Dermatology Flashcards

Question

Answer 1

Palpable purpuric papules

Answer 2

Telangiectasia

Answer 3

Scaly papules

Answer 4

Annular non scaling plaque

Answer 5

Crust (in impetigo)

Answer 6

Erythoderma

Answer 7

Sclaey plaque

Answer 8

Ecchymosis seen in vasculitis

Answer 9

Elliptical shape including saftey margin of normal skin to allow for closure

Answer 10

MORE THAN 5 EPISODES OF SUNBURN UNDER 10 YEARS OF AGE Sun exposure Sun beds Immunosupression Burns easily Multiple moles (>100) Atypical naevus syndrome moles Family history of melanoma Skin type 1 Previous history of melanoma Large congenital melanocytic naevus

Answer 11

Duct tape Topical therapies Cryotherapy

Answer 12

Shiny smooth papules with central dimple secondary to viral infection . Self limiting but can us antiseptic wash +/- abx if appear infected

Answer 13

Multiple household members with same condition. Linear burrows (may be tortuos), rubber nodules, papules, excoriations, Scabies presents with incredibly itchy small red spots, possibly with track marks where the mites have burrowed. The classic location of the rash is between the finger webs, but it can spread to the whole body. History of contact with symptomatic individuals, puritus worse at night Common sites include fingers, finger webs, wrists, elbows, ankles, feet, nipples and genitals

Answer 14

Erythematous rash Itchy Papules and plaques Some annular/targetoid leisions Tense blisters/bulla on an erythematous base Preceded by a non-specific itchy rash Usually effects the trunk and limbs (Mucosal involvement less common)# Often affecting elderly patients

Answer 15

In a dermatomal distribution Erthymatous, erosions, crust

Answer 16

Fast growing Ulcerated lesion May have shiny edges and telangiectasia Bleeding and crust present

Answer 17

Type of early skin cancer Bowen's Disease appears as an irregular, red, keratinised, scaly plaques classically located on areas of sun exposed skin

Answer 18

The general rule is to use the weakest steroid for the shortest period required to get the skin under control. Steroids are very good for settling down the immune activity in the skin and reducing inflammation, but they do come with side effects. They can lead to thinning of the skin, which in turn make the skin more prone to flares, bruising, tearing, stretch marks and enlarged blood vessels under the surface of the skin called telangiectasia. Depending on the location and strength of the steroid there may be some systemic absorption of the steroid. The risks of using steroids need to be balanced against the risk of poorly controlled eczema. The thicker the skin, the stronger the steroid required. Only weak steroids used very cautiously should be applied to areas of thin skin such as the face, around the eyes and in the genital region. It is best to completely avoid steroids in these areas in children.

Answer 19

Emollient should be applied first Use fairly genourously when active and thinner when improving

Answer 20

A chronic inflammatory condition, with or without localised infection disorder of the pilosebaceous units (containing hair follicles and sebaceous glands) causing comedones, papules and pustules to form. Commodomal - less severe, Pustular more severe

Answer 21

Secondary syphilis develops as a maculopapular rash covering the torso and limbs as well as the palms and soles. Patients generally feel very unwell and have lymphadenopathy.

Answer 22

Potent topical corticosteroid + topical vitamin D is the first line treatment for plaque psoriasis.

Answer 23

Contact Dermatitis is a type of Eczema which occurs following exposure to a causative agent. The rash is typically eczematous and commonly located on the hands in an asymmetrical distribution.

Answer 24

Bullous Pemphigoid is an autoimmune blistering skin condition which affects the elderly. It is more common in those with neurological diseases such as Parkinson's Disease or dementia. Bullous Pemphigoid is caused by autoantibodies against antigens between the epidermis and dermis, resulting in a sub-epidermal split. Initially, it presents as pruritic, tense, fluid-filled bullae (large blisters) on an erythematous base. In the image shown, some of the bullae have ruptured, leaving post-inflammatory hyperpigmentation. The lesions can be localised or widespread, often occurring in skin folds.

Answer 25

Impetigo is a superficial bacterial skin infection, usually caused by the staphylococcus aureus bacteria. A “golden crust” is characteristic of a staphylococcus skin infection. It is also less commonly caused by the streptococcus pyogenes bacteria. It occurs when bacteria enter through a break through the skin and is highly contagious. It can be classified as non-bullous or bullous

Answer 26

Occurs around the nose or mouth Exudate from the lesions dries to form a golden crust Pt not unwell Common in children

Answer 27

- Topical fusidic acid, antiseptic cream (hydrogen peroxide 1%) - Oral flucloxacillin in more wide spread or severe impetigo

Answer 28

Advise not to touch or scratch lesions Hand hygine Avoid shairing face towels and cutlery Stay off school until lesions have healed (crusted over) - usually 7 to 10 days - or treated with antibiotics for at least 48hrs If bullous patients should be isolated

Answer 29

Staphylococcus aureus only. These bacteria can produce epidermolytic toxins that break down proteins that hold skin cells together, causing 1-2cm fluid filled vesicles to form on the skin.

Answer 30

Painful ithcy lesions: 1-2cm fluid filled vesicles form, growing in size and then bursting forming a ''golden crust'' More common in under 2s Systemic symptoms may occur: fever, lethargy

Answer 31

Flucloxacillin - oral or IV if very unwell or at risk of complications

Answer 32

Complication of bullous impetigo - severe infection with widespread lesions

Answer 33

Swabs of the besides can confirm diagnosis bacteria and antibiotic sensitivities

Answer 34

Cellulitis if the infection gets deeper in the skin Sepsis Scarring Post streptococcal glomerulonephritis Staphylococcus scalded skin syndrome Scarlet fever

Answer 35

Inflammation of a hair follicle resulting in papules or pustules (pimples). Most commonly caused by a staphylococcus aureus infection (gram negative folliculitis can occur after prolonged antibiotic treatment for acne)

Answer 36

Eosinophilic folliculitis is a sterile folliculitis that is caused by immunosuppression, most commonly due to HIV. Diagnosis is by skin biopsy, which reveals eosinophils in the skin surface. Treatment is with HAART and topical corticosteroids.

Answer 37

Bacterial soft tissue infection of the dermis and deep subcutaneous tissue

Answer 38

Advancing age Immunocompromised e.g. diabetic Predisposing skin condition e.g. ulcers, pressure sores, trauma, lymphoedema

Answer 39

Generally caused by Streptococcus and/or Staphylococcus organisms.

Answer 40

Erythema Calor (heat) Swelling Pain Poorly demarcated margins Systemic upset: fever, malaise Lymphadenopathy Often evidence of breach in skin barrier e.g. trauma, ulcer, etc

Answer 41

Blood tests including culture Skin swab for culture Oral or IV antibiotics depending on severity - flucloxacillin first line Mark the area of erythema to aid in detection of rapidly spreading cellulitis Elevate if possible Wound debridement may be necessary Sterile dressing, analgesia

Answer 42

Folliculitis

Answer 43

Cellulitis

Answer 44

Chicken pox

Answer 45

Viral wart

Answer 46

Molluscum contagiosum

Answer 47

dermatophytosis (ring worm)

Answer 48

candidiasis Candidal intertrigo

Answer 49

HSV-1 - most common cause of oral herpes (and genital) HSV-2 causes genital herpes, more likely to cause recurrent anogenital symtpoms

Answer 50

May be entirely asymptomatic Multiple painful genital ulcers Dysuria Vaginal or urethral discharge Lesions typically crust and heal, at which point virus ceases to be shed from the lesions. In some cases may have symptoms of fever, malaise, headache and urinary retention. Recurrent episodes are usually less severe than a primary episode. There may not be a clearly identifiable trigger. The recurrent episode may have a prodromal phase, such as tingling.

Answer 51

The most effective method of diagnosis is to obtain a swab from the base of the ulcer and analyse using nucleic acid amplification tests (NAATs).

Answer 52

HSV is transmitted from skin-to-skin. The virus can be shed in the prodromal phase and during phases of recurrence or when displaying clinical symptoms for the first time. Virus can also be shed when the patient is asymptomatic The current guidance advises patients to abstain from sex during clinical recurrence or when they are experiencing prodromal symptoms. In the case of oral HSV kissing or any skin to skin contact with the lesion should be avoided until completely healed. There is a risk of transmission to the eye if contact lenses become contaminated

Answer 53

Oral antivirals are the primary treatment for genital herpes simplex infection — treatment should commence within 5 days of the start of the episode, or while new lesions are forming for people with a first clinical episode of genital herpes simplex virus (HSV). Aciclovir, Valaciclovir, Famciclovir

Answer 54

Usually self limiting Can reccomend soft diet if eating is painful NICE advises against prescribing topical anaesthetic or analgesic preparations, mouthwash or lip barrier preparations. Paracetamol, ibuprofen Choline salicylate gel for pain control of cold sores can be bought over the counter (this is contra-indicated under the age of 16 due to Reye's syndrome). Topical antiviral agents are minimally benificial but can be used if initiated at the onset of symptoms before vesicles appear purchased OTC Aciclovir 5% (age range is not specified by the manufacturer),

Answer 55

For immunocompetent individuals, oral antivirals are not routinely indicated for the treatment of cold sores but may be indicated in severe episodes. If possible this should be done from the time of the prodrome - ie before vesicles appear. Seek specialist advice for people who are immunocompromised (including people with HIV), antivirals may be warrented or even admission. Aciclovir is active against herpes viruses but does not eradicate them. It can be used as systemic and topical treatment of herpes simplex infections of the mucous membranes and is used orally for severe herpetic stomatitis. Valaciclovir is an ester of aciclovir. It is licensed for herpes simplex infections of the skin and mucous membranes.

Answer 56

Dehydration, especially in children. Recurrent lesions at the same site may occasionally cause atrophy and scarring. Secondary bacterial infection, including impetigo, can occur. Eczema herpeticum can complicate atopic eczema. Bell's palsy is possibly a complication of herpes simplex infection. Rare complications include dissemination, herpes encephalitis, meningitis, corneal dendritic ulcers (ocular herpes simplex) and erythema multiforme.

Answer 57

Eczema herpeticum is a rare and serious skin infection caused by one of the herpes viruses. It causes a blistery, painful skin rash. It most often affects children who have eczema Herpes simplex virus 1 (HSV-1) is the most common causative organism The eczema causes breaks in the skin which allows the virus in Considered an emergency as it can spread quickly Often mistaken for chickenpox, however differes as spots are smaller and closer together A typical presentation is a patient who suffers with eczema that has developed a widespread, painful, vesicular rash with systemic symptoms such as fever, lethargy, irritability and reduced oral intake. There will usually be lymphadenopathy (swollen lymph nodes).

Answer 58

Antiviral medicine such as aciclovir is usually very successful for treating eczema herpeticum. It may be given as a liquid or a tablet (mild to moderate). For people who are too unwell to take it as a liquid or a tablet, it can be given by a drip intravenously (severe) Viral swab of vesicles to confirm diagnosis STEROID CREAM WILL WORSEN

Answer 59

Pt generally unwell with fever Usually children w history of atopic eczema Fluid filled vesicles - usually on face or neck Spreads Vesicles may weep or become crusted over Lymphandopathy may be present

Answer 60

Chickenpox is caused by the varicella zoster virus (VZV). It causes a highly contagious, generalised vesicular rash. It is common in children. Once a child has had an episode of chickenpox, they develop immunity to the VZV virus and will not be affected again.

Answer 61

When the lesions scab over

Answer 62

A couple of days before rash appears

Answer 63

Widespread, erythematous, raised, vesicular blistering lesions Rash usually starts on trunk or face and spreads outwards affecting the whole body over 2-5 days Fever is often the first symptom Itch General fatigue and malaise

Answer 64

10 days to 3 weeks

Answer 65

Chickenpox is highly contagious and spread through direct contact with the lesions or through infected droplets from a cough or sneeze.

Answer 66

Bacterial superinfection Dehydration Conjunctival lesions Pneumonia Encephalitis (presenting as ataxia) After the infection the virus can lie dormant in the sensory dorsal root ganglion cells and cranial nerves reactivate later in life as shingles or Ramsay Hunt syndrome.

Answer 67

If they are not immune, varicella zoster immunoglobulins can be given to protect them against the virus after exposure. Before 28 weeks: potential for congenital varicella syndrome - developmental problem in fetus Around time of delivery: can lead to life threatening neonatal infection, requires treatment with varicella zoster immunoglobulins and aciclovir

Answer 68

Chickenpox is usually a mild self limiting condition that does not require treatment in otherwise healthy children. Aciclovir may be considered in immunocompromised patients, adults and adolescents over 14 years presenting within 24 hours, neonates or those at risk of complications. Complications such as encephalitis require admission for inpatient management. Symptoms of itching can be treated with calamine lotion and chlorphenamine (antihistamine). Patients should be kept off school and avoid pregnant women and immunocompromised patients until all the lesions are dry and crusted over. This is usually around 5 days after the rash appears.

Answer 69

Shingles is a reactivation of the varicella zoster virus which can lie dormant in nerve ganglia following primary infection (chickenpox). It commonly occurs in the elderly and shingles in young adults should prompt investigation for an underlying immune condition.

Answer 70

Tingling feeling in a dermatomal distribution Progression to erythematous papules occuring along one or more dermatones within a few days, which develop into fluid dilled vesicles which then crus over and heal Fever Headache Malise

Answer 71

Secondary bacterial infection of skin lesions Corneal ulcers, scarring and blindness if eye involved Post-herpetic neuralgia - Pain occurring at site of healed shingles infection - Can cause neuropathic type pain (burning, pins and needles) - Can cause allodynia (perception of pain from a normally non-painful stimulus e.g. light touch)

Answer 72

Oral antiviral (e.g. valaciclovir 1g three times per day for 7 days) if eye involvement or if immunocompromised. IV antiviral if severe disease Advise avoiding contact with pregnant women, babies and those who are immunocompromised until the lesions are fully crusted over, as transmission can occur via skin contact

Answer 73

Patients in their 70s

Answer 74

human papillomavirus (HPV)

Answer 75

Cutaneous (verruca, papiloma) Mucosal

Answer 76

School aged children Patients with dermatitis (defective skin barrier) Immunosupressed patients: azathioprine, ciclosporine, HIV

Answer 77

Skin to skin contact or autoinoculation (picking or scratchin a ward may cause a subungal wart (under nail) or a wart being spread to another area of skin. Autoinoculation of the virus in a scratch can result in a line of warts (pseudo-koebnerisation)

Answer 78

Up to 12 months depending on amount of virus inoculated

Answer 79

Cutaneous viral warts have a hard, keratinous surface. Tiny red or black dots visible in the wart are papillary capillaries.

