Core conditions 6 Flashcards
1
Q
Overview of osteoarthritis
A
- 4 cardinal symptoms: pain, stiffness, swelling, loss of function/ difficulty in activities of daily living
- Pain: worse during or after activity
- Stiffness: can be in the mornings (tend to be less than 30 minutes) and on or after activity
- Bony swelling
- Difficulty in ADL
2
Q
Joint involvement in osteoarthritis
A
spine (spondylosis), carpometocarpal joint, distal interphalangeal joint, knees, in the big toe the metatarsal pharyngeal joint
3
Q
Risk factors for osteoarthritis include
A
- Age
- Gender (females gender is associated with higher prevalence and severity)
- Genetic predisposition
- Previous injury to a joint
- Anatomic features (eg Developmental Dysplasia of the Hip)
- Obesity (which surprisingly is associated even with hand OA)
- Occupation (e.g. heavy manual work, whole-body vibration – such as heavy goods vehicle drivers)
4
Q
Conservative management of OA
A
- Diet: weight loss even in non-weight bearing limbs i.e. the hand. May need referral to weight management programmes, access to a exercise and pharmacological or surgical intervention. Loosing >10% body weight causes a 50% reduction in pain
- Exercise: builds muscle strength reducing pain in joints and stabilising them. Some exercises may not be appropriate, ask a physio. Best exercises in arthritis is swimming and cycling
- Splints, braes, walking aids
- Education around self management
5
Q
MDT approach to OA
A
- Physiotherapist (Exercise regime and pain relieving modalities)
- Occupational therapist (Joint protection, aids and adaptations, coping strategies)
- Podiatrist (splinting, insoles, footwear advice, minor foot surgery)
- Social worker (financial implications of disability, housing)
- Appliance officer (splints, braces, walking aids)
- Psychologist (coping strategies, chronic pain management)
6
Q
Joint replacement in OA
A
- Indicated for severe disease: severe pain, sleep disturbance, impairement of function, gross restriction of mobility
- More risks associated when obese, encouraged to loose weight
- When conservative measures have failed
- OA is the biggest cause of hip replacement
- X-ray changes by themself do not indicate hip replacement
7
Q
Acne- four factors involved
A
- Increased sebum production
- Hypercornification of the pilosebaceous duct (blackhead/comedone)
- Abnormality of microbial flora- Propionibacterium acnes
- Inflammation
8
Q
Acne types
A
open comedones (whitehead), closed comedones (blackhead), papules, pustules, cysts, scars (ice pick, hypertrophic)
9
Q
Acne topical treatments
A
- Benzoyl peroxide- can be bought OTC
- Topical retinoids- useful for comedones
- Topical antibacterials- Clindamycin and Erythromcyin
10
Q
Acne oral therapies
A
- Oral antibiptics: Teracyclines (Oxytetracycline, doxycyckine, Limecycline, Erythromycin
- Hormonal treatment: COCP can be an alternative to oral antibiotics in women. Shouldn’t be used with topical agents
- Isotretinoin: pregnancy is a contraindication to topical and oral retinoids
11
Q
Acne risk factors
A
- Family history
- Hormones: androgens, such as testosterone and dehydroepiandrosterone sulfate (DHEAS)
- Adolescence
- Environmental factors: diet, stress, exposure to pollutants
12
Q
Drug induced acne and acne fulminans
A
Drug induced acne: monomorphic i.e. pustules tend to be seen in steroid use
Acne fulminans: severe acne associated with systemic upset i.e. fever. May need hospital admission and oral steroids
13
Q
Classification of acne
A
- mild: open and closed comedones with or without sparse inflammatory lesions
- moderate acne: widespread non-inflammatory lesions and numerous papules and pustules
- severe acne: extensive inflammatory lesions, which may include nodules, pitting, and scarring
14
Q
Acne step up management scheme
A
- single topical therapy (topical retinoids, benzoyl peroxide) if contraindicated use azelaic acid
- topical combination therapy (topical antibiotic, benzoyl peroxide, topical retinoid): avoid direct sunscreen and use SPF. Use moisturisers as can cause dry skin
- oral antibiotics: tetracycline (doxycycline). Tetracyclines should be avoided in pregnancy, breastfeeding and <12. Erythromycin can be used in pregnancy. A single oral antibiotic should be used for a maximum of 3 months
- Non resposnse to antibiotics or scarring: referral to dermatology for Isotretinoin
- A topical retionoid or benzoyl peroxide should be co-prescribed with oral antibiotics to reduce antibiotic resistance. Dont use oral and topical antibiotics in combination
15
Q
Conservative acne treatment
A
- Avoid over cleaning the skin
- Use non-comedogenic makeup
- Avoid picking or squeezing spots
- Acne treatment takes 8 weeks to work
16
Q
Acne: refer to dermatology if
A
- A severe variant of acne such as acne conglobata or acne fulminans (immediate referral)is suspected.
