Session 5.5a - Transatlantic Journey Flashcards
4:00 - bottom left
Describe the appearance of this image.
Little grouped vesicles all next to each other.
4:00 - bottom left
Give a differential diagnosis.
Cold sore virus caused by HSV.
4:00 - middle right
Describe the appearance of this image.
Little shiny, a bit umbilicated lesions.
4:00 - middle right
Give a differential diagnosis.
Molloscum contagiosum
4:00 - middle right
Give an age group these lesions are common in.
Molloscum contagiosum - common in children
4:00 - middle right
What type of infection is this?
Molloscum contagiosum - viral rash
4:00 - middle right
What is the normal treatment for this patient?
Molloscum contagiosum - normally goes away on its own
4:00 - top right
Give a differential diagnosis for this condition
Kaposi’s sarcoma
4:00 - top right
Which group of patients are most likely to get Kaposi’s sarcoma?
A condition that HIV patients can have
4:00 - top right
What is Kaposi’s sarcoma?
A rare type of malignant condition (cancer) that HIV patients can have
4:00 - top right
What colour are Kaposi’s sarcoma lesions?
Quite purple, these ones are a bit red but they can be quite purple too.
4:00 - top left
What is this?
Leukoplakia on the inside of the cheek
4:00 - top left
What is leukoplakia?
Leukoplakia generally refers to a firmly attached white patch on a mucous membrane which is associated with an increased risk of cancer - pre-malignant cells
4:00 - top left
Is leukoplakia cancerous?
They are pre-malignant cells
4:00 - top left
What colour is leukoplakia?
white areas
4:00 - top left
What type of leukoplakia is common to those with HIV?
Hairy leukoplakia - type of leukoplakia caused by the Epstein-Barr virus.
It often affects people with a weakened immune system, particularly those with HIV and AIDS or who have had an organ transplant and are taking immunosuppressant medication.
4:00 - middle left
Give a differential diagnosis.
Candida (oral thrush)
4:00 - bottom right
Give a differential diagnosis
Folliculitis
4:00 - bottom right
What is folliculitis?
Where hair follicles become inflamed - ingrown hairs
4:00 - middle bottom
Give a differential diagnosis.
Dry skin
4:00
Categorise these into:
non-malignant
pre-malignant
malignant
Non-malignant
- Oral thrust (middle left)
- Cold sores (bottom left)
- Molloscum contagiosum (middle right)
- Folliculitis (bottom right)
- Dry skin (middle bottom)
Pre-malignant
- Leukoplakia (top left)
Malignant
- Kaposi’s sarcoma (top right)
4:00
What do all of these images have in common?
They are all infectious diseases (except dry skin)
What is phototherapy?
The term phototherapy is a form of treatment where fluorescent light bulbs are used to treat skin conditions. Natural sunlight has been known to be beneficial in certain skin disorders for thousands of years, and it is the ultraviolet part of the radiation produced by the sun that is used in phototherapy, in particular the ultraviolet A (UVA) and ultraviolet B (UVB) wavelengths of light.
What conditions is phototherapy used to treat?
To name a few, psoriasis and atopic eczema.
[UVB - psoriasis, atopic eczema, polymorphic light eruption, generalised itching, pityriasis lichenoides, cutaneous T cell lymphoma, lichen planus, vitiligo and other less common conditions.
PUVA - chronic plaque psoriasis (if UVB ineffective), vitiligo, polymorphic light eruption and cutaneous T-cell lymphoma.
PUVA is often used second line if UVB is ineffective.
PUVA is favoured over UVB for some indications, such as mycosis fungoides
beyond patch stage, adult pityriasis rubra pilaris, hand and foot eczema.]
What does phototherapy involve?
Going to a ‘sunbed’ twice a week
Both UVA and UVB treatments are given in a hospital outpatient department in a walk-in light box containing fluorescent light bulbs. The treatment schedule varies from two to three times a week and an average course lasts between 15 and 30 treatments. There are no limits to the numbers of treatments patients may have over their lifetime. Having more than 200 PUVA or over 500 UVB treatments means that you will need annual skin checks to look for skin cancer.
8:00 - top right
What does this show?
Normal skin
Pink stains are Langerhans cells (dendritic cells which are part of the immune system)
8:00 - bottom left
These show an experiment assessing the skin damage in phototherapy for exposed areas and non exposed areas. What does this tell you?
Photo-damaged skin does not have as many Langerhans cells.