Answer 80

Common warts (verruca vulgaris) present as cauliflower-like papules with a rough, papillomatous and hyperkeratotic surface ranging in size from 1 mm to 1 cm or more. They may be solitary or multiple. Common warts are found most often on the knees, backs of fingers or toes, and around the nails (periungual).

Answer 81

Plantar warts (verruca plantaris) include tender inwardly growing myrmecia on the sole caused by HPV 1, and clusters of superficial less painful mosaic warts due to HPV 2. Myrmecial warts are typically tender with lateral and direct pressure, are surrounded by yellow hyperkeratotic callus-like skin showing accentuated skin markings, but with discontinuation of the skin lines through the actual wart.

Answer 82

Plane warts are typically multiple small flat-topped skin-coloured papules located most commonly on the face, hands, and shins. On the shins and beard-area of the face the virus is often spread by shaving resulting in numerous warts. Plane warts are mostly caused by HPV types 3 and 10.

Answer 83

A filiform wart is a cluster of fine fronds emerging from a narrow pedicle base usually found on the face. They are also described as digitate (finger-like).

Answer 84

Viral warts are infectious to the patient and others Cutaneous warts can have significant psychosocial effects such as teasing at school, embarrassment, permission refused for swimming lessons. Periungual warts can cause nail dystrophy and destruction. Pain due to plantar warts (myrmecia type) interferes with walking and sporting activities, causing knee or hip pain. In epidermodysplasia verruciformis (rare autosomal recessive condition suscepitable to skin infection) the specific HPV types involved can cause cutaneous squamous cell carcinomas.

Answer 85

Pinpoint red or black dots (papillary capillaries) are revealed when the wart is pared down. Patent capillaries cause pinpoint bleeding. Plantar corns lack the papillary capillaries. Location of a plantar wart is not restricted to pressure sites whereas a plantar callus or corn is always at a pressure site. Tenderness is maximal with lateral pressure for a plantar wart whereas a corn or callus is more tender with direct pressure.

Answer 86

Seborrhoeic keratosis Squamous cell carcinoma Plantar corn and callus.

Answer 87

Work by removing virus containing skin - HPV infects the basal cell layer of the epidermis so wards can recur rapidly if the virus has not been eradicated Topical: salicylic acid or podophyllin containing treaments (remove surface skin cells). Most resolve within 12 weeks of daily applications. Cryotherapy with liquid nitrogen at one to two week intervals to cause peeling of surface layers for 3-4 months Electosurgery for large resistant warts

Answer 88

Endophthalmitis is the most dangerous complication and the first thing any doctor should rule out when presented with a patient complaining of visual symptoms following intraocular surgery. Patients typically present within days of surgery with severe pain, loss of vision and hyperaemia. They should be admitted and seen immediately by an ophthalmologist. Posterior lens capsule pacification is a relatively common complication of cataract surgery that usually occurs a few weeks following the operation. The typical patient complains of blurry vision as if their cataract has returned, and a white opacity may be visible on observation. The condition can be treated easily with a simple laser procedure which can be carried out as an outpatient. Other rare complications to be aware of are: • Retinal detachment Macular oedema Glaucoma • Corneal oedema

Answer 89

Eczema herpeticum

Answer 90

UV B: sunburn, DIRECT DNA DAMAGE AND CARCINOGENESIS UV A: Photo ageing! Potentiates UV-B carcinogenesis, Immunological effects

Answer 91

A melanocytic naevi is a benign skin lesion due to a local proliferation of pigment cells (melanocytes), occuring in childhood. Evolves in three steps: Junctional: flat + pigmented (due to melanocytes at the basal layer of the epidermis) - small, flat, and black Compound: raised + pigmented, hyperkerratotic, and/or hairy (due to melanocytes at the basal layer of the epidermis + deep in the dermis) Intradermal: raised + pale - usually dome-shaped papules or nodules (due to melanocytes deep in the dermis) Typical mole appearance

Answer 92

Moles present from birth, tend to be large, pigmented and hairy monitor but not of much concern

Answer 93

An atypical naevus that may resemble a melanoma, by having 'ABCDE' features. (ie. Asymmetry, colour changes) Asymettrical shape Border irregularity Colour irregularity Diameter over 7mm Evolution of lesion Symptoms (bleeding, itching) They may be part of a syndrome called Familial Atypical Multiple Mole-Melanoma (FAMMM) syndrome, where there are multiple naevi (>50) many of which are atypical and an increased risk of melanoma.

Answer 94

• A is for asymmetrical shape. Look for moles with irregular shapes, such as two very different-looking halves. • B is for irregular border. Look for moles with irregular, notched or scalloped borders — the characteristics of melanomas. • C is for changes in colour. Look for growths that have many colours or an uneven distribution of colour. • D is for diameter. Look for new growth in a mole larger than about 6mm. • E is for evolution. Look for change in the mole, includes changes in shape, size and elevation.

Answer 95

Black: stratum corneum Brown: loss of pigment may mean regression, immune system attacking lesion Grey: papillary dermis Blue: pigment invading into the deep melanin - concern

Answer 96

Multi component haemangioma Intracorneal haemorrhage Subungual haematoma Benign longitudinal melanonhchia Pigmented sebkeratosis

Answer 97

Multi component haemangioma

Answer 98

Intracorneal haemorrhage

Answer 99

Actinic keratosis partial dysplasia, Bowens complete Actinic keratosis has much lower mallignant potential

Answer 100

Seborrheic keratosis are typically dull and darkly pigmented, round or oval in shape, and often appear like a scab of a healing wound. They can be flat or slightly raised. Typically reported as a new skin lesion

Answer 101

Eczema Psoriasis Acne Actinic keratosis Melanoma SCC BCC Lichen planus Sebhorric warts Urticaria

Answer 102

Start topical abx: treclin gel, epidura Topical treatments: benzy peroxide acid Oral abx: doxycyline - 3 months

Answer 103

Note requires baseline bloods Dry skin and lips Dry mucous membranes Photosensitivity of the skin to sunlight Depression, anxiety, aggression and suicidal ideation. Patients should be screened for mental health issues prior to starting treatment. Rarely Stevens-Johnson syndrome and toxic epidermal necrolysis Teratogenic Fragile skin (avoid waxing) Slower wound healing Headaches Joint pains Hyperlipidemia

Answer 104

failure of 3 month course of oral abx

Answer 105

Eczema herpeticum (rare but serious medical emergency, treated with acyclovir) Secondary bacterial infection (impetigous eczema)

Answer 106

Moderate to strong for 5 days Weaker for 1-2 weeks following

Answer 107

Metabolic syndrome Nail psoriasis describes the nail changes that can occur in patients with psoriasis. These include nail pitting ( punctate depressions of the nail plate), Onychomycosis (thickening), discolouration, ridging and onycholysis (separation of the nail from the nail bed). Psoriatic arthritis (occurs in 10 – 20% of patients with psoriasis and usually occurs within 10 years of developing the skin changes. It typically affects people in middle age but can occur at any age) Psychosocial implications of having chronic skin lesions, which may affect mood, self esteem and social acceptance and cause depression and anxiety. Other co-morbidities that increase the risk of cardiovascular disease are associated with psoriasis, particularly obesity, hyperlipidaemia, hypertension and type 2 diabetes.

Answer 108

Basal cell carcinoma is the most common form of skin cancer, slow growing, locally invasive mallignant tumour of the EPIDERMAL KERATINOCYTES Typically presenting as a slow-growing tumour, most commonly of the head or neck. Nodular BCC is the most common subtype, presenting as a shiny nodule with associated telangiectasia, central ulceration and ‘pearly, rolled edges’. Tend to occur in older individuals They are associated with a history of sun exposure

Answer 109

Pyoderma gangrenosum is a neutrophil dermatosis characterised by the formation of enlarging ulcers, usually on the lower limbs, with a characteristic yellow purulent surface and black/ blue outer edge. This condition is commonly associated with several systemic diseases (e.g. inflammatory bowel disease); however, it can also be drug-induced (cocaine)

Answer 110

Sunburn like

Answer 111

Impetigo is a contagious bacterial infection that is most commonly seen in the paediatric population. The infection is classically caused by group A Streptococcus and Staphylococcus aureus. Children living in warm, humid climates are most commonly affected. Skin lesions typically begin as papules and vesicles which eventually break down to give a characteristic golden or honey-coloured crusted appearance. Lesions typically occur on the face and limbs and systemic manifestations are minimal. Topical treatment can be used for localized disease, however, an oral antibiotic like flucloxacillin should be prescribed for severe infections.

Answer 112

The gold standard management for this condition is topical steroids. A very potent topical steroid is often prescribed as first-line therapy (e.g. clobetasol propionate). In conjunction with this treatment, other conservative measures are often used, including washing the affected area a couple of times per day with water, avoiding restrictive clothing, prompt management of incontinence if present and the application of emollients to alleviate the itch.

Answer 113

Easily-burst faccid bullous lesions appear first in the mouth before later appearing on the skin, forming eroisions and crusts. Lesions are often painful. Usualy affecting mucosal areas. It is an autoimmune disease with a peak incidence in the 6th decade that is more prevalent in Ashkenazi Jews. Be aware that it is a medical emergency that is treated with steroids and supportive measures. positive Nikolsky sign

Answer 114

If the test result is positive, the very thin top layer of skin will shear off, leaving skin pink and moist, and usually very tender. A positive result is usually a sign of a blistering skin condition. People with a positive sign have loose skin that slips free from the underlying layers when rubbed.

Answer 115

infantile haemangioma or ‘strawberry haemangioma’. Strawberry naevi may be present at birth or develop in the first few weeks after birth, they are the most common tumours of infancy. They typically begin as small flat red areas and then develop into raised dimpled lesions. The lesions continue to grow until the child reaches 3-4 years, at which point they begin to regress spontaneously.

Answer 116

This is a condition that typically affects fair-skinned people and is characterised by erythema, telangiectasia, papules and pustules on the forehead, nose, cheeks and often chin. It typically begins with flushing and is often worse after alcohol ingestion, as in this case. The first-line treatment for acne rosacea is topical metronidazole. Topical azelaic acid can be used if topical metronidazole is not tolerated or fails to improve the condition. Oral abx (tertracyclines) may be used, topical brimonidine for temporary vasoconstirction may be used, for rhinophyma - surgery or laser ablation. Advise patients to avoid triggers (spicy food, heat, sunlight, wind, alcohol, hot foods and liquid), wear sun protection and to use bland emollients to mositurise to wash with

Answer 117

Increases skin turnover

Answer 118

Topical Azeliac acid or topical antibiotic such as metronidazole

Answer 119

Nodular BCC Nodular lesion, erythematous with pearly white rolled out lesion, ulcerated center Spreads into the dermis usually extends over 1mm into the skin may be well defined, may be symmetrical Duration - long history, 1-2mm per year, slow growing

Answer 120

Superficial-type BCC Appears as a patch May have crusting Erythematous Serpentine vessels Superficial BCCs often appear as pink or red dry, scaly spots. They slowly enlarge and may develop a raised edge. Often, people mistake a superficial BCC as a dry patch of skin or a non-itching rash that won't go away. This subtype of BCC is most often found on the trunk (chest or upper back), arms, or legs.

Answer 121

Infiltrative basal cell carcinoma The cancer grows with a “root system” which is embedded into the dermis of the skin. Because of this root system, infiltrative basal cell carcinomas require certain procedures, including excision or Mohs surgery, to make sure that all of the roots are removed completely This specific type presents differently than other basal cell skin cancers, in that it forms in thin, small clusters, making it more difficult to spot. Isolated lesion, no history of trauma to explain a scar Infiltrating or morpheaform BCCs tend to appear as scar-like growths on the skin. They can be slightly shiny, and sometimes have telangiectasias, sores (erosions), or scabs on their surfaces. These skin changes can be subtle.

Answer 122

Chemotherapy creams: Fluorouracil (efudix 5% BD for 4 week), Imiquimod cream (Aldara 5% used 5 days of a week OD for 6 weeks) Cyrotherapy Radiotherapy (curative, palliative, adjunct to surgery) Phototherapy Only curative for superficial BCC, but may be used if patient declines or is unsuitable for surgery Small low risk lesions

Answer 123

Superficial BCC Bowens disease Actinic keratosis

Answer 124

Bowens disease

Answer 125

Actinic keratosis

Answer 126

Superficial BCC

Answer 127

Nodular BCC

Answer 128

Infiltrive BCC

Answer 129

Surgical exision Curettage and cautery 'Mohs' micrographic surgery (excision og the lesion and tissue borders are progressively excised until specimens are microscopically free of tumour) - for recurrent, high risk tumours Direct closure if small (under 1cm) Elliptical excision/excision with flap formation/excision with graft from clavicle Margin of safety 4mm

Answer 130

Appears in weeks to months (no longer than 6, usually up to 3-4)

Answer 131

Surgical excision, if not suitable can consider potential palliative or curative radiotherapy Chemotherapy for large metastic disease

Answer 132

1. BCC 2. SCC 3. Malignant melenoma

Answer 133

1. Malignant melanoma 2. SCC 3. BCC

Answer 134

Squamous Cell Carcinoma A Cutaneous Squamous Cell Carcinoma (SCC) is a locally invasive malignant tumour of epidermal keratinocytes or its appendages. SCCs can cause pain, tenderness or bleeding and grow over weeks or months. SCCs sometimes metastasise, which can be fatal.

Answer 135

Superficial spreading melenoma Nodular melenoma Lentigo maligna melanoma Acral lentiginous melanoma.

Answer 136

Symeterical and minimal colour variation most key Asymptomatic (no itching or bleeding) Regular boarder Depth of infiltration Diameter does not indicate prognosis

Answer 137

De novo melenoma - New mole in older patient - pleomorphic cells Melanomas arising from common and congenital nevi - less common, congenital mole changes - composed of roundish, monomorphous cells

Answer 138

Excisional margin with 2mm (more can interfere with sentinel lymph node - false abnormalities) Radiosensitive dye injected by the scar (entinel lymph node biopsy (SLNB)) Wide local exision potentially later surgery

Answer 139

Epidermis, dermis, hypodermis (fat) Particularly important for SCC and melanoma

Answer 140

Excision with 2mm margin and sentiel node biopsy Second procedure after histology diagnosis if required 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.

