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CFB > WCS08 Dermatology 1 > Flashcards

WCS08 Dermatology 1 Flashcards

1
Q

Description of lesions

A

Macule
- circumscribed alteration in ***colour of skin <1 cm

Patch
- circumscribed alteration in ***colour of skin >1 cm

Papule
- circumscribed palpable elevation
- <0.5 cm in diameter

Nodule
- solid mass observed as an elevation / can be palpated
- >0.5 cm in diameter

Plaque
- elevated area of skin
- >=2 cm in diameter
- small plaque sometimes used for such lesions 0.5-2 cm in diameter

Petechiae
- punctate haemorrhagic spot
- 1-2 mm in diameter

Ecchymosis (bruise)
- macular area of haemorrhage
- >2 mm in diameter

Vesicles
- visible accumulations of fluid within / beneath epidermis
- <0.5 cm in diameter (small)
- often grouped

Bullae
- >0.5 cm
- Multilocular (coalesced vesicles in eczema) / Unilocular

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2
Q

Clinical assessment of lesions

A

Primary:
- Macule —(↑ in size)—> Patch
- Papule
—(↑ in size)—> Plaque
—(↑ in volume)—> Nodule
- Pustule
- Vesicle —(↑ in volume)—> Bulla
- Blister
- Wheal
- Telangiectasia

Secondary:
- Crust
- Scaling
- Fissure
- Erosion
- Ulcer
- Excoriation
- Atrophy
- Lichenification
- Lichenoid
- Necrosis
- Scar
- Exfoliation

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3
Q

Morphology of lesion

A
  1. Colour
    - white
    - brown
    - purple (purpuric)
    - red (erythematous)
    - pink
  2. Shape
    - round
    - oval
    - polygonal
    - annular
    - umbilicated
    - serpiginous (snake-like)
  3. Surface
  4. Margin
    - well
    - ill-defined
  5. Pattern
    - linear
    - annular
    - grouped
    - dermatomal
  6. Palpate
  7. Distribution
    - generalised
    - localised (extensor surfaces, flexural area, body folds, palms, soles, acrofacial)
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4
Q

Palpation of cutaneous lesions

A
  1. Soft / Firm / Hard
  2. Compressible / Non-compressible
  3. Tender / Non-tender
  4. Blanchable (e.g. Erythema) / Non-blanchable (e.g. Purpura)
  5. Rough / Smooth
  6. Mobile / Fixed to underlying structure
  7. Dermal / Subcutaneous
  8. Temperature normal / elevated
  9. Thrill, Pulsation etc.
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5
Q

History taking in Dermatology (+ SC Medicine)

A

History of present illness:
1. Onset
2. Site
3. Symptoms
- Itch, Pain, Numb
- Constitutional symptoms: Fatigue, Weakness anorexia, Weight loss, Malaise, Recent acute illness (e.g. URTI, fever, chills), Joint pains
4. Persistent / Transient / Seasonal variation
5. Duration
6. Pattern of spread + Extent of involvement
7. Evolution
8. Provocative factors (heat, cold, sun, exercise, travel history, drug history, pregnancy, season) / Alleviating factors
9. Previous treatment
10. Cosmetic concern
11. Implication to patient’s life (sleep and work)

Past medical history:
1. Hospitalisation
2. Operation
3. Allergies (esp. Drug)
4. Drug / Treatment history
5. Smoking, Drug abuse
6. Atopic history (Asthma, Allergic rhinitis, Atopic dermatitis)
7. Family history of atopy / skin diseases
8. Social history
9. Sexual history

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6
Q

Physical examination in Dermatology

A
  1. Distribution
    - Neck
    - Antecubital fossa
    - Popliteal fossa
  2. Associated changes
    - psoriasis: nails, naval cavity, scalp, joints
  3. Other sites
    - Oral mucosa
    - Scalp
    - Ears
    - Genitalia

SC Medicine:
1. Distribution and arrangement
2. Colour
3. Border
4. Surface features - scaling
5. Palpate
6. Types of lesion - morphology
7. Associated features e.g. hair, nails, genitalia, mucous membrane

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7
Q

***Investigations in Dermatology

A
  1. Dermoscopy (magnification with hand lens)
  2. Woods lamp (365nm)
    - Dermatophytosis (green to yellow)
    - Erythrasma (coral red) (caused by Corynebacterium minutissimum)
    - Porphyria (pinkish red)
  3. Skin patch, Skin prick test
    - test for allergens
  4. Laboratory tests
    - Gram stain
    - Fungal smear
    - Scabies scrape
    - Skin swab
  5. Skin biopsy
    - Histopathology
    - IF
    - EM
    - Culture
  6. Serum serology
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8
Q

Treatment in Dermatology (SC Medicine)

A
  1. Topical agents
  2. Systemic: Oral / IV
  3. Phototherapy: UVA / UVB
  4. Laser
  5. Surgery
    - Cryotherapy
    - Cauterisation
    - Excision
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9
Q

Common dermatoses (skin pathology)

