Derm1 Flashcards
(126 cards)
1
Q
What conditions does atopic dermatitis constellate with? Often presents with a family history of these condition?
A
Asthma, allergic rhinitis and Atopic dermatitis - atopic conditions which constellate and run in families
2
Q
Which demographic group is atopic dermatitis more common in?
A
More common in kids.
3
Q
What are the characteristics of rash in atopic dermatitis?
A
Dry. ITCHY. Erythematous Patches can be anywhere on skin but favour face, cubital and popliteal fossae, ankles and wrists.
4
Q
What is the aetiology of atopic dermatitis?
A
Genetic predisposition + Trigger = Atopic dermatitis flare
5
Q
What triggers are associated with atopic dermatitis?
A
- Environmental allergens - pollen, dustmites, animal dander, grasses. sand 2. Temperature associated triggers - hot and cold temperature. Rapid changes in temp. Low environmental humidity. Sweating 3. Intercurrent illness - Viral illness, URTI, 4. Irritiants - soaps, shampoos, chlorinated water, bubble bath, detergents, chemicals. Woolen clothes. Perfumes. 5. Emotional stress
6
Q
Do food allergies cause atopic dermatitis?
A
No. They can cause urticaria not dermatitis. Young people with food allergies may ALSO present with atopic dermatitis but these are different. However food can irritate the skin around the mouth. eg egg, beef, chicken, citrus, tomotoes. Apply Greasy barrier around lips and hands before eating such foods for irritation protection. This is not an allergy. Food restrictions/modification are not indicated for atopic dermatitis.
7
Q
History features of atopic eczema?
A
DIagnoistic criteria: 1) Typical distribution - General inspection of rash. 2) Dry skin - Inspect ‘normal’ skin for signs of dryness. 3)Itchy rash - (Ask about whether the rash is itchy?) 4) Chronic, relapsing nature of rash - (Ask about time course of rash) 5) Family history of atopy (Is there a family history of atopy?)
8
Q
What are the features of infantile atopic dermatitis?
A
Onset - around 3 months of age Distribution: Face, scalp, neck folds, extensor surfaces of limbs, spreads to flexures and groin. Face affected first. Nappy area might be spared due to frequent moisturising.
9
Q
How does atopic dermatitis present in a toddler?
A
flexures predominantly. Cubital and popliteal fossae a dryer/thicker rash develops. It can be DRY, ITCHY and secondary to scratching/excoriation can become THICK, FISSURED and PAINFUL
10
Q
How does atopic dermatitis present in preschool aged children?
A
As kids start moving around - eczema becomes more localised and thickened. Toddlers scratch vigorously. Eczema can look raw and uncomfy. In this age group eczema often affects the extensor surfaces of joints - elbows, knees, wrists, ankles. Can also affect genitals.
11
Q
How does atopic dermatitis present in school aged children?
A
As the child becomes older, the pattern frequently changes to involve flexure areas of elbows, knees, wrists, ankles. Less extensor involvement. In some children extensor pattern persists into later childhood. Frequent scratching and rubbing leads to lichenification - dry/thickening of skin.
12
Q
How does atopic dermatitis present in adults?
A
Skin is often more dry and lichenified than in children Commonly - persistent localised eczema - sometimes confined to hands, flexures, eyelids, nipples or all of these areas. Recurrent staph aureus infections may be prominent. Atopic derm is a major RFactor for occupational irritant contact dermatitis. Most often affects hands that are frequently exposed to water, detergents and/or solvents. Atopic dermatitis doesn’t exclude contact allergic dermatitis - confirmed by patch testing.
13
Q
How would you manage a patient with atopic dermatitis?
