Tutorial 4 - Dermatology (A) - conditions

Question 1

Name some steroids in order of potency (weakest to most potent).

Answer 1

• Hydrocortisone
• Clobetasone butyrate
• Betamethasone valerate (betnovate)
• Clobestasol porprionate (dermovate)
• Prednisolone (oral)

Question 2

1. What is acne vulgaris?
2. How does it present?
3. What treatment is provided?

Answer 2

1. Acne vulgaris is a chronic inflammatory condition affecting mainly the face, back and chest. It is caused due to the blockage of the pilosebaceous units (hair follicle, hair shaft and sebaceous gland) by excess sebum.
2. Mix of inflammatory and non-inflammatory lesions. Non inflammatory include open and closed comedones (blackheads / whiteheads). Inflammatory lesions including papules, nodules, pustules and cysts. May present with hyperpigmentation and scarring.
3. Ladder of treatment depending on severity / history of relapse. Benzoyl peroxide gel, topical antibiotic such as clindamycin, topical retinoid such as tretinoin, oral antibiotic such as a tetracycline like lymecycline.

Question 3

1. What is atopic dermatitis (eczema)?
2. How does it present?
3. What treatment is provided?

Answer 3

1. Eczema is a chronic inflammatory skin condition, it affects people of all ages, but often presents before the age of 5. It’s called atopic because it is a condition linked with others such as hay fever, food allergy and asthma due to the overactivity of the immune system, and dermatitis because it is inflammation of the dermis.
2. Dry, cracked, itchy, discoloured skin (red - white skin, purple/brown - coloured skin), can become blistered / crusted - all mainly confined to flexor surfaces
3. Depending on severity recommend a liberal use of emollients and a topical corticosteroid of appropriate strength.

Question 4

1. What is shingles?
2. How does it present?
3. What are its risk factors?
4. What treatment is provided?

Answer 4

1. Shingles is a viral infection caused by the herpes zoster virus. The virus often lays dormant in the dorsal root ganglion, when a patient becomes immunocompromised it becomes reactivated and causes a rash along the dermatome of the nerves root that it was reactivated in.
2. Fluid filled blisters, burning pain, itchy - often effects face or stomach and unilaterally.
3. Old age and immunocompromised patient.
4. If suspect meningitis, encephalitis or observe Hutchinson sign (rash on tip of nose - risk of permanent vision loss). Otherwise provide antiviral therapy i.e. acyclovir for 7 - 10 days.

Question 5

1. What is urticaria, angioedema andanaphylaxis?
2. How does it present?
3. What are its risk factors?
4. What treatment is provided?

Question 6

1. What is contact dermatitis?
2. How does it present?
3. What treatments are provided for it?

Answer 6

1. Contact dermatitis is an inflammatory skin condition either due to an allergen (type 4 hypersensitivity reaction with sensitivity and subsequent re - exposure) or due to an irritant contact i.e., soaps.
2. Itchy, blistered, dried, cracked skin appearance.
3. Liberal emollient use, topical corticosteroid, avoidance of irritant / allergen.

Question 7

1. What is rosacea?
2. How does it present?
3. What treatments are provided?

Answer 7

1. Rosacea is chronic inflammatory skin condition affecting mainly the central forehead, nose, chin and cheeks.
2. Red flushes, burning sensation, papules and pustules.
3. Avoid triggers such as spicy foods.

Question 8

• What are the 3 main skin cancers?

Answer 8

• Squamous cell carcinoma
• Basal cell carcinoma
• Melanoma

Question 9

What are the main risk factors for skin cancer?

Answer 9

• Sun UV exposure
• Immunosuppression i.e., following a renal transplant
• Fair skin
• Family history

Question 10

How does a melanoma present?

Answer 10

• Use A-E - to determine if the mole is unusual.
• Hidden melanomas: Occular, mucosal and nail melanomas.
• Black/brown/tan/red/pink pigmented

Question 11

How does a squamous cell carcinoma present?

Answer 11

• Firm, red nodule.
• Red rough sore in mouth
• Rough scaly patch on lips that may develop into an open sore
• Red wart on genitals.

Question 12

How does a basal cell carcinoma present?

Answer 12

• Shiny, translucent skin coloured bump

Question 13

How do you diagnose and treat skin cancers?

Answer 13

• Diagnose: you will take an in depth history, physical examination and if a more sinister skin change is seen - a biopsy is ordered which will detect if skin cancer is present and if present which type too.
• Treatment: Various depending on degree of spread, Curet and electrodessication (C&E), freezing with liquid nitrogen (after use of curet). For cancer that’s spread maybe chemotherapy.

