Week 10 Dermatology Flashcards
Necrobiosis Lipoidica
Diabetic skin change
Waxy, yellow
Usually on shins
Can ulcerate and scar
Diabetic dermopathy
Small, round, brown, atrophic skin
Usually shin
Scleredema
Diabetic skin change
Progressive, thickening of skin
Upper back, shoulders
Diabetic ulcers
Open sores/wound
Bottom of foot
Granuloma Annulare
Diabetic skin change
Smooth, discoloured plaque
“Ring” (annular) shaped
Cushings disease
Increased cortisol
Signs:
- acne
- central adiposity
- moon face, buffalo hump
- global skin atrophy
- striae on abdomen, thighs
- pupura (reduced connective tissue)
Addison’s disease
Decreased cortisol
- Hyperpigmentation
- Acanthosis Nigricans
Malignancy
- Necrolytic migratory erythema
- Erythema gyratum repens
- Acanthosis nigricans
Necrolytic migratory erythema
Glucagonoma syndrome (tumour causing excess glucagon)
Erythematous, scaly plaques
Acral, intertriginous (areas where skin rubs against each other) areas
Assoc. with pancreatic islet cell tumours
Other signs: hyperglycaemia, weight loss
Treatment: remove tumour
Erythema gyratum repens
Red, concentric band with whorled pattern
(Gyratum “gyrate” - moving in circular motion)
Severe itch and peripheral eosinophilia
Strongly assoc with lung cancer
Assoc with breast, cerval cancer
Treatment: underlying malignancy
Acanthosis nigricans
Smooth, velvet like, hyperkeratotic (thickening of outer layer of skin) plaque
Intertriginous areas (e.g. groin, axilla)
3 types:
Type I: malignancy (most common: adenocarcinoma of GI)
Type II: autosomal dominant
Type III: obesity, insulin resistance. Most common
Sweet’s syndrome
Small, red, bumps, can ulcerate
Assoc. with leukaemia
Sister Mary, Joseph nodule
Nodule bulging into umbilicus
Mestatic cancer in abdomen, pelvis
Erythema Annulare
Red, ring shaped, skin rash
Assoc. with haemotoglical cancers e.g. Hodgkin’s Lymphoma
Cutaneous (affecting skin, nails etc.) features associated with nutritional deficiency
Vitamin B
Vitamin C
Zinc
Vitamin B deficiency
Vit B6: pyridoxine - Dermatitis
Vit B12: cobalamin - Angular cheilitis
Vit B3: niacin - Pellagra (3Ds: dermatitis, dementia, diarrhoea)
Zinc deficiency
Acrodermatits Enteropathica
Pustules, bullae, scaling
Acral, perioral
Inherited - mutation in SLC39A (Zn transporter in intestines)
In infants can occur with breast feeding, when breast milk contains low amounts of Zn
In adults, can occur: alcoholism, malabsorption, IBD
Treatment: Zn supplement
Vitamin C deficiency
Scurvy
- Punctate purpura (non-blanching rash)
- dry curly hair
- dry skin
- inflamed gums-
non-healing wounds
Features of Erythema nodosum and some diseases it may be associated with
- Inflammatory condition
- Red nodules/lumps on skin due to inflammation of fat cells under skin
- Both shins
Associated with: Streptococcal infection, TB, IBD, infectious mononucleosis, sarcoidosis
Describe features of Pyoderma gangrenosum and some diseases it may be associated with
- Inflammatory skin condition
- Small, red blisters that form deep ulcers (with purple edges)
(“pyoderma” infection of skin with pus)
- Usually legs
Associated with: IBD (Chron’s, UC), Rheumatoid Arthritis, Myeloma
Describe hair and nail changes associated with systemic disease
- Alopecia areata (autoimmune)
- Hair thinning: B12, iron deficiency, hypothyroidism
Male pattern baldness - androgen excess
Nail clubbing - Lung Ca, IE, Liver cirrhosis, IBD, Interstitial pulm. fibrosis
Nail fold telangectasia (widened venules) - Scleroderma, SLE
Changes in skin are markers of what diseases?
