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MRCP > Dermatology > Flashcards

Dermatology Flashcards

1
Q

how does erythema nodosum heal

A

without scarring in 1-2 MONTHS

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2
Q

causes of erythema nodosum

A 
Infection: strep, TB 
Pregnancy 
Systemic disease: sarcoid, IBD, behcet's  
Drugs: COCP, sulphonamides, penicillin  
Malignancy/lymphoma
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3
Q 
what skin lesion?
Slowly growing over 2-3 months 
On a sun exposed area
Round, raised, flesh coloured lesion 
Central depression 
Rolled edges 
Telangiectasia
A

nodular BCC

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4
Q

tx of BCC

A 
Surgical removal 
Curettage 
Cryotherapy 
Topical cream: imiquimod, fluorouracil 
Radiotx
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5
Q

non-healing ulcer at site of burn injury = what disease

A

SCC

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6
Q

RF for SCC

A

Excessive sun or psoralen UVA therapy exposure

Actinic keratoses, bowen’s

Immunosuppression EG transplant, HIV

SMOKING

Long term leg ulcers - marjolins ulcer [grows from burns/scars/badly healed wounds]

Genetic conditions EG xeroderma pigmentosum, oculocutaneous albinism

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7
Q

tx of scc

A

if <20mm, surgical removal w 4mm margins

If >20mm, then need 6mm margins

Moh’s surgery if cosmetic site or high risk pt

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8
Q

poor prognostic indicators for scc

A

Good: well differentiated tumour, <20mm, <2mm deep, no other diseases

Poor: poorly differentiated, >20mm, >4mm deep, immunosuppressed

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9
Q

what has a herald patch

A

pityriasis rosea

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10
Q

sore throat then 2wks later widespread rash w Multiple erythematous lesions <1cm diameter Covered in fine scale

A

guttate psoriasis

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11
Q

cause & mx of guttate psoriasis

A

Cause : Strep infection 2-4wks prior

Tear drop papules on trunk and limbs

Mx 
Resolve spon in 2-3months 
Topical agents as per psoriasis 
UVB phototherapy 
Tonsillectomy if recurrent
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12
Q

mx of pityriasis rosea

A

Features
HERALD PATCH
Then 1-2 wks later: multiple erythematous slightly raised oval lesinos w fine scale on outer aspect of lesions
Can be classic distribution of fir tree

Mx: Self resolves after 6wks

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13
Q

?malignant acantosis nigricans - most important Ix to do

A

OGD (+ CT) - most common cancer is GI adenocarcinoma

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14
Q

causes of acanthosis nigricans

A

T2DM

GI cancer

Obesity

PCOS

Acromegaly

Cushing’s

Hypothyroid

Familial

Prader-willi

Drugs: COCP, nicotinic acid (aka niacin, tx for b3 deficiency)

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15
Q

acanthosis nigricans description

& malignant AN fts

A

AN = symmetrical brown velvety plaques in neck/axilla groin

Malignant AN
more likely when older pt & rapid onset
More typical to get itchy lesion w involvement of palms/soles/mucosa
OGD + CT for ?gastric cancer (RF: smoking, male)

Description in Q for malignant
Rapidly growing itchy rash
Mainly axilla, but also hands and soles of feet
Thickened patches of skin; discoloured (light brown)
Skin tags aroudn the lesions
Small finger-like projections from lips

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16
Q

33y old M recurrent nose bleeds, ID anaemia, SOB – found to have pulmonary AV malformation - ?most likely dx

A

hereditary haemorrhagic telangiectasia

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17
Q

HHT diagnostic criteria (hereditary haemorrhagic telangiectasia)

A

4 criteria.

Spontaneous recurrent nosebleeds

Telangiectases - multiple at characteristic sites (lips, mouth, fingers, nose)

Visceral lesions: EG GI telangiectasia, pulmonary AV malformations

1st degree relative with it

If have 2 = possible HHT

If 3 = definite

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18
Q

hereditary haemorrhagic telangiectasia - cause?