Answer 141

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.

Answer 142

Subtype of melenoma Most common Best prognosis Typically begins as a dark spot that is asymettric, has irregular boarders, or changes colour Spread horizontally Doesn't tend to infiltrate deeply Common on lower limbs Young and middle aged adults Related to intermittent high intensity UV exposure It is most likely to develop on the trunk in males, on the legs in females, and on the upper back in both sexes.

Answer 143

Subtype of melenoma, starting as a raised spot - dark or light - and grows vertically Most aggressive form Usually invasive at time of diagnosis Common on the trunk Young and middle aged adults related to intermittent high-intensity UV exposure The bump is usually black, but it may be: blue gray white brown tan red the same color as the surrounding skin

Answer 144

Subtype of melenoma Appears as irregular growth or patch on palms of hands or sole of feet (pain when walking) or under nails Changes colour and size Only melenoma that doesn't have a link to UV raditation Occurs in the elderly population An early sign might be an oddly shaped black, gray, tan, or brown mark with irregular borders. When ALM begins in the nails, it may appear as a streak under the nail. Most cases of ALM on the nails occur on the big toe or thumb. The surface may be flat, but there may be deep inward growth. Some tumors involve a loss of color or no change in color. ALM tumors often take on an irregular shape or color or a rough texture as they grow. ALM may resemble a plantar wart or a fungal infection.

Answer 145

Lentigo maligna is an early form of melanoma in which the malignant cells are confined to the tissue of origin, the epidermis, hence it is often reported as ‘in situ’ melanoma. It occurs in sun damaged skin so is generally found on the face or neck, particularly the nose and cheek. It grows slowly in diameter over 5 to 20 years or longer. Starts as an irregular shaped tan or brown spot growing slowly over years Lentigo maligna melanoma is diagnosed when the melanoma cells have invaded into the dermis and deeper layers of skin. Lentigo maligna has a lower rate of transformation to invasive melanoma than the other forms of melanoma in situ (under 5% overall). However, the risk of invasive melanoma is greater in larger lesions, with up to 50% of those with diameter of greater than 4 cm being reported to have an invasive focus. Common on the face in elderly population, related to long term cumulative UV exposure May become raised or change colours, can be multipigmented

Answer 146

lentigo maligna/lento maligna melenoma

Answer 147

Acral lentiginous melanoma

Answer 148

Superficial spreading melenoma

Answer 149

Nodular melenoma

Answer 150

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.

Answer 151

Type I or II skin (fair skin which always burns and never or rarely tans) History of frequent or severe previous sun burn Outdoor occupation or hobbies Personal or family history of skin cancer Immunosuppression Increasing age Male sex

Answer 152

Management of a BCC depends on its size, location, type and local guidelines - but the majority are managed surgically. Treatment options include; Surgical excision with a 4mm margin Curettage and cautery Mohs micrographic surgery if the BCC is in a cosmetically sensitive area or appears ill-defined. This involves examining the excised tissue under the microscope as it is removed to ensure all the cancerous cells are removed whilst preserving the maximum amount of healthy tissue. Cryotherapy Photodynamic therapy Radiotherapy is used as an adjunct or if surgery is inappropriate Topical therapies such as Imiquimod or 5-Fluorouracil

Answer 153

Mohs micrographic surgery if the BCC is in a cosmetically sensitive area or appears ill-defined. This involves examining the excised tissue under the microscope as it is removed to ensure all the cancerous cells are removed whilst preserving the maximum amount of healthy tissue.

Answer 154

Nodular Superficial spreading Infiltrative Pigmented Cystic Keratotic

Answer 155

SCCs typically appear as an irregular, ill-defined red keratotic (scaley and crusty) nodule which may ulcerate. They often occur on sun exposed areas of skin such as the face, scalp, ears, hands and shins.

Answer 156

SCCs are caused by DNA mutations following exposure to ultraviolet (UV) light, certain human wart viruses or other forms of skin damage such as burns. Genetic factors can predispose to these mutations. Risk factors Risk factors for the development of SCCs; Type I or II skin (fair skin which always burns and never or rarely tans) History of frequent or severe previous sun burn Outdoor occupation or hobbies Personal or family history of skin cancer Immunosuppression, especially following an organ transplant Smoking Premalignant skin conditions such as Actinic Keratosis or Bowen's Disease. (Bowen's Disease is also known as Intraepidermal SCC or SCC in Situ. It is pre-malignant as tumour cells are confined to the epidermis.) Increasing age Male sex

Answer 157

A Pyogenic Granuloma is a reactive overgrowth of capillary blood vessels. It is a benign lesion, but can cause discomfort and frequent, easy bleeding. Pyogenic Granulomas are relatively common, occurring mostly in children and young adults and in females more often than males. Pyogenic Granulomas appear as a single, shiny, red nodule of up to 1cm, often described as ""raspberry-like". This nodule will have grown rapidly from a painless, small, discoloured spot. Pyogenic Granulomas are most commonly located on the fingers and hands.

Answer 158

Pyogenic Granulomas appear as a single, shiny, red nodule of up to 1cm, often described as ""raspberry-like". This nodule will have grown rapidly from a painless, small, discoloured spot. Pyogenic Granulomas are most commonly located on the fingers and hands.

Answer 159

Minor trauma, such as a pin prick Infection, commonly Staphylococcus aureus Pregnancy Some medications, such as oral Retinoids

Answer 160

The diagnosis of a Pyogenic Granuloma is clinical, but can be confirmed by biopsy and histological examination. This is required to rule out the more sinister differential diagnosis of an Amelanotic Melanoma. Pyogenic Granulomas can be managed by; Surgical excision Laser surgery Curettage and cautery Cryotherapy

Answer 161

A naevus that is blue in colour because the melanocytes are very deep in the skin.

Answer 162

A becker naevus is an irregular, hyperpigmented patch usually affecting the shoulders of males. During puberty it darkens and becomes hairy.

Answer 163

A halo naevus is melanocytic naevus that is surrounded by a white halo.

Answer 164

A red, dome-shaped papule that is commonly found on the face of children.

Answer 165

Spitz naevus

Answer 166

Halo Nevus

Answer 167

Beckers Naevus

Answer 168

Congenital Melanocytic Naevus

Answer 169

First line treatment is by applying baby oil, vegetable oil or olive oil, gently brushing the scalp then washing off. When this is not effective, white petroleum jelly can be used overnight to soften the crusted areas before washing off in the morning. The next step is a topical anti-fungal cream such as clotrimazole or miconazole, used for up to 4 weeks. Severe or unresponsive cases may need referral to a dermatologist.

Answer 170

Seborrhoeic dermatitis is an inflammatory skin condition that affects the sebaceous glands. The sebaceous glands are the oil producing glands in the skin. It affects areas that have a lot of these glands, such as the scalp, nasolabial folds and eyebrows. It causes erythema, dermatitis and crusted dry skin. In infants it causes a crusted dry flaky scalp, often called cradle cap. It is thought that Malassezia yeast colonisation has a role to play in the development of seborrhoeic dermatitis, and the condition improves with anti-fungal treatment. This condition most commonly affects babies under 3 months of age, young adults, the elderly and those with a combination of oily and dry skin. It is exacerbated by cold weather and partially relieved by sun exposure. It presents with diffuse scalp scale, blepharitis and scaly skin located in the facial folds (i.e. on either side of the mouth).

Answer 171

Erythema multiforme is an uncommon skin rash that is thought to be a hypersensitivity reaction to some medications and infections. It characteristically causes ‘target lesions’ which consist of a central dusky or dark red area with peripheral pink ring and are demonstrated in the image shown. In practice, lesions can have a variable appearance and only a few ‘targets’ may be seen. It is often asymptomatic but can be pruritic. The most common cause is herpes simplex virus but multiple other infections such as typhoid, mycoplasma pneumonia and tuberculosis can trigger it. There are numerous other causes such as medications and inflammatory disorders. It is usually an asymptomatic and self-limiting condition and so treatment is often not needed, although investigations should be considered to investigate an underlying cause. Mucosal involvement is either absent or limited to only one mucosal surface

Answer 172

20-30 mins as to avoid diluting the steroid and affecting its efficacy

Answer 173

Contact dermatitis is an inflammatory skin condition induced by exposure to an external irritant or allergen. It is a type IV hypersensitivity reaction. The appearance of contact dermatitis is highly variable. It may affect any area of the body and may be any shape. It is often an erythematous and pruritic rash. Lighter skin can become red, and darker skin can become dark brown, purple or grey. Diagnosis is made clinically or with patch tests in some cases. Type IV hypersensitivity is also known as delayed hypersensitivity, as the reaction typically occurs 24 to 72 hours after antigen exposure. Unlike types I to III, it is not antibody-mediated but T-cell-mediated. It is involved in the processes of contact dermatitis.

Answer 174

When strawberry naevi affect the visual axis, they will likely require a referral to paediatrics for further management. Otherwise no management needed, should stop growing and begin to regress by ages 3-4

Answer 175

Molluscum contagiosum

Answer 176

The papules resolve by themselves without any treatment, however this can take up to 18 months. Once they resolve the skin returns to normal. Scratching or picking the lesions should be avoided as it can lead to spreading, scarring and infection.

Answer 177

Rarely, if bacterial superinfection infection occurs in the lesions as a result of scratching, this may require treatment with antibiotics. Options include topical fuscidic acid or oral flucloxacillin. Immunocompromised patients and those with very extensive lesions or lesions in problematic areas such as the eyelid or anogenital area may require referral to a specialist. Specialist treatment options include: Topical potassium hydroxide, benzoyl peroxide, podophyllotoxin, imiquimod or tretinoin Surgical removal and cryotherapy (freezing with liquid nitrogen) is an option but can lead to scarring

Answer 178

It is spread through direct contact or by sharing items like towels or bedsheets.

Answer 179

Molluscum contagiosum is a viral skin infection caused by the molluscum contagiosum virus, which is a type of poxvirus.

Answer 180

Ringworm is a fungal infection of the skin. It is also known as tinea and dermatophytosis. Fungal infections have specific names depending on the area they affect: Tinea capitis refers to ringworm affecting the scalp (caput meaning head) Tinea pedis refers to ringworm affecting the feet, also known as athletes foot (pedis meaning foot) Tinea cruris refers to ringworm of the groin (cruris meaning leg) Tinea corporis refers to ringworm on the body (corporis meaning body) Onychomycosis refers to a fungal nail infection

Answer 181

The most common type of fungus that causes ringworm is called trichophyton

Answer 182

Ringworm presents as an itchy rash that is erythematous, scaly and well demarcated. There is often one or several rings or circular shaped areas that spread outwards, with a well demarcated edge. The edge is more prominent and red and the area in the centre is more faint in colour. Tinea capitis can present with well demarcated hair loss. There will also be itching, dryness and erythema of the scalp. This is more common in children than adults. Tinea pedis (athletes foot) presents with white or red, flaky, cracked, itchy patches between the toes. The skin may split and bleed. This is often the result of sharing changing rooms with someone that has athletes foot and is more likely to occur when feet are sweaty and damp for prolonged periods. Onychomycosis (fungal nail infections) presents with thickened, discoloured and deformed nails.

Answer 183

Anti-fungal creams such as clotrimazole and miconazole Anti-fungal shampoo such as ketoconazole for tinea capitis Oral anti-fungal medications such as fluconazole, griseofulvin and itraconazole Fungal nail infections can be treated with amorolfine nail lacquer for 6 – 12 months. Resistant cases may need oral terbinafine, however the patient will need their LFTs monitoring before and whilst taking this. A mild topical steroid can help settle the inflammation and itching. A common combination is miconazole 2% and hydrocortisone 1% cream (Daktacort). Advice: Wear loose breathable clothing Keep the affected area clean and dry Avoid sharing towels, clothes and bedding Use a separate towel for the feet with tinea pedis Avoid scratching and spreading to other areas Wear clean dry socks every day

Answer 184

Tinea incognito refers to a more extensive and less well recognised fungal skin infection that results from the use of steroids to treat an initial fungal infection. This often occurs when the initial presentation of ringworm was misdiagnosed as dermatitis and a topical steroid was prescribed. The steroid improves the itching and inflammation but accelerates the growth of the fungal infection by dampening the immune response in the local area. When the steroid is stopped the itchy rash caused by the fungus returns and is much worse than previously. It may be less recognisable as ringworm due to a less well-demarcated border and fewer scales, giving rise to the incognito name.

Answer 185

Oral candidiasis is also called oral thrush. It refers to an overgrowth of candida, a type of fungus, in the mouth. This results in white spots or patches that coat the surface of the tongue and palate. Several common factors can predispose someone to develop oral candidiasis: Inhaled corticosteroids (particularly with poor technique, not using a spacer and not rinsing with water afterwards) Antibiotics (disrupt the normal bacterial flora giving candida a chance to thrive) Diabetes Immunodeficiency (consider HIV) Smoking Treatment options are: Miconazole gel Nystatin suspension Fluconazole tablets (in severe or recurrent cases)

Answer 186

The most common is Candida albicans.

Answer 187

Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause) Poorly controlled diabetes Immunosuppression (e.g. using corticosteroids) Broad-spectrum antibiotics

Answer 188

The symptoms of vaginal candidiasis are: Thick, white discharge that does not typically smell Vulval and vaginal itching, irritation or discomfort More severe infection can lead to: Erythema Fissures Oedema Pain during sex (dyspareunia) Dysuria Excoriation

Answer 189

A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night A single dose of clotrimazole pessary (500mg) at night Three doses of clotrimazole pessaries (200mg) over three nights A single dose of fluconazole (150mg)

Answer 190

Warn women that antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.

Answer 191

Recurrent infections (more than 4 in a year) can be treated with an induction and maintenance regime over six months with oral or vaginal antifungal medications. This is an off-label use.

Answer 192

Often treatment for candidiasis is started empirically, based on the presentation. Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5). A charcoal swab with microscopy can confirm the diagnosis.

Answer 193

Candidal intertrigo refers to superficial skin-fold infection caused by the yeast, candida.

Answer 194

The hot and damp environment of skin folds, which is conducive to the growth of candida species, particularly Candida albicans[1] Increased skin friction [2] Immunocompromise [3].

