Skin and systemic disease

Question 1

What skin manifestations may be seen in neurofibromatosis?

Answer 1

Multiple fibromas

Cafe au lait spots

Question 2

What infective skin problem may be a sign of diabetes?

Answer 2

Candidiasis

Question 3

What is the appearance of candida balanitis?

Answer 3

Erythema
Itch
Scaling
Papules and pustules
Affecting the foreskin and the glands penis

Question 4

What are granuloma annulare?

Answer 4

Papular lesions that are often slightly hyperpigment and depressed centrally. They typically occur on the dorsal surface of hands and feet (often over knuckles) and on the extensor aspect of the arms and legs.

Question 5

Describe the appearance of granuloma annulare

Answer 5

Smooth discolored plaques
Often overlying the knuckles or the dorsal surface of the hands and feet
Often annular- ring shaped
Disseminated type is composed of lots of small papules

Question 6

Who do granuloma annulare typically affect?

Answer 6

Children
Teenagers
Young adults
Older adults less commonly

Question 7

What are granuloma annulare associated with?

Answer 7

Localised granuloma annulare are associated with autoimmune thyroiditis

Extensive granuloma annulare are associated with diabetes mellitus, hyperlipidemia and rarely with lymphoma, HIV and solid tumours

Question 8

What is necrobiosis lipoidica?

Answer 8

Granulomatous skin disorder that affects the shins of insulin dependent diabetics. Cause is not known.

Shiny, painless areas of yellow/red skin on the shins

Question 9

What does necrobiosis lipoidica look like?

Answer 9

Tender yellow brownish patches on the shins
Round, oval or irregular in shape
Prominent blood vessels at the centre- telangiectasia
Minor injuries to the patches can cause them to ulcerate

Question 10

What is necrobiosis lipoidica a sign of?

Answer 10

Diabetes- often insulin dependent.

Question 11

What are diabetic shin spots a sign of?

Answer 11

Microvascular pathology as they are essential areas of small infarct that have healed. Also called diabetic dermopathy.

Most common cutaneous sign of diabetes.

Question 12

What do diabetic shin spots look like?

Answer 12

Light brown or reddish
Oval or round
Slightly indented scaly patches
Most often seen on the shins

Question 13

What does the prayer sign indicate in diabetes?

Answer 13

Diabetes can cause stiffening of the skin, thought to be due to glycosylation processes. This results in and inability to fully extend the fingers in order to bring them together for a prayer position. Can also cause Dupuytren’s contracture and appear similar to systemic sclerosis.

Question 14

Which drugs may induce photosensitivity?

Answer 14

Tetracyclines

Amiodarone

Question 15

What skin manifestation could indicate hyperlipidemia?

Answer 15

Xanthelasma

Question 16

What skin change is seen in Addison’s disease?

Answer 16

Hyperpigmentation- ACTH stimualtes melocytes

Question 17

What can vitiligo be a sign of?

Answer 17

Other autoimmune disease

Check TFTs, B12, Folate, Adrenal function..

Question 18

What are the features of pityriasis versicolor?

Answer 18

Areas of hypopigmentation typically seen on the chest due to overgrowth of Malassezia furfur. Anti-fungal creams (e.g. Imidazole) should be used for localised disease and oral antifungals if this fails

Question 19

What is pretibial myxoedema a sign of?

Answer 19

Often associated with Grave’s disease.
Asymptomatic but appears as firm, non-pitting asymmetrical plaques or nodules that can form scaly, thickened and hardened skin areas.

Question 20

What is the name for tender, red diffuse lesions affecting patient’s shins?

Answer 20

Erythema nodosum- due to inflammation in the subcutaneous fat

Question 21

What can erythema nodosum be a sign of?

Answer 21

Sarcoidosis (most common cause in western word)
TB
Inflammatory bowel disease- Crohn’s, UC
Drugs inc. OCP

Question 22

What are some causes of splinter-haemorrhages?