A
- Identify and avoid triggers. Minimise contact with irritants such as: soap, shampoo, bubble bath rough clothing, sheepskin, wool, sand, grass, carpet heavily chlorinated pools and spas. 2a). Improve the condition of normal skin - Mositurising Dry skin exacerbates atopic dermatitis. Frequent use of non perfumed emmolients to improve skin condition is essential. 2b). Cleansing Daily bathing is not harmful if avoid soaps and bubblebath Use soap substitutes Use Dispersible oils if skin is dry when bathing and showering (put oil in water if bathing) If skin is very itchy use oatmeal bath AFTER bath - Dry skin - then apply emmolient to skin 3. Treat infection. Eczematous skin is vulnerable to infection which exacerbates inflammation. If there’s infection - a) consider takin a swab - if significant crusting or pustules are present; flaring of dermatitis despite topical steroid and emmolient therapy. Bacteria - swab m/c/s Virus - PCR for HSV (eczema herpeticum) b) prescribe antibiotics mild - mupirocin ointment 2% to affected area severe: FLucloxacillin 500mg (12.5mg/kg) qid x 10 days if allergic - cephalexin 4. Prescribe a topical steroid medication to treat inflammation. Principles: Think skin - eg face/axilla - mild steroid eg Hydrocortisone 1% Moderately thick skin - trunk and limbs - moderate steroid eg Triamcinolone 0.02 % Thick skin - soles, palm, scalp - Strong steroid eg Mometasone 0.1% Use until resolved - usually 7-14 days Choose appropriate prepartion: L- lotion to scalp O- ointment for rest of body C- cream for weeping areas Apply a) once daily b) liberally all over lesions c) apply emollient to all other areas d) until all dermatitis settles e) resume promptly during a flare For severe dermatitis/lichenified areas - apply wet dressings 5. Provide a management plan for carers 6. Sedating anti-histamine can be helpful for sleep (non sedating is not indicated) 8. Severe cases may need UV therapy or Immunomodulators
14
Q
Is allergy testing required for well controlled mild-moderate eczema?
A
Not required for mild - mod (well controlled)
15
Q
Which antibiotics would you use in localised infection of dermatitis?
A
Mupirocin 2% ointment or cream twice daily for five days
16
Q
Widespread infection of dermatitis? Abx choice?
A
Use oral flucloxacillin 500mg (12.5mg/kg) 6 hourly orally for 5 to 10 days
17
Q
Infection of dermatitis with patients with delayed hypersensitivity to penicillin
A
Cephalexin 1g (25mg/kg) 12 hourly orally for 10 days
18
Q
Infection of dermatitis in patients with immediate hypersensitivity to penicillin?
A
Clindamycin 450mg (10mg/kg) 8 hourly for at least 5 days
19
Q
Another option for recurrent infection of dermatitis?
A
Consider bleach baths Add Sodium hypochlorite 6% solution, 60 ml per bath, twice a week
20
Q
You prescirbe 1% hydrocortisone ointment for facial eczema (or axilla/groin eczema). It has not resolved after 7 days. What else might you try?
A
Methylprednisolone aceponate 0.1% ointment topically, once daily for 7 to 14 days
21
Q
If first line steroid to flexures of trunk or limbs fail what would you try?
A
Mometasone furoate 0.1% ointment once daily until skin is clear
22
Q
Treatments for severe refractory atopic dermatitis in a)children b) adults
A
A) kids with Severe lichenification/scale - wet dressings b) Adults - UV therapy or Immunomodulators like azathioprine, methotrexate, cyclosporin minimal role for prednisolone as its often followed by a rebound
23
Q
What is the aetiology of seborrheic dermatitis?
A
Due to sebaceous gland secretions and infection with malassezia. Hence present in hear bearing areas and skin folds.
24
Q
What are the features of rash in seborrheic dermatitis?
A
yellow, scaly, greasy crust. Surrounding inflamation of skin. A feature of seborrheic dermatitis is that unlike atopic dermatitis it is NOT itchy. Seborrheic scale is greasy and yellowish, unlike silvery scale in psoriasis.
25
What are the two types of seborrheic dermatitis?
Infantile and adult
26
Features of infantile seborrheic dermatitis?
Distribution - cradle cap, nappy rash, then skin folds - neck, axillae, groin, natal cleft, knee, elbow NOT ITCHY Usual onset is early - before 3 months - eg 1 month - when androgen action most obvious commonly affects nappy area
27
How would you differentiate seborrheic dermatitis from atopic dermatitis in an infant?
Usual Onset - less than three months in seb, over 12 months in atopic Presence of itch - seb NON itchy, atopic very itchy Distribution - seb cradle cap, nappy area and skin folds, atopic starts in face, cheeks neck, extensors - then flexures Rash - yellow, greasy, scale in seb, in atopic tends to be dry and erythematous, cracked Nappy rash - common in seb, rare in atopic General skin condition is good in seb, dry in atopic,
28
Management of infantile seborrheic derm?
