Dermatology Flashcards
Impetigo is caused by _____.
What is the Management?
Staphylococcus Aureus / Group A Strep (Strep pyogenes)
- Incredibly contagious
- Mostly in children
- May be febrile
- Conservative*
- Hygiene (don’t share towels. etc)
- Phamacological*
- 1st line : Topical antibiotic - hydrogen peroxide cream (if localised) (crystacide) / Topical fusidic acid (max 2 weeks as develops resistance to staph quickly)
- For more widespread infection - Oral flucoxacillin or Antibiotic syrup arithromycin/clarithromycin
- Acne Vulagaris is a common (vulgaris) inflammatory skin condition that involves blockage of the _____ with bacteria (_____ acnes aka Cutibacterium acnes), cellular debris and oil (sebum)
- Non-inflammatory lesions (mild acne) causes Comedones (small bumps - if open they are called blackheads)
- Moderate/severe acne Causes Inflammatory pustules, papules (Raised skin lesion <1cm) nodules (>1cm), scarring and sometimes cysts.
- Treatment:
If mild acne as below -
Or Severe -
Acne Vulgaris
pilosebaceous unit
Propionibacterium acnes
- Benzoyl Peroxide (antiseptic cream)
And
- Topical antibiotic - Lymecycline (oral) / Clindamycin (oral)
OR
- Retinoid (vit. A derivative) – Adapalene (as a combo treatment w/ Benzoyl peroxide it is known as Epiduo)
OR
- COCP (Dianette – beware has a higher incidence of VTE)
*Treatment needs at least 6 weeks to have an effect*
If standard therapy doesn’t work patient or patient has severe scarring/cystic acne go straight for more potent treatment rather than wasting months for ineffective antibiotic treatment.
*Isotretinoin* (oral potent retinoid – very effective in treating severe cystic/scarring acne)
NB Severely teratogenic and so patient must be on at least one form of contraception and advised not to get pregnant.
Patient must also be admitted and monitored on the ward and thus in primary care we must refer. Can cause raised LFT’s and photosensitivity.
Remember patients with persistent acne and hirsutism need to be investigated for hyperandrogenism. The most common cause of which is PCOS.
*Erythromycin is the most useful antibiotic if patient is pregnant as retinoids - isotretinoin/adapalene and tetracyclines -clindamycin/lymecycline/doxycycline and also trimethoprim are contraindicated.
How do we manage the below image?
Stop Topical Steroids!
Oral aciclovir
and
Antibiotics (Flucoxacillin)
Eczema Herpeticum is caused by HSV which can spread rapidly especially in damaged eczematous skin and with use of topical steroids
Basal Cell Carcinoma
- Often present in the elderly following 6-months of non - healing as a shiny pearly nodule with surface telangectasia as below.
- Ulceration may occur in large lesions but not here
- _____ with a 3-4mm margin is the gold standard of treatment.
- The central face (nasolabial folds), behind the ears (posterior auricular sulcus) and around the eyes are danger areas. BCC at embryological fusion lines may invade deeply making the risk of recurrence higher. Excision of tumour with clear margins is necessary in these areas.
- nasolabial folds are a danger area.
A BCC can be nodular or superficial - superficial presents as a red scaly plaque with rolled edge and sometimes pearly border.
Superficial management?
1st Line: Surgical excision for non superficial BCC (Mohs Surgery -under histological guidance)
2nd line: Radiotherapy
Nodular
Superficial
Superficial BCC Management:
- Curettage and cauterisation (most effective)
- Photodynamic therapy (8/10)
- Imiquimod cream (8/10 effective)
- Efunix (5 -Fluro-uracil)
Risk Factors for Malignant Melanoma
- Fair skin (Fitzpatrick)
- Family history (at least two 1st generation family member)
- Previous melanoma
- Severe sunburn in childhood (intense intermittent burn rather than chronic)
- Multiple dysplastic naevi
- Large congenital naevi
- Immunosuppression
What is the management of Malignant Melanoma?
Management - refer 2ww dermatologist
Surgical
- Surgical excision biopsy (take the whole thing don’t want to leave room for error not worried about scar)
- Lymph node resection
Medical
- Immunotherapy
- Targeted therapy
- Palliative radiotherapy (melanoma itself not usually sensitive to radiotherapy this is thus used for mets)
*Follow up needed for 5 years if lesion is >0.8 mm Breslow thickness depth*
- Every 3 months for 3 years.
- And every 6 months for 2 years
Every 12 months if Breslow thickness is <0.8 mm
Breslow thickness interpretation:
Histology is used to diagnose melanoma and a Breslow thickness is established. The Breslow thickness is the depth of the tumour and is a strong predictor of outcome.