A

Genetic fts

AD

20% occur spon without FHx

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19
Q

TEN causes

A

Phenytoin

Sulphonamides

Allopurinol

Penicillins

Carbamazepine

NSAIDs

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20
Q

TEN mx

A

Stop causative drug

Supportive care – usually ITU – volume loss and electrolyte derangement need tx

IV Ig now used 1st line

Sometimes use: immunosuppresion (cyclosporin, cyclophosphamide), plasmapheresis

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21
Q

Positive nikolskys sign - what is it and what disease

A

TEN

Positive nikolskys sgin – epidermis seperates with mild lateral pressure

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22
Q

features of TEN

A

Systemically unwell: fever, tachycardic

Positive nikolskys sgin – epidermis seperates with mild lateral pressure

widespread red rash > now large fluid filled blisters 30% body surface area

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23
Q

psoriasis triggers and complications

A 
Factors may exacerbate psoriasis:
	• trauma
	• alcohol
	• drugs: b-blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs, ACE i, infliximab
	• withdrawal of systemic steroids

Complications
• psoriatic arthropathy (10%)
• increased incidence of metabolic syn, CV disease and VTE

24
Q

psoriasis mx

A

Summary

- Face, flexural and genital: Mild or moderate steroid OD or BD for max 2 weeks
- Scalp 1st line: potent topical steroid OD for 4wks
- Chronic plaque 1st line:  potent topical steroid OD + topical vitamin D analogue OD. (one AM, one eve) - for up to 4wks

Chronic plaque mx
Throughout: regular emollients (reduce scale loss and itching)
1. 1st line: potent topical steroid OD + topical vitamin D analogue OD. (one AM, one eve) - for up to 4wks
2. 2nd line: no improvement after 8wks: vitamin D analogue BD
3. 3rd line: no improvement by 8-12wks:
○ Topical steroid BD for up to 4 weeks
○ OR Coal tar prep OD or BD
- Short-acting dithranol can also be used

Scalp
• Potent topical steroid OD for 4 weeks
If no improvement: either use a different formulation of it and/or topical agents to remove the adherent scale (EG having salicyclic acid, emollients and oils) before putting on the steroid

25
Q

venous ulceration

  • useful Ix? normal and abn values?
  • where are they ususally?
  • mx?
A

Ix most useful in determining mx: ABPI
Mx: compression bandaging, usually four layer

NOTES
typically seen above the medial malleolus

Investigations
• ABPI: important in non-healing ulcers to assess for poor arterial flow which could impair healing
○ ‘normal’: 0.9 - 1.2
○ <0.9: arterial disease
○ >1.3 may also indicate arterial disease, in the form of false-negative results secondary to arterial calcification (e.g. In diabetics)

26
Q

systemic mastocytosis

  • fts
  • dx
A
  • Features: flushing, abdo pain + urticaria pigmentosa
    ○ UP: produces a wheal on rubbing (Darier’s sign)
    • Dx: urinary histamine
    • Cause: neoplastic proliferation of mast cells
    • Ix: high serum tryptase, high urinary histamine, monocytosis on blood film
27
Q 
pityriasis versicolor
 cause
tx
features
rf
A
  • Cause: Malassezia furfur
    • Tx: ketoconazole shampoo (2nd line oral itraconazole + skin scraping to confirm dx)
    • Multiple hypopigmented/pink/brown patches on trunk w scale and itch.
    • RF: cushings, immunosuppression, malnutrition
28
Q

alopecia areata mx

A 
Mx: watchful waiting for spontaneous remission
Other treatment options include:
	• topical or intralesional corticosteroids
	• topical minoxidil
	• phototherapy
	• dithranol
	• contact immunotherapy
	• wigs
29
Q

seborrhoeic dermatitis

  • fts
  • ass w ?
  • comps: 2
A
  • Itchy rash over face/scalp + otitis externa, blepharitis
    • Cause: malassezia furfur
    • Ass HIV and PD
    • Scalp: over the counter stuff, then ketoconazole.
      Face/body: topical ketoconazole
30
Q 
lichen sclerosus
- fts
- dx
- mx
risk of?
A

LS: itchy white spots typically seen on the vulva of elderly women

NOTES
Features: can occur on genitals, thighs, anal region.
In M: glans penis usually = balanitis xerotica obliterans

Dx: usually clinical, but can do biopsy if atypical fts
Mx: topical steroids and emollients
Increased risk of vulval cancer