8:00 - bottom left
Using this image, explain why it is thought you are more likely to get a cold sore if you are exposed to the sun a lot?
There are less Langerhans cells present in sun damage, which are dendritic immune cells, thus you are more likely to get an infection
What is type I hypersensitivity?
Type I hypersensitivity (or IMMEDIATE hypersensitivity) is an ALLERGIC reaction provoked by reexposure to a specific type of antigen referred to as an allergen.
What is type IV hypersensitivity?
Type IV hypersensitivity is often called DELAYED type hypersensitivity as the reaction takes several days to develop. Unlike the other types, it is not antibody-mediated but rather is a type of CELL-MEDIATED response.
Give some examples of type I hypersensitivity reactions.
Type I hypersensitivity reactions are allergies:
e. g.
- grass and tree pollen – an allergy to these is known as hay fever (allergic rhinitis)
- dust mites
- animal dander (tiny flakes of skin or hair)
- food – particularly nuts, fruit, shellfish, eggs and cows’ milk
- insect bites and stings
- medication – including ibuprofen, aspirin and certain antibiotics
- latex – used to make some gloves and condoms
- mould – these can release small particles into the air that you can breathe in
- household chemicals – including those in detergents and hair dyes
What can a severe type I hypersensitivity reaction lead to?
Anaphylaxis
What is anaphylaxis?
Anaphylaxis is a severe and potentially life-threatening reaction to a trigger such as an allergy.
What are Carba mix and Thiuram mix found in?
The manufacturing of rubber
If a patient is allergic to Carba mix and/or Thiuram mix what does this indicate?
They have a type IV hypersensitivity (allergy) to products related to rubber (i.e. not latex itself but products used to manufacture it)
What are some products that may contain carba mix?
Antabuse (medication for alcoholism) - disulfiram Mancozeb Fungicides Rubber Goods • Boots • Bottle nipples • Condoms • Diaphragms • Ear-and headphones • Elastic • Goggles • Hoses • Masks • Racquet and club handles • Rubber bands • Shoes • Swimwear • Toys • Tubing • Utility gloves • Wetsuits • Other products made of natural rubber, butyl rubber, nitrile, or neoprene Zineb Fungicides
What are some products that may contain thiuram mix?
Animal Repellent Antabuse Medication for Alcoholism - disulfiram Chemicals Used to Prevent Mildew or Mold Fungicides and Pesticides Products Made with Natural Rubber, Butyl Rubber, Nitrile or Neoprene • Adhesives • Anesthesia equipment • Aprons • Condoms and diaphragms • Cords • Dental dams • Ear and headphones • Erasers, mats, and utility gloves • Gloves • Goggles • Hoses • Insulation • Masks • Mats • Plugs • Racquet and club handles • Respirators • Rubber bands • Sheeting • Shoes/boots • Swimwear • Toys • Tubing • Utility gloves • Wetsuits Yard Care • Seed protectant
How is allergic contact dermatitis diagnosed?
The best way to test for a reaction to allergens is by patch testing.
What is patch testing used for?
To determine what allergens can cause a type IV hypersensitivity reaction in the patient (allergic contact dermatitis).
What is patch testing?
Three visits to hospital are required.
On the first visit, each substance to be tested will be applied to your back in special small disc (about 1cm in diameter) containers held in place by hypoallergenic tape. The location of the containers is identified by marking your back with ink. Occasionally the arms or the thighs are also used to patch test. Itching of the test areas is normal, but you are strongly advised not to scratch. You should allow up to 2 hours for this first visit.
The substances will remain taped in place until your next visit, when the taping is removed and any reactions noted. Additional patches are sometimes added at this stage. The marking ink and/or tape will remain on your back for a further two days.
On the third visit, your back will be examined and any reactions will be discussed with you.
Why does patch testing for allergic contact dermatitis require THREE visits to the hospital/clinic?
Allergic contact dermatitis is a type IV hypersensitivity reaction, thus, the reaction is DELAYED - i.e. it does not come up immediately but 48-72 hours after.
Therefore, 3 visits are required: one to put the patches on, one to take the off and first reading, and a third one to examine your back after patch testing is completed.
What commonly causes allergic contact dermatitis?
Allergens that commonly cause allergic contact dermatitis include:
- cosmetic ingredients – such as preservatives, fragrances, hair dye and nail varnish hardeners
- metals – such as nickel or cobalt in jewellery
- some topical medicines (medicines applied directly to the skin) – including topical corticosteroids, in rare cases
- rubber – including latex, a type of naturally occurring rubber
- textiles – particularly the dyes and resins that are contained in them
- strong glues – such as epoxy resin adhesives
- some plants – such as chrysanthemums, sunflowers, daffodils, tulips and primula
What are some chemicals that are used in patch testing?
