Derm2

Question 1

What are the main risk factors for melanoma?

Answer 1

elderly male

blistering sunburn as child or adolescent

fair complexion, blue eyes rather than brown and tendency to burn rather than tan

marked solar skin damage

multiple common malaenocytic naevi

dysplastic naevus syndrome

PHx - hx of previous melanoma or non melanoma skin cancer

Drug Hx and Past MHx - immune defeciency

Family Hx - hx of melanoma

Question 2

What are the ABCDE’s of melanoma?

Answer 2

Asymmetry

Border irregularity

Colour variation within the lesion

Diameter greater than 6mm (can be diagnosed smaller, increasing diameter is more important than size)

Evolution - changing or evolving

Question 3

What are the typical dermatoscope findings in melanoma

Answer 3

asymettric pigmentation

blue white veil

multiple brown dots

radial streaming

pseudopods

Blue whale with radio steaming - covered in brown dots - with ear pods in and an asymetric pig on top

Question 4

Most important question on history of melanoma? Whats the commones symptom of invasion?

Answer 4

Is it changing?

Invasion sign - itch!

can also bleed and crust

Question 6

What are the types of melanoma?

Answer 6

1. Superficial spreading
2. Nodular melanoma (EFG - elevated, firm, growing)
3. Acral lentiginous melanoma (palms, soles and and nails - often dark skin)
4. Lentigo maligna (in situ melanoma) - can develop into lentigo maligna melanoma (so treat)
5. Hypomelanotic melanoma (pink)

Question 7

Examination in Melanoma

Answer 7

Examine entire skin surface under good lighting

Examine lymph nodes in the appropriate region

Question 8

How is the diagnosis of melanoma made?

Answer 8

Complete excision with 2mm borders of skin and upper subcutis (subcutaneous fat)

Question 10

Can you do a wide excision first?

Answer 10

NO
May lead to excesive or inadequate tumour clearance

it will be impossible to map the draining lymph nodes thereafter

Question 11

What is Breslow thickness?

Answer 11

Vertical depth of the lesion from the granular layer of the epidermis to the deepest part within the dermis or subcutaneous tissue

Question 12

Once you know Breslow thickness from histology - whats the next step

Answer 12

Depends on how thick -

If its melanoma in situ - REPEAT excision with wide 5mm margins

if its Melanoma less than 1.0mm** - then repeat excision with wide **1cm margin (as long as no metastasis - clinical stage less than 3) margins UNLESS it has ulceration - then refer - as may need sentinel biopsy first.

If its Melanoma over 1mm - refer as these need sentinel biopsy before wide excision.

Question 13

How deep should an excision go for melanoma

Answer 13

Down to, but not including deep fascia

Question 14

What are the 3 R’s for nodular amelanotic lesion

Answer 14

Red, raised, recent change

Question 15

What are the clinical stages of Melanoma based on? WHat are they

Answer 15

Based on 1) Breslow thickness 2)LN involvement and 3) Distant spread

STAGE 0: <1.0mm - melanoma is in the top layer of skin - epidermis - insitu

STAGE 1: <2mm without ulceration or up to 1mm with ulceration

STAGE 2: >2mm or >1mm with ulceration

STAGE 3: Spread to Lymph nodes

STAGE 4: Distant spread

Question 16

What’s the follow up for Melanoma?

Answer 16

1. STAGE ONE DISEASE - 6monthly for 5 years and then yearly
2. STAGE 2 and 3 - Followed up every 3 months

LDH is used as a marker of severity in stage 4 disease

Question 17

What is the differential for subungal melanoma

Answer 17

Subungal melanoma -is malignant

Longitudinal melanonichya - benign (dark skin)

Subungal heamatoma - benign

Question 18

What is the DDx of Lentigo Maligna

Answer 18

Solar Lentigo

Flat Seb K

Pigmented Solar Keratosis

Question 19

What are the four most important prognostic indicators in melanoma?

Answer 19

1. Breslow thickness
2. SLN status
3. Presence of ulceration
4. Tumour Mitotic rate

Question 20

Who would you refer to for a sentinel lymph node biopsy consideration

Answer 20

Surgical oncologist

Question 21

What is the management if SLN is positive

Answer 21

Complete lymph node Dissection

Question 22

Management of metastatic disease

Answer 22

Regional lymph node dissection

Staging with PET/CT

For systemic metastatses: Immunotherapy or BRAF inhiibitors

Question 23

What are the causes of fungal skin infection? Typical rashF

Answer 23

1. Trichophytum rubrum
2. Microsporum canis (dog ring worm) - aggresive. woods lamp - green fluorsecence

Typical rash is annular with central clearing as it expands. Scaly and itchy.

DDx - dermatitis, ptyriasis rosea, annular psoriasis, granuloma annulare

Question 24

What is the topical therapy for tinea?

Answer 24

Terbinafine 1% topically cream or gel twice daily for 7 to 14 days.

Question 25

When would you use oral treatment for tinea? What dose and how long?

