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Patient Sem 1 > Skin > Flashcards

Skin Flashcards

1
Q

What are the three layers of the skin?

A
  • epidermis
  • dermis
  • hypodermis
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2
Q

What are the four layers of the epidermis?

A
  • stratum corneum
  • stratum granulosum
  • stratum spinous
  • stratum basale
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3
Q

What are the three cells of the epidermis?

A
  • kertainocytes
  • melanoyctes
  • langerhans cells
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4
Q

What is the main function of the epidermis?

A

replaces damaged cells by continually producing keratinocytes, and pushing them up through the 4 layers - - this takes 28 days

protects the body from UV radiation by producing melanin

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5
Q

Stratum Basale

A
  • single layer of keratinocytes
  • these undergo division and push up through the stratum spinosum
  • melanocytes contain melanin
  • this is distributed to the adjacent keratinocytes
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6
Q

Stratum Spinosum

A
  • anchors cells together by interlocking cytoplasmic processes
  • cells are prickle cells
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7
Q

Stratum Granulosum

A
  • cells undergo enzyme induced
  • cells lose their nuclei and organelles
  • lipidrich secretions - water sealant
  • keratin laid down to mesh the structure together
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8
Q

Stratum Corneum

A
  • dead cells, flattened cells filled with keratin

- corneocytes are shed from the skin

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9
Q

What is the function of the dermis?

A
  • strength (collagen and fibroblasts)
  • elasticity (eklastin)

specialised structures:

  • sweat glands
  • hairs
  • sebaceous glands
  • smooth muscle
  • cutaneous lympathics
  • nerves
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10
Q

What is the function of the hypodermis?

A
  • contains nerves, blood supplies and fat

- cushions and insulates the tissue

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11
Q

What are the four main functions of the skin?

A
  1. Production of Vitamin D
  2. Sensory organ - touch, pain, temperature
  3. Control of body temperature
  4. Barrier to protect tissues and organs
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12
Q

Production of Vitamin D in the skin

A
  • cholesterol in the skin produces Vit D3 (Cholecaciferol) in the presence of sunlight
  • Vit D3 converted to Calcidol in the Liver
  • Calcidol converted Calcitriol in the Kidney
  • Increases calcium levels by producing more carrier proteins for Ca in the blood
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13
Q

What are the sources of vitamin D?

A
  • sunlight
  • oily fish
  • eggs
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14
Q

What are the conditions associated with a deficiency of Vitamin D?

A

Children: Rickets
Adults: Osteomalacia

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15
Q

What are the receptors present in the skin to allow it to act as a sensory organ?

A
  • mechanoreceptors (touch)
  • thermoreceptors (temperature)
  • nocireceptors (pain)
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16
Q

How does the skin control body temperature?

A
  • vasodilation
  • vasoconstriction
  • sweat glands secrete water and salt
  • a weak insulator
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17
Q

How does the skin act as a barrier?

A

corny hard waterproof outer layer to protect from:

  • bacteria and toxins
  • dehydration
  • UV radiation
  • mechanical damage and trauma
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18
Q

How does the skin initiate an immune response?

A
  • Langerhans cells ingest foreign particles
  • acts as an antigen presenting cell
  • presents the particle to T/B cells
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19
Q

How does the skin heal if the injury only affects the epidermis?

A
  • where the keratinocytes break away from the stratum basale
  • cells enlarge and move across the wound
  • growth stops when there is contact inhibition
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20
Q

What are the four stages of the skin healing process?

A
  1. Haemostasis (stop bleeding)
  2. Inflammatory (clean the wound)
  3. Proliferative (healing)
  4. Maturation (scarring)
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21
Q

Haemostasis Phase

A

formation of a plug:
- platelets recognise exposed collagen
- release Thromoxane A2
- activated platelets aggregate together to form a plug
vasoconstriction:
- activated platelets release serotonin
- reduces blood supply to minimise blood loss
trapping red blood cells:
- damaged tissue releases thromboplastin
- thromboplastin + calcium = fibrin
- fibrin traps red blood cells

dries to form a scab

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22
Q

Inflammatory Phase

A

langerhans cells release inflammatory mediators:

  • bradykinin (pain)
  • leukotrienes (increases blood flow)

white blood cells move into the area due to increased capillary permeability
- WBCs produces neutrophils to digest bacteria

monocytes move to the wound - mature into macrophages to continue cleaning the wound