Answer 22

Subacute bacterial endocarditis

Question 23

What side effects can steroid treatment cause in the skin?

Answer 23

Purpura- Ecchymosis (bruising) (senile purpura occur naturally with age but steroids increase the rate of this happening).
Striae

Question 24

What might symmetrical lesions of palpable purpura be a sign of?

Answer 24

Vasculitis

This is most commonly found on the lower legs

Question 25

What is pyoderma gangrenosum?

Answer 25

A rapidly enlarging painful ulcer that is often found on the legs. Tend to growth from the site of a minor injury. It is due to an auto-inflammatory process.

Question 26

What disease are associated with the formation of pyoderma gangrenosum?

Answer 26

Inflammatory bowel disease (UC, Crohn's)
Rheumatoid Arthritis
Myeloma  + MGUS
GPA
Leukaemias

Question 27

What are the features of pyoderma gangrenosum?

Answer 27

Often starts suddenly, commonly from the site of minor injury
May start as a small pustule, red bump or blister
Skin breaks down resulting in an ulcer which can deepen and widen rapidly
Edge of ulcer if often purple
Very painful ulcers

Question 28

How should pyoderma gangrenosum be managed?

Answer 28

Swab the wound in case of secondary infections
Necrotic tissue should be gently removed, wide surgical debridement should be avoided during the active phase.
Antibiotics to prevent infection

Small ulcers-
Topical steroids, tacrolimus, ciclosporin, dressings and bandaging

Larger ulcers-
Systemic steroids, ciclosporin, methotrexate, biologics

Question 29

What should recurrent episodes of thrombophlebitis suggest the possibility of?

Answer 29

Lung or pancreatic cancer

Question 30

What is acanthosis nigricans?

Answer 30

Thickened darkened patches of skin that can occur almost anywhere but are prone to develop in the armpits, groin and neck. It can be a sign of a number underlying skin diseases.

Question 31

What can acanthosis nigricans be a sign of?

Answer 31

Cushing's
PCOS
Steroid use
Obesity
Insulin resistance
Internal malignancy- most often of the GI tract (especially stomach cancer). If suspecting there could be malignancy work-up for this should be done urgently

Question 32

What is erythema gyratum repens a sign of?

Answer 32

Skin rash that looks like wood grain and is indicative of an internal tumour. It has a very unique wavy pattern. The rash is very itchy. Requires full work up for malignancy- CXR, bloods, tumour markers, CT, MRI head, endoscopy, colonoscopy…

Question 33

What is pityriasis rosea?

Answer 33

Pityriasis rosea is an acute self limiting rash which tends to affect young adults. There is an initial herald patch followed by erythematous, oval, scaly patches.

Usually self limiting and disappears after 4-12 weeks

Question 34

What is lichen planus?

Answer 34

An autoimmune skin rash where there is keratinocyte death due to cytotoxic T cells.

Question 35

What are the features of lichen planus?

Answer 35

There is thickening of skin that often affects the wrists and elbows.
Oral involvement is called oral lichen planus.
Rash is flat topped- Planar
Polygonal shape
Papular or plaque
Purple colour
Pruritic- Itching

Plaques often have a shiny top
Plaques may be crossed by white lines called Wickham striae

Question 36

What is the treatment for lichen planus?

Answer 36

Topical steroids
Topical tacrolimus
Topical retinoids
Steroid injections

systemic treatment for severe forms includes oral steroids with steroid sparing agents.

Question 37

What are some systemic causes of pruritus?

Answer 37

Renal failure- uraemic puritis
Liver disease- jaundice cause itch
Polycythaemia vera (itching after warm water- baths or showers)
Iron deficiency anaemia (glossitis and angular stomatitis seen too)
Grave’s disease
Paraneoplastic itch is seen with lymphomas (as about night sweats too)

Question 38

What should Erythema gyratum raise concerns of?

Answer 38

Malignancy- especially of the lung