1. Baby oil, coconut oil or safflower oil. (Avoid olive or nut based) Gently remove scales with oil and then wash. Change wet nappies frequently. Keep affected areas dry and clean. Keep skin exposed to as much air as possible. Use a soap substitue such as cetaphil lotion. 2. If scalp lesions persist use: salicylic acid 2% + LPC 2% + Sulfur 2% in aqueous cream on scalp FOR 6 to 8 hrs. Then wash off with soap substitute. Use daily until scalp clears. Review in one week. 3. If sig erythema to scalp use Desonide 0.05% lotion daily after bath. 4. For lesions apart from scalp - Desonide 0.05% lotion twice daily until skin clears. Napkin area may mix 1% hydrozole with equal parts miconazole cream ( like hydrozole effectively).
29
Distribution of seborrheic dermatitis in adults?
Scalp, eye, eyebrow, eyelids, interscapular, presternal, intertriginous areas - groin/perianal Face - medial cheeks, nasolabial folds, nose Most common cause of a butterfly rash (Can also get in SLE but spares nasolabial folds) Non itchy Red rash with yellow greasy scales Dandruff on scalp Worse with stress and fatigue chronic, relapsing condition
30
How would you treat seborrheic dermatitis on the scalp of an adult?
1st line - normal shampoo daily. If ineffective antiyeast shampoo eg ketoconazole shampoo twice daily for 4 weeks. other antiyeast shampoos include selenium sulfide, miconazole, coal tar, If ITCHY or SCALY - add a steroid to the shampoo Mometasone furoate 0.1% lotion topically, applied once daily to scalp at night for seven nights IF antiyeast plus a steroid is insufficient - add a tar Coal tar prepared 1% emulsion - apply to scalp at night once or twice a week then wash off in the morning with antiyeast shampoo
31
How would you treat seborrheic dermatitis to face, flexures, scrotum or trunk?
Advise patient to use a low irritant skin cleanser, and for facial seb Derm advise that regular shampoo will reduce yeast load of the scalp. Then hydrocortisone 1% + clotrimazole 1% cream topically in combination, once a day until skin clears IF combination product has no effect after 2 weeks (Separate them) Mometasone aceponate 0.1% topically once a day for two weeks AND clotrimazole 1% topically twice a day for two weeks IF this fails - a weak tar can be used LPC 2% in aqueous or sorbolene - once a day until skin is clear for up to two weeks NB tacrolimus can be used as a steroid alternative
32
DDx for facial rash?
1. Seborrheic dermatitis 2. Acne vulgaris 3. Acne rosacea 4. Perioral dermatitis 5. Contact dermatitis SLE can also cause a facial rash
33
Aetiology of psoriasis?
Inflammatory hyperplastic condition of the skin. Polygenetic inheritance. Immune mediated inflammatory condition. Usually environmental trigger.
34
Most common age demographics for psoriasis
YOung adults and teenagers - 10-30 years
35
HOw does infantile psoriasis present?
Can present as cradle cap and nappy rash
36
What disease can mimic psoriasis?
Pityriasis rubra pilaris
37
What are the types of psoriasis?
Plaque Erythrodermic Generalised Pustular guttate
38
Why is psoriasis in flexures difficult to diagnose
DUe to the moisture they can be missing the silvery scale - however well demarcated border is a differentiator
39
Features of plaque psoriasis?
Most common WEll demarcated Pink with silvery scale Extensor surfaces - elbows, knees, sacrum and scalp Can affect - scalp, trunk limbs, palms, soles, nails, flexures including genitals and face
40
What are the triggers of psoriasis?
Infection - viral or bacterial - group A betahaemolytic strep Trauma Tetracyclines Mental stress LITHIUM BETA BLOCKER ACE INHIBITOR calcium deficiency CHLOROQUINE NSAID INTERFERON STEROID WITHDRAWL OCP Menarche Menopause Sunburn Capital letters - common
41
What is the treatment for generalised pustular psoriasis and erythrodermic psoriasis?
Require hospital admission Generalised pustular - usually fever and systemic symptoms (unlike localised). This can be pregnancy induced also. Erythrodermic - entire skin surface affected, fever, systemic symptoms. Cx include heart failure, infection, malabsorption, anaemia
42
What are features of guttate psoriasis? How would you manage?
Red scaly teardrop like lesions. After a streptococcal infection. Usually - Trunk, upper arms and thighs Treat the underlying streptococall infection then treat with LPC 6% + Sal A 3% twice a day AND mometasone furoate 0.1% ointment once daily.