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23
Q

Proliferative Stage

A
  • macrophages initiate this phase
  • low oxygen = macrophages release angiogenic growth factors to develop blood vessels
  • provides more oxygen
  • macrophages also attract granulation tissue to produce new connective tissue
  • fibroblasts are activated to produce a collagen network
  • myofibroblasts act like muscle to contract and close the wound
  • epithelial cells move over the granulation tissue, contact inhibition to stop growing
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24
Q

Maturation Stage

A
  • collagen re-aligned to improve strength
  • collagen strands pull the wound inwards
  • extra blood vessels close
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25
Q

What are the intrinsic patient factors that will affect wound healing?

A
  • patient nutrition
  • skin perfusion
  • age
  • weight
  • co-morbidity including medication
  • smoking
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26
Q

What are the extrinsic wound factors that affects wound healing?

A
  • moist wound (moist enough for epithelial cells to grow, but not too moist for infection)
  • wound temperature
  • tissue oxygenation
  • pH
  • infection delays wound healing
  • clean wound surface
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27
Q

What is the most common form of eczema?

A

Atopic

  • where there is a common allergy link (Ig E)
  • co-presenting symptoms of hay fever and asthma
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28
Q

What is the epidemiology of atopic eczema?

A
  • affects all ages, but common in children
  • most cases clear by 7/16
  • some cases chronic, where it flares up, caused by triggers
  • some adults do develop
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29
Q

What is the pathophysiology of atopic eczema?

A

a dysfunctional skin barrier

  • altered conversion of keratinocytes to protein/lipid scales
  • half of cases traced to the gene for filaggrin
  • T helper cell dysregulation involved, linked to Ig E and Mast Cells

this causes

  • water loss from the skin, dehydration
  • hyper-reactivity to allergens
  • infection (staph aureus)
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30
Q

What are the risk factors for developing atopic eczema?

A
  • stress
  • genetics
  • pollen and pets
  • rough clothes/dyed clothes/tight fitting
  • contact allergens
  • extremes of temperatures
  • hormones
  • skin infections
  • certain foods
  • house dust mites
  • soap and allergens
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31
Q

What are the symptoms for diagnosing atopic eczema?

A
  • itching
  • inflamed, dry, red skin
  • papules (raised red bumps)
  • papules coalesce to form plaques (secretion of sebum)
  • weeping, crusted, blistered, scaling, thick
  • sleep disturbance
  • onset in a young age
  • flexures
  • asthma?
  • family member?
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32
Q

What are the different areas eczema can affect?

A

young children:
- face, cheeks, scalp, chin

older children:
- flexures, wrists, ankles

adults:
- & the hands

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33
Q

What are the characteristics of mild, moderate, severe and infected eczema?

A

mild:
- dry skin, itching, some redness
moderate:
- dry skin, itching, redness, thickening, more areas affected
severe:
- widespread symptoms, thickening, bleeding, oozing
infected:
- weeping, crusted, pustule and possibly systemic symptoms

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34
Q

What are the treatments for mild eczema?

A
  • emollients

- mild topical steroid if inflamed skin

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35
Q

What are the treatments for moderate eczema flare ups?

A
  • increase emollient use
  • moderate potency topical steroid
  • trial of non-sedating antihistamine
  • occlusive bandages
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36
Q

What are the treatment options for moderate eczema between flares?

A
  • low potency steroid, intermittent use

- topical calcineurin inhibitors

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37
Q

What are the treatments for severe eczema?

A
  • increase emollient use
  • potent topical steroid
  • non-sedating/sedating antihistamine
  • topical calcineurin inhibitor (between flares)
  • oral steroids
  • bandages
  • phototherapy
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38
Q

What are the treatments for infected eczema?

A

oral antibiotics

  • flucloxacillin
  • erythromycin
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39
Q

What are the different types of emollient?

A 
light:
- E-45
- Diprobase
moderate:
- oilatum 
- hydrous cream
greasy:
- 50% white soft
- liquid epaderm
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40
Q

What are examples of low potency steroid creams?

A

hydrocortisone

  • 0.1
  • 0.5
  • 1
  • 2.5
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41
Q

What are examples of moderate potency steroid creams?

A
  • clobetasone butyrate 0.05 (EUMOVATE)

- betamethasone valerate 0.025% (Betnovate RD)

42
Q

What are examples of potent steroid creams?