Answer 195

Occlusive clothing, gloves and footwear Obesity Excessive sweating (hyperhidrosis) Incontinence causing irritant contact dermatitis (incontinence-associated dermatitis) Diabetes mellitus Immune deficiency conditions, such as human immunodeficiency virus infection (HIV) or immune suppression by medications (chemotherapy, systemic corticosteroids) [2-5].

Answer 196

Candidal intertrigo classically presents as erythematous and macerated plaques with peripheral scaling. There are often associated superficial satellite papules or pustules [2,5,6].

Answer 197

Predisposing factors should be addressed primarily, such as weight loss, blood glucose control, and avoidance of tight clothing Patients should be advised to maintain cool and moisture-free skin. This may be aided by regular use of a drying agent such as talcum powder, especially if infection is recurrent Topical antifungal agents such as CLOTRIMAZOLE cream are recommended as first-line pharmacological treatments Severe, generalised and/or refractory cases may require oral antifungal treatments such as fluconazole or itraconazole

Answer 198

It can take up to 8 weeks for any symptoms or rash to appear after the initial infestation.

Answer 199

Sarcoptes scabiei (tiny mites)

Answer 200

Treatment is with permethrin cream (Lyclear) or malathion (Prioderm). This needs to be applied to the whole body, completely covering skin. It is best to do this when the skin is cool (i.e. not after a bath or shower) so that a layer of cream remains on top of the skin and does not get absorbed. The cream should be left on for 8 – 12 hours and then washed off. This should be repeated a week later to kill all the eggs that survived the first treatment and have now hatched. Oral ivermectin as a single dose that can be repeated a week later is an option for difficult to treat or crusted scabies. Antihistamines may be used to relieve itch Scabies is contagious to all household and close contacts. When one person is diagnosed, all household and close contacts should also be treated in exactly the same way, even if asymptomatic. This is because they may be infected and not yet have symptoms. All clothes, bedclothes, towels and other materials in contact with scabies need to be washed on a hot wash to destroy the mites. Thorough hoovering of carpets and furniture is also essential. Itching can continue for up to 4 weeks after successful treatment. Crotamiton cream and chlorphenamine at night at night can help with the itching.

Answer 201

Crusted scabies is also known as Norwegian scabies. It is a serious infestation with scabies in patients that are immunocompromised. These patient may have over a million mites in their skin. They are extremely contagious. Rather than individual spots and burrows, they have patches of red skin that turn into scaly plaques. These can be misdiagnosed as psoriasis. Immunocompromised patients may not have an itch as they do not mount an immune response to the infestation. They may need admission for treatment as an inpatient with oral ivermectin and isolation.

Answer 202

Head lice are the Pediculus humanus capitis parasite, which causes infestations of the scalp, most commonly in school aged children. Head lice are commonly known as nits, however nits are egg shells that have hatched or contain unviable embryos and not the lice themselves. Head lice are spread by close contact with someone that has head lice, usually in schools or amongst family members. Transmission is by head to head contact or by sharing equipment like combs or towels. Presentation Infestation causes an itchy scalp. Often the nits (eggs) and even lice themselves are visible when examining the scalp.

Answer 203

Dimeticone 4% lotion can be applied to the hair and left to dry. This is left on for 8 hours (i.e. overnight), then washed off. This process is repeated 7 days later to kill any head lice that have hatched since treatment. Special fine combs can be used to systematically comb the nits and lice out of the hair. They can be used for detection combing to check the success of treatment. NICE clinical knowledge summaries recommend The Bug Buster kit.

Answer 204

Eczema is a chronic atopic condition caused by defects in the normal continuity of the skin barrier, leading to inflammation in the skin. The simplified pathophysiology is that eczema is caused by defects - loss of function of various varients of the protein filaggrin - in the barrier that the skin provides. Tiny gaps in the skin barrier provide an entrance for irritants, microbes and allergens that create an immune response, resulting in inflammation and the associated symptoms.

Answer 205

Eczema usually presents in infancy with dry, red, itchy and sore patches of skin over the flexor surfaces (the inside of elbows and knees) and on the face and neck. Patients with eczema experience periods where the condition is well controlled and periods where the eczema is more problematic, known as flares.

Answer 206

The key to maintenance is to create an artificial barrier over the skin to compensate for the defective skin barrier. This is done using emollients that are as thick and greasy as tolerated, used as often as possible, particularly after washing and before bed. Patients should avoid activities that break down the skin barrier, such as bathing in hot water, scratching or scrubbing their skin and using soaps and body washes that remove the natural oils in the skin. Emollients or specifically designed soap substitutes can be used instead of soap and body washes when showering or washing hands.

Answer 207

Some patients find certain environmental factors play a role in making their eczema symptoms worse or better. For example, it may completely resolve on holiday in warm, humid countries, only to flare on returning to the cold air in the UK. Environmental triggers, such as changes in temperature, certain dietary products, washing powders, cleaning products and emotional events or stresses can also play a role.

Answer 208

Flares can be treated with thicker emollients, topical steroids, “wet wraps” (covering affected areas in a thick emollient and applying a wrap to keep moisture locked in overnight) and treating any complications such as bacterial or viral infections. Very rarely IV antibiotics or oral steroids might be required in very severe flares. Other specialist treatments in severe eczema include zinc impregnated bandages, topical tacrolimus, phototherapy and systemic immunosuppressants, such as oral corticosteroids, methotrexate and azathioprine.

Answer 209

E45 Diprobase cream Oilatum cream Aveeno cream Cetraben cream Epaderm cream

Answer 210

50:50 ointment (50% liquid paraffin) Hydromol ointment Diprobase ointment Cetraben ointment Epaderm ointment

Answer 211

The steroid ladder from weakest to most potent: Mild: Hydrocortisone 0.5%, 1% and 2.5% Moderate: Eumovate (clobetasone butyrate 0.05%) Potent: Betnovate (betamethasone 0.1%) Very potent: Dermovate (clobetasol propionate 0.05%)

Answer 212

Opportunistic bacterial infection of the skin is common in eczema. The breakdown in the skin’s protective barrier allows an entry point for infective organisms. The most common organism is staphylococcus aureus. Treatment is with oral antibiotics, particularly flucloxacillin. More severe cases may require admission and intravenous antibiotics.

Answer 213

The rash is usually widespread and can affect any area of the body. It is erythematous, painful and sometimes itchy, with vesicles containing pus. The vesicles appear as lots of individual spots containing fluid. After they burst, they leave small punched-out ulcers with a red base.

Answer 214

Acne results from increased production of sebum, trapping of keratin (dead skin cells) and blockage of the pilosebaceous unit. This leads to swelling and inflammation in the pilosebaceous unit. Androgenic hormones increase the production of sebum, which is why acne is exacerbated by puberty and improves with anti-androgenic hormonal contraception. Swollen and inflamed units are called comedones. The Propionibacterium acnes bacteria is felt to play an important role in acne. This is a bacteria that colonises the skin. It is thought that excessive growth of this bacteria can exacerbate acne. Many of the treatments of acne aim to reduce these bacteria.

Answer 215

Macules are flat marks on the skin Papules are small lumps on the skin Pustules are small lumps containing yellow pus Comedomes are skin coloured papules representing blocked pilosebaceous units Blackheads are open comedones with black pigmentation in the centre Ice pick scars are small indentations in the skin that remain after acne lesions heal Hypertrophic scars are small lumps in the skin that remain after acne lesions heal Rolling scars are irregular wave-like irregularities of the skin that remain after acne lesions heal

Answer 216

No treatment may be acceptable if mild Topical benzoyl peroxide reduces inflammation, helps unblock the skin and is toxic to the P. acnes bacteria Topical retinoids (adapalene) and oral (chemicals related to vitamin A) slow the production of sebum (women of childbearing age need effective contraception) Combination gels: Epiduo gel (adapalene with benzoyl peroxide) Topical antibiotics such as clindamycin, erythromycin,(prescribed with benzoyl peroxide to reduce bacterial resistance) Spironolactone Oral antibiotics such as lymecycline, doxycycline - caution can induce sun sensitivity Oral contraceptive pill can help female patients stabilise their hormones and slow the production of sebum Oral retinoids for severe acne (i.e. isotretinoin) is an effective last-line option, although it is only prescribed by a specialist after other methods fail. This needs careful follow-up and monitoring and reliable contraception in females. Retinoids are highly teratogenic.

Answer 217

Co-cyprindiol (Dianette) is the most effective combined contraceptive pill for acne due to it’s anti-androgen effects. It has a higher risk of thromboembolism, so treatment is usually discontinued once acne is controlled and it is not prescribed long term.

Answer 218

Propionibacterium acnes

Answer 219

Reducing production of sebum, reducing inflammation and reducing bacterial growth

Answer 220

Psoriasis is a chronic autoimmune condition that causes recurrent symptoms of psoriatic skin lesions. There is a large variation in how severely patients are affected with psoriasis. There appears to be a genetic component but no clear genetic inheritance has been established. Around a third of patients have a first degree relative with psoriasis. The symptoms start in childhood in a third of patients.

Answer 221

Autoimmune process Patches of psoriasis are dry, flaky, scaly, faintly erythematous skin lesions that appear in raised and rough plaques, commonly over the extensor surfaces of the elbows and knees and on the scalp. These skin changes are caused by the rapid generation of new skin cells, resulting in an abnormal buildup and thickening of the skin in those areas.

Answer 222

Auspitz sign: small points of bleeding when plaques are scraped off Koebner phenomenon: refers to the development of psoriatic lesions to areas of skin affected by trauma Residual pigmentation of the skin after the lesions resolve

Answer 223

Auspitz sign refers to small points of bleeding when plaques are scraped off in psoriasis

Answer 224

Koebner phenomenon refers to the development of psoriatic lesions to areas of skin affected by trauma

Answer 225

Plaque psoriasis is the most common form of psoriasis in adults. Guttate psoriasis is the second most common form of psoriasis and commonly occurs in children. Guttate psoriasis is often triggered by a streptococcal throat infection, stress or medications. Pustular psoriasis is a rare severe form of psoriasis Erythrodermic psoriasis is a rare severe form of psoriasis Seborrhoeic (naso-labial and retro-auricular)

Answer 226

Plaque psoriasis features the thickened erythematous plaques with silver scales, commonly seen on the extensor surfaces and scalp. The plaques are 1cm – 10cm in diameter. This is the most common form of psoriasis in adults.

Answer 227

Plaque psoriasis

Answer 228

Guttate psoriasis

Answer 229

Guttate psoriasis is the second most common form of psoriasis and commonly occurs in children. It presents with many small raised papules across the trunk and limbs. The papules are mildly erythematous and can be slightly scaly. Over time the papules in guttate psoriasis can turn into plaques. Guttate psoriasis is often triggered by a streptococcal throat infection, stress or medications. It often resolves spontaneously within 3 – 4 months.

Answer 230

Guttate psoriasis is often triggered by a streptococcal throat infection, stress or medications. It often resolves spontaneously within 3 – 4 months.

Answer 231

Pustular psoriasis is a rare severe form of psoriasis where pustules form under areas of erythematous skin. The pus in these areas is not infectious. Patients can be systemically unwell. It should be treated as a medical emergency and patients with pustular psoriasis initially require admission to hospital.

Answer 232

Pustular psoriasis

Answer 233

Erythrodermic psoriasis is a rare severe form of psoriasis with extensive erythematous inflamed areas covering most of the surface area of the skin. The skin comes away in large patches (exfoliation) resulting in raw exposed areas. It should be treated as a medical emergency and patients require admission.

Answer 234

Erythrodermic psoriasis

Answer 235

Infections Low calcium Withdrawal of oral corticosteroids (prednisone) Withdrawal of excessive use of strong topical corticosteroids Strong coal tar preparations Certain medications including lithium, antimalarials and interleukin II Excessive alcohol consumption

Answer 236

Dehydration Heart failure Infection Hypothermia Protein loss and malnutrition Oedema (swelling), particularly of lower legs Death

Answer 237

Hospitalisation for supportive care including intravenous fluids and temperature regulation Bland emollients and cooling wet dressings Bed rest Treatment of complications (for example antibiotics, diuretics (water tablets), nutritional support) Low-dose methotrexate, ciclosporin or acitretin Individual cases have been reported to have successful outcomes with biologic agents,

Answer 238

Sudden withdrawal of injected or oral corticosteroids Drugs such as lithium, aspirin, indomethacin, iodide and some beta-blockers Infection Pregnancy.

Answer 239

Generalised pustular psoriasis is characterised by recurrent acute flares. Initially, the skin becomes dry, fiery red and tender. Within hours, 2–3 mm pustules appear. After a day, the small pustules coalesce to form lakes of pus These dry out and peel to leave a glazed, smooth surface on which new crops of pustules may appear. Successive crops of pustules may appear and erupt every few days or weeks.

Answer 240

Fever and chills (or hypothermia) A headache Rapid pulse rate Loss of appetite and nausea Thirst and dehydration Muscle weakness Leg swelling.

Answer 241

Secondary bacterial infection The blood count may show anaemia, neutrophilia, lymphopenia Raised inflammatory markers such as C-reactive protein (CRP) Disturbed protein and electrolyte balance, low albumin, low calcium and low zinc High-output cardiac failure Renal and liver impairment Protein-losing enteropathy Peripheral neuropathy Malabsorption of nutrients and therapeutic drugs.

Answer 242

Generalised pustular psoriasis can be life-threatening, so hospitalisation is usually required. The aim is to prevent further fluid loss, stabilise body temperature and restore electrolyte imbalance. Specialist care is essential. Affected areas are treated with bland topical compresses using emollients and low potency topical steroid creams. Systemic medications may include: Antibiotics for confirmed or suspected infection Acitretin Systemic corticosteroids (cautiously) Ciclosporin (cautiously) Methotrexate Colchicine Biologic agents including infliximab, etanercept, ustekinumab, adalimumab, and anakinra.

Answer 243

In children the distribution and presentation of psoriasis may differ from adults. Guttate psoriasis (Presenting with many small raised erythematous, slightly scaly papules across the trunk and limbs, which can turn into plaques over time, often resolves spontaneously within 3 – 4 months) is more common in children, often triggered by a throat infection. Plaques of psoriasis are likely to be smaller, softer and less prominent.

