Dermatology Flashcards
Define Acne Vulgaris.
Skin disease affecting the pilosebaceous unit characterised by comedones, papules, pustules,
nodules, cysts and/or scarring primarily on the face and trunk
When does acne vulgaris begin?
May begin 1-2 years before onset of puberty following androgenic stimulation of the sebaceous glands and an increased sebum excretion rate.
Inflammation also present
Obstruction to the flow of sebum in the sebaceous follicle initiates the process of acne
Menstrual and emotional stress may be associated with exacerbations
Usually resolves in late teens, but may persist
What are the clinical features of acne vulgaris?
Initially open comedones (blackheads) or closed comedones (whiteheads) progressing to papules, pustules, nodules and cysts
Mainly on back, chest, face and shoulders
More cystic and nodular lesions can produce scarring
What are the ix for acne vulgaris?
Clinical diagnosis
What advice do we give for acne vulgaris?
Advice
- Avoid over-cleaning the skin (may cause dryness and irritation - twice daily washing with gentle soap is adequate)
- If make-up, emollients and cleansers are used, non-comedogenic preparations are recommended with a pH close to the skin
- Avoid picking and squeezing scars due to the risk of scarring
- Treatments are effective but may take a while to work (up to 8 weeks) and may initially irritate the skin
- Maintain a healthy diet
- Support and information:
- NHS choices leaflet on acne
- British association of dermatologists
What is the treatment for mild to moderate acne?
What is the treatment for moderate acne not responding to treatment?
- Consider adding oral antibiotics for a maximum of 3 months
- Lymecycline or Doxycycline
- Topical retinoid or benzoyl peroxide co-prescribed with antibiotic (to reduce risk of resistance)
- Change to an alternative antibiotic after 3 months if no improvement
- Oral antiandrogens e.g. cyproterone +/- spironolactone if signs of hyperandrogenism
- If not responding after 2 courses of antibiotics or if they are scarring, refer to dermatology for consideration of treatment with isotretinoin (Roaccutane)
-
COCP in combination with topical agents can be used as an alternative to systemic antibiotics in girls
- Note: progesterone only contraceptives or progestin implants with androgenic activity may worsen acne
How should we manage severe acne?
Refer to dermatologist
Oral isotretinoin
High-dose oral antibiotics for 6 months or longer
Systemic corticosteroids
When should you refer a patient with acne to a specialist?
- Severe variant (e.g. acne conglobata or acne fulminans)
- Severe acne with scarring or risk of scarring
- Multiple treatments have failed
- Significant psychological distress
- Diagnostic uncertainty
What is the follow-up routine for acne patients?
- Review each treatment step at 8-12 weeks
- If there is an adequate response, continue treatment for at least 12 weeks
- If acne has cleared or almost cleared - consider maintenance therapy with topical retinoids or azelaic acid
- If there is NO response, consider adherence to treatment, adverse effects, progression to more severe acne and discuss the next step in the management
How do we assess severity of acne?
Define Atopic eczema.
An inflammatory skin condition characterised by dry, pruritic skin with a chronic relapsing course
What is eczema caused by?
Genetic deficiency of skin barrier
How common is eczema in the UK?
20%
When is eczema onset?
Onset of atopic eczema is usually in the first year of life. It is, however, uncommon in the first 2 months, unlike infantile seborrhoeic dermatitis, which is relatively common at this age
What is eczema associated with?
There is often a family history of atopic disorders: eczema, asthma, allergic rhinitis (hay fever).
Around one-third of children with atopic eczema will develop asthma.
Exclusive breastfeeding may delay the onset of eczema in predisposed children but does not appear to have a significant impact on the prevalence of eczema during later childhood.
What are the causes of exacerbations of atopic eczema?
o Bacterial infection e.g. Staphylococcus, Streptococcus
o Viral infection e.g. HSV
o Ingestion of an allergen e.g. egg
o Contact with an irritant or allergen
o Environment: heat, humidity
o Change/reduction in medication
o Psychologicalstress
o Unexplained
How commonly does eczema resolve?
Atopic eczema is mainly a disease of childhood, being most severe and troublesome in the first year of life and resolving in 50% by 12 years of age, and in 75% by age 16 years.
What are the complications of eczema?
o Inflammation increases the avidity of skin for S aureus and reduces expression of antimicrobial peptides→S aureus thrives on atopic skin and release superantigens which can maintain and worsen eczema
o HSV can spread on eczema skin causing an extensive vesicular reaction, eczema herpeticum
o Regional lymphadenopathy is common and marked in active eczema – resolves when skin improves
What are the clinical features of eczema?