- Perfume
- Thiuram mix
- Carba mix
- PPD (para-phenylenediamine)
- Nickel
- Chrome
What products contain PPD (para-phenylenediamine)?
- Black henna
- Hair dye
Why are nickel and chrome tested for in patch testing?
They are found in cement - allergy common in builders etc.
What occupation is likely to have nickel and chrome allergic contact dermatitis?
Nickel and chrome are found in cement
- builders
9:00 top right
This man is manufacturing rubber. What can patients be allergic to?
Thiuram mix and carba mix
9:00 middle
What is this most likely allergy to cause?
Type I latex allergy
9:00 bottom right
What condition is this patient suffering?
An allergic reaction to something (thiuram mix and carba mix)
9:00 middle left
Why is this image related to allergies?
Application of henna can lead to type IV allergic contact dermatitis (PPD is the allergen)
9:00 bottom left
What has this patient suffered?
An allergic reaction to a henna tattoo, therefore the PPD
Delayed type IV allergic contact dermatitis (eczema)
9:00 bottom left
Describe the appearance of this rash.
Skin is red (erythematous) and flaky.
Draw an image of how a type IV hypersensitivity allergic contact dermatitis would manifest locally.
See 9:00 bottom left
Draw an image of how a type IV hypersensitivity allergic contact dermatitis would manifest on a patients’ face.
See 9:00 bottom right
12:00 top left
Explain what would happen if you felt here and told the patient to close their eyes.
The person would be unable to feel it because there is loss of sensation
12:00 top left
You examine the patient and find there is loss of sensation in the affected area when touching - the patient cannot feel you touching them. What might this indicate?
Loss of sensation in the patient due to a problem with the nerves
12:00 top left
Give a differential diagnosis
Leprosy
What is leprosy?
Leprosy, also known as Hansen’s disease, is a chronic infectious disease caused by Mycobacterium leprae. The disease mainly affects the skin, the peripheral nerves, mucosal surfaces of the upper respiratory tract and the eyes. Leprosy is known to occur at all ages ranging from early infancy to very old age. Leprosy is curable and early treatment averts most disabilities.
It is not very common in the UK, but common in Brazil and India.
What are 2 clinical signs that are in line with leprosy?
- Rash where there is loss of sensation in the patient
- Enlarged nerves in the area
Why is leprosy easy to miss?
Because it is not very common in the UK
12:00 bottom left
What is shown here?
Special staining, biopsy of leprosy patient
Few little pink bacilli are shown here - mycobacterium leprae
What organism causes leprosy?
Mycobacterium leprae
What does mycobacterium leprae look like?
Little pink bacilli
12:00 bottom left
Give a differential diagnosis
Paucibacillary leprosy (few bacilli)
How does paucibacillary leprosy appear on a gram stain?
Few bacilli
Which type of leprosy has few bacilli on the gram stain?
Paucibacillary
12:00 bottom middle
Explain what this image is showing.
Special staining, biopsy, from a leprosy patient
Each little red/pink line is a little bacilli (Mycobacterium leprae)
12:00 bottom middle
Give a differential diagnosis
Lepromatous leprosy (lots of mycobacteria leprae)
How does lepromatous leprosy appear on histology/
Lots of mycobacteria leprae
What disease has a lot of mycobacteria leprae?
Lepromatous leprosy
What are typical features of lepromatous leprosy?
- Some features are more prominent, e.g. nose
- Organs may have sustained injuration and redness
Why is Leicester interesting for dermatology?
Leicester hosts a wide variety of people with different skin colours: erythema appears different in people with darker skin colours.
You also see patients of all ages.
How is erythema detected in a darker skinned patient?
It may manifest as hyperpigmentation
15:00 Middle
What is this image showing?
A little skin surgery
15:00 Top left
Give a differential diagnosis for this child
Congenital melanocytic nevus (CMN)
What is a congenital melanocytic nevus?
A giant mole that patients are born with (birthmark). It is a benign lesion. This type of birthmark occurs in an estimated 1% of infants worldwide; it is located in the area of the head and neck 15% of the time.
15:00 Top middle
Give a differential diagnosis for this teenager.
Becker’s nevus
How does Becker’s nevus usually present?
A mole that normally develops around puberty on the torso or upper arm, that becomes hairy.