Answer 244

Management depends on the severity of the condition. Psoriasis in children is usually managed and followed up by a specialist. It can be difficult to treat and psychosocial support is very important. The treatment options include: Topical steroids Topical vitamin D analogues (calcipotriol) Tazarotene gel (vit A),Enstilar foam (calcipotriol & Betnovate combination ) Topical dithranol Topical calcineurin inhibitors (tacrolimus) (usually only used in adults) Phototherapy with narrow band ultraviolet B light is particularly useful in extensive guttate psoriasis (children) Where topical treatments fail with severe and difficult to control psoriasis, systemic treatment under the guidance of an experienced specialist. This might include methotrexate, cyclosporine, retinoids or biologic medications. Oral immunosuppressants –Methotrexate , ciclosporin ,mycophenolate Biologics injectable eg Humira (adalimumab) oral ( aprimilast ) Potent steroid+vitamin D analogues: Dovobet (gel) Enstilar (spray)

Answer 245

Nail pitting ( punctate depressions of the nail plate), Onychomycosis (thickening), discolouration, ridging and onycholysis (separation of the nail from the nail bed).

Answer 246

Onychomycosis (thickening)

Answer 247

onycholysis (separation of the nail from the nail bed)

Answer 248

Urticaria are also known as hives. Swelling involving the superficial dermis, riasing the epidermis, itchy wheals They are small itchy lumps that appear on the skin. They may be associated with a patchy erythematous rash. This can be localised to a specific area or widespread. They may be associated with angioedema and flushing of the skin. Urticaria can be classified as acute urticaria or chronic urticaria.

Answer 249

Urticaria are caused the release of histamine and other pro-inflammatory chemicals by mast cells in the skin. This may be part of an allergic reaction in acute urticaria or an autoimmune reaction in chronic idiopathic urticaria.

Answer 250

Acute urticaria is typically triggered by something that stimulates the mast cells to release histamine. This may be: Allergies to food, medications or animals Contact with chemicals, latex or stinging nettles Medications Viral infections Insect bites Dermatographism (rubbing of the skin)

Answer 251

Chronic idiopathic urticaria describes recurrent episodes of chronic urticaria without a clear underlying cause or trigger. Chronic inducible urticaria describes episodes of chronic urticaria that can be induced by certain triggers Autoimmune urticaria describes chronic urticaria associated with an underlying autoimmune condition, such as systemic lupus erythematosus.

Answer 252

Sunlight Temperature change Exercise Strong emotions Hot or cold weather Pressure (dermatographism)

Answer 253

Fexofenadine

Answer 254

Antihistamines (fexofenadine) Oral steroids can be trialled short term Speciallist refferal if severe to consider: Anti-leukotrienes such as montelukast Omalizumab, which targets IgE Cyclosporin

Answer 255

Staphylococcal scalded skin syndrome (SSSS) is a condition caused by a type of staphylococcus aureus bacteria that produces epidermolytic toxins. These toxins are protease enzymes that break down the proteins that hold skin cells together. When a skin infection occurs and these toxins are produced, the skin is damaged and breaks down

Answer 256

This condition usually affects children under 5 years. Older children and adults have usually developed immunity to the epidermolytic toxins.

Answer 257

A red rash with wrinkled tissue or paper-like consistency Typically starts on the face and flexural regions (groin, axillae, and neck), then spreads rapidly to other parts of the body including the arms, legs, and trunk. Following the rash, the formation of large fluid-filled blisters Frequently occur in areas of friction (such as axillae, groin, and buttocks), the centre of the face and body orifices (such as the nose and ears). Fluid contents range from a sterile cloudy fluid to frank yellow pus. Blisters easily rupture leading to the top layer of the skin (epidermis) peeling off easily, often in large sheets. Exposure of the underlying, moist, reddish tissue leaves the skin with a burned-like appearance. Gentle rubbing of the skin causes exfoliation (Nikolsky sign is positive). Systemic symptoms include fever, irritability, lethargy and dehydration. If untreated it can lead to sepsis and potentially death.

Answer 258

Most patients will require admission and treatment with IV antibiotics. Fluid and electrolyte balance is key to management as patients are prone to dehydration. When adequately treated, children usually make a full recovery without scarring.

Answer 259

Staphylococcal scalded skin syndrome

Answer 260

Scarring Loss of bodily fluids and salts leading to dehydration and electrolyte imbalance Hypothermia Secondary infections such as sepsis, cellulitis, and pneumonia Renal failure.

Answer 261

Skin swabs can be taken from the suspected source of infection and/or the blister fluid to confirm the presence of S. aureus. However, these can frequently be negative given the condition is toxin mediated. Blood cultures are undertaken when sepsis is of concern. Tzanck smear Skin biopsy is occasionally undertaken to exclude other causes of blisters, and occasionally is a justification for frozen section histology SSSS reveals non-inflammatory intra-epidermal splitting at the granular layer.

Answer 262

Steven–Johnsons syndrome/Toxic Epidermal Necrolysis (SJS/TEN) Bullous impetigo Drug hypersensitivity reaction Viral exanthem Thermal burns.

Answer 263

flucloxacillin MRSA: vancomycin

Answer 264

Mild seborrhoeic dermatitis of the scalp presents with flaky itchy skin on the scalp (dandruff). More severe cases cause more dense oily scaly brown crusting. This commonly occurs in adolescents and adults rather than children. First line treatment is with ketoconazole shampoo, left on for 5 minutes before washing off. Topical steroids may be used if there is severe itching. It often reoccurs after successful treatment.

Answer 265

Seborrhoeic dermatitis of the face and body presents with red, flaky, crusted, itchy skin. It commonly affects the eyelids, nasolabial folds, ears, upper chest and back. First line treatment is with an anti fungal cream, such as clotrimazole or miconazole, used for up to 4 weeks. Localised inflamed areas may benefit from a topical steroids, such as hydrocortisone 1%. Severe or unresponsive cases should be referred to a dermatologist or paediatrician.

Answer 266

Pityriasis rosea a generalised, self limiting rash that has an unknown cause. It often occurs in adolescents and young adults. It may be caused by a virus such as human herpes virus (HHV-6 or HHV-7), but no definitive causative organism had been established.

Answer 267

There may be prodromal symptoms prior to the rash developing. These include headache, tiredness, loss of appetite and flu-like symptoms. The rash starts with a characteristic herald patch. This is a faint red or pink, scaly, oval shaped lesion that is 2cm or more in diameter, usually occurring somewhere on the torso. It appears 2 or more days prior to the rest of the rash. If you suspect pityriasis, ask and look for a herald patch. Most, but not all, patients have a herald patch. The rash consists of widespread faint red or pink, slightly scaly, oval shaped lesions, usually less than 2 cm in diameter. On the torso they can be arranged in a characteristic “christmas tree” fashion, following the lines of the ribs. In dark skinned patients the lesions can be grey coloured, lighter or darker than their skin colour. Other symptoms may be present: Generalised itch Low grade pyrexia Headache Lethargy

Answer 268

Herold patch Pityriasis Rosea

Answer 269

The rash resolves without treatment within 3 months. It can leave a discolouration of the skin where the lesions were, however these will also resolved within another few months.

Answer 270

There is no treatment for the rash. It will resolve spontaneously without any long term effects. Patient education and reassurance is all that is required. It is not contagious and they can continue all their normal activities. They may require symptomatic treatment if bothered by itching. This may include emollients, topical steroids or sedating antihistamines at night to help with sleep (e.g. chlorphenamine).

Answer 271

Stevens-Johnson Syndrome (less than 10% of the body, Widespread erythematous or purpuric macules or ﬂat atypical targets) Toxic epidermal necrolysis (over 10% of body without spots, 30% with spots, Widespread purpuric macules or ﬂat atypical targets)

Answer 272

Blistering and shedding of top layer of skin

Answer 273

Note: Risk increased by certain HLA genetic types Medications Anti-epileptics Antibiotics Allopurinol NSAIDs Infections Herpes simplex Mycoplasma pneumonia Cytomegalovirus HIV

Answer 274

Patients usually start with non-specific symptoms of fever, cough, sore throat, sore mouth, sore eyes and itchy skin. (Prodromal illness) They then develop a purple or red rash that spreads across the skin and starts to blister. A few days after the blistering starts, the skin starts to break away and shed leaving the raw tissue underneath. Pain, erythema, blistering and shedding can also happen to the lips and mucous membranes. Eyes can become inflamed and ulcerated. It can also affect the urinary tract, lungs and internal organs.

Answer 275

Fever > 39 C Sore throat, difficulty swallowing Runny nose and cough Sore red eyes, conjunctivitis General aches and pains.

Answer 276

There is then an abrupt onset of a tender/painful red skin rash starting on the trunk and extending rapidly over hours to days onto the face and limbs (but rarely affecting the scalp, palms or soles). The maximum extent is usually reached by four days. The skin lesions may be: Macules — flat, red and diffuse (measles-like spots) or purple (purpuric) spots Diffuse erythema Targetoid — as in erythema multiforme Blisters — flaccid (ie, not tense). The blisters then merge to form sheets of skin detachment, exposing red, oozing dermis. The Nikolsky sign is positive in areas of skin redness. This means that blisters and erosions appear when the skin is rubbed gently.

Answer 277

Eyes (conjunctivitis, less often corneal ulceration, anterior uveitis, panophthalmitis) — red, sore, sticky, photosensitive eyes Lips/mouth (cheilitis, stomatitis) — red crusted lips, painful mouth ulcers Pharynx, oesophagus — causing difficulty eating Genital area and urinary tract — erosions, ulcers, urinary retention Upper respiratory tract (trachea and bronchi) — cough and respiratory distress Gastrointestinal tract — diarrhoea.

Answer 278

Dehydration and acute malnutrition Infection of skin, mucous membranes, lungs (pneumonia), septicaemia (blood poisoning) Acute respiratory distress syndrome Gastrointestinal ulceration, perforation and intussusception Shock and multiple organ failure including kidney failure Thromboembolism and disseminated intravascular coagulopathy.

Answer 279

Stevens-Johnson Syndrome (less than 10% of the body, Widespread erythematous or purpuric macules or ﬂat atypical targets) Toxic epidermal necrolysis (over 10% of body without spots, 30% with spots, Widespread purpuric macules or ﬂat atypical targets)

Answer 280

Skin biopsy is usually required to confirm the clinical diagnosis and to exclude staphylococcal scalded skin syndrome (SSSS) and other generalised rashes with blisters.

Answer 281

Anaemia occurs in virtually all cases (reduced haemoglobin). Leucopenia (reduced white cells), especially lymphopenia (reduced lymphocytes) is very common (90%). Neutropenia (reduced neutrophils), if present, is a bad prognostic sign. Eosinophilia (raised eosinophil count) and atypical lymphocytosis (odd-looking lymphocytes) do not occur. Mildly raised liver enzymes are common (30%), and approximately 10% develop overt hepatitis. Mild proteinuria (protein leaking into the urine) occurs in about 50%. Some changes in kidney function occur in the majority.

Answer 282

SCORTEN is an illness severity score that has been developed to predict mortality in SJS and TEN cases.

Answer 283

Other severe cutaneous adverse reactions (SCARs) to drugs (eg, drug hypersensitivity syndrome) Staphylococcal scalded skin syndrome and toxic shock syndrome Erythema multiforme, particularly erythema multiforme major (with mucosal involvement) Mycoplasma infections Bullous systemic lupus erythematosus Paraneoplastic pemphigus

Answer 284

SJS and TEN are medical emergencies and patients should be admitted to a suitable dermatology or burns unit for treatment. Good supportive care is essential, including nutritional care, antiseptics, analgesia and ophthalmology input. Treatment options include steroids, immunoglobulins and immunosuppressant medications guided by a specialist. Give pain relief as pain can be severe Temperature maintenance — as body temperature regulation is impaired, the patient should be in a warm room (30–32C) Hospital admission with reverse isolation and sterile handling procedures

Answer 285

Drug hypersensitivity syndrome is a specific, severe, unexpected reaction to a medicine, which affects several organ systems at the same time. It typically causes a combination of: High fever Morbilliform eruption Haematological abnormalities Lymphadenopathy Inflammation of one or more internal organs. Drug hypersensitivity syndrome is sometimes also called drug reaction with eosinophilia and systemic symptoms (DRESS), and drug-induced hypersensitivity syndrome (DIHS).

Answer 286

DRESS syndrome ( drug reaction with eosinophilia and systemic symptoms ) Acute generalised exanthematous pustulosis (AGEP) Stevens–Johnson syndrome / toxic epidermal necrolysis (SJS/TEN)

Answer 287

The most common drugs to cause this reaction are a number of anticonvulsant drugs (particularly carbamazepine, phenobarbital, and phenytoin), the anti-gout drug, allopurinol, olanzapine, and the sulphonamide group of antibiotics.

Answer 288

Drug hypersensitivity syndrome is a delayed T cell-mediated reaction. Tissue damage is due to cytotoxic T cells and cytokine release. There is a genetic predisposition to drug hypersensitivity syndrome. A defect in the way the liver metabolises drugs may be responsible. Re-activation of human herpesvirus 6 (HHV6, the cause of roseola) or Epstein-Barr virus (EBV) may also be important.

Answer 289

Drug hypersensitivity syndrome usually develops over several days, with onset 2-8 weeks after starting the responsible medicine. A high fever of 38–40 C is usually noticed first. This is quickly followed by a widespread skin rash. Characteristics of the rash are diverse. Morbilliform eruption affects 80% of cases, with varying morphology including targetoid lesions, blisters and pustules Erythroderma or exfoliative dermatitis (involving > 90% body surface area) may follow in about 10% Facial swelling affects 30% Mucosal involvement affects 25% (lips, mouth, throat, genitalia) The rash can last many weeks.

Answer 290

2-8 weeks following initiation of drug

Answer 291

Drug erruption in DRESS syndrome?

Answer 292

Enlarged lymph nodes in several sites (75%) Haematological disorders: raised white count (or less often, reduced white count), eosinophilia (in 30% this is > 2.0 x 109/L), atypical lymphocytes, thrombocytopenia, anaemia, haemophagocytic syndrome Liver enlargement, hepatitis, and rarely hepatic necrosis with liver failure. Abnormal liver function tests are found in most patients Kidneys are affected in about 10%, and is usually a mild interstitial nephritis. Renal failure is rare. Inflammation of the heart (myocarditis) or pericarditis causing chest pain, breathlessness, and lowered blood pressure Lung involvement causes shortness of breath and cough (interstitial pneumonitis, pleuritis, pneumonia and acute respiratory distress syndrome) Neurological involvement may lead to meningitis and encephalitis, polyneuritis, causing headache, seizures, coma, and palsies Gastrointestinal symptoms: gastroenteritis, pancreatitis, bleeding and dehydration. In severe cases, acute colitis and pancreatitis can occur, and chronic enteropathy may follow. Endocrine abnormalities: thyroiditis and diabetes Myositis Uveitis.