Pruritus
Dry skin
Distribution changes with age
o Infants: face and trunk
o Young children: extensor surfaces o Older children: flexor surfaces
Affected skin is erythematous, oedematous with prominent weeping and crusting
Over time, prolonged scratching can lead to lichenification (accentuation of normal skin markings)
What are the investigations of eczema?
Clinical diagnosis
If disease is severe, atypical or associated with unusual infections/faltering growth→exclude an immune deficiency disorder
How should we assess severity of eczema?
• Assessment of Eczema (Severity)
o CLEAR - normal skin with no evidence of active eczema
o MILD - areas of dry skin and infrequent itching
o MODERATE - areas of dry skin, frequent itching and redness (with/without excoriation and localised skin thickening)
o SEVERE - widespread areas of dry skin, incessant itching and redness (with/without excoriation and localised skin thickening)
o INFECTED - eczema is weeping, crusting or there are pustules with fever and malaise
o IMPORTANT: remember to assess the psychological impact of eczema on the child
▪ Consider using questionnaires such as the Children’s Dermatology Life Quality Index (CDLQI)
What are the conservative measures for eczema?
- Identify and education of triggers (e.g. food allergens, contact allergens, inhalational allergens, irritants like soaps)
- Emollients
- Cut nails short to avoid scratching especially in children
How should we treat clear eczema?
Conservative
How should we treat mild eczema?
How should moderate eczema be managed?
What is the management of severe eczema?
How should infected eczema be treated?
- Swab the affected area
- Advise about maintaining good hygiene when using emollients and other creams (e.g. using a spatula, not leaving it open)
-
1st line: Flucloxacillin (oral if extensive, topical if local)
- Penicillin allergy: erythromycin (alternative: clarithromycin)
- Use antibiotics for no longer than 2 weeks
- Recurrent infections: antiseptics (e.g. chlorhexidine) can be used to decrease bacterial load (do not use in long-term)
- Eczema Herpeticum
- Oral aciclovir
- If widespread, start aciclovir immediately and refer for same-day dermatological advice
- If around the eyes, refer for same-day ophthalmological and dermatological specialist review
- Provide parents and children advice on how to identify eczema herpeticum (rapidly worsening painful eczema, clustered blisters, punched-out erosions)
Explain the use of emollients in eczema?
Use emollients in large amounts and often
Examples: e45, cetraben, diprobase, aveeno
Emollients should be applied on the whole body
Emollients should be used as a soap substitute (also instead of shampoo or use unperfumed shampoos)
Explain the use of topical corticosteroids in eczema.
- Use once or twice daily (duration can vary from 3-14 days depending on how long the skin takes to respond)
- Only apply to areas of active eczema
- Do not use potent corticosteroids in children < 12 months without specialist advice For areas prone to flares, consider using topical corticosteroids for 2 consecutive days per week to prevent flares (review after 3-6 months)
- If a topical corticosteroid is deemed ineffective, consider using a different type of steroid of a similar potency before increasing the potency
- Mild Potency for Mild Eczema: hydrocortisone 1%
- Moderate Potency for Moderate Eczema: betamethasone valerate 0.025% or
- clobetasone butyrate 0.05%
- Potent for Severe Eczema: betamethasone valerate 0.1%, mometasone
- If very severe and extensive: consider oral steroids
Explain the use of topical calcineurin inhibitors in eczema.
- IMMUNOMODULATOR
- Topical tacrolimus may be considered as 2nd line treatment of moderate to severe eczema in children > 2 years that has not been controlled with steroids
- Alternative: pimecrolimus
- This should only be applied to areas with active eczema
- Do not use under occlusive bandages
Explain the use of bandages in eczema.
Can be used with emollients for areas of chronic lichenified skin
Can be used for short-term flares (7-14 days)
Whole-body occlusive dressings may be used by specialists
What are the indications for a specialist referral for eczema?
Eczema herpeticum (immediate referral)
Urgent referral (2 weeks) if severe atopic eczema has not responded to optimum therapy within 1 week or treatment to bacterially infected eczema has failed
Refer if diagnosis is uncertain, atopic eczema on the face is not responding, contact allergic dermatitis is suspected, causing significant social and psychological problems or severe recurrent infections
What advice should be given to parents for atopic eczema?
Explain the use of dietary elimination in eczema.
Define haemangioma.
Strawberry naevi (haemangioma): will often rapidly increase in size in first few months then slowly spontaneously resolve leaving almost no mark.