- Acne is severe, there is visible scarring or the person is at risk of scarring or significant hyperpigmentation.
- Multiple treatments in primary care have failed.
- Significant psychological distress is associated with acne, regardless of severity.
- There is diagnostic uncertainty.
17
Q
Acne follow up
A
- Follow up should be 8-12 weeks after initiation of treatment
- If there has been an adequate response, treatment should be continued for at least 12 weeks.
- If acne has cleared or almost cleared, maintenance therapy with topical retinoids (if not contraindicated) or azelaic acid should be considered.
- Can be diagnosed to dermatologist if severe psychological burden regardless of severity
18
Q
acne treatment: Isotretinoin
A
- affects night vision, have to declare if piolet
- Side effects: dry mucosal membranes. mood changes, arthralgia/myalgia, Teratogenicity, hypertriglyceridaemia
- Use in caution in re-puberty
- Should be on Pregnancy Prevention Programme: pregnancy tests every month and after stopping treatment. Should have effective contraception a month before, during and a month after treatment. Ideally use two types of contraception (dont use POP, condoms cant be used alone)
- Interacts with vitamin A, Tetracyclines and Warfarin
- Caution with suicide risk
19
Q
Eczema
A
A chronic atopic condition caused by defects in the skin barrier leading to microbe entry this creates an immune response causing inflammation and associated symptoms.
20
Q
Eczema: areas affected and triggers
A
Areas affected: Dry, red, itchy and sore patches of skin on flexor surfaces (the inside of elbows and knees) and on the face and neck
Triggers: change in temperature, certain dietary products, washing powders, cleaning products, emotional events or stresses
21
Q
Eczema treatment
A
- Maintenance: emollients (3 times a day), avoid bathing in hot water, scratching or scrubbing the skin and using soaps or body washes
- Flares- thicker emollients, topical steroids, ‘wet wraps’ and treating any bacterial or viral infections. Immunomodulators, oral antihistamine and treatment of secondary infections
- Specialist treatment: zinc impregnated bandages, topical tacrolimus, phototherapy, systemic immunosuppressants such as iral corticosteroids, methotrexate and azathioprine
Use emollients that are as thick as tolerated and required to maintain the eczema
22
Q
Eczema presentation
A
- Inflammatory condition: papaules and vesicles on an erythematous rash
- Presentation: dry, itchy erythematous patches, typically the flexor aspects of adults. Chronic changes include lichenification (tough skin)
- Complications: secondary bacterial or viral infection
- Excoriated papules
- Pruritus
23
Q
Eczema: types of emollients
A
- Thin creams: E45, Diprobase cream, Oliatum cream, Aveeno cream, Cetraben cream, Epaderm cream
- Thick, greasy emollients- 50:50 ointment, Hydromol ointment, Diprobase ointment, Cetraben ointment, Epaderm ointment
24
Q
Eczema: steroids
A
- Use the weakest steroid for the shortest time period to get the skin under control
- Side effects- thinning of the skin. Meaning its more prone to flares, bruising, tearing, stretch marks and enlarged blood vessels called telangiectasia
- The thicker the skin, the stronger the steroid used
- Only weak steroids are over the face, around the eyes and in the genital region
25
Steroid ladder: from weakest to most potent
- Mild: Hydrocortisone 0.5%, 1% and 2.5%
- Moderate: Evumovate (clobetasone butyrate 0.05%)
- Potent: Betnovate (betamethasone 0.1%)
- Very potent: Dermovate (clobetasol propionate 0.05%)
26
Eczema bacterial infection
The most common is staphylococcus aureus. Treatment is with oral antibiotics, particularly flucloxacillin. More severe cases require admission and intravenous antibiotics
27
Eczema herpeticum and eczema appearance
Eczema herpeticum: viral infection caused by the herpes simplex virus (HSV) or varicella zoster virus (VZV). Give IV aciclovir. Presents as erupted punched out ulcers. Commonly affects the head, face, neck and trunk