Answer 293

Causes of death from drug hypersensitivity syndrome include: Acute liver failure causing coagulation problems, jaundice, and impaired consciousness Multiorgan failure Fulminant myocarditis Haemophagocytosis.

Answer 294

High fever Extensive skin rash Organ involvement Supported by deranged LFTs and eosinophilia

Answer 295

Skin biopsy usually shows dense infiltration of inflammatory cells, including lymphocytes and eosinophils, extravasated erythrocytes, and oedema.

Answer 296

Blood count and coagulation studies Biochemical tests: at least liver function, renal function, muscle enzymes Viral serology: hepatitis B, C, EBV, CMV, HHV-6 Endocrine function: thyroid, glucose levels Genetic susceptibility tests. Urinalysis is undertaken to assess renal damage Skin biopsy Cardiac and pulmonary evaluation may include electrocardiograph (ECG), echocardiogram, and chest X-ray. Scans may be performed to evaluate the liver, kidneys, and brain depending on clinical findings and the results of initial tests.

Answer 297

Systemic corticosteroids (eg, prednisone) are generally used in the more severe cases of drug hypersensitivity syndrome with significant exfoliative dermatitis, pneumonitis, and/or hepatitis Supportive management and close monitoring Ciclosporin? Additional treatment may include intravenous immunoglobulin, plasmapheresis, and immunomodulatory drugs such as cyclophosphamide, mycophenolate, and rituximab. Supportive treatment for the skin rash may include: Dressings Topical steroids Emollients Oral antihistamines. Abx if secondary infection

Answer 298

More at risk of developing autoimmune disease Risk of relapse

Answer 299

Cutaneous lesions develop at the peripheries before spreading centrally. Distribution is usually symmetrical with a preference for extensor surfaces. May be painful, pruritic, or swollen. Early lesions present as round, erythematous papules which later develop into target lesions. Target lesions consist of three concentric rings of colour variation: A central, dusky area of epidermal necrosis Surrounded by a lighter oedematous area With a peripheral erythematous margin. Atypical lesions may be present with typical lesions. Atypical lesions are raised with poorly defined borders and/or fewer zones of colour variation. In severe disease, up to hundreds of lesions may be present in different developmental stages, at times making it difficult to identify characteristic lesions.

Answer 300

Many patients report prodromal symptoms including fatigue, malaise, myalgia, or fever. These likely represent the course of precipitating illness rather than true prodrome.

Answer 301

Lesions develop as blisters, which then break to reveal shallow erosions with a white overlying pseudo-membrane. Erythema multiforme favours oral membranes, but may also present with urogenital and, rarely, ocular lesions. Mucous membrane involvement can be painful and significantly limit oral intake; lesions may precede or follow cutaneous lesions.

Answer 302

Cutaneous lesions resolve without scarring, though hyperpigmentation may persist for several months. Ocular involvement can lead to more serious complications including: Keratitis Conjunctival scarring Uveitis Permanent visual impairment.

Answer 303

Symptoms are expected to self-resolve within 4 weeks from onset (or up to 6 weeks in severe disease).

Answer 304

Acute generalised exanthematous pustulosis, or AGEP, is an uncommon pustular drug eruption characterised by superficial pustules. Over 90% of cases of AGEP are provoked by medications, most often beta-lactam antibiotics (penicillins, cephalosporins and quinolones) Typically, AGEP starts on the face or in the armpits and groin and then becomes more widespread. It is characterised by the rapid appearance of areas of red skin studded with pinhead-sized sterile pustules. There tends to be more disease in skin folds. Facial swelling often arises. Oral lesions affect about 20% of patients with AGEP. The onset of AGEP is usually within 2 days of exposure to the responsible medication. Can lead to severe systemic symptoms (10%)

Answer 305

Necrotising fasciitis is a life-threatening infection of the subcutaneous soft tissue with secondary tissue necrosis, with spread along the fascial planes but not the underlying muscle.

Answer 306

Patients present with rapidly spreading cellulitis and are systemically very unwell - fever, tachycardia. Blistering and necrotic skin Severe pain There is often a history of risk factors i.e. a cutaneous portal of entry for the bacteria (trauma/surgery(abdominal)/co-morbidities(diabetes and malignancy). On physical examination the affected region will be blistering and erythematous. In early stages mild oedema may be the only sign. There will either be severe pain or anaesthesia over the site of cellulitis. In advanced cases, the skin may be grey, with overlying crepitus (subcutaneous emphysema). The patient is typically pyrexial, tachycardic, tachypnoeic, and hypotensive. X-ray may show soft tissue gas

Answer 307

The most common are type 1 (polymicrobial infection with anaerobes) and type 2 (monomicrobial infection with group A streptococci).

Answer 308

Management is with haemodynamic support, urgent debridement surgery, and broad-spectrum antibiotics. Radiography or CT/MRI can confirm the diagnosis, but should not delay surgery.

Answer 309

Examples: Aqueous cream, emulsifying ointment, liquid paraffin and white soft paraffin in equal parts Quantitiy: 500g per tub Indications: To rehydrate the skin and re-establish a surface lipid layer. Useful for dry scaling conditions Side effects: Reactions may be irritant or allergic

Answer 310

30g - enough to cover the whole body once

Answer 311

Allergic and immune reactions, inflammatory skin conditions, bullous and blistering disorders, connective tissue disorders, vasculaitis Anti inflammatory and anti proliferative effects

Answer 312

Skin atrophy Telangiectasia Striae Acne or perioral dermatitis Allergic contact dermititis May mask, cause or exaccerbate skin infections

Answer 313

Cushing's syndrome Immunosupression Hypotension DM Osteoperosis Cataract Steroid induced psychosis

Answer 314

Viral infections due to herpes simplex and herpes zoster virus

Answer 315

GI upset Raised liver enzymes Reversable neurological reactions Haematological disorders

Answer 316

Nonsedatives: Fexofenadine Cetirizine Loratadine Sedative anti-histamines: Chlorphenamine Hydroxyzine

Answer 317

Type 1 hypersentivity reactions and eczema Block histamine receptors from producing an anti-pruritic effect

Answer 318

Antichollenergic effects: dry mouth, blurred vision, urinary retention, constipation

Answer 319

Fusidic acid Mupirocin (Bactroban) Neomycin

Answer 320

Bacterial skin infections Acne vulgaris

Answer 321

Local skin irritation/allergy Fusidic acid - abx resitance

Answer 322

Chlorhexidine Cetrimide Povidone-iodine

Answer 323

Acne Psoriasis Disorders of keritisation

Answer 324

Three years

Answer 325

Monocloncal antibodies: Infliximab, adalimumab, ustekinumab Fusion antibody proteins: Etanercept Recombinant human cytokines and growth factors (interlukins)

Answer 326

Psoriasis Atopic dermatitis Hidradenitis suppurativa

Answer 327

Local: resness, swelling, brusing at site of injection Systemic: allergic reaction, antibody formation, flu-like symptoms, infections,, hepaitis, demyelinating disease, HF, blood problems, lymphome, SSC+BCC

Answer 328

Erythema nodosum is an uncommon skin condition that causes dusky red/blue tender nodules due to inflammation of the underlying subcutaneous tissue. It is most commonly found on the shins and calves and is frequently symmetrical. The image shown demonstrates the typical features of erythema nodosum with poorly demarcated edges and the dusky blue/red colouration. Erythema nodosum has many causes including some infections, malignancies and inflammatory bowel disease. It can also occur in pregnancy, as in this case in this scenario. It is usually self-limiting. Discrete tender nodules which may become confluent, appear for 1-2 weeks and leave a bruise-like discoloration as they resolve. Lesions do not ulcerate and resolve without atrophy or scarring

Answer 329

Erythema nodosum

Answer 330

UV expoxusre History of frequent or severe sunburn in child hood Skin type 1 Increasing age Male Previous history of skin cancer Immunosupression Genetic predisposition

Answer 331

Head and neck

Answer 332

Local tissue invasion and destruction Depends on tumour sizem site, type, growth pattern, histological sbutype, failure of previous treatment/recurrence and immunosupresison

Answer 333

UV expoxusre History of frequent or severe sunburn in child hood Skin type 1 Increasing age Male Previous history of skin cancer Immunosupression Genetic predisposition Long standing non healing lesion

Answer 334

Depends on the tumor size, site, histological pattern, depth of invasion, perineural involvement and immunosuppression

Answer 335

T<2mm thick N0 M0

Answer 336

T>2mm thick, N0, M0

Answer 337

Idiopathic, Food (e.g. nuts, sesame seeds, shellfish, dairy products) Drugs (e.g. penicillin, contrast media, NSAIDs, morphine, ACEi, Insect bites, Contact (latex) Viral Parasite Autoimmune Heridatry angiodema

Answer 338

Local increase in permeability of capilaries and small venules A large number of inflammatory mediators (including prostaglandins, leukotrienes, and chemotactic) play a role but histamine derived from skin mast cells appear to be the major mediator Local mediator release from mast cells can be induced by immunological or non-immunological mechanisms

Answer 339

Urticaria: swelling involving the SUPERFICIAL DERMIS, riasing the epidermis (itchy wheals) Angiodema: deeper swelling involving the dermis and subcutaneous tissue - swelling of tounge and lips Anaphylaxis: bronchospasam, facial and laryngeal odema, hypotension, may present initially with urticaria and angiodema

Answer 340

Anithistamines Corticosteroids for severe acute angiodema

Answer 341

Corticosteroids

Answer 342

Urticaria is normally uncomplicated Angioedema and anaphylaxis can lead to asphyxia, cardiac arrest and death

Answer 343

Group A beta-haemolytic steprococcus Primary tuberculosis Chlamydia Leprosy

Answer 344

Steven's Johnson Syndrome is characterized by mucocutaneous necrosis with at least two muscosal sites involved. Extensive necrosis.

Answer 345

Epitheilial necrosis with few inflammatory cells

Answer 346

Full thickness epidermal necrosis with subepidermal detachment

Answer 347

A serious communicable infection transmitted via respiratory secretions, bacteria get into the circulating blood. Gram negative doplococcus Neisseria meningitdis is the causative organism. Presents with features of menigitis, septicemia (hypotension, fever, myalgia) and a typical rash: Non blanching purpiric rash on the trunk and extermities which may be preceded by a blanching maculopapular rash, and can rapidly progress to ecchymoses, hemorrhagic bullae and tissue necrosis

Answer 348

Progression to ecchymoses, hemorrhagic bullae and tissue necrosis Septicaemic shock DIC Multiorganfailure and death

Answer 349

Abx: benzylpenicillin Prophylatic abx (e.g. rifampicin) for close contacts ideally within 14 days of exposure

Answer 350

Exfoliative dermatitis involving at least (90% of the skin surface. Caused by previous skin disease (e.g. eczema, psoriasis), lymphoma, drugs (e.g. sulphonamides, gold, suphonylureas, penicillin, allopurinol, captopril) and idiopathic Presents with inflamed skin, edematous and scaly, systemically unwell with lymphadenopathy and malaise Managed by treating the underlying cause, where known, emollients and wet-wraps to maintain skin moisutre, topical steroids may help to relieve inflammation Complications can include secondary infection - fluid loss and electrolyte imbalance, hypothermia, high-output cardiac failure, capillary leak syndrome

Answer 351

Eczema herpeticum

Answer 352

Herpres hepatitis Encephalitis Disseminated intrvascular coagulation (DIC) Death (rarely)

Answer 353

An acute superfical form or cellulitis and involves ther dermis and UPPER (as opposed to deep) subcutaneous tissue Well-defined, red raised border Patients more likely to be systemically unwell

Answer 354

Streptococcus pyogenes and staphylococcus aureus

Answer 355

erysipelas

Answer 356

Develops within a few hours to a few days, and may be worse over the face, neck, axillae or groins A scald like skin appearence is followed by a large flaccid bulla Perioral crusting is typical There is intraepidermal blistering in this condition Lesions are very painful Sometimes the eruption is more localised Recovery is usally 5-7 days

Answer 357

Abx (flucloxacillin, erythromycin, or appropriate cephalosporin) Analgesia

Answer 358

Dermatophytes (tinea/ringworm) Yeasts (e.g. candidasis, malassezia) Moulds (aspergillus)

Answer 359

Tinea infection of the trunk and limbs - itchy, circular or annular lesions with a clearly defined raised and scaly edge is typical

Answer 360

Tinea infection of the groin and natal cleft - very itchy, similar to tinea corporis (itchy circular or anullar lesions with a clearly definied raised and scaley edge)

Answer 361

Atheletes foot - moist scailing and fissuring in the toewebs, spreading to the sole and dorsal aspect of the foot

Answer 362

Tine infection of the hand - scailing and drying in the pamar creases

Answer 363

Scalp ringworm Patches of broken hair, scailing and inflammation

Answer 364

Infection of the nail - yelow discolouration, thickened and crumbly nail

Answer 365

Inappropriate treatment of tinea infection with topica; or systemic corticosteroids - ill defined and less scaly lesions

Answer 366

White plaques on mucosal areas, erythema with satellite lesions in flexures

Answer 367

Infection with Malassezia furfur Scaly pale brown patches on upper trunk that fail to tan on sun exposure Usually asymptomatic

Answer 368

Skin scrapings Hair or nail clippings (dermatophytes) Skin swabs (yeasts)

Answer 369

Topical antifunga

Answer 370

Severe, widespread or nail fungal infections

Answer 371

Can lead to tinea incognito

Answer 372

Moist environment - incontinence, sweating, not drying skin properly Immunosupression -steroids, DM,

Answer 373

Grey/brown (as opposed to erythematous)

Answer 374

Lichenification

Answer 375

Pitting and ridging

Answer 376

Tacrolimus, pimecrolimus

Answer 377

Azathioprine Ciclosporin Methotrexate

Answer 378

Inflmmatory lesions may appear this way in highly pigmented skin May aso signifiy ongoing inflamation