31
Q

eczema herpeticum

  • causes
  • mx
  • presentation
A

HSV 1 or 2
(uncommonly coxsackievirus)
Admit children for IV aciclovir (as potentially fatal)

NOTES
PC: rapidly progressing painful rash
- In kid with atopic eczema
monomorphic punched-out erosions (circular, depressed, ulcerated lesions) usually 1–3 mm in diameter

32
Q

rosacea mx

A

Management
• Mild: topical metronidazole (i.e. Limited number of papules and pustules, no plaques)
• Mainly flushing (limiting telangiectasia): topical brimonidine gel
• more severe: systemic antibiotics e.g. Oxytetracycline
Also
• high-factor sunscreen OD
• camouflage creams may help conceal redness
• laser therapy if prominent telangiectasia
• patients with a rhinophyma: refer to derm

33
Q

pemphigus vulgaris v pemphigoid

A

PEMPHIGUS VULGARIS
KEY BITS
- Flaccid vesicles + mucosal involvement
- Abs against desmoglein 3

NOTES

- 30-50y old
- more common in the Ashkenazi Jewish population.

Features
- mucosal ulceration: common. Oral involvement in 50-70%
- skin blistering - flaccid, easily ruptured vesicles and bullae.
○ painful but not itchy
○ Can be months after mucosal symptoms.
○ Nikolsky’s describes the spread of bullae following application of horizontal, tangential pressure to the skin
- Biopsy: acantholysis

Mx: 1st line steroids

PEMPHIGOID

- Subepidermal blistering
- Due to Abs against hemidesmosomal proteins BP180 and BP230.

Elderly pt with

- itchy, tense blisters typically around flexures
- usually heal without scarring
- no mucosal involvement

Biopsy: immunofluorescence shows IgG and C3 at the dermoepidermal junction

Mx

1. Refer for biopsy and confirmation
2. Oral steroids
34
Q

Koebner phenomenon ?

A

Koebner phenomenon (new skin lesions at the site of trauma)

35
Q

Lichenoid drug eruptions - causes:

A

• gold
• quinine
Thiazides

36
Q

pregnancy skin related lesions 4

A
  • Melasma = big brown patch on face, benign. No tx
    • Atopic eruption of pregnancy = itchy red eczematous rash. No tx
    • Polymorphic eruption of pregnancy = last trimester. Itchy lesions in abdominal striae.
    • Pemphigoid gastationis: itchy blistering lesions. Oral steroids.
37
Q

niacin deficiency

  • what vitamin is it
  • fts
  • other name
  • causes
A

Niacin/nicotinic acid (b3 def): dermatitis, diarrhoea and dementia

Can be due to isoniazid
More common in alcoholics.

38
Q

erythema nodosum
fts
causes
mx

A 
Overview
= inflam of subcutaneous fat
	• Painful red nodular lesions 
	• Usually on shins but can be elsewhere EG forearms
	• Heal by themselves in 6 weeks
	• Heal without scarring

Causes
• Infection: strep, TB
• Pregnancy
• Systemic disease: sarcoid, IBD, behcet’s
• Drugs: COCP, sulphonamides, penicillin
• Malignancy/lymphoma

39
Q

allergic v irritant contact dermatitis

A
  • Irritant: common, non-allergic reaction, due to weak acids/alkalis (eg detergent). Often on hands. Erythema.
    • Allergic: type 4 hypersens reaction. Uncommon: often on head after dyes. Acute weeping eczema affecting margins of hairline (not scalp). Tx topical steroid
      Cement: can cause both together
40
Q

retinoids SE

  • what do you not prescribe them with
  • most common SE
A

Adverse effects
• Teratogenicity (women should use 2 forms of contraception)
• dry skin, eyes and lips/mouth (most common SE)
• low mood
• raised triglycerides
• hair thinning
• nose bleeds (due to dryness of the nasal mucosa)
• intracranial hypertension (so do NOT give with tetracyclines)
• photosensitivity

41
Q

erythema multiforme

  • describe
  • causes
A 
Features
	• target lesions
	• 1st back of the hands/feet >>  torso
	• upper limbs (more than LLs)
	• pruritus is occasionally seen and is usually mild