A haemangioma is a collection of small blood vessels that form a lump under the skin. They’re sometimes called ‘strawberry marks’ because the surface of a haemangioma can look like the surface of a strawberry.
What is this?
A haemangioma.
Who more commonly get haemangiomas?
They are more common in:
- girls
- premature babies
- low birth weight babies
- multiple births (twins, triplets and quadruplets).
Haemangiomas aren’t inherited, but families often say a relative had a haemangioma in childhood, because they’re very common.
How common are haemangiomas?
1 in 10
What are the clinical features of haemangiomas?
Superficial haemangiomas
- are usually a raised, bright red area of skin
- feel quite warm because the abnormal blood vessels are close to the surface
- might at first appear as a small area of pale skin on which a red spot develops
Deep haemangiomas
- might look bluish in colour because the abnormal blood vessels are deeper in the skin
- aren’t always noticeable for the first few weeks, only appearing as a lump
Haemangiomas don’t usually develop until a few days or weeks after a baby is born, but often grow rapidly in the first three months. It’s unusual for haemangiomas to grow after six to 10 months of age, when most of them tend to have a ‘rest period’ and start to shrink.
Most haemangiomas appear on the head or neck – mainly on the cheek, lips, or upper eyelids – but they can develop anywhere on the body. Some children have multiple haemangiomas, but this mostly happens in twins or other multiple birth babies.
What are the investigations for haemangiomas?
Clinical diagnosis
Might need to do ultrasound and/or MRI scans on a child who has a haemangioma that is deep, near their eye, or affecting internal organs.
How do we treat haemangiomas?
Usually are asymptomatic and undergo involution
Does not necessarily need treatment
Needs to be looked after as they can bleed when scratched
If there is functional impairment (near eyes, nose, mouth) or cosmetic disfigurement:
o Beta-blocker :PO (propranolol) o rtopical (timolol)
o Corticosteroid: PO or topical
o Until theoretical involution or 12m
o May need surgery
Cryotherapy Electrotherapy Vascular laser surgery
If it is ulcerated:
o Barrier protection and Burow’s solution for gentle debridement
o May need topical antibiotics (metronidazole)
o Beta blocker may be used if haven’t previously been treated with it
Define milia.
1-2 mm pearly white pappules which resolve spontaneously in the new born
Most often appear on a newborn’s upper cheeks, nose, chin, or forehead. They’re harmless and very common.
What is this?
milia
How do you manage milia?
Most cases eventually clear by themselves (within a few weeks in infants)
May be removed if not cosmetically pleasing
o Can do it using a fine needle
o Cryotherapy can be used
o Laser treatment
o Dermabrasion
o Chemical peeling
Define molluscum contagiosum. How is it spread?
Viral skin infection caused by pox virus
Transmission usually by direct skin contact
What are the clinical features of molluscum contagiosum?
Firm, smooth, skin coloured, pearly umbilicated papules
May be single but usually multiple
Usually 2-5mm in diameter
In children, tend to occur on trunk and extremities
What are the investigations of molluscum contagiosum?
Clinical exam
What is this?
Molluscum contagiosum
What is this?
Nappy rash due to candida infection
What is this
Cradle cap - seborrheic dermatitis
What is this?
Seborrheic dermatitis with involvement of face, axillae and napkin area.
How do you manage seborrheic dermatitis?
What is the management of ringworm?
What is this
Guttate psoriasis
What is the management of scabies?
School exclusion until treated.
Atopic eczema
Infantile seborrheic dermatitis
Candida
Scabies
Ringworm
Psoriasis
Acne vulgaris
Urticaria
Henoch Schonlein purpura
Erythema multiforme
Erythema nodosum
Erythema infectiosum / fifth disease /slapped cheek syndrome
Meningococcal septicaemia
This is a typical presentation of pityriasis versicolor, a common fungal skin infection. It often becomes more noticeable after spending time in the sun - as the healthy skin becomes darker, the white/light brown patches become more prominent.
Treatment consists of topical antifungals - NICE recommends ketoconazole shampoo. If only a very small area is affected, a topical antifungal cream may also be appropriate. In this case, both back and chest are affected, so a shampoo would be much easier to use.
Pityriasis rosea. The exact cause remains unclear, although there are links to certain viruses. It is a self-limiting disease that tends to resolve within 12 weeks with no long term complications. Most patients will not require any treatment.
If patients complain of itch we can consider emollients, topical corticosteroids or antihistamines. Steroids are unlikely to shorten the duration of the rash itself, so should only really be used if there is pruritus present and for the shortest amount of time.