It generally first appears as an irregular pigmentation (melanosis or hyperpigmentation) on the torso or upper arm (though other areas of the body can be affected), and gradually enlarges irregularly, becoming thickened and often hairy (hypertrichosis).
What is Becker’s nevus?
Becker’s nevus is a skin disorder predominantly affecting males. The nevus can be present at birth, but more often shows up around puberty. It generally first appears as an irregular pigmentation (melanosis or hyperpigmentation) on the torso or upper arm (though other areas of the body can be affected), and gradually enlarges irregularly, becoming thickened and often hairy (hypertrichosis). The nevus is due to an overgrowth of the epidermis, pigment cells (melanocytes), and hair follicles.
What epidemiology does Becker’s nevus primarily affect?
Males around puberty
What is the pathophysiology of Becker’s nevus?
The nevus is due to an overgrowth of the epidermis, pigment cells (melanocytes), and hair follicles.
15:00 bottom right
Give a differential diagnosis
Skin cancer
15:00 bottom right
What are two risk factors of skin cancer for this patient
- Sun damage/exposure
- Smoking
15:00 bottom right
Describe the appearance of the lower lip.
Hard and injurated - although these symptoms don’t always show!
What do you need to worry about in patients who have a long sun exposure?
Skin cancer
What is an infantile haemangioma?
A haemangioma is a collection of small blood vessels that form a lump under the skin. They are sometimes called ‘strawberry marks’ because the surface of a haemangioma may look a bit like the surface of a strawberry (strawberry naevus)
What is a strawberry naevus?
Birthmark called infantile haemangioma
Why are infantile haemangiomas treated with propanolol?
Propranolol belongs to a group of drugs known as beta-blockers, which are used to treat high blood pressure and fast heart rate. They work by slowing the heart and narrowing blood vessels. The latter is helpful in haemangiomas, as it reduces the blood flow through them, fading the colour and making them softer. Also, the cells that cause the growth of the haemangioma are affected by propranolol so that the haemangioma starts to reduce in size.
It was first discovered when a baby had both CV problems and a haemangioma.
When is a baby with infantile haemangioma given propanolol?
A beta blocker called propranolol may be needed when the haemangioma is near the eye, lips, or nappy area. Treatment may need to continue for 18 months or longer but results are promising.
- areas that really compromise the eye, or in a very cosmetic sensitive area, or umbilical area or on the foot etc.
How is propanolol given to babies with a haemangioma?
Orally
What is propanolol?
Propranolol belongs to a group of medicines called beta blockers. It’s used to treat heart problems, help with anxiety and prevent migraines.
If you have a heart problem, you can take propranolol to:
treat high blood pressure
treat illnesses that cause an irregular heartbeat, like atrial fibrillation
prevent future heart disease, heart attacks and strokes
prevent chest pain caused by angina
Propranolol can help reduce your symptoms if you have too much thyroid hormone in your body (thyrotoxicosis). You’ll usually take it together with medicines to treat an overactive thyroid.
What must you always remember when diagnosing patients with skin conditions?
How it will affect them and impact on their life - please remember to take their psychosocial status into account.
S’s patient story 01
Give a problem representation.
Patient had been noticing large, crusty, erythematous lesions on his scalp, legs and skin which was progressively getting drier from 15 years old. His brother has had a similar condition that has been present from birth as it was so severe.
S’ patient story 01
Patient had been noticing large, crusty, erythematous lesions on his scalp, legs and skin which was progressively getting drier from 15 years old. His brother has had a similar condition that has been present from birth as it was so severe.
Give a DDx.
Psoriasis
S’ patient story 01
Patient had been noticing large, crusty, erythematous lesions on his scalp, legs and skin which was progressively getting drier from 15 years old. His brother has had a similar condition that has been present from birth as it was so severe.
Suggest some possible treatments.
- creams to moisten the skin
- creams to put on the scalp to stop the crispiness
S’ patient story 02
How can psoriasis affect someone’s life?
It can lead to psychosocial problems due to the cosmetic impact.
In young children/teenagers, this can lead to bullying because they are ‘different’ to other pupils, due to the lesions and scales on visible areas of skin.
S’ patient story 03
What advice would you want to give to medical students now for pts with skin problems?
Make your own mind up about the diagnosis from your individual experience of listening and examining the patient - don’t just follow what other doctors have diagnosed/prescribed to that patient before - make sure you check.
S’ patient story 03
What should you do if you don’t know something in clinic?
Ask for advice