43
DDx for guttate psoriasis
1. Syphilis (would involve palms and soles) 2. Drug eruption (started on new med) 3. Dermatitis group - numular eczema, atopic derm, contact derm 4. Ptyriasis rosea 5. HIV - seroconversion with fever and flu like illness 6. EBV infection 7. Ptyriasis Lichenoides
44
Non medical advice for psoriasis?
1. Lifestyle modification and CV risk factor monitoring - some studies suggest its an independent CV risk factor. 2. Avoid irritants. Suggest soap substitutes. 3. Gentle sunshine exposure is beneficial. 4. Conduct a medication review - certain drugs make psoriasis worse. 5. Special diets have no role in psoriasis. 6. Refferal for advice.
45
How would you manage plaque psoriasis on the limbs or trunk?
LPC 6% + SSA 3% twice daily for one month Add Mometasone Furoate 0.1% topically daily for 2 to 6 weeks. IF not settled Calcipotriol + Betamethasone Diproprionate 50+500mcg/g daily topically for 6 weeks
46
How would you manage guttate psoriasis
Treat strep infection LPC 6% + SSA 3% twice daily for one month Add Mometasone Furoate 0.1% topically daily for 2 to 6 weeks. IF not settled Calcipotriol + Betamethasone Diproprionate 50+500mcg/g daily topically for 6 weeks
47
How would you treat localised pustular psoriasis?
LPC 6% + SSA 3% twice daily for 2 weeks Add Mometasone Furoate 0.1% topically daily for 3 weeks. IF not settled Change to Betmethasone 0.05 in optimised vehicle (OV) for 2 to 6 weeks If needs steroids more than two months consider: Calcipotriol + Betamethasone Diproprionate 50+500mcg/g daily topically for 6 weeks
48
How would you treat scalp psoriasis?
Mometasone Furoate lotion 0.1% topically daily for 2 to 6 weeks. If not improving after two weeks Change to Betmethasone 0.05 for 2 to 6 weeks If no improvement: Calcipotriol + Betamethasone Diproprionate 50+500mcg/g gel daily topically until skin is clear (Except a response in two weeks)
49
How would you treat hyperkeratotic psoriasis? palms and soles of feet?
LPC 6% + SSA 3% twice daily for one month IF not settled Calcipotriol + Betamethasone Diproprionate 50+500mcg/g daily topically for 6 weeks
50
How would you treat face or flexural (including genitals) psoriasis?
Methylprednisolone aceponate 0.1% ointment daily until skin clears (no longer than 2 weeks in child wearing nappies) LPC 2% ointment (without SSA for felxures/with SSA 2% for face) once flare settling For a child with facial psoriasis - use 1% hydrocortisone ointment topically daily
51
What is sunburn?
Erythema and/or odema secondary to exposure to ultraviolet radiation from the sun.
52
What are the signs and symptoms of sunburn? When do they typically occur?
Usually occur 2-4 hours after sun exposure. Peak 12-24 hours.
Erythema (redness)
Oedema (Swelling)
Tenderness and/or irritation
Skin feels hot to touch
Pain
Blistering (Severe)
chills and fever (severe)
53
How can severe sun burns present?
Second degree burns
dehydration
electrolyte imbalance
secondary infection
shock
54
How can you treat sunburn?
1. Analgesia - paracetamol 1g qid PO PRN
Take 2 aspirin 100mg tablets immediately and then after 4 hours.
2. Soothing treatments - Aloe vera, moisturisers, cool baths
3. Hydrocortisone ointment 0.1% bd for two to three days.
4. Education regarding sun protection - Avoid sun exposure (esp between 10am and 2pm), Wear protective clothing including a wide brimmed hat, Regularly apply a sun screen with a Sun protection Factor (SPF) of 50+.
55
What advice would you give a patient in regards to sun protection?
Avoid sun exposure (esp between 10am and 2pm), Wear protective clothing including a wide brimmed hat, Regularly apply a sun screen with a Sun protection Factor (SPF) of 50+.
56
A patient with significant sun burn presents with HR 105 and BP 100/70. Why?
Mild hypovolaemia secondary to increased vascular permeability from circulating inflammatory mediators and resultant vasodilatation. They may also feel cold and thirsty.
Oral fluids - supported with IV fluids if needed.
57
How can you reduce itching as a burn dries out?
Simple moisturising creams.
58
What should you do with blistered sun burn?