Answer 25

Refractory to topicals - **2 weeks** Tinea capitis - **4 weeks** Onychomychosis (fingernails) -**6 weeks** Onychomycosis (toenails) - **12 weeks** **After scrapings/clippings for M/C/S** Oral terbinafine **Children under 20kg - 62.5mg** **Children 20-40kg - 125mg** **Over 40kg - 250mg**

Question 26

What general advice would you give treatment for different kinds of tinea?

Answer 26

CRURIS soak area in bath and dry area well Then apply cream. cruris - apply to area + 2cm from border - if itch is severe can add 1% hydrocortisone PEDIS Dry well between toes. Put wet footwear in sun to dry CAPITIS Check family members for infection - suggest ketoconazole shampoo 2% for carriers.

Question 27

side effects of terbinafine

Answer 27

Not suggested for those with liver or renal impairment Not for use during pregnancy or breastfeeding Local side effects - urticaria Severe but rare - SJS

Question 28

How would you treat an umbilical granuloma in an infant?

Answer 28

topical silver nitrate

Question 29

Indications for treating viral warts? Method?

Answer 29

Pain, cosmetic, interferes with function, risk of malignancy 1. Salicylic acid or podophyllum resin - keratolytic (precaution in DM) 2. Cryotherapy 15-20 second applications ever 2 weeks - may need multiple 3. Topical retinoids/imiquimod 4. Laser therapy - derm 5. Advice to prevent spread - dont walk barefoot- avoid sharing of footwear and towels - change socks daily

Question 30

What is vitiligo? What conditions are associated? What is the treatment?

Answer 30

Acquired **depigmenting** disorder. Mikly white patches on skin. Associated with **autoimmune disease** - DM, Thyroid, pernicious anaemia Treatment - **Betamethasone diproprionate 0.05% daily for 3 months** If refractory - phototherapy

Question 32

How would you identify a venous leg ulcer? Mx?

Answer 32

RF's - obesity, previous DVT, reduced mobility Usually in the 'gaiter' area - lower one third of leg irregular in shape, haemosiderin deposition DO ABPI first to exclude arterial involvement Mainstay of treament is graduated compression therapy - toe-knee

Question 33

Arterial ulcer management?

Answer 33

Often distal, punched out, necrotic, with rest pain Acutely - revascularisation/ amputation **Adequate analgesia** to address severe pain stop smoking, control DM and cholesterol Revasc

Question 34

What is the management of a pressure ulcer?

Answer 34

1. Remove all pressure on the wound 2. increase nutrition 3. topical and cavity products

Question 35

How is a wound bed preparation assessed? Which elements are looked at?

Answer 35

Tissue Inflammation/infection Moisture Edge/Epithelialisation

Question 37

Factors that influence wound healing

Answer 37

_Extrinsic_ - **comorbidities** - Patient n**utrition** **Age** related skin changes Health status **Immune** function _INTRINSIC_ **Maceration** **Dessication** **Mechanical stress** **Debris**

Question 38

Types of interactive dressings?

Answer 38

Hydrocolloid Hydrogel Hydroactive **F**ilm dressing **F**oam dressing **A**lginate

Question 39

Best dressings for heavy exudate, malodorous exudate, chronic wound with moderate exudate in chronic venous ulcers

Answer 39

ALGINATES -eg kaltostat are good for **heavy exudate** Cadoxemer Iodine (Iodosorb) - good for **malodorous** exudate **Foam** dressings (allevyn) - good for **granulating wound with not much exudate** **Hydrocolloid (comfeel)** - Good for Chronic wound with moderate exudate

Question 40

How does dermatitis herpetiformis present

Answer 40

Extremely itchy rash in knees, elbows and buttocks Excoriated 90% will have coeliac. Do coeliac serology (tTG, total IGA, DGP deamidated gliadin peptide) Skin biopsy for Direct Immunofluorescence - looking for IgA deposition (lesional and perilesional) Treatment is with **GLUTEN FREE DIET and** **DAPSONE** (needs FBE monitoring, exclude sulfur allergy and G6PD def)

Question 41

What is the DDx of dermatitis herpetiformis

Answer 41

1. Scabies 2. Pompholyx eczema 3. HSV 4. Bullous pemphigoid 5. HZV

Question 42

Answer 42

Cafe au lait macule Congenital NF1

Question 43

Answer 43

Acral lentiginous melanoma

Question 44

Answer 44

Acral Naevus - A - is early melanoma

Question 46

What is Hutchinsons sign?

Answer 46

Pigment in the proximal nail fold - Subungal melanoma! Clinical signs separating subungual melanoma from benign counterparts (eg benign longitudinal melanonychia) are the extension of pigmentation onto the proximal nail fold (Hutchinson’s sign), heterogeneity of pigment colour, expansion of the width of pigment distribution or proximal growth. It can be amelanotic and may destroy the nail plate if advanced. In contrast, pigment in a subungual haematoma appears reddish-brown and homogeneous and shows evidence of distal migration in the nail.