Causes
• viruses: herpes simplex virus (the most common cause), Orf
• idiopathic
• bacteria: Mycoplasma, Streptococcus
• drugs: penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill, nevirapine
• connective tissue disease e.g. Systemic lupus erythematosus
• sarcoidosis
• malignancy

hypersens reaction
EM major: mucosal involvement

42
Q 
pyoderma gangrenosum
fts
causes
dx
mx
A
  • Painful skin ulceration (esp on LLs or site of minor injury/stoma)
    • Biopsy: dense infiltration of neutrophils

Causes

- idiopathic in 50%
- IBD in 10-15% (UC or crohns)
- rheum: RA, SLE
- haem: lymphoma, myeloid leukaemias, myeloproliferative disorders, monoclonal gammopathy (IgA)
- granulomatosis with polyangiitis 
- PBC

Presentation
- Sudden: small pustule, red bump or blood-blister
- Then skin breaks down > painful ulcer with an edge that’s purple, violaceous and undermined.
○ Ulcer may be deep and necrotic
- Can get systemic syms (fever, myalgia)

Dx: often clinical + histology (not specific but r/o other causes)
- Ddx malignancy so refer to derm to consider biopsy

Management
- 1st line: oral steroids
- potential for rapid progression is high in most
- Difficult cases: other immunosup EG ciclosporin and infliximab
any surgery should be postponed until the disease process is controlled on immunosuppression to avoid risk worsening of the disease (pathergy)

43
Q 
pyoderma gangrenosum
fts
causes
dx
mx
A
  • Painful skin ulceration (esp on LLs or site of minor injury/stoma)
    • Biopsy: dense infiltration of neutrophils

Causes

- idiopathic in 50%
- IBD in 10-15% (UC or crohns)
- rheum: RA, SLE
- haem: lymphoma, myeloid leukaemias, myeloproliferative disorders, monoclonal gammopathy (IgA)
- granulomatosis with polyangiitis 
- PBC

Presentation
- Sudden: small pustule, red bump or blood-blister
- Then skin breaks down > painful ulcer with an edge that’s purple, violaceous and undermined.
○ Ulcer may be deep and necrotic
- Can get systemic syms (fever, myalgia)

Dx: often clinical + histology (not specific but r/o other causes)
- Ddx malignancy so refer to derm to consider biopsy

Management
- 1st line: oral steroids
- potential for rapid progression is high in most
- Difficult cases: other immunosup EG ciclosporin and infliximab
any surgery should be postponed until the disease process is controlled on immunosuppression to avoid risk worsening of the disease (pathergy)

44
Q

mx of guttate psoriasis

A

Usually self-resolves but can give UVB phototherapy to accelerate resolution

• Resolve spon in 2-3months
• Topical agents as per psoriasis
• UVB phototherapy Tonsillectomy if recurrent
45
Q

granuloma annulare

A
  • Papular lesions: often abit hyperpigmented and depressed centrally
    • Usually on dorsal hands and feet, extensors of arms nd legs
    • Ass w DM (weakly)
46
Q

scabies mx

  • normal
  • norwegian
A 
Mx
	1. Permethrin 5%
	2. Malathion 0.5%
Itching for 4-6wk after eradication
all household and close physical contacts should be treated at the same time, even if asymptomatic

Crusted (norwegian) scabies
- patients with suppressed immunity, especially HIV.
- crusted skin will be teeming with hundreds of thousands of organisms.
Mx: Ivermectin + isolation is essential

47
Q

dermatitis herpetiformis

  • cause
  • fts
  • mx
A
  • Caused by IgA deposition in dermis

NOTES
- Mx: gluten-free diet + dapsone

PC: itchy, vesicular skin lesions on extensor surfaces (e.g. elbows, knees, buttocks)

Dx = skin biopsy: direct immunofluorescence shows deposition of IgA in a granular pattern in the upper dermis

48
Q

erythema ab igne

  • fts
  • cause
  • risk?
A
  • If not treated can > squamous cell carcinoma

NOTES
- cause: over exposure to infrared radiation.
- PC: reticulated, erythematous patches with hyperpigmentation and telangiectasia.
Often elderly women who always sits next to an open fire.