Large blisters can be debrided and dressed with a silver impregnated dressing.
59
When should you refer a burn to a burns unit?
1. Burn area is extensive - **greater than 15 %**
2. Patient requires **IV fluid** replacement
3. Patients requirement for _opiate analgesia_ renders Outpatient management impractical.
60
A 30 year old woman presents with a papular, erythematous rash around mouth and eyes, sparing area directly around lips. Has been taking a topical steroid which seems to make symptoms worse. Dx? Mx?
Periorificial dermatitis
Mx. 1) Discontinue topical steroid, cosmetics and facial creams
2) Commence oral doxycycline once daily for 8 weeks.
3) If contraindicated - can take Metronidazole gel 0.75% bd for 6 weeks.
61
How does Perioroficial dermatitis present?
1. More common in females between 20 and 50.
2. Erythema and clusters of papules around lips, eyes and nostrils (can also be around gentials). Spares rim around lips. (Perioral,periocular, perinasal)
3. Can be unilateral or bilateral.
4. Spares cheeks and forehead.
5. Flaky skin
6. Burning irritation.
7. Induced by topical steroids, cosmetics and facial creams.
62
What is the management strategy for periorificial dermatitis?
. 1) Discontinue topical steroid, cosmetics and facial creams
2) Commence oral doxycycline once daily for 8 weeks.
3) If contraindicated - can take Metronidazole gel 0.75% bd for 6 weeks.
(Mild cases can be treated by discontinuing facial creams /soaps and using cold compresses for symptomatic treatment)
63
What demographic groups are most affected by rosacea?
30 -50 years most affected
Fair skin/blue eyes
Celtic origin
Women more frequently
Rinophymatous disease more common in males
Often Preceded by increased FLushing and Blushing
64
How does rosacea present?
1. R - P -P
**Redness, papules, pustules** - **central facial** erythema, telangiectasia, sterile inflammatory papules, pustules and nodules
2. **Ocular manifestations (may precede skin) in 50% of patients** - conjunctivitis and blepharitis are most common. Also keratitis, marginal keratitis and corneal ulcer (feeling of dirt or grit in the eyes).
3. in Severe cases - nasal complications - inflamed sebaceous glands and connective tissue - **rhinophyma** (whole nose may be tender, red and swollen).
65
Triggers for rosoacea?
1. Weather - hot and cold weather, wind, sun exposure, hot drinks, hot baths or showers.
2. Emotional stress
3. Exercise
4. Medications (topical steroids, betablockers)
5. skin care products and cosmetics
6. Foods - Alcohol, spicy foods, dairy products
7. Pregnancy
66
What are complications of Rosacea?
1. Ocular manifestations - blepharitis, conjunctivitis, keratitis and corneal ulcer.
2. Rhinophymatous disease.
3. Lowered mood and Depression secondary to poor self image
67
What are the non pharmacological therapies for Rosacea?
1. Apply cold packs.
2. Avoid causes of facial flushing - hot drinks, sun exposure, wind, spicy food, alcohol
3. Sun protection
4. Use an emollient soap-free cleanser
68
How would you treat mild rosacea with minimal lesions
**NON PHARM MANAGEMENT ONLY REQUIRED FOR MILD Sx**
1. Apply cold packs.
2. Avoid causes of facial flushing - hot drinks, sun exposure, wind, spicy food, alcohol
3. Sun protection
4. Use an emollient soap-free cleanser
If skin is sensitive or treatment desired for cosmetic purposes:
**Metronidazole gel 0.75% bd for up to 3 months.**
69
How would you treat moderate - severe rosacea?
Metronidazole gel 0.75% bd AND oral doxycycline 100mg daily for 8 weeks
If recurs within one month - consider minocycline 50mg daily for 8 weeks (can be used for longer periods up to 12 months)
If refractory to oral abx then refer for consideration of other therapies such as isotretinoin.
70
How would you treat ocular rosacea?
First line therapy are ocular lubricants, daily lid massage, and firm eyelid massage towards the margins.
If not controlled by these measures - oral doxycycline 100mg daily for 8 weeks.
71
How would you treat Erythrotelangiectatic changes in rosacea?
Brimonidine Tartrate 5mg/g (equivalent to brimonidine3.3mg/g) gel topically once daily in the morning
Laser therapy may be of benefit.
72
What treatment options are available for rhinophyma?