A
  1. Urticaria / Hives
    - composed of Wheals (Transient edematous papules + plaques)
    - pruritic ∵ edema of ***Papillary body
  2. Angioedema
    - larger edematous area involving **Dermis + **SC tissue
    - deep, ill-defined

—> Both involve same edematous process
—> But at different levels of cutaneous vascular plexus

  1. Atopic Dermatitis / Eczema
  2. Contact Dermatitis
    - Irritant Dermatitis
    - Allergic Contact Dermatitis
  3. Psoriasis
    - Psoriasis vulgaris
    - Psoriatic erythroderma
    - Pustular psoriasis
  4. Impetigo
  5. Dermatophyte infection / Superficial fungal infection
  6. Viral warts
  7. Shingles / Herpes zoster
  8. Acne vulgaris
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10
Q
  1. Urticaria
A

Clinical types

  1. Acute
    - common
    - acute onset
    - <6 weeks
    - ***IgE-dependent with atopy (e.g. triggered by parasites, infections, drugs, alimentary agents)
    - can be complement-mediated (e.g. serum-sickness like reaction)
  2. Chronic
    - idiopathic mostly
    - >6 weeks
    - rarely IgE-dependent
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11
Q

Etiology of Urticaria

A
  1. Idiopathic (78%)
  2. Immunological (3%)
    - IgE-mediated
    - Complement-mediated
    - Autoimmune
    - Immune contact
  3. Physical (13%)
    - Dermographism (i.e. scratching)
    - Cold
    - Solar
    - Cholinergic
    - Pressure
    - Vibratory
  4. Genetic (1%)
    - Distinct angioedema (+ Urticaria) syndromes
    - e.g. Hereditary angioedema, Angioedema-urticaria-eosinophilia syndrome
  5. Others
    - Vascular / Connective tissue autoimmune disease
    - Urticaria due to mast-cell releasing agents, ACE inhibitors
    - Non-immune contact urticaria e.g. Exogenous urticants
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12
Q

DDx of Urticaria esp. unresolving, new onset

A
  1. Urticarial vasculitis
  2. Drug eruption
  3. Viral exanthem
  4. Bites / Papular urticaria
  5. Bullous pemphigoid
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13
Q

Treatment of Urticaria

A
  1. Discontinue suspected triggers
  2. ***Anti-histamines: Type 1 (+ 2) histamine receptor antagonists
  3. ***Prednisone: only for those not controlled on anti-histamines on a short term basis
  • Topical steroids: not generally effective
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14
Q
  1. Atopic Dermatitis / Eczema
A

Chronic relapsing pruritic exanthematous dermatosis characterised by:
- Allergic diathesis (tendency)
- Erythema
- Oozing
- Crusting
- Excoriations
- Lichenification
- Dehydration of involved skin

Established criteria for diagnosis
1. Hanifin and Rajka’s criteria
2. 1994 UK Working Party’s diagnostic criteria

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15
Q

Distribution of Atopic Dermatitis / Eczema

A

Age-dependent
- Infant: Extensor surfaces
- Child: Flexures, Trunk
- Adolescent: Neck, Face, Extensor surfaces of upper + lower limbs, Breasts

Morphology:
- **Indistinct border
- **Symmetrical
- **Acute: Erythematous, Exudative, Vesicular, Crusting
- **Chronic: Dry, Scaly, Lichenified, Hyperpigmented
- May be infected

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16
Q

DDx of Atopic Dermatitis

A
  1. Seborrhoeic dermatitis
  2. Contact dermatitis
  3. Psoriasis
  4. Scabies
  5. Genetic / Metabolic disorders
    - feat. Atopic eczema with / without raised IgE level
    - e.g. Ataxia telangiectasia, Wiscott Aldrich syndrome
17
Q
  1. Contact Dermatitis
A
  1. Irritant Dermatitis
    - inflammatory reaction resulting from exposure to a substance that causes an eruption in most people who come in contact with it
  2. Allergic Contact Dermatitis
    - **acquired sensitivity to various substances that produce inflammatory reactions in those and only those who have been **sensitised to the allergen
18
Q

Patch test

A
  • Intact, uninflammed skin, upper back
  • Non-irritating concentration of suspected substances / allergens
  • Thin-layer rapid-use epicutaneous (TRUE) test / Finn chambers mounted on tape
  • Removed after 48 hours
  • Assess for reaction at **48 hours + **96 hours

Look for:
- **Erythematous papules, vesicles, edema
- **Pustules possible with nickel, mercury, potassium iodide
- “Excited skin syndrome”: state of hyper-irritability. Negative test may appear as weakly positive

19
Q
  1. Psoriasis
A

Classification:
1. Psoriasis vulgaris
- **Chronic plaque type
- **Acute guttate type
- Inverse
- Palmoplantar

  1. ***Psoriatic erythroderma
  2. ***Pustular psoriasis (嚴重版)
    - Pustular psoriasis of von Zumbusch
    - Palmoplantar pustulosis
    - Acrodermatitis continua
20
Q

