Week 6 - Dermatology (B) and ENT (B)

Question 1

Eczema - state the following:
- Pathophysiology
- Presentation

Answer 1

Pathophysiology:
- Chronic inflammatory skin condition
- Thought to be caused by skin barrier dysfunction and immune dysregulation
- Most commonly diagnosed before 5 years
- Affects 10% to 20% of children

Presentation:
- Itchy, dry, cracked and sore skin
- Most often affects the hands, elbows creases, knee creases and the face / scalp
- Goes through periods of remission and flares
- May have other atopic conditions e.g. hay fever or asthma

Question 2

Outline the stepwise management of acute eczema

Answer 2

Acute flare:
1) Emollients - should be used in large amounts and more often (compared to the other treatments)
2) Consider intermittent topical corticosteroids, tailored to the severity of eczema if not responsive to emollients
3) May require topical/oral antibiotics if evidence of infection
4) May consider oral corticosteroid e.g. Prednisolone for severe acute flares

Question 3

Briefly outline how emollients help in eczema treatment

Answer 3

• Emollients improve skin barrier function by rehydrating the skin
• Emollients contain an agent that promotes hydration of the stratum corneum and an agent that reduces evaporation
• Can improve symptoms of itch and pain, alongside decreasing exposure to bacteria and sensitising antigens

Question 4

Outline the stepwise management of chronic eczema

Answer 4

Chronic eczema:
1) Emollients - should be used in large amounts and more often (compared to the other treatments)
2) Consider continuous use of low-mid potency topical corticosteroid e.g. topical Hydrocortisone
3) Consider topical anti-inflammatory Calcineurin inhibitor
4) Consider topical anti-inflammatory Eucrisa (Crisaborole)

For more stubborn cases:
- UV light therapy
- Continuous use of high potency topical corticosteroid
- Systemic immunosuppressive agent

Question 5

Outline reasons why a further referral to secondary care may be required in eczema management

Answer 5

Immediate hospital admission:
- If eczema herpeticum is suspected

Referral to a dermatologist if:
- Diagnosis is uncertain
- Eczema is not controlled with current treatment
- Recurrent secondary infection.
- High risk of complications
- Treatment advice is needed (such as bandaging techniques)

Question 6

Outline eczema herpeticum, how it presents and management

Answer 6

Disseminated infection of skin with herpes simplex virus that develops in a patient with eczema

Presentation:
- Red vesicles on face and neck
- Itchy and painful vesicles
- In a patient with eczema
- Fever
- Lymphadenopathy
- Malaise

Referral into secondary care for antiviral medications

Question 7

List a type of topical steroid for each strength of topical steroid in the management of eczema
- Low potency
- Middle potency
- High potency

Answer 7

Low potency: Hydrocortisone

Middle potency: Fluticasone

High potency: Betamethasone

Question 8

List 3 specific examples of emollients

Answer 8

1. E45 cream
2. Aquadrate
3. Eucerin

Question 9

List some pieces of advice to give to patients about the use of topical corticosteroids

Answer 9

• Only apply to affected areas of skin, never apply to the face
• Only use a thin layer, in the direction the hair grows (finger tip amount to cover the area similar to the surface of your palms)
• If you use both topical corticosteroids and emollients, you should apply the emollient first, then wait about 30 minutes before applying the topical corticosteroid
• Always wash your hands before and after application

Question 10

List some adverse effects of topical corticosteroids

Answer 10

• Burning or stinging on application
• Thinning of the skin (skin more vulnerable to damage)
• Folliculitis
• Stretch marks (likely to be permanent)
• Contact dermatitis
• Acne, or worsening of acne
• Rosacea
• Changes in skin colour
• Excessive hair growth on the area treated

Question 11

Outline the differences between these different types of emollients:
- Ointment
- Cream
- Lotion

Answer 11

Ointment - highest oil content (best for dry skin)
Cream - less oil content, so lighter and easier to leave on the skin
Lotion: least oil content (least effective for dry skin)

Question 12

List some differentials for urticaria/allergic reactions

Answer 12

• Drug reaction
• Insect bite
• Eczema
• Contact dermatitis
• Viral exanthems (reaction to virus)
• Erythema multiforme
• Stevens-Johnson syndrome

Question 13

Outline how a patient with urticaria commonly presents

Answer 13

Also known as hives, weals or nettle rash
Superficial swelling of the skin (angio-oedema is a deeper form of this)

Presentation:
- Itchy, red, raised rash
- Rash initially has a pale centre and progresses to red
- Acute (< 6 weeks) or chronic (> 6 weeks)

Question 14

List some important aspects of a history in a patient presenting with urticaria

Answer 14

Duration - acute or chronic
Presence of triggers e.g. acute viral infection or allergic reaction (milk, insect bite, medications)
Whether there is evidence of systemic angio-oedema leading to airway obstruction

Question 15

Outline how a urticarial rash should be described

Answer 15

• Distinct
• Multiple
• Erythematous plaques

Question 16

Outline the management of urticaria

Answer 16

Assess whether they have anaphylaxis - ABCDE assessment

• Identify and manage underlying triggers where possible (avoidance or discontinue irritating medications)
• If not, may need to do a symptom diary or further investigations
• Can do urticaria quality of life questionnaire
• Consider referral to dermatologist / immunologist

Medications:
- Oral antihistamine (non-sedating) e.g. Cetirizine or Fexofenadine
- If severe, short course of oral corticosteroid
2nd line
- LRTA e.g. Montelukast
- Calamine lotion (topical antipruritic)