A
  • betamethasone valerate 0.1% (Betnovate)

- betamethasone diproprionate 0.05%

43
Q

What are examples of very potent steroid creams?

A
  • clobetasol propinate 0.05%
44
Q

What are the counselling points for steroid creams?

A
  • spread thinly using FTUs
  • use the next step down steroid for sensitive areas (neck/face/flexures/genitals)
  • maximum use 7 - 14 days
  • maximum use 5 days on sensitive areas (more absorption across thinner skin)
  • continue 48 hours after inflammation has reduced
  • OD/BD, short periods of time
  • apply 30 minutes after emollients
45
Q

What are the counselling points for emollients?

A
  • use regularly and liberally, even when you don’t have flares
  • apply emollients before steroid to increase penetration
  • avoid sharing tub preparations - pump
  • do not use aqueous cream
  • one doesn’t work try another
  • use greasier preparations at night
  • flammable warnings
  • don’t rub in, stroke in
  • gently dry skin after washing and apply to trap moisture
46
Q

What are the other counselling points when treating asthma?

A
  • don’t scratch the skin, cut nails/mittens, rub area instead
  • link to other conditions?
  • avoid exposure to triggers
  • recognise flares + treat promptly
  • diet alteration?
  • discard old topical products to avoid cross-contamination
47
Q

What are example of non-sedating antihistamines?

A
  • cetirizine
  • loratidine
  • fexofenadine
48
Q

What is an example of a sedating antihistamine?

A
  • chlorphenamine
49
Q

How often should treatment be reviewed in asthma?

A
  • review steroid/tacrolimus use every 3 - 6 months
50
Q

What is the most common type of psoriasis?

A
  • vulgaris
  • chronic, inflammatory disorder of the skin and joints
  • systemic condition
51
Q

What is the epidemiology of psoriasis?

A
  • mainly Caucasians

- less common in children (15 - 25 years), then 55 - 60

52
Q

What is the pathophysiology of psoriasis?

A

inflammatory cells in all layers of psoriatic skin

  • T Cells
  • TNF alpha
  • Interleukins

cause hyper-proliferation (large turnover of cells) and vascular changes (may bleed on scratching)

53
Q

What are the risk factors of psoriasis?

A
  • obesity
  • smoking
  • alcohol
  • genetics - huge family link
  • hormones (pregnancy - protective factor, puberty/menopause risk factors)
  • medications
  • skin injury
  • stress
  • infection
54
Q

What are the symptoms of psoriasis?

A
  • red plaques, with overlying white scale
  • commonly affects buttocks, lower back, scalp, elbows, knees, nails
  • thick, scaly skin
  • may bleed if scales scraped off
55
Q

What are the complications of psoriasis?

A
  • psoriatic arthritis, screen for symptoms
  • depression, anxiety
  • metabolic syndrom & CVD
56
Q

What are the treatments for psoriasis on the trunk and limb?

A
  • vitamin D analogues
  • & potent corticosteroid for 4 weeks (will take 1 - 2 weeks to work)
  • coal tar if these aren’t effective (avoid if allergic to aspirin, apply 1/7) - takes 3 - 4 weeks to work
57
Q

What are the treatments for psoriasis on the scalp?

A
  • potent corticosteroid (try a different formulation if not effective) for 4 weeks
  • try a formulation with salicylic acid to remove scales THEN
  • &/ vitamin D analogue (combination better than each alone)
58
Q

What are the treatments for psoriasis on the face, flexures and genitals?

A
  • mild-moderate steroid 2 weeks
  • DO NOT USE vitamin D analogue
  • calcineurin inhibitor (Tacroline)
59
Q

What makes psoriasis ‘severe’?

A
  • if over 10% of the body is affected, 1% = one palm of the hand
  • significant distress/impairment
  • failure of treatment
60
Q

What are the treatments for mild psoriasis?

A
  • emollients
  • topical corticosteroid (potent)
  • tacrolimus (calcineurin inhibitor)
  • coal tar /dithranol
61
Q

What are the treatments for moderate psoriasis?

A
  • all of mild psoriasis
  • phototherapy
  • oral methotrexate/ciclosporin
  • oral acitretin
62
Q

What are the treatments for severe psoriasis?

A
  • add biological agent

- apremilast

63
Q

What are examples of Vitamin D analogues?