All eczema has minute vesicles histologically (spongiosis). However eczema can vary in appearance from weepy to dry
28
Classifying eczema
- Exogenous v Endogenous
- Acute v chronic
- Weepy v vesicular v dry and scaly
29
Exogenous eczema
- Contact dermatitis (irritant and allergic)
- Photosensitive
- Lichen simplex- eczema due to scratching
- Asteatotic- crazy paving
30
Eczema investigations
- Patch testing- type IV delayed hypersensitivity
- Prick testing- type I immediate hypersensitivity
31
Endogenous eczema
- Atopic eczema
- Discoid
- Eczema due to venous insufficiency (varicose/venous)
32
Diagnosis of eczema
An itchy skin condition in the last 12 months, pus three more of:
- Onset below 2 years
- History of flexural involvement
- History of generally dry skin
- Personal history of other atopic disease
- Visible flexural dermatitis
33
Atopic triad and areas affected in eczema
Atopic triad: asthma, eczema and allergic rhinitis
Areas affected in eczema:
- Infant: widely distributed, typically starts on the cheeks
- Child: extensor surface of joint
- Adults: flexor surface
34
Eczema: explanation of different types of medication 1
- Topical calcineurin inhibitors: for example Tacrolimus. Can be used in face or skin folds where steroids are contraindicated. Initiated by dermatologist
- Antimicrobials: short course or topical or oral antibiotics in a secondary bacterial infection. Topical antisepetics can be used to reduce bacterial colonisation and prevent infection.
- Phototherapy: use ultraviolet B in moderate to severe eczema who haven't responded to topical therapies
35
Eczema: explanation of different types of medication 2
- Systemic immunosuppressive agents: ciclosporin, azathioprine or methotrexate can be used in severe refractory eczema by a dermatologist
- Biological therapy: Dupilumab, a monoclonal antibody targeting IL-4 and IL-13 pathways, dermatologist
- Management of itch: sedating antihistamine such as hydroxyzine or chlorphenamine. Non-sedating antihistamine i.e. cetirizine or loratadine are less good at itch but can be good for other allergic symptoms
36
Chronic plaque psoriasis
- 85-90%
- Well defined patches of redness with a thick silver scale
- Typically on extensor surfaces like elbows and knees
- Very itchy
- Inflamed and red: dilated blood vessels
- Often occurs with scalp and nail psoriasis: i.e. pitting
37
Nail psoriasis
- Pitting
- Leukonychia: areas of white on the nail plate which run parallel to the nail bed
- Onycholysis: painless separation of the nail plate from the underlying nail bed and hypnychium, the affected distal nail plate appears white or yellow
- Subungual hyperkeratosis: scaling under the nail
38
Causes of psoriasis
- Intense proliferation and abnormal keratinocytes proliferation in the epidermis, triggered by an active cellular immune system. Will increase epidermal cell turnover
- Role for T cells, dendritic cells and cytokines- immunological response, causes excess inflammation
- Genetic factors: associated HLA-B13, -B17 and Cw6
- Type 1 psoriasis (young onset) most strongly associated with CW0602 (PSORS1)
- Environmental triggers i.e. trauma, infection, drugs, EtOH
- Auspitz sign: localised spots of bleeding where the scale has been removed
39
Psoriasis histology
- Psoriatic epidermis contains scattered neutrophils
- Neutrophil microabcesses can form
- Psoriasis may be pustular
40
Types of psoriasis
- Guttate psoriasis: small, red individual spots on trunk and limbs. Started in childhood, can be triggered by infection
- Inverse/flexural psoriasis: smooth and shiny red lesions that lack scales. Tend to form within skin folds i.e. the groin. Prone to colonisation by candida
- Pustular psoriasis: red skin with small white elevations of pus. Tender form on hands and feet