Question 14

1. What is psoriasis?
2. How does it present?
3. What treatment is provided?

Answer 14

1. Psoriasis is a systemic, immune mediated, inflammatory skin condition which as a chronic relapsing - remitting pattern.
2. Erythematous, scaly plaques, on extensor surfaces mainly.
3. Emollients and corticosteroids i.e. hydrocortisone.

Question 15

1. What is cellulitis?
2. How does it present?
3. What are its risk factors?
4. What tests can be done?
5. What is the management?

Answer 15

1. Cellulitis is acute bacterial infection of the dermis and hypo-dermis. It often affects the legs, but can affect other parts of the body i.e., face, upper limb.
2. Skin looks red, hot, inflamed, swollen, tender, warm, painful to touch.
3. Lymphoedema, leg oedema, co - morbidities such as diabetes predispose to infection.
4. swab for culture, WBC count/ CRP count.
5. If stage 1 cellulitis (i.e., no systemic signs and no co - morbidities) then treat in primary care with strong antibiotic course of flucloxacillin, if allergic then clarithromycin. Otherwise refer on to dermatologist / infection specialist.

Question 16

1. What is necrotising fascitis(NF)?
2. How does it present?
3. What are its risk factors?
4. What tests can be done?
5. What is the management?

Answer 16

1. NF is a rare, life threatening skin infection. It is also called the “flesh eating disease”. Often caused by group A streptococcus. Necrotising - tissue death, fascitis - inflammation of the fascia (layer deep to skin, containing blood vessels/nerves etc)! This infection rapidly spreads in the body too.
2. Red, swollen, warm, tender, painful leg, fever, fatigue, later on can ulcerate/blister/black spots form/ ooze pus.
3. People with co - morbidities, which make it harder to fight infection i.e, cancer, diabetes, liver cirrhosis, kidney disease.
4. Biopsy, imaging I.e., CT, blood works for signs of infection / muscle damage.
5. Urgent IV antibiotics / surgery may be needed as the infection damages blood vessels - so the antibiotics cannot perfuse to area of infection!

Question 17

1. What is seborrheic keratosis?

Question 18

1. What is erythema nodosum?
2. How does it present?
3. What causes it?
4. How is it diagnosed?
5. How is it treated?

Answer 18

1. Erythema nodosum is a type of panniculitis (inflammation of hypo - dermis).
2. Bilateral erythematous nodules on the anterior shin. Can also present with fever and joint pains.
3. Streptococcal infection, medications i.e., amoxaciillin, having rheumatoid arthiritis/other autoimmune conditions.
4. Clinical diagnosis.
5. Treatment of underlying cause i.e., throat infection , sarcoidosis, TB. Corticosteroids for inflammation. Should spontaneously resolve in 8 weeks.

Question 19

1. What is erythema multiform(EM)?
2. How does it present?
3. What are its risk factors?
4. What tests can be done?
5. What is the management?

Answer 19

1. EM is a hypersensitivity reaction often triggered by infection i.e., HZV.
2. Targeted lesions, normally begins on back of hands, tops of feet, then becomes more generalised.
3. Often infection i.e., HSV. Antibiotics such as penicillins.
4. Clinical diagnosis
5. Treatment of underlying condition. Often self limiting. Itching/irritation can be treated with corticosteroids. Eye involvement should be referred to ophthalmology.

Question 20

1. What is Steven Johnson syndrome (SJS)?
2. How does it present?
3. What are its risk factors?
4. What tests can be done?
5. What is the management?

Answer 20

1. SJS is a life threatening skin reaction to certain medications.
2. Prodromal symptoms of flu - sore throat, fever,runny nose, followed by erythematous skin, macules, targeted lesions, blisters. Followed by mucosal involvement (eyes, mouth,pharynx,GI tract, urinary tract).
3. Certain medications including epileptic medication - carbamazeapine, genetic predisposition, immunocompromised.
4. Skin biopsy.
5. Replace causative medication, supportive treatment i.e., IV fluids, pain relief. Immunomodulation i.e. corticosteroids.

Question 21

1. What is impetigo?
2. How does it present?
3. What are its risk factors?
4. What tests can be done?
5. What is the management?

Answer 21

1. Bacterial infection of the skin. Cn be non bullous or bullous. Usually form from pre - existing skin condition such as eczema but can also develop on its own as a primary cause.
2. Red sores / blisters which can burst to give golden crusty presentation(like cornflakes).
3. Skin trauma or pre-existing skin conditions can be invaded by bacteria such as S.Aureus. MRSA infection becoming more common.
4. Swabs. Clinical diagnosis.
5. Topical antibiotic.