A
  • do not use on sensitive areas
  • Calcipotriol (Scalp solution)
  • Calcitriol
  • Tacalitol (lotion)

all of these are ointments too

64
Q

What are the counselling points of Vitamin D analogues?

A
  • can cause skin irritation
  • can cause photosensitivity
  • sun cream
  • avoid sunbeds
  • will take 1 - 2 weeks to work
65
Q

What is the advice for flare treatment in psoriasis?

A
  • treat in 4 week blocks
  • then break for 4 weeks
  • use Vit D analogues in between flares
  • report joint symptoms immediately
  • avoid scratching and picking
66
Q

What is the most common type of acne?

A

vulgaris

67
Q

What is the epidemiology of acne?

A
  • teenagers most common
  • affects more men than women when younger
  • affects more women than men when older
68
Q

What does the pilosebaceous follicles involve in the pathophysiology of acne?

A
  • inflammatory action
  • increased production/altered composition of sebum (due to androgens in puberty)
  • growth/activity of Cutibacterium acnes within sebum in hair follicles (more sebum available to grow)
  • keratonicyte proliferation stimulated by Cutibacterium acne, blocked and inflamed
69
Q

What is comedogenesis?

A

blocked follicles

70
Q

What is hypercornification?

A

hardening of the skin

71
Q

What does comedogensis and hypercornification lead to?

A
  • blockage of the pilosebaceous follicles and acne lesions
  • closed comedones (whiteheads)
  • open comedones (blackheads - where the melanin reacts with the sun)
72
Q

What are the risk factors of acne?

A
  • family members
  • high glycemic index foods - increases androgens
  • medications
  • polycystic ovary syndrome - linked to increased androgens
  • smoking
  • stress
  • cosmetics (need non-comedogenic makeup)
73
Q

What are papules?

A

small red raised bumps

- less than 5mm in diameter

74
Q

What are pustules?

A

same as papules but with yellow/white filled fluid

- less than 5mm in diameter

75
Q

What are nodules?

A

harder, more painful, deeper spots that can lead to scarring

- over 5mm in diameter

76
Q

What are cysts?

A

deep, large, puss-filled spots

- over 5mm in diameter

77
Q

How is the severity of acne determined?

A
  • large area affected
  • scarring/lesions
  • treatment failure
  • severe distress
78
Q

What is the treatment for mild-moderate acne?

A
  • topical retinoid
  • benzoyl peroxide (antibacterial)
  • azelaic acid (milder acne, not as potent)
  • topical antibiotic
  • emollient (oil free/non-comedogenic)

treat for 6 - 8 weeks then refer to GP

79
Q

What is an example of a topical retinoid?

A
  • adapaline 0.1% gel/cream
  • isotretinoin (only for 18+)
  • OD/BD
  • disrupt & inhibit formations of comedones
  • anti-inflammatory
80
Q

What topical antibiotic is used for mild-moderate acne?

A
  • clindamycin with BPO

- clindamycin with BPO and Retinoid

81
Q

What are the treatments moderate severity acne?

A
  • oral antibiotic + topical retinoid
  • add BPO
  • maintenance treatment long term (BPO/Retinoid/Azelaic Acid)

treat for 6 - 8 weeks, repeat courses but not recommended as long-term treatment

82
Q

What are the oral antibiotics used for moderate acne?

A
  • doxycycline
  • lymecicline
  • erythromycin
83
Q

What are the counselling points for someone with acne?

A
  • don’t over clean the skin, may dry out skin
  • don’t pick/squeeze lesions, scarring
  • use non-comedogenic/no oil products
  • BPO can bleach hair and clothing
  • skin irritation, can reduce application frequency or switch products
  • avoid sun beds BPO/retinoids/oral antibiotics
  • avoid triggers
  • avoid contact with eyes and mucous membranes
  • avoid retinoids/oral antibiotics in pregnancy
  • apply to whole affected area
  • gels - apply after washing, wash off after a few hours
  • washes - apply after washing, wash off after few mins
  • retinoids - pea sized amount to area, then wash off after 30 - 60 mins
84
Q

What is Isotretinoin?

A
  • an oral retinoid
  • used for acne unresponsive to topical treatments/antibiotics
  • specialist treatment
  • 16 week course
  • can repeat the course in a relapse
85
Q

What are the actions of isotretinoin?