Shave excision,
Laser ablation
Isotretinoin
73
Which patients have an absolute contraindication to using 5 Fluorouracil
Patients with Dihydropyrimidine Dehydrogenase deficiency (DPD) deficiency
74
What is the mechanism of inflammation in Acne?
Inflammation of the pilosebaceous unit.
ONLY occurs in presence of androgens
Usually - increased sensitivity of pilosebaceous unit to androgens.
Rarely due to increased androgens.
75
Mechanism of skin changes in acne?
Increased sebum production by action of androgens on the pilosebaceous unit
hypercornification of pilosebaceous duct, with formation of keratin plugs
Overgrowth of propionibacterium acnes
inflammation
76
What are comedones?
Blocked pores - open(blackheads)
closed (whiteheads)
Papules frequently found on forehead and chin of people with acne
A single lesion is a comedo
COMEDONAL acne is a type of acne where most of the lesions are comedones - typically affects forehead and chin
77
What is required for a diagnosis of acne
All THREE of :
comedones, pustules, papules
78
79
Mild acne signs?
Have a few comedones and papulopustules but no scarring -lesions often confined to forehead, nose and chin (The T section of the face)
80
Signs of moderate acne?
Numerous papulopustules and comedones, with some nodules but no scarring, - lesions affect extensive areas of the face and sometimes the trunk
81
Signs of severe acne?
nodules, cysts and scarring, lesions may be confined to face but often also affect the trunk.
82
How can acne lesions be classified?
**NON INFLAMMATORY**
open and closed comedones
**INFLAMMATORY**
pustules, red papules, nodules and cysts
**Resolving**
macules and scars
83
What systemic drugs and topical steroids affect acne?
**Systemic drugs or topical steroids**
androgens,
Anabolic steroids,
Some OCPs with higher dose of levonorgestrel and POP - switch them to anti-androgenic OCP
Fluconazole
Phenytoin
Lithium
***Acne treatment is effective if the patient can stop taking the acnegenic drug. Ineffective if they cannot***
* Ensure all topical creams, cosmetics and sunscreens are _noncomedogenic and nonacnegenic._*
* Most 'oil free' products are non comedogenic and less likely to aggravate acne*
However mislabelling occurs.
84
What hormonal conditions in women can exacerbate/trigger acne?
Acne can be a sign of androgenisation
Consider: PCOS, Cushings, CAH, Androgen secreting tumours
If woman also has menstrual irregularity, hursuitism and obesity consider PCOS
85
What occupational or leisure activities could exacerbated acne?
1. **_Exposure to comedogenic substances_** - halogens (bromides, chlorine at swimming pools, iodides), cosmetics, sunscreens, industrial oils used by mechanics, grease (fast food outlets)
2. **_Hot, humid, environments in which the face is exposed to steam,_** at work (eg chef, barista) or leisure (sauna, spas
86
What social and psychological impacts can acne have on a patient?
Assess magnitude of psychosocial impact.
***This does not necessarily correlate with severity of symptoms***
In some patients, Acne can lead to:
* social withdrawl
* preoccupation with acne
* distorted body image
* low self esteem and self confidence
* Depression
* Suicidal ideation
***A patients emotional state affects choice of therapy***
87
What is the treatment for Acne?
**TOPICAL**
**A** - Topical Vitamin A analogues - promote removal of keratin plugs, prevent reblocking of pores, suppress inflammation - given to Comedones AND inflammation
**B** - Benzoyl Peroxide - are Antiinflammatory and suppress bacteria - hence give if inflammation is present.
**C** - Clindamycin - are anti inflammatory and suppress bacteria - hence give if inflammation is present
**S**- Salicylic acid -unblock pores by removing keratin plugs - Given to Comedones
88
89
Plantar warts - how frequently should cryotherapy occur, hpw long should topical wart pain be used?
If the top of a viral wart is removed, pinpoint dots will be visible which are clotted capillaries. Cryotherapy is successful in about 70% of cases if regular treatment (every 1 - 2 weeks) is performed over 3- 4 months. A hard freeze with liquid nitrogen may cause temporary numbness and a permanent white mark / scar. Approximately 20% of warts will recur within several months following curettage and cautery. Topical wart paint used over a 12 week period has a success rate of approximately 70%.
90
What regime of Imiquimod is used in treatment of superficial BCC?
Imiquimod should be applied 5 days per week for 6 weeks, with a rest of 1 week or more during therapy if the local skin reaction is severe or intolerable.