49
Q

impetigo
fts
causes
mx

A

Golden crusted skin lesions – usually around mouth
Causes: staph aureus, strep pyogenes

Mx
1st line: hydrogen peroxide 1% cream (for systemically well and low risk of complications)

Next options
• Topical fusidic acid
• If resistant to this: topical mupirocin

Extensive disease:
• Oral fluclox
• Pen-allergic: oral erythromycin

Kids should stay off school until lesions crusted/healed OR 48h after starting abx

50
Q

BCC

A 
Classic description
	• Slowly growing over 2-3 months
	• On a sun exposed area EG nose
	• Round, raised, flesh coloured lesion
	• Central depression
	• Rolled edges
	• Telangiectasia

If suspect > routine referral

Morphoeic BCC = firm/rough/qxy patch often on cheek, poorly defined edge. Mx: mohs surgery

NOTES
• Grows slowly, locally invasive - rare to metastasise
• Most common cancer in western world

Features
	• most common type = nodular BCC
	• Sun-exposed areas esp head and neck
	• Initially pearly, flesh coloured papule w telangiectasia
	• Then can ulcerate > central crater 
Mx
	• Surgical removal
	• Curettage
	• Cryotherapy
	• Topical cream: imiquimod, fluorouracil
	• Radiotx
51
Q

BCC

A 
Classic description
	• Slowly growing over 2-3 months
	• On a sun exposed area EG nose
	• Round, raised, flesh coloured lesion
	• Central depression
	• Rolled edges
	• Telangiectasia

If suspect > routine referral

Morphoeic BCC = firm/rough/qxy patch often on cheek, poorly defined edge. Mx: mohs surgery

NOTES
• Grows slowly, locally invasive - rare to metastasise
• Most common cancer in western world

Features
	• most common type = nodular BCC
	• Sun-exposed areas esp head and neck
	• Initially pearly, flesh coloured papule w telangiectasia
	• Then can ulcerate > central crater 
Mx
	• Surgical removal
	• Curettage
	• Cryotherapy
	• Topical cream: imiquimod, fluorouracil
	• Radiotx
52
Q

SCC

A

RF
• Excessive sun (most common cause) or psoralen UVA therapy exposure
• Actinic keratoses, bowen’s
• Immunosuppression EG transplant, HIV
• SMOKING
• Long term leg ulcers - marjolins ulcer [grows from burns/scars/badly healed wounds]
• Genetic conditions EG xeroderma pigmentosum, oculocutaneous albinism

Overview
• Most common skin cancer
• Rare to met: 2-5%

Tx
• If <20mm, surgical removal w 4mm margins
• If >20mm, then need 6mm margins
• Moh’s surgery if cosmetic site or high risk pt

Prognosis
Good: well differentiated tumour, <20mm, <2mm deep, no other diseases
Poor: poorly differentiated, >20mm, >4mm deep, immunosuppressed

53
Q

most important prognostic factor in melanoma

A

Invasive depth of tumour = most important prognostic factor (breslow thickness)

54
Q

acne mx

A

Management
1. One topical (retinoid, benzoyl peroxide)
2. Combo of topicals (R, BP or topical abx)
3. Oral abx (lymecycline, oxytetracycline or doxycycline): max 3 mos
a. Always give with topical R or BP - reduces risk of abx resistance dev
4. Alt to oral abx: oral COCP in women
a. Use with topical agent
5. oral isotretinoin: only under specialist supervision
○ pregnancy is a contraindication to topical and oral retinoid treatment

More detail on mx
Abx
- Tetracyclines: avoid in pregnancy, BF or <12y old
- Pregnancy: use erythromycin
- Gram-negative folliculitis: comp of long-term antibiotic use - tx: high-dose oral trimethoprim

55
Q

anti histamines

  • one that causes least drowsiness
  • generally sedating (1)
  • non sedating 2
A

Least drowsiness causing: loratidine
Non-sedating antihistamines: loratidine, cetirizine
Sedating: chlorphenamine

56
Q

keloid mx

A

Treatment
• early keloids: intra-lesional steroids e.g. triamcinolone
excision is sometimes required

57
Q

bullous pemphigoid mx

A

Mx
1. Refer for biopsy and confirmation
Oral steroids

MRCP (16 decks)

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