A
  • reduces skin sebum secretion by 90% after six week
    so also see a reduction in C acnes concentrations
  • decreases hyperkeratinisation
    so this interferes with comedogensesis, no blocking of particles
  • anti-inflammatory properties
86
Q

What are the risks of using isotretinoin?

A

TERATOGENIC - PPP, pregnancy prevention programme
- effective contraception 1 month before and 1 month after treatment
- effective contraception = CIUD/IUD/Implant
DEPRESSION/ANXIETY/SUICIDAL IDEATION
- collect psychiatric history, stop if mental health deteriorates
IMPAIRED NIGHT VISION
- sensitive to headlights
DRY SKIN/JOINT PAIN as it reduces secretions
FRAGILE SKIN
- need UV protection SPF 50
- no hair removal treatments during or 6 - 12 month after
LIVER RISKS
HIGH BLOOD LIPIDS

87
Q

What are the two types of phototherapy in psoriasis?

A

Narrowband UVB (First Line)

  • better tolerated
  • 2/3 times a week

Psoralen and UVA

  • psoralen 2 hours before UVA exposure
  • UVA exposure activates psoralen
  • inhibits basal cell proliferation
  • 3 times weekly
  • clears in 5 - 6 weeks
88
Q

What are the adverse effects of phototherapy in psoriasis?

A
  • teratogenic (contraception)
  • premature skin ageing
  • skin pigmentation
  • cataract formation (UVA eye protection)

would need regular skin examinations for pre-malignant changes

89
Q

What is acitretin used for?

A
  • moderate psoriasis

- synthetic retinoid (similar to isotretinoin)

90
Q

How does acitretin work?

A
  • decreases hyperkeratinisation and normalises cell proliferation, differentiation and cornification
  • longer half life
  • so, treatment is longer than 16 weeks
91
Q

What are the risks of acitretin?

A
  • contraception for 3 years after, due to half life
  • CI in hyperlipidaemia
  • Hepatotoxic (monitor liver function every three months, every 2 weeks to start)
  • Cannot drink alcohol as alcohol increases serum levels of the drug
92
Q

What is methotrexate?

A

a folic acid antagonist

  • used in moderate psoriasis and eczema
  • takes 1 - 3 months for full effect
93
Q

How does methotrexate work?

A
  • inhibits dihydrofolate reductase
  • blocks DNA synthesis
  • this slows down basal cell proliferation in psoriasis
  • anti-inflammatory action in eczema
94
Q

What are the risks of methotrexate?

A
  • liver cirrhosis (LFTs, every month, then 3 months)
  • blood disorders (FBCs every week, then every month)
  • GI symptoms
    so give folic acid once weekly same as methotrexate, but on a different day to the methotrexate
  • alopecia
  • family planning
  • infection risk (dampens down the immune system)
  • avoid trimethoprim and NSAIDs
95
Q

What is ciclosporin?

A
  • used in psoriasis and eczema
  • 2 - 4 months
  • BD
96
Q

How does ciclosporin work?

A
  • IL 2 blocked
  • Blocks proliferation of T lymphocytes and cytokines (anti-inflammatory, eczema)
  • Blocks proliferation of keratinocytes (psoriasis thickening)
97
Q

What are the risks of ciclosporin?

A
  • Nephrotoxic
  • Hypertension
  • Teratogenic (but can be used last line in pregnancy if needed)
  • Immunosuppressant - infection risk
  • Avoid grapefruit juice
98
Q

What are biologics?

A
  • treatment for severe psoriasis
  • anti TNF monoclonal antibodies (mAb)
  • highly effective with responses seen in 6 weeks
  • therapy continued 6 months - 2 years
  • can switch between mAbs if needed, if one isn’t working try another
99
Q

What are the risks of biologics?

A

increased risk of infection
(TB concerns, no raw/part cooked meat, fish, eggs or dairy)
cardiovascular risk
worsening of underlying neurological disease
cancer risk in patients

100
Q

What biologic is used in the treatment of eczema?

A

Dupilumab

  • inhibits activation of T helper cells
  • inhibits expression of filaggrin
101
Q

What is the risk of dupilumab?

A
  • predisposes to worm infection
  • dose every 2 weeks
  • review at 16 weeks
  • only use if no response/intolerance to all other treatments

Patient Sem 1 (8 decks)

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