91
What kind of sun exposure is melanoma associated with? Risk factors?
Episodic, intense burns (rather than continuous)
RF's
Elderly male
blistering sunburn as a child or adolescent
fair complexion, blue eyes rather than brown, and a tendency to sunburn (rather than tan)
marked solar skin damage (episodes of intense sun exposure)
multiple common melanocytic naevi
dysplastic naevus syndrome
PMHx - history of previous melanoma or non melanoma skin cancer
Drug Hx and PHx - Immunodeficiency
Fhx - Family history of melanoma
92
What is dermatomyositis and polymyositis?
They are inflammatory disorders of voluntary muscle. Dermatomyositis is accompanied by a characteristic rash (heliotrope, and gottrons pappules)
93
What factors are associated with the development of dermatomyositis?
Genetic predisposition
Infectious trigger
Underlying cancer
Underlying Autoimmune condition
Drug induced - eg statins, hydroxyurea
94
Clinical features of dermatomyositis?
Symmetrical proximal muscle weakness (same time as rash or can follow - weeks, months, days) - look for proximal muscle weakness and wasting,
AND
periorbital reddish-purple erythema (heliotrope rash)
flat-topped papules over the dorsum of the interphalangeal joints of the hands (Gottron papules)
erythema over the dorsum of the knuckles (Gottron sign)
photodistributed erythema and oedema on sun-exposed neck and shoulder (shawl sign)
characteristic nail fold changes and ragged cuticles.
Can have associated joint involvement and raynauds phenomenon
95
How does symetrical proximal muscle weakness in dermatomyositis present?
Problems with everyday movements
Climbing stairs or walking
Rising from sitting or crouched position
Lifting objects
Raising arms above shoulders (Eg combing hair)
Difficulty swallowing
(affected muscles can sometimes become tender to touch)
96
Investigations for Dermatomyositis/ Polymyositis?
Serum CPK or aldolase - elevated
ANA, Anti-Mi2 and Anti-Joi - elevated
Skin biopsy
Muscle biopsy
EMG
MRI of muscle
In patients over 60 years - consider investigation for neoplastic causes
97
Management considerations in dermatomyositis
1. Refer to Rheumatologist
2. Topical steroids and hydroxychloroquine are usually first line. Can sometimes require disease modifying drugs like methotrexate.
3. Stress the importance of sun protection because sun exposure exacerbates the disaese.
4. Consider investigating for underlying neoplastic process in patients over the age of sixty.
98
99
What is dermographism?
Increased wealing tendency when the skin is stroked - commonest form of inducible urticaria.
100
Clinical features of hidradenitis suppurativa?
Affects apocrine gland bearing skin in axillae, groin and under breasts.
Recurrent boil like nodules and abcesses, culminating in pus like discharge, difficult to heal open wounds and scarring.
Significant impact on mental health - body image, depression
101
Who is at risk of hidradenitis suppurativa?
Obesity/insulin resistance/metabolic syndrome
Cigarette smoking
Inflammatory bowel disease
Follicular occlusion disorders: acne conglobata, pilonidal sinus
102
Causes of hidradenitis ?
**Autoinflammatory disorder**
Friction from clothes and body folds
abberant response to commensal bacteria
abnormal cutaneous biome
follicular occlusion
secondary bacterial infection
certain drugs
103
Management of hidradenitis suppurativa?
1. Wear loose clothing
2. Stop smoking
3. Healthy diet and weight loss if appropriate
PHARMACOTHERAPY
1. Clinamycin 1% lotion topically, twice daily for three months then review
2. Second line - oral doxycycline 100mg daily for 6 weeks then review
in women: can use COCP or spironolactone (Contraindicated in pregnancy)
3. Surgical managment - incision and drainage
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Clinical features of acanthosis nigricans?
_hyperpigmented, hyperkeratotic areas_, usually s**ymmetrically distributed, on the axillae, groin, neck** and cubital and popliteal fossae.
Multiple skin tags are common. It can affect the mucosal surfaces and the back of the hands and the feet, especially when associated with malignancy.
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Causes of acanthosis nigricans?
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Impetigo management?
**If non-endemic with localised skin sores:**
Mupirocin 2% ointment three times a day for five days
**Multiple Skin sores or recurrent infection:**
Flucloxacillin (12.5mg/kg) up to 500mg 6 hrly for five days
CLeanse wound; moist soaks to gently remove crusts
Antiseptic 2-3 times a day for five days eg chlorhexidine
Cover the affected areas
**IN endemic communities**
Benzathine Benzylpenicillin Intramuscularly (Dose as per eTG)
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What are the complications of impetigo?
