Responding To Symptoms: Skin Flashcards
What are the three functions of the skin?
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
What are the three layers of the skin?
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
Discuss the types of cells found in the epidermis:
Keratinocytes - produce keratin
Melanocytes - Produce melanin pigment
Langerhans cells - from bone marrow = provide immunity
Merkel cells - form the touch receptor with the sensory neuron
Describe the layers of the epidermis:
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
Describe the barrier functions of the epidermis
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
Describe the layers of the dermis and discuss the types of tissue and glands found in this layer
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
Describe what happens to the dermis during hot and cold temperatures
Blood vessels = excretion and temperature control
Hot = sweating, vasodilation, insensible perspiration
Cold = reduced sweating, vasoconstriction, shivering and increased metabolism
Discuss skin pathologies
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
What questions should patients with skin conditions be asked during history taking?
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
How to use differential diagnosis for skin conditions
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
Discuss the red flags in skin conditions
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
What groups of patients are at risk?
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)
Treatment principles when dealing with skin conditions
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
Discuss what is dry skin, the symptoms and who dry skin is more common in
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
What is eczema and dermatitis? What are the different types?
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
Causes of dermatitis and eczema
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
Signs and symptoms of dermatitis:
Red, sore, itchy skin
Populous ever and vesicles may appear
Blistering
Crusting
Fissures
Weeping
Can be chronic or acute
Differential diagnosis of dermatitis:
Psoriasis
Fungal skin infections
Pompholyx
When to refer somebody for dermatitis:
Widespread, severe or broken skin
Lesions on the face not responding to emollients
OTC treatment failure
Children under 10 years old who need steroids
Discuss the treatment of dermatitis:
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
Give an example of emollients, steroids, humectants, antiseptics, antipruritics
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
What are the formulations of dermatitis treatments
Bath oil
Cream
Gel
Lotion
Oil
Ointment
Pastels
Shower gel
Describe the formulations of ointments, creams and lotions
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
What are the causes of seborrhoeic dermatitis:
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
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
Differential diagnosis of seborrhoeic dermatitis
Atopic dermatitis
Psoriasis
When to refer seborrhoeic dermatitis:
OTC treatment failure
Lesions are weeping, broken skin or widespread
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
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
What are the causes of erythema multiform
Adverse drug reaction e.g. antibiotics such as tetracyclines, NSAIDs
Triggered by infection (viral infection)
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)
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
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
What medications can causes Stevens-Johnson syndrome (SJS)
Allopurinol
Fluconaozle
Paracetamol
Phenytoin
Carbamazepine
NSAIDs (e.g. ibuprofen)
Phenobarbital
Sertraline
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
What medicines cause toxic epidermal necrolysis (TEN)
Allopurinol
Ampicillin
Anti-convulsants (carbamazepine, phenytoin)
Corticosteroids
NSAIDs
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)
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
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
Describe the stages of acne
Normal follicle
Blackhead (ope comedo)
Whitehead (closed comedo)
Papule
Pustule
Nodule/cyst
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
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
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
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
,
Treatment principles of acne vulgaris
Underlying cause
Preventative measures
Topical or systemic therapy
Formulation
Allergies/sensitivities to excipients
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
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
Epidemiology of rosacea
Common in patients over 40 years old
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
When to refer rosacea:
Cannot treat OTC so must refer
What is the treatment for rosacea?
Oral or topical antibiotics (e.g. metronidazole) prescribed
What is rhinophyma?
Thickening of the skin around the nose
Red
Lumpy
Sometimes associated with alcoholism
What is the epidemiology of impetigo?
Common in children
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
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
When to refer patients with impetigo?
Most cases required referral
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
What is the proper name for a stye?
Hordeolum
What causes a stye?
Staphylococcal infection of a hair follicle at the base of an eyelash
What are the signs and symptoms of a stye?
Swollen, painful, tender, irritated eyelid
Pus filled lesion
When to refer a stye?
Suspected blepharitis
Pain in the eye or blurry vision
Treatment for a stye:
Resolves spontaneously within a few days
Warm compress
Propamidine isetionate (brolene eye drops)
What causes fungal skin infections?
Candidiasis yeasts
Dermatophytes
Where is tinea captis found?
Scalp
Where is tinea cruris found?
Groin
Where is tinea corporis found?
Body
Where is tinea pedis found?
Foot
Where is tinea unguium found?
Nails or nail bed
Where is intertrigo found?
Skin folds
Differential diagnosis of fungal skin infections:
Eczema
Psoriasis
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)
Treatment principles for fungal skin infections:
Underlying cause
Preventative measures
Formulation
Allergies
When to refer fungal skin infections
Large areas affected
Face or scalp affected
OTC treatment failure
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
What are fungal nails called?
Onchomycosis
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
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
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
What causes chickenpox?
Varicella zoster virus
Contagious - droplet transmission or direct contact
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
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
When to refer for chickenpox?
Babies under 4 weeks old
Immunocompromised
OTC treatment failure
Secondary infection
Pregnant/ breastfeeding women