If the Breslow thickness is >1mm a sentinel node biopsy should be carried out, which can look for evidence of metastases and stage the cancer.
Management based on staging
Based on the stage, a wider excision margin may be taken around the lesion to ensure the cancer has been removed:
Stage 0 = 0.5cm
Stage I = 1cm
Stage II = 2cm
Stage III and IV are metastatic, so adjuvant immunotherapy or chemotherapy is given.
Prognosis Based on depth of invasion **Breslow thickness **
Melanoma in situ cured by excision
Advanced melanoma Immunotherapy / targeted therapy.
Asymmetry
Border irregularity (melanoma often has a ‘scalloped’ border)
Colour variation (a variegated lesion is one that consists of many colours)
Diameter >6mm
Evolves over time
Additionally an ‘ugly duckling sign’ can be used to identify malignant lesions- any lesion that stands out from the rest should be suspected.
Squamous cell carcinomas
Non shiny/non telangectasia/ not scab in the middle but just keratinocytes / Large area of ulceration/ and also grows quicker than a BCC
- SCC often occurs in scars
- Often grows quicker than bcc
- Central keratin resembles scab
What is the management?
**Excision** (metastases unlikely but can occurs and happens more than bcc)
w/ 3 yr follow up
Radiotherapy also works well.
SCC often have precancerous or in situ form (unlike bcc - either have bcc or you don’t) called ______ (aka Solar keratosis)
What is the management?
Actinic keratosis / Actinic field change
NB - Cryotherapy and curettage not suitable if multiple lesions
What is the management of Eczema?
Topical Steroids (Hydrocortisone > Eumovate (clobetasone butyrate) / > Elocon (mometasone furoate) / > Betnovate Dermovate).
*lichenification requires more potent steroid*
And
Emollients (aqueous cream, glycerine & cetomacrogol cream, white soft paraffin/liquid paraffin mixed, wool fat lotions).
O
ther options:
Phototherapy
Oral/Topical Antibiotics (most commonly flucoxacillin – used especially if weeping, sticky or crusted)
Oral Anti-histamines (help with itching which may be quite distressing for patient – they do not clear the underlying dermatitis however -also act as a sedative)
Systemic steroids (in severe cases)
Protect the skin from injury
Calcineurin Inhibitors (tacrolimus/Pimecrolimus)
What is the management of psoriasis?
Management
● General measures - avoid known precipitating factors, emollients to reduce scales
● Topical therapies (for localised and mild psoriasis)
- Vitamin D analogues
- Topical corticosteroids,
- Coal tar preparations
- Topical retinoids
- keratolytics and scalp preparations
● Phototherapy (for extensive disease)
- phototherapy i.e. UVB and photochemotherapy i.e. psoralen+UVA
● Oral therapies (for extensive and severe psoriasis, or psoriasis with systemic involvement)
- methotrexate
- retinoids
- ciclosporin (DMARD)
- mycophenolate mofetil
- fumaric acid esters
- biological agents (e.g. etanercept, adalimumab, ustekinumab)
Rosacea (previously called Acne Rosacea despite the lack of relation to acne) is a common, chronic skin condition causing flushing of the forehead, nose, cheeks and chin. The flushing can be transient, recurrent or persistent. It usually presents at age 30 to 60. Rosacea is most common in those with pale skin and affects females more commonly than males (although it can affect males more severely).
Rosacea presents with a red rash over the central face. The rash consists of papules and pustules on an erythematous background, often with telangiectasia (dilated, superficial, small blood vessels).
Rosacea is exacerbated by factors causing facial flushing such as sun exposure, hot weather, warm baths, stress and spicy foods.
The cause of Rosacea is not fully understood and is thought to involve genetics, immune, vascular and environmental factors.
What is the Management?
General measures:
- Camouflage creams
- Sun protection
- Avoiding factors causing facial flushing
Pharmacological:
- Topical treatments such as Brimonidine (first-line according to NICE - alpha adrenergic agonist), Azelaic acid, or Ivermectin (anthelmintics- antiparasite)
- Topical antibiotics, such as Metronidazole (oral antibiotics can also be used if symptoms are more severe)
Adjunct: an emollient can be used as a soap substitute to help improve symptoms if the skin is dry
Adjunct: laser therapy can be used to manage persistent telangiectasia
*Azelaic acid is a naturally occurring acid found in grains such as barley, wheat, and rye. It has antimicrobial and anti-inflammatory properties, which make it effective in the treatment of skin conditions like acne and rosacea. The acid can prevent future outbreaks and clean bacteria from your pores that causes acne
What are the complications of Rosacea?
Complications of untreated Rosacea include;
Rhinophyma, which describes skin thickening, enlargement and disfiguration of the nose
Ocular involvement such as blepharitis, conjunctivitis or keratitis