- Endocrine disorders
- Internal malignancies
- Nutritional deficiencies
- Systemic infection
- Systemic inflammatory conditions
Endocrine skin changes
- Thyroid
- Diabetes
- Steroids
- Sex hormones
Endocrine:
Skin changes assoc with thyroid disorders
Thyroid:
- dry skin (hypothyroidism)
- thyroid dermopathy/pretibial myxoedema (Grave’s) - waxy, discoloured skin on anterior lower leg
- thyroid acropathy (Grave’s) - swelling of soft tissue of hands, clubbing of fingers
Endocrine:
Diabetic skin changes
Necrobiosis lipoidica
Sclerederma
Diabetic dermopathy
Diabetic ulcers
Granuloma annulare
Endocrine:
Skin changes in steroid imbalance
Cushing’s disease (excess steroids)
Addison’s disease (insufficient steroids)
Cutaneous signs that may indicate internal malignancy
Necrolytic migratory erythema
Erythema gyratum repens
Acanthosis nigricans
Erythema annulare
Sweet’s syndrome
Sister Mary Joseph nodule
Skin changes in systemic infection
Erythema nodulosum
Skin changes in systemic inflammatory disease
Pyoderma gangrenosum
Effects of UV light on skin
DNA damage on keratinocytes causing neoplastic transformation
Damages host’s immune system
Main type of skin cancer
- Basal cell carcinoma (BCC)
- Squamous cell carcinoma (SCC)
- Malignant melanoma
Basal cell carcinoma
- Most common
- Basal cells’s DNA control formation of new skin cells
- Mutation in DNA causes basal cells to proliferate rapidly and eventually form a tumour
- PTCH gene mutation associated
- 80% BCC found on head/neck/UV exposed sites
- Rarely metastises
Types:
Nodular -
Raised lesion/nodule, shiny, telangectasia (dilated blood vessels), uclerate centrally
Superficial -
Scaly, flat
Pigmented
Morpheic/sclerotic
Treatment:
Surgical excision: 2-3 mm margin
Cutterage and cautery
Cryotherapy
Mohs micrographic surgery
Squamous cell carcinoma
Most often on skin that has been regularly exposed to sunlight or UV radiation
Originates from keratinocytes
Pre-malignant types: Actinic keratoses
Bowen’s disease (SCC in situ)
Risk of metastasis
- Appeares keratinized, crusty, scaly
Treatment:
- Surgical excision: 4mm margin
Cautery and cutterage
Pre malignant/SCC in situ:
Cryotherapy
Topical imiquimod (immune repsonse modifier)
Malignant melanoma
Differentials:
Melanocytic nevi (moles), seborrhoiec keratoses (warts), actinic keratoses, bowen’s disease
Malignant melanoma: Irregular pigmented lesions on sun exposed area
Aietiology:
Due to UV damage
2 phases: radial growth phase - vertical growth phase
Risk factors: Genetic, UV radiation, Sun exposure, skin type I and II, immunosuppression, genetic CDK2NA
Appearence
Asymmetrical
Borders (unveven)
Colour (lots of different ones)
Diameter (more than 6mm)
Evolution (size, colour has changed)
Prognostic factors:
Clinical appearence - size, depth (blue/grey colour means it is deeper), location, ulceration
Histological appearence: Breslow’s depth (<1mm good prognosis), Clark level (anatomical level in skin) high mitotic rate
Types:
Superficial spreading malignant melanoma
Nodular melanoma
Acral melanoma (hands and feet)
Subungal melanoma (nail)
Amelanotic melanoma
Lentigo melanoma (pre-malignant form) (arises in a lentigo - flat brown lesion)
Melanoma in situ
Treatment:
Surgical excision - margin based on Breslow thickness (1cm margin: <1mm Breslow)
Chemotherapy - BRAF inhibitors, MEK inhibitors
Immunotherapy - Nivolumab, ipilimumab
Assess lymph node spread
Imaging - CT, MRI
Steven Johnson Syndrome
Affects skin and mucous membranes
Flu-like symptoms followed by red/purple rash that forms blisters
Less severe form of TEN
Drug induced - antivulsants e.g. carbamepazine
Toxic epidermal necrolysis
- Dermatological emergency
- Flu like symptoms, skin blisters and epidermis peels off forming painful, raw areas
- Mostly drug induced e.g. anticonvulsants or antibiotics
- Forms a spectrum of disease with Steven Johnson Syndrome (<10% = SJS, TEN more severe)
- SCORTEN severity scale
Treatment:
- Analgesia, fluids, special matresses, infection control, non adherent dressings
Differential: Staphylococcal scalded skin syndrome
Nodular melanoma
Acral melanoma
Subungal melanoma
Amelanotic melanoma
Melanoma in situ
Nodular BCC
Superficial BCC
Pigmented BCC
Morphoeic/sclerotic BCC
Erythema multiforme
- Self-limiting allergic reaction
- Multiple erythematous rash and bullae