Clinical features of Psoriasis

A
  1. Chronic large ***plaque
  2. Guttate (一點點)
  3. Pustular
  4. Erythrodermic (> 90% skin is red)
  5. ***Nail
    - pitting
    - onycholysis
    - subungual hyperkeratosis
    - oil-drop sign
    - nail dystrophy
  6. ***Scalp, joints
  7. **Auspitz sign (punctate bleeding spots when scales scraped off **vs Eczema)
  8. ***Koebner phenomenon (skin lesions on lines of trauma)
21
Q

Management of Psoriasis

A

Choice of therapy depends on:
- Age
- Type
- Site, extent of involvement
- Previous treatments
- Associated medical disorders
- Lifestyle of patients

**Treatment:
1. Topical
- **Emollient
- **Corticosteroid
- **Vitamin D analogue
- **Coal tar
- **Dithranol (aka Anthralin)
- ***Tazarotene (Retinoid)

  1. ***Phototherapy
    - NBUVB, PUVA
  2. ***Systemic treatment
    - Methotrexate
    - Retinoids
    - Cyclosporine
  3. **Biologics
    - **    Infliximab (mAb), ***Adalimumab: Successfully treat psoriasis, associated arthritis
    - Ustekinumab (human mAb against IL-12, IL-23)
    - Secukinumab (human mAb against IL-17A)
    - Guselkumab (human mAb against IL-23)
22
Q

Biologics in treatment of Psoriasis

A

TNF-α: plays a role in inflammatory process
- **Infliximab (mAb), **Adalimumab: Successfully treat psoriasis, associated arthritis
- Ustekinumab (human mAb against IL-12, IL-23)
- Secukinumab (human mAb against IL-17A)
- Guselkumab (human mAb against IL-23)

23
Q
  1. Impetigo
A

***Staph. aureus / Strept. pyogenes
In skin damaged by previous minor trauma e.g. scratching / insect bite

Clinical features:
- **Vesicles / Pustules that arise on **Erythematous base with ***Crusting formation

DDx:
1. Discoid eczema
2. Herpes simplex
3. Varicella

Management:
Topical / Systemic antibiotics
- Cloxacillin
- Cefuroxime
- Erythromycin

Complication:
- Post-infective glomerulonephritis

24
Q
  1. Dermatophyte infection / Superficial fungal infection
A
  • Onychomycosis (Nail)
  • Tinea pedis (Feet)
  • Tinea cruris (Groin)
  • Tinea corporis (Trunk)
  • Tinea manuum (Hand)
  • Tinea capitis (Scalp)

Management:
- Anti-fungal

25
Q
  1. Viral warts
A

HPV
- transmitted by ***Contact
—> Genital wart: Sexually transmitted

Clinical presentation:
- **Warty lesions with blood vessels beneath surface
- Painful in sole
- Genital wart can be associated with **neoplastic changes e.g. SCC in-situ, SCC

Management:
- **Salicylic acid
- **Cryotherapy
- Cauterisation
- ***Topical 5% Imiquimod

26
Q
  1. Shingles / Herpes zoster
A
  • Reactivation of latent varicella-zoster virus
  • ***Dermatomal distribution
  • Usually elderly

Clinical presentation:
- Presents with **painful erythematous eruption followed by **vesicle and pustule formation that clustered into a ***herpetiform arrangement
- Affect eye if involved CN5

Complications:
- Immune competent patients:
—> Peripheral nerve **palsies
—> **Encephalitis
—> Myelitis
—> Contralateral hemiparesis

Herpes Zoster Ophthalmicus
- reactivation of latent VZV in Trigeminal ganglia (V1, V2)
- ***Hutchinson’s sign (Nasociliary nerve affected —> more likely to have Intraocular inflammation)

Management:
- ***Aciclovir 800mg 5x/day

27
Q
  1. Acne vulgaris
A
  • common in teenage (80%)
  • ***Male > Female
  • positive family history
  • often neglected: asymptomatic, not life-threatening
  • some patients / parents consider acne to be “normal” for puberty

Pathogenesis:
1. ***Seborrhoea
- Excessive sebum production ∵ over-response to androgen / excessive androgen secretion

  1. ***Comedogenesis
    - Hypercornification of pilosebaceous ducts
  2. Infection
    - ***Propionibacterium acnes (P. acnes)
  3. Inflammation
    - Lipolysis of sebum of P. acnes
    - Superantigen from P. acnes triggers inflammation of comedones
    - Inflammatory mediators from ductal corneocytes

Clinical features:
1. Comedones: open / closed
- non-inflamed

  1. Papules, pustules
    - superficial inflamed lesions
  2. Nodules, cysts
    - deep inflamed lesions

Management:
1. Topical therapy
- **Retinoids
- **Benzoyl peroxide
- Azelaic acid
- Antibiotics

  1. Oral therapy
    - Antibiotics
    - **Isotretinoin (Roaccutane): Stop contraception **1 month after completion of isotretinoin
  2. Photodynamic / Light source therapy

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