- Erythrodermic psoriasis: fire red scales that cover any large area of the skin. Extremely itchy and painful. Scales fall off in large sheets
- Psoriatic arthritis: inflammation in the joints, nail pitting
- Scalp psoriasis
41
Treatment of psoriasis
- First line treatment of Psoriasis: Calcipotriol, Tar, Dithranol (anthralin) for chronic plaque psoriasis, topical steroids. Moisturisers and plaques to clear plaques and minimise itchiness
- Topical & systemic immunosuppressive therapies
- Photo: PUVA, UVB- causes DNA damage in the keratinocytes stopping their proliferation
- Systemic: biologics, ciclosporin, methotrexate, retinoids
- The systemic treatment is more toxic then first line
42
Diagnosing psoriasis
Clinically but can do biopsy to confirm histological changes
43
First line topical treatments for psoriasis
- Use a potent corticosteroid and vitamin D for 4 weeks once daily
- Next try vitamin D twice daily for 8-12 weeks
- Then try twice daily corticosteroids or coal tar for 4 weeks
- Steroids can cause skin thinning and striae especially in face and genitals
44
Second line topical treatments for psoriasis
- Phototherapy: if plaque or guttate pattern psoriasis cant be controlled by topical alone. Contraindications: poor response <3 months, rapid relapse, risk of skin cancer
- Systemic: if phototherapy fails or isn't appropriate, topical treatments can be used simultaneously
- Non-biological: Methotrexate (1st line, hepatotoxic and teratogenic), Ciclosporin (for patients considering conceiving, for rapid/short term control), Acitretin (if tried both previous and didnt work)
- 4th line: Biologics, very specialist medication i.e. adalimumab, infliximab and etanercept
45
Psoriatic arthritis
- Asymmetrical oligoarthritis
- Dactylitis (swelling of whole digits)
- Psoriatic nail changes
46
Psoriasis co-morbidities
- Depression and anxiety
- Cardiovascular disease: should have CVD risk assessment at presentation and at least every 5 years
- Metabolic syndrome
- Increase risk of VTE in surgery
47
Asthma
A chronic inflammatory condition of the airways which is characterised by recurrent symptoms and airflow obstruction which is usually variable and reversible
48
Asthma pathophysiology
inhaled allergens stimulate the development of T helper cells which produce a variety of cytokines which stimulate the production of IgE, eosinophils and mast cells. IgE then binds to mast cells and is cross linked by antigens lead to cell degeneration and the release of mediators such as histamine, prostaglandin and leukotrienes. This causes bronchoconstriction and the early athematic response. The late asthmatic response is associated with increased airway inflammation and is driven mainly by Eosinophils.
49
When to consider asthma
- Symptoms of SOB, cough, wheeze and chest tightness
- Recurrent/variable nature of symptoms
- Diurnal variation in symptoms- morning increase in symptoms and overnight
- Personal and family history of atopy
- Identifiable triggers i.e. exercise, infection, pollen, dust, animal dander, NSAID’s etc
50
Asthma common investigations: PEF, spirometry and reversibility
- Peak expiratory flow (PEF)- measures maximum speed of expiration, usually monitored over 2-4 weeks. Variability of 20% or more is significant
- Spirometry: main investigation for identifying obstruction, measures how much air is breathed out and how quickly. An FEV1/FVC ratio of less than 70% means there is an obstruction
- Reversibility: for patients with obstructive spirometry, patient is given dose of bronchodilator and spirometry is re-performed. Increase in FEV1 of both 12% and 200mL in volume is positive
51
asthma investigations: FeNO, skin prick test
- Fractional exhaled Nitric oxide (FeNo): a positive FeNo (>40ppb) suggests eosinophilic inflammation
- Skin prick testing, serum IgE and eosinophil: not routinely offered as not diagnostic. Offer after a formal diagnosis to identify triggers
- These investigations have a high rate of false negatives