Answer 379

Post inflammatory hyperpigmentation, scarring, deformity, psycholoigcal and social effects

Answer 380

Infection (e.g. tonsilitis) Trauma (Koebner phenomenom) Drugs (lithium) Stress Alcohol

Answer 381

General measures - wound dressings where required, mointor for signs of infection Topical therapies for localised disease - topical steroids Oral therapise for widespread disease = oral steroids, combination of ora tetracycline and nicotinamide, immunosupressive agents (azathioprine, mycophenolate mofetil, methotrexate)

Answer 382

General measures: wound dressings where required, monitor for signs of infection, good oral care (if oral mucosa involved) Oral therapies - high dose oral steroids, immunosupressive agents (e.g. methotrexate, azathioprine, cyclophosphamide, mycophenolate mofetil, other)

Answer 383

An aquired depigmenting disorder where there is a complete loss of pigment cells (melanocytes) Thought to have autoimmune aetiology, where the innate immune system causes destruction of loss of melanocytes, leading to loss of pigment formation in the skin Presentation: any age, single or multiple patches or depigmentation, often symettrical Common sites are exposed areas such as face hands and feet, as well as body folds and genitalia Favours sites of injury - Koebner phenomenon Mx: Minimise skin injury, topical treatments such as steroids and calcineurin inhibitors, phototherapy such as UVB therapy, oral immunosupressants such as methotrexate, ciclosporin, mycophenolate mofetil

Answer 384

An aquired chornic skin disorder where there is increased pigmentation in the skin Thought to be due to genetic predisposition and triggered by factors such as sun exposure, hormonal changes such as pregnancy and contraceptive pills The pigmnetation is caused by and overproduction of pigment (melanin) by pigment cells (melanocytes) Presents with brown macules (freckle like spots) or larger patches with an irregular border Symettrical distribution Common sites include forhead cutaneous upper lips and cheeks Mx: Lifelong sun protection, discontinuation of hormonal OCP, cosmetic camouflage, topical treatments that aim at inhibiting the formation of new melanin such as hydroquinone, azelaic acid, kojic acid, vit C

Answer 385

Often painful, worse on standing History of venous disease (varicose veins, DVT) Typically occur in the malleolar area (more common over the medial than lateral malleolus) Lesions are large, shallow, irregular ulcers with exudative and granulating bases Associated features include warm skin, normal peripheral pulses, leg oedema, haemosiderin and melanin deposition (brown pigment), lipodermatoclerosis, and atrophie blanche (white scarring with dilated capillaries) ABPI withh be normal 0.8-1

Answer 386

VENOUS -Malleolar areas - Large - Shallow - Irregular - Exudative and granulating base - Surrounding hyperpigmentation (haemosiderin and melanin deposition) - Skin appears hard surrounding (lipodermatosclerosis) - White scarring with dilated capilaries (atrophie blanch)

Answer 387

Painful ulcers (especially at night, worse when legs elevated) History of arterial disease (atheroslerosis) Occur at pressure and trauma sites, e.g. pretibial, supramalleolar and at distal points. Small, sharply definied deep ulcers, with necrotic base Cold skin, weak or absent peripheral pulses, shiny pail skin, loss of hair ABPI<0.8 Dopple studies and angigraphy may be performed Managed by vascular reconstruction - COMPRESSION BANDAGING IS CONTRAINDICATED

Answer 388

ARTERIAL At pressure area, distal point Relatively small Sharply defined Deep Partially necrotic base Shiny pale skin surrounding Hair loss surrounding

Answer 389

Often painless, abnormal sensation, history of diabetic or neurological disease Occur at pressure sites such as soles, heels, toes, metatarsal heads, scaram Variable in size and depth Have a granulating base May be surrounded by a hyper keratotic lesion (callus) ABPI<0.8 implies a neuroischaemic ulcer X-ray to exclude osteomyelitis Wound debridement, regular repositioning to manage

Answer 390

NEUROPATHIC ULCER Occuring at a pressure site Granulating base Surrounded by hyperkeratotic lesion (e.g. callus)

Answer 391

Lichen nitidus is an uncommon inflammatory skin condition that usually presents with tiny skin-coloured bumps Can be the pattern which eczema presents in darker skin

Answer 392

Vesicular and exudative

Answer 393

Patch testing Serum IgE levels Skin swab

Answer 394

Skin scrabe, extraction of mite and view under microscope

Answer 395

Secondary eczema and impetigo

Answer 396

Forarms, wrist and legs May occur on oral mucosa (always examine)

Answer 397

Lichen planus (LP) is a chronic inflammatory condition affecting the skin and mucosal surfaces. There are several clinical types: Cutaneous lichen planus Mucosal lichen planus Lichen planopilaris (scalp) Lichen planus of the nails Lichen planus pigmentosus Lichenoid drug eruption.

Answer 398

Violaceous *Iliac) flat-topped paules or hyperpigmented papules (in darker skin) Symmetrical distrubtion - Note that lichen planus in darker skin types has a typical purplish tinge

Answer 399

Nail changes and hair loss Lacy white streaks on the oral mucosa and skin lesions (Wickham's striae)

Answer 400

Corticosteroids Antihistamines

Answer 401

Benign: Melanocytic naevi, sebhorric wart Mallignant: Malignant melanoma

Answer 402

Women: legs Men: trunk

Answer 403

Warty greasy papules or nodules Stick on appearence with well definied edges Commonly occur on the face ad trunk in middle aged or elderly patients Often multiple, asymptomatic, may be managed if symptomatic with: Curette and caturey, cryotherapy

Answer 404

Sebhorric wart

Answer 405

Usually asymptomatic, but if not: May be shaved or completely excised

Answer 406

Meningococcal septicemia DIC Vasculitis Senile purpura

Answer 407

Non-palpable purpura with surrounding atrophic thin skin, occuring on the extensor surfaces of hands and forarms in the elderly population (with sun damaged skin) Such skin is easily traumatised Patients are systemically well Bloods, urinalysis, skin biopsy may be undertaken No treatment is needed

Answer 408

Painful lesions Dependent areas (e.g. legs, buttocks, flanks) Palpable purpura (often painful) Systemic illness Bloods and urinalysis, skin biopsy, may be performed Requires treatment of underlying cause (not skin lesions) such as steroids and immunosuppressants if there is skin involvement

Answer 409

History: trauma, malignancy, sepsis, obstertic complications, transfusions, or liver failure Common sites: Spontaneous bleeding from the ear, nose and throat, GI tract, respiratory tract and wound site Lesion: Petechiae, ecchymoses, haemorragic, bullae and/or tissue necrosis Associated features; Systemically unwell Management: Treat underlying cause, transfuse for coagulation deficiencies, anticoagulants for thrombosis

Answer 410

Cellulitis/erysipelas Venous thrombosis Chronic venous insufficiency

Answer 411

Patients with suspected erysipelas/cellulitis

Answer 412

Cause of red swollen leg History: pain, swelling, redness, prolonged bed res/longhaul flight/clotting tendancy may preceed symtpoms Lesion: Complete venous occlusion may lead to cyantoic discolouration Associated features: Systemically unwell, PE Possible investigations: D-dimer, Doppler ulrasound and/or venography

Answer 413

History: heaviness or aching of leg, which is worse on standing an relieved by walking, history of venous thrombosis Lesion: discloured (blue-purple), odeama which improves in mornings, venous congestion and varicose veins Associated features: Liodermatosclerosis (erythematous induratuion, creating champagne bottle' appearance, stasis dermatitis (eczema with inflammatory papules, scaly, crusted erosions), haemosiderin deposition, venous ulcer Possible investigations: Doppler USS and/or venography Management: Leg elevation and compression stockings, sclerotherapy or surgery for varicose viens

Answer 414

IIHH - warn about new severe headaches Increased sun sensitivity - emphasise the importance of sun cream Hives

Answer 415

Moisturisers – cetraben , epaderm, zeroderm etc Soap substitutes – epaderm, hydromol , dermol 500 lotion Topical Steroid – Hydrocortisone (mild) Eumovate - clobetasone (Moderate) Betnovate (betamethasone 0.1%) (potent) Dermovate –clobetasol (superpotent) Calcineurin inhibitors –steroid sparing agents. Tacrolimus oint 0.05 & 0.1% and Pimicrolimus cream (Elidel) Oral immunosuppressants – oral steroids , methotrexate, ciclosporin Phototherapy - UV treatment Biologics – injectable and oral

Answer 416

Methotrexate

Answer 417

Offer a potent corticosteroid applied once daily plus vitamin D or a vitamin D analogue applied once daily (applied separately, 1 in the morning and the other in the evening) for up to 4 weeks as initial treatment for adults with trunk or limb psoriasis.

Answer 418

Offer narrowband ultraviolet B (UVB) phototherapy to people with plaque or guttate-pattern psoriasis that cannot be controlled with topical treatments alone. Treatment with narrowband UVB phototherapy can be given 3 or 2 times a week depending on patient preference. Tell people receiving narrowband UVB that a response may be achieved more quickly with treatment 3 times a week.

Answer 419

Offer systemic non-biological therapy to people with any type of psoriasis if: it cannot be controlled with topical therapy and it has a significant impact on physical, psychological or social wellbeing and 1 or more of the following apply: psoriasis is extensive (for example, more than 10% of body surface area affected or a Psoriasis Area and Severity Index (PASI) score of more than 10) or psoriasis is localised and associated with significant functional impairment and/or high levels of distress (for example, severe nail disease or involvement at high-impact sites) or phototherapy has been ineffective, cannot be used or has resulted in rapid relapse (rapid relapse is defined as greater than 50% of baseline disease severity within 3 months).

Answer 420

Methotrexate

Answer 421

Clear — if there is normal skin and no evidence of active eczema. Mild — if there are areas of dry skin, and infrequent itching (with or without small areas of redness) Moderate — if there are areas of dry skin, frequent itching, and redness (with or without excoriation and localized skin thickening). Severe — if there are widespread areas of dry skin, incessant itching, and redness Infected — if eczema is weeping, crusted, or there are pustules, with fever or malaise.

Answer 422

None — no impact on quality of life. Mild — little impact on everyday activities, sleep, and psychosocial well-being. Moderate — moderate impact on everyday activities and psychosocial well-being, and frequently disturbed sleep. Severe — severe limitation of everyday activities and psychosocial functioning, and loss of sleep every night.

Answer 423

Prescribe generous amounts of emollients, and advise frequent and liberal use. Consider prescribing a mild topical corticosteroid (such as hydrocortisone 1%) for areas of red skin. Treatment should be continued for 48 hours after the flare has been controlled.

Answer 424

Prescribe a generous amount of emollients, and advise frequent and liberal use (more than usual). If the skin is inflamed, prescribe a moderately potent topical corticosteroid (for example betamethasone valerate 0.025% or clobetasone butyrate 0.05%) to be used on inflamed areas. Treatment should be continued for 48 hours after the flare has been controlled. For delicate areas of skin (such as the face and flexures), consider starting with a mild potency topical corticosteroid (such as hydrocortisone 1%) and increase to a moderate potency corticosteroid only if necessary. Aim for a maximum of 5 days' use. Occlusive dressings or dry bandages may be of benefit; however, treatment should only be started by a healthcare professional trained in their use (otherwise consider referral). If there is severe itch or urticaria, consider prescribing a one-month trial of a non-sedating antihistamine (such as cetirizine, loratadine, or fexofenadine). If there are areas of infected skin, antibiotics may be required Consider prescribing a maintenance regimen: 1)of topical corticosteroids to control areas of skin prone to frequent flares (not recommended for the face, genitals, or axillae). Options include a 'step down approach' or 'intermittent treatment'. 2)Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are a second-line option. However, they should only be prescribed by a specialist (including GPs with a specialist interest in dermatology).

Answer 425

Prescribe a generous amount of emollients and advise frequent and liberal use (more than usual). If the skin is inflamed, prescribe a potent topical corticosteroid (for example betamethasone valerate 0.1%) to be used on inflamed areas. For delicate areas of skin such as the face and flexures, use a moderate potency corticosteroid (such as betamethasone valerate 0.025% or clobetasone butyrate 0.05%). Aim for a maximum of 5 days' use. Do not use potent corticosteroids in children under 12 months old, or very potent corticosteroids in children of any age, without specialist dermatological advice. Occlusive dressings or dry bandages may be of benefit; however, treatment should only be started by a healthcare professional trained in their use (otherwise consider referral). If there is severe itch or urticaria, consider prescribing a one-month trial of a non-sedating antihistamine (such as cetirizine, loratadine, or fexofenadine). If itching is severe and affecting sleep, consider prescribing a short course (maximum of two weeks) of a sedating antihistamine (such as chlorphenamine). If there is severe, extensive eczema causing psychological distress, consider prescribing a short course of an oral corticosteroid (refer children under 16 years of age). There are no data from controlled trials, but 30 mg prednisolone taken in the morning for 1 week should be sufficient. If there are signs of infection, abx may be required. Consider prescribing a maintenance regimen: 1) Topical corticosteroids to control areas of skin prone to frequent flares (not recommended for the face, genitals, or axillae). Options include a 'step down approach' or 'intermittent treatment'. 2) Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are a second-line option. However, they should only be prescribed by a specialist (including GPs with a specialist interest in dermatology).

Answer 426

ANY SEVERITY: Fixed combination of topical adapalene with topical benzoyl peroxide, applied once daily in the evening Fixed combination of topical tretinoin with topical clindamycin, applied once daily in the evening MILD TO MODERATE: Fixed combination of topical benzoyl peroxide with topical clindamycin, applied once daily in the evening MODERATE TO SEVERE: Fixed combination of topical adapalene with topical benzoyl peroxide, applied once daily in the evening, plus either oral lymecycline or oral doxycycline taken once daily Topical azelaic acid applied twice daily, plus either oral lymecycline or oral doxycycline taken once daily

Answer 427

If acne fails to respond adequately to a 12‑week course of a first-line treatment option and at review the severity is: mild to moderate: offer another option from the table of treatment choices (see table 1) moderate to severe, and the treatment did not include an oral antibiotic: offer another option which includes an oral antibiotic from the table of treatment choices (see table 1) moderate to severe, and the treatment included an oral antibiotic: consider referral to a consultant dermatologist-led team.

