mouth Start as red and itchy patches which turn into vesicles Vesicles rupture and weep = golden sticky crust Highly contagious - so children should be kept off of school until it clears
56
When to refer patients with impetigo?
Most cases required referral
57
Treatment for impetigo
Antibiotics: topical (fusidic acid) or systemic antibiotics (flucloxacillin) - not available OTC Hydrogen peroxide: available as 1-5% cream acts as an antiseptic E.g. crystacide cream 1% can be used for mild skin infections like impetigo 2 to 3 times daily for up to 3 weeks General hygiene: Don’t share towels Keep nails short - prevent scratching the lesions Avoid touching the area- risk of secondary infection
58
What is the proper name for a stye?
Hordeolum
59
What causes a stye?
Staphylococcal infection of a hair follicle at the base of an eyelash
60
What are the signs and symptoms of a stye?
Swollen, painful, tender, irritated eyelid Pus filled lesion
61
When to refer a stye?
Suspected blepharitis Pain in the eye or blurry vision
62
Treatment for a stye:
Resolves spontaneously within a few days Warm compress Propamidine isetionate (brolene eye drops)
63
What causes fungal skin infections?
Candidiasis yeasts Dermatophytes
64
Where is tinea captis found?
Scalp
65
Where is tinea cruris found?
Groin
66
Where is tinea corporis found?
Body
67
Where is tinea pedis found?
Foot
68
Where is tinea unguium found?
Nails or nail bed
69
Where is intertrigo found?
Skin folds
70
Differential diagnosis of fungal skin infections:
Eczema Psoriasis
71
What are the treatments for fungal skin infections?
Imidazoles: Clotrimazole +/- hydrocortisone - dermatophyte and candida infections (canesten and canesten HC) Ketoconazole - athletes foot, groin, sweat rash (daktarin gold) Miconazole +/- hydrocortisone - fungal skin and nail infections (daktarin and daktacort) Terbinafine; Athletes foot, groin infection, ringworm (lamisil) Griseofulvin: Athletes foot (grisol AF). Tolnaftate: Athletes foot (scholl athletes foot) Undecenoic acid (undencoates): Athletes foot (mycota) Benzoic acid (+salicylic acid): Rarely used now (whitfields ointment)
72
Treatment principles for fungal skin infections:
Underlying cause Preventative measures Formulation Allergies
73
When to refer fungal skin infections
Large areas affected Face or scalp affected OTC treatment failure
74
General treatment points for fungal skin infections
Treat affected area and skin surrounding rea Treat until infection has gone and up to one week after Keep skin dry/air it Wear natural fibres (cotton socks) Dust shoes with anti-fungal powder Use own towels for washing
75
What are fungal nails called?
Onchomycosis
76
What treatment is available for fungal nail infections and how does it work?
Amorolfine 5% nail lacquer e.g. curanail Mode of action: interferes with membranes of fungal cells Has a broad spectrum of activity Should be applied to affected nails weekly OTC sales: Can only treat two nails and only for 18+ Takes 9 to 12 months to work Expensive
77
When to refer fungal nail infections:
More than two nails infected/widespread infection Under 18 years old Pregnant women Recurrent problem OTC treatment failure People with long term conditions
78
Key questions to ask patients presenting with fungal nail infections:
Who is it for? Athletes foot is common in younger males Fungal nail infections are more common in older patients What are the symptoms? Itchy, red, define edges, isolated/widespread lesions How long have they had it for? Recurring infection Action taken? OTC treatment failure Medication? Diabetic, immunocompromised
79
What causes chickenpox?
Varicella zoster virus Contagious - droplet transmission or direct contact
80
Signs and symptoms of chickenpox:
Incubation period of 10 to 20 days before rash appears Prodromal symptoms= fever, headache and sore throat Extremely itchy rash = small red spots develop into blisters Vesicles crust over after 3 to 5 days Risk of secondary bacterial infection developing
81
Chickenpox differential diagnosis:
Insect bites: Often single inflamed lesions Scabies: grey, burrowing pattern Impetigo: golden crust Measles: Kopliks spots Mumps; hamster face, no rash Meningitis: purple, blotchy, non-blanching rash
82
When to refer for chickenpox?
Babies under 4 weeks old Immunocompromised OTC treatment failure Secondary infection Pregnant/ breastfeeding women

PHAM 1128 (1 decks)

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