Skin changes

Question 1

Venous insufficiency

Answer 1

Clinical signs: pigment changes due to hemosiderin deposits, ulceration, oedema, lymphoedema, lipodermatosclerosis (fibrosing panniculitis characterised by advanced hyperpigmentation and induration, resembling an inverted champagne bottle), dilated veins
Symptoms: leg pain, leg heaviness, aching, swelling, dry skin, tightness, skin irritation, muscle cramps, itching

Question 2

Lipodermatosclerosis

Answer 2

Fibrosing panniculitis of the subcutaneous tissue.
Due to severe chronic venous insufficiency.
Thickening and red discolouration of the skin due to diminished blood flow, usually caused by local or regional venous obstruction.
Severe cases - skin overlying the panniculitis is heavily pigmented and bound down to the subcut tissues, the fibrosis may girdle and strangle the lower leg further impeding lymphatic venous flow
Can resemble an inverted champagne bottle.

Question 3

Panniculitis

Answer 3

Inflammation of the subcutaneous fat characterised by development of single or multiple cutaneous nodules.
Inflammation of the panniculus adiposus (subcutaneous fat)

Question 4

Basal Cell Carcinoma

Answer 4

Common, locally invasive, keratinocytic skin cancer.
Slow growing plaque or nodule
Skin coloured, pink or pigmented
Varies in size - few mm to several cm
Spontaneous bleeding or ulceration
+/- central depression or ulceration (rolling edges)

Slow-growing skin mass (chronic, scaly)
Scab
Ulceration 
\+/- pigmentation
Often pearl-like

Tiny proportion grow rapidly, invade deeply, and/or metastasise to local lymph nodes

Question 5

Squamous Cell Carcinoma

Answer 5

Keratinocytic skin cancer derived from epidermis.
Can metastasize and be fatal.
Fast growing - wks to mths
May ulcerate
Tender or painful
Located on sun-exposed sites
Size - few mm to several cm

Raised, slightly pigmented
Ulceration or exudate
Chronic scab
Itching
Sign of metastases - palpable lymph nodes

Marjolin’s ulcer - SCC arising in area of chronic inflammation e.g. burn, chronic fistula, osteomyelitis

Question 6

Necrobiosis lipoidica

Answer 6

Rare granulomatous skin disorder which can affect the shins of insulin dependent diabetics but may occur in non-diabetic people also.
One or more tender yellowish-brown patches develop slower over months.
Round, oval or irregular in shape
Central area becomes pale, thinned and shiny with telangiectasia (prominent blood vessels)
Minor injuries cause ulceration

Question 7

Characteristics of ulcers

Answer 7

Venous:
shallow, wet, irregular borders that look white and fragile

Arterial:
deep, punched-out, dry, often elleptical in shape

Neuropathic:
thick, raised, keratinised edges (thick skin referred to as a callus)

Pressure: same as neuropathic ulcers

Pyoderma gangrenosum (associated with IBD and haematological malignancies): dark blue/purple halo