Answer 428

Overgrowth of scar tissue which tends to be larger than the original wound itself Thought to be due to overproduction of the collagen during wound healing after: minor injuries, insect bites, skin surgery, acne spots in generically predispostiioned individuals More common in darker skin types Presents as firm, smooth hard nodule which may be itchy and/or painful Topical treatments such as steroids and silocone gel can potentially flatten the scar and improve symptoms - intralesional steroid injection if not effective, surgery as last resort as may result in largery keloid scar

Answer 429

Patients with eczema thats difficult to control, especially children

Answer 430

Avoid soaps Avoid using only water Utilise moisturisers as a soap substitute

Answer 431

Gently Generously 2-4 times a day On entire skin surface

Answer 432

Low humidity in the winter can exacerbate skin dryness and then the eczema is more likely to flare

Answer 433

Widespread erythematous macules and papules which are confluent in many areas, symetrical

Answer 434

Measels Rubella EBV HIV

Answer 435

New drug: 1-3 weeks A drug that has been given before: 1-3 days

Answer 436

Ampicillin/amoxicillin - as is infectious mononucleosis (similar presentation) rather than strep, a serious reaction may occur - ie. maculopapular drug erruption

Answer 437

Avid drug and drugs of same class Make sure allergy is recorded in pts notes and inform GP Encourage pt to inform NOK Re-exposure may result in a more severe reaction Consider medic alert bracelet if severe cutaneous reaction

Answer 438

PR unaffected PV worse

Answer 439

Guttate psoriasis Acne

Answer 440

Yellow green flouresence demonstrated not seen in other conditions

Answer 441

Fungal hyphae and spores in a distinctive 'spaghetti and meatball' appearence

Answer 442

Selenium sulfid shampoo or ketoconazole shampoo applied to SKIN and left on for 10 minuites in affected area before showering off Topical azole creams including clotrimazole, miconazole, econazole and ketoconazole or terbinafine These should be applied to the affected areas in the evening and may require several weeks of treatment Pigmentary changes can take months to return to normal after sucsessful treatment

Answer 443

Sweating and humidity

Answer 444

Erythematous annular ring with a slightly depressed centre Asymptomatic Can be differntiated from ringworm with biopsy if unsure, although lack of itchiness and scales gives a clue Usually resolves on its own, if causing distress can use potent of very potent corticosteroid or even cryotherapy

Answer 445

2-3 weeks, followed by shorter bursts

Answer 446

Mupirocin Fusidic acid

Answer 447

Nasal carriage of SA is common and may not be irradicated by oral or topical treatment of lesions - may require erradicatoon using antibacterial nasal ointments (usually mupirocin) and antiseptic skinwashes

Answer 448

Protect hands with gloves where possible (caution in latex/rubber) Avoid direct contact with irritating chemicals (e.g. detergents, soaps, but also foods such as citrus fruits, potato, onion, etc.) Regular use of emmolients. Potentially topical steroids for flares

Answer 449

Can develop an intractable hand dermititis

Answer 450

Stasis eczema

Answer 451

Urticarial rashes

Answer 452

Total IgE + IgE to specific suspected allergens Pinprick testing for allergies

Answer 453

Urticarial vasculitis

Answer 454

COeliac diease SLE Thyroid disease Urticarial vasculitis

Answer 455

Itching without rash to account for it, does not respond to use of emmolients Can be drug induce, endocrine related (thyroid, DM), metabolic (kidney and liver failure), or haematological (lymphoma, iron def aneamia, polycythemia )

Answer 456

A topical coal tar preparation is recommended if no improvement is seen within 8-12 weeks of using the topical corticosteroid and topical vitamin D preparation.

Answer 457

A topical coal tar preparation is recommended if no improvement is seen within 8-12 weeks of using the topical corticosteroid and topical vitamin D preparation.

Answer 458

. Ketoconazole 2% shampoo can be applied to the skin every 1-2 weeks to prevent seborrheic dermatitis. The patient should be advised to leave the preparation on for 3-5 minutes before rinsing.

Answer 459

Skin patch testing is recognised by NICE to be the gold standard test when diagnosing contact dermatitis in certain circumstances (e.g. when there is no obvious cause for the dermatitis or it is resistant to corticosteroids).

Answer 460

Sudden hair loss in a patchy distribution Enlargement of patches Hair regrowth.

Answer 461

Usually in cases of acne vulgaris, a simple visual inspection is usually enough to make the diagnosis. However, skin lesion culture may be warranted in patients who do not respond to escalating treatment, to exclude Gram-negative folliculitis.

Answer 462

This disruption of the skin barrier can result in spongiosis being seen histologically; this refers to the abnormal accumulation of fluid within the epidermis, resulting in increasing space between adjacent squamous cells.

Answer 463

Colloid bodies may be seen histologically in the setting of lichen planus; a common skin condition that can give pruritic, raised, violaceous lesions, most commonly over the wrists or trunk.

Answer 464

Keratinisation refers to the production of keratin, most commonly carried out by squamous cells. An excessive level of keratinisation may be seen on biopsy in the setting of squamous cell carcinoma.

Answer 465

With the use of topical corticosteroids regular review is required, usually at around 3 months, and a step-down management plan put in place to manage symptoms

Answer 466

In discoid type eczema

Answer 467

Phototherapy (UVB or PUVA) Systemic retinoids (Acitretin) Methotrexate Ciclosporin Dimethyl fumarate Biological agents

Answer 468

Used twice with applications a week apart Treat whole body from chin downwards including web spaces of toes and fingers In children aged up to 2 years and in elderly and immunocompromised people application should be extended to the scalp, neck, face and ears

Answer 469

Burrow: a short, wavy, scaly grey line on the skin surface These can easily be missed if the skin has been scratched, has become secondarily infected or if eczema is also present

Answer 470

Rosacea may cause rhinophyma (enlarged, swollen nose), swoleen forehead, eyelides, earlobes and chin as a result of sebaceous gland hyperplasia. This is more commonly observed in men

Answer 471

May cause blephritis, conjuncitvitis,episcleritis and sebaceous gland hyperplasia leading to swollen eyelids.

Answer 472

Immunosupressive drug, used as topical second line preperation in the treatment of eczema affecting the face and neck Patients should stop using it if they develop a coldsore as it increases the risk of eczema herpeticum

Answer 473

Bruising, swelling, minor bleeding, black-eye post-op (if lesion near eye) Minor discomfort Scar - contraction may cause local problems - ie. ectropian if below eyelid leading to watery eye Wound infection Numbeness around scar Incomplete surgical removal causing a local recurrence

Answer 474

Between 11am and 3PM

Answer 475

IgG antibodies along the basement membrane zone (dermo-epidermal junction)

Answer 476

Non-adherent dressings to any eroded skin which has been caused by burst blisters Deflate large intact blisteres with a sterile needles Topical very potent corticosteroids Systemic corticosteroids (mainstay of treatment) Oral doxycline can be used for anti-inflammatory effects Other immunosupressants may be required as steroid sparing agents

Answer 477

Peptic ulceration DM HTN Weight gain Fat redistribution (moon facies and buffalo hump) Osteoperosis Skin atrophy and fragility leading to easy burising and tearing Striae Cataracts Increased risk of infection Proximal myopathy Growth suppression in children Mood changes

Answer 478

Psoriasis Lichen planus Eczema Alopecia areta

Answer 479

Lichen planus

Answer 480

Most common change is pitting, other changes include brittle nails with vertical ridging and splitting, onycholysis

Answer 481

Lips, ears

Answer 482

Photophobia

Answer 483

Lichen plans. The inflammatory process can sometimes lead to fusion between the nail fold and underlying nail bed and matrix (pterygium). Lichen plans of the skin typically presents as itchy shiny violaceous flat-topped plaques. Lichen plans can also affect mucous membranes

Answer 484

Potent topical steroids rubbed into the nail fold in active disease Triamcinolone injection into the proximal nail fold could be considered but can be very painful even under local anaesthesia. Prednisolone or ciclosporin for severe scarring disease as this can result in permanent nail loss or dystrophy.

Answer 485

A Well circumscribed pink nodule with peripheral pigmentation with smooth surface with lack of scaling suggesting a dermal lesion. The lesion will be firm on palpation and when gently pressed on the lateral edges will demonstrate central dimpling This is a benign lesion with no malignant potential. Treatment is therefore not routinely required. On occasions lesions may become itchy, tender or bleed if traumatised (e.g. by shaving). Excision under local anaesthetic can be considered.

Answer 486

Plantar pustulosis. There is usually involvement of the palms too, and this disorder is generally known as palmoplantar pustulosis or palmoplantar pustular psoriasis. The presence of pustules should always prompt consideration of infection, particularly by Staphylococcus aureus or (here) dermatophyte infection (Trichophyton species) causing tinea pedis. If in doubt, burst a pustule with a sterile needle and take a swab of pus for bacteriological investigation or take a skin scraping for mycology. In this case, the presence of multiple 2-5mm pustules, which evolve to leave brown macules on red, scaly palms and soles is typical of palmoplantar psoriasis. These pustules are sterile. This condition may occur in isolation, or there may be psoriasis

Answer 487

Extensive alopecia areata that persists for longer than 6 months can be treated with diphencyprone topical immunotherapy, though efficacy is limited.

Answer 488

typically terbinafine for 6 weeks for fingernails and 12 weeks for toenails

Answer 489

Anti-Jo1 antibodies would be detected

Answer 490

Oedema in the subcutaneous tissue with poor lymphatic and capillary drainage, leading to inadequate nutrients and oxygen reaching the skin. This causes skin to die and ulcers to arise.

Answer 491

Oedema in the subcutaneous tissue with poor lymphatic and capillary drainage, leading to inadequate nutrients and oxygen reaching the skin. This causes skin to die and ulcers to arise.

Answer 492

Oedema in the subcutaneous tissue with poor lymphatic and capillary drainage, leading to inadequate nutrients and oxygen reaching the skin. This causes skin to die and ulcers to arise.

Answer 493

Refractive error Optometrist

Answer 494

Lagophthalmos is the inability to fully close the eyelids, secondary to the proptosis

Answer 495

Henoch-Schonlein purpura is a vasculitic disorder that results in a purpuric rash, abdominal pain and arthralgia

Answer 496

The side effects of ciclosporin can be remembered by the 5 H’s: hypertrophy of the gums, hypertrichosis, hypertension, hyperkalaemia and hyperglycaemia

Answer 497

Bullous pemphigoid occurs more commonly in the elderly and is characterised by numerous tense bullae which may be preceded by a pruritic urticarial eruption. IgG autoantibodies bind to bullous pemphigoid antigens in the hemidesmosomes at the basement membrane zone. The disease is self-limiting in many cases and usually treated with low dose steroids.

Answer 498

Typical palpable purpura of Henoch Schönlein Purpura Henoch-Schonlein Purpura Henoch-Schonlein purpura (HSP) is a small vessel vasculitis that usually affects children. It is an IgA mediated disease that is thought to be triggered by a viral upper respiratory tract infection. HSP usually presents with a classical triad of purpura over the extensor surfaces of the lower limb, abdominal pain and arthritis. Renal involvement is often present- usually haematuria, proteinuria, nephritic syndrome or nephrotic syndrome. In young children, intussusception may also occur.

Answer 499

Hidradenitis suppurativa is a chronic, painful, inflammatory skin disorder is characterized by nodules, pustules, sinus tracts, and scars in intertriginous areas

Answer 500

no mucosal involvement (in exams at least*): bullous pemphigoid mucosal involvement: pemphigus vulgaris

Answer 501

Hirsutism is androgen dependent Hypertrichosis androgen independent

Answer 502

Trichophyton rubrum For Trichophyton rubrum infection, NICE guidelines say that the first line oral treatment should be oral terbinafine. Before commencing terbinafine, it is important to check liver function before and at regular intervals as it can cause hepatotoxicity.

Answer 503

with oral terbinafine, if there are no contraindications.

Answer 504

Spider naevi can be differentiated from telangiectasia by pressing on them and watching them fill. Spider naevi fill from the centre, telangiectasia from the edge

Answer 505

A potent topical corticosteroid plus a topical vitamin D preparation (both applied once a day, but at different times of day).

Answer 506

Impetigo occurs when bacteria enter via a break in the skin. This may be in otherwise healthy skin or may be related to eczema or dermatitis.

Answer 507

Non-bullous impetigo typically occurs around the nose or mouth. The exudate from the lesions dries to form a “golden crust”. They are often unsightly but do not usually cause systemic symptoms or make the person unwell.

Answer 508

Topical fusidic acid can be used to treat localised non-bullous impetigo. Draft NICE guidelines from August 2019 suggest using antiseptic cream (hydrogen peroxide 1% cream) first line rather than antibiotics for localised non-bullous impetigo. Oral flucloxacillin is used to treat more wide spread or severe impetigo. Flucloxacillin is the antibiotic of choice for staphylococcal infections. Advise about measure to avoid spreading the impetigo. Patients should be given advice about not touching or scratching the lesions, hand hygiene and avoiding sharing face towels and cutlery. They need to be off school until all the lesions have healed or they have been treated with antibiotics for at least 48 hours.

Answer 509

Bullous impetigo is always caused by the staphylococcus aureus bacteria. These bacteria can produce epidermolytic toxins that break down the proteins that hold skin cells together. This causes 1 – 2 cm fluid filled vesicles to form on the skin. These vesicles grow in size and then burst, forming a “golden crust”. Eventually they heal without scarring. These lesions can be painful and itchy. This type of impetigo is more common in neonates and children under 2 years, however it can occur in older children and adults. It is more common for patients to have systemic symptoms. They may be feverish and generally unwell. In severe infections when the lesions are widespread, it is called staphylococcus scalded skin syndrome. The condition is very contagious and patients should be isolated where possible.

Answer 510

Treatment of bullous impetigo is with antibiotics, usually flucloxacillin. This may be given orally or intravenously if they are very unwell or at risk of complications

Answer 511

Swabs of the vesicles can confirm the diagnosis, bacteria and antibiotic sensitivities.

Answer 512

Cellulitis if the infection gets deeper in the skin Sepsis Scarring Post streptococcal glomerulonephritis Staphylococcus scalded skin syndrome Scarlet fever

Answer 513

Aim for a 4 week break in between courses of topical corticosteroids in patients with psoriasis

Answer 514

‘windblown’ appearance of the keratinocytes and the presence of Pagetoid cells.

Answer 515

Keloid scars are most common on the sternum

Dermatology Flashcards

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