1. Staphylococcal scalded skin syndrome
2. Toxic shock syndrome.
3. Rheumatic fever.
4. Post strep GN
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Infective agent in impetigo?
non endemic - stap. aureus
endemic - strep pyogenes
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When should a swab be taken in impetigo?
In refractory or recurrent cases
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What causes bullous impetigo?
Exfoliative toxins of staph. aureus
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What is the natural history of an infantile haemangioma?
Take **three to ten years** to regress/involute.
Nearly all FLAT haemangiomas regress.
Bulky ones can leave an atrophic scar
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A six month old infant presents with blanching erythematous maculopapular rash to the trunk and limbs. Had a temperature three days ago. Now afebrile. Diagnosis?
**Roseola Infantum (HHV 6)**
Viral rash - 6months to 2 year old infants
Mainly red blanching rash to trunk and limbs.
Sparing face.
Starts with sudden fever (up to 40) three days before. As fever stops. Rash begins.
Self limiting. Disappears in two days. No desquamation.
Support oral fluid intake. Symptomatic treatment only
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What is this condition?
Ink spot lentigo
Benign
Wirey reticulated on dermoscopy
Usually occurs after sunburn
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In which populations do classic kaposi sarcoma occur?
Not associated with HIV
in older men of mediterranean and middle eastern descent
associated with Diabetes in these cases
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What are the four types of kaposi?
1. Classic
2. Hiv associated
3, Endemic/African Kapos
4. Iatrogenic (From immune suppression)
HHV 8
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What is a fordyce spot
Benign spots that appear on shaft of penis, inside the vermillion border, on the inner cheek or the vulva of a female.
Variant of sebaceous glands without the hair follicle
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What is Erythema multiforme? How does it present? Management?
A hypersensitivity reaction which usually has a infective trigger eg. Herpes Virus
or mycoplasma pneumoniae, also EBV, HZV, CMV,
Skin lesions - backs of hands, tops of feet - spread across limbs to trunk
Pappules, plaques and target lesions - three concentric colour regions
Lesions show Koebner phenomenon (they can develop at previous sites of skin trauma)
**Minor** - limited to skin
**Major**- also one mucosal surface - usually lips, can be palate, eyes, genitals, anus,
**Self limiting disease** - treat the triggers, symptomatic treatment for painful lesions or itch
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How does a dermatofibroma present?
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How is dermatitis herpetiformis diagnosed?Distribution
skin biopsy - IgA immune complex deposits on direct immunofluorescence
Elbows, knees, buttocks and shoulders - ITCHY +++ - excoriated skin
Investigate for **coeliac disease, thyroid disease and micronutrient** defs associated eg B12,iron folate, CMP, TSH
Treatment is with Dapsone - Specialist initiated
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Management of Asteatotic eczema?Eczema craquele
Usually very dry skin (Crazy paving), fine, scaly, superficial cracking
in elderly
Hypothyroid
ON statins or diuretics
Treatment is topical moisturiser
soap substitute
Mild steroid ointment eg hydrocortisone 1%
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Management of cellulite?
Reassure This is found in almost all women
It is not harmful but can be embarassing.
Options are weight loss to achieve healthy BMI
other options include liposuction, subcision therapy, topical retinoic acid used over 6 month period
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What are chill blains and management
Itchy and/or tender red or purple bumps that occur a few hours after exposure to the cold.
Management
STOP SMOKING
Keep warm - gloves, warm clothing
Increase ambient temperature of home
topical steroid may assist
otherwise topical antibiotic for secondary infection
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WHat is chondrodermatitis nodularis helicis?
Exquisitely PAINFUL and grows in the helix of the ear (often a history of head scarf or of call centre head set) - THere is a central keratin plug
May need to exclude **SCC** or BCC w
The most important differential here is SCC
If patient is young with minimal sun exposure - then:
No headphones, loosen headdress, sleep on unaffected side- may need to use a donut neck pillow
If not improving - then refer to derm for Biopsy
Once malignancy excluded - intralesional steroid injection may be performed
In refractory cases - curretage is used
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What is the difference between a corn and a callus? What is the treatment
Both have localised areas of hard thickened skin
callus is painless
corn is painful