- Due to HSV, EBV, sometimes drug
- Target lesions
Cutaneous vasculitis
- inflammation of blood vessels in skin
Triggers: infection, drugs, connective tissue disease e.g. RA
- Need to check for systemic vasculitis (inflammation of blood vessels in body)
- Often localised, not progressive
- Less unwell than in meningococcal rash
Acute pupura (meningococcal sepsis)
- Pupura (red spots that are non-blanching) rash
- Fever, nausea/vomiting, joint pain, cold hands and feet, tachycardia, tachypnoea, hypotension
- Nisseria meningitidis
Dermatomyosistis
- Inflammation of muscles
- Affects muscles and skin
- Presents with itchy, red/[urple rash, usually on sun-exposed surfaces
- Muscle weakness
Immunobullous disordes
Bulluos pemphoid
Mucous membrane pemphigoid
Paraneoplastic pemphigoid
Pemphigus vulgaris
Autoimmune blistering disease due to autoantiodies against basement membrane proteins
Dermatitis herpetirformis (itchy vesicles grouped together, assoc. with coeliac) - treated with topical streoids, gluten free diet
Adult varicella
VZV
Acute blistering condition
Complications in adults: pneumonia, neurogical complications
Linear IgA disease
- Blistering condition
- IgA antibodies deposited in the epidermis in a line
- Itchy rash with small blisters
Erythoderma
Descriptive term
80-90% erythema
Causes: psoriasis, eczema, drug reaction, cutaneous lymphoma
Treatment: treat underlying disorder
Acute pustular psoriasis
- Red paiunful skin with white, pus-filled bumps
Treatment: ciclosporin, methotrexate
Uticaria
Itchy, wheals
Lesions last <24 hours
Non-scarring
Commnest skin condition presenting at AandE
Immune mediated: Type I allergic IgE repsonse
Non-immune mediated: mast cell degranulation e.g. opiates
Causes: viral infectios, parasitic infections, NSAIDs, physical stimulants - cold
Treatment: antihistamines, steroids
:
Eczema
Inflammatory skin condition characterised by dry, itchy skin that is chronic and relapsing.
Aetiology:
Mutation for filaggrin - abnormal filaggrin causing barrier defect (increased permeability so bacteria can enter)
Types:
Endogenous: Atopic eczema, Seborrhoeic
Exogenous: Contact, Photoreaction
Atopic eczema - itchy, inflammatory condition, assoc with astha, hayfever (atopy), high IgE levels. Type I HS
Clinical features: Red dry symmetrical patches on face, flexor surfaces e.g. behind knees (between fingers suggest contact dermatitis)
Symptoms: tiredness, psychological impact, growth reduction
Causes atopic eczema: baterial - staph. aureus, viral: molluscum, eczema herpeticum
Investigations:
Bacterial swab (if skin broken)
Fungal mycology skin scrape
IgE RAST test
Skin prick testing - used more in children, detects food allergies
Allergic contact dermatitis - patch test
Treatments:
- Irritant avoidance
- Emoillents
- Steroids (mild, moderate, potent, super potent)
SE: perioral dermatitis, thinnning of skin
- Anti histamines
- Oral retinoid
- UV therapy
- Immunosuppressive agents - Methotrexate, Ciclosporin
Biologics - Dupilumab (anti-IL4/13)
Venous/varciose dermatitis
Underlying venous disease
Affects lower legs, can look brown (due to haemosiderin accumulation)
Valve incompetence, leading to increased hydrostatic pressure, fluid leaks out leading to skin to stretch and inflammation
Symmetrical
Treatment: Emoillents, Steroids, Compression
Psoriasis
Chronic inflammatory relapsing skin disease characterised by scaly papules and plaques
Peak onset: 20-30, 50-60
Aetiology:
T cell immune mediated.
Abnormal infiltration of T cells - release of inflammatory cytokines and TNF - increased keratinocyte proliferation
20% pts develop psoriatic arthritis, assoc with metabolic syndrome
Types:
Plaque
Guttate (looks like rain drops)
Pustular
Clincal features : symmetrical, salmon pink, scaly, well demarcated, extensor surfaces (elbows, knees), pitting nails, onycholysis (separation of nail from nail bed)
Risk factors:
Genetics, infection e.g. streptococcal infection (provokes guttate psoriasis, drugs e.g. lithium
Treatments:
Topical creams - moisterisers, steroids, vit D analogues, coal tar, dithranol, retinoid
Phototherapy (immunosuppressant, decreases T cell proliferation, increaeses Vit D)
Acitretin (oral retinoid/vit D)
Immunotherapy - methotrexate, ciclosporin
Biologics - adalimumab (anti - TNF)
(in order of increasing effectiveness/toxicity)
