Dermatology Flashcards
(182 cards)
1
Q
Functions of skin?
A
Barrier to infection, thermoregulation, protection against trauma, protection against UV, vitamin D synthesis, regulate H20 loss
2
Q
Normal proliferation occurs in what layer? To balance new cells in the basal layer of the epidermis, what are shed from the surface of the stratum corneum? Process called what? This involves what? Normal pH of the skin?
A
Just in the basal layer
Mature corneocytes
Degradation of the extracellular corneo-desmosomes under the action of protease enzymes= desquamation
5.5(allows proteases to remain on the skin)
3
Q
3 layers of skin?
A
1) Epidermis
2) Dermis
3) SC tissue
4
Q
Layers of the epidermis?
A
Stratum corneum(keratin layer,) lucidum, granulosum, spinous, basale(dividing cells)
5
Q
What’s in the dermis? SC layer?
A
Meissner’s corpuscle- light touch, Pacinian corpuscle- coarse touch/ vibration
Fat
6
Q
What is the stratum corneum made up of in the epidermis? What do the corneo-desmosomes keep together? Increased/ decreased numbers in what conditions?
A
Corneo-desmosomes + desmosomes
Corneocytes
Psoriasis/ atopic eczema
7
Q
Cell types of the epidermis?
A
Keratinocytes- produce keratin
Langerhans cells- present antigens + activate T cells
Melanocytes= produce melanin
Merkel cells- specialised nerve endings for sensation
8
Q
Common causes of itch with a rash? Without a rash?
A
Urticaria, atopic eczema, psoriasis, scabies
Renal failure, jaundice, iron deficiency, lymphoma, polycythaemia, pregnancy, drugs, diabetes, cholestasis, skin ageing
9
Q
What does acne affect? Epidemiology?
A
Expansion + blockage of the hair follicle
Usually starts in adolescence, often resolves in mid-20s, prevalence= 70-87% in teenagers, affects face, back and chest, usually seen in 13-20 y/o
10
Q
Pathophysiology of acne?
A
Narrowing of hair follicle–> hypercornification blocking entrance–> increased sebum production, some becomes trapped, stagnates–> propionibacterium acnes multiply, breaks down triglycerides in sebum–> fatty acids–> neutrophils attraction–> pus + inflammation
11
Q
Sx of acne?
A
Whiteheads= closed comedones
Blackheads= open comedones
Skin-coloured papules
Inflammatory lesions= the closed wall of comedones ruptures
Papules
Pustules- white/ yellow spots
Nodules- large red bumps
(Commonly face, chest and upper back)
12
Q
Ix for acne? Tx for mild and severe acne?
A
Usually clinical Ix, skin swabs for microscopy + culture. females= hormonal tests
Mild: benzyl peroxide gel/ cream(increases skin turnover, clears pores + reduces bacterial count, causes dryness due to keratolytic effect)
Topical ABx= clindamycin/ erythromycin gel
Topical retinoids= tazarotene gel(inhibit formation + reduce number of microcomedones)- S/E= burning, stinging, dryness + scaling
Severe: oral doxycycline–> oral minocycline- 4 months, CI in pregnancy + children
Hormonal: failed/ menstruation control required, anti-androgen= suppresses sebum production e.g. oral Co-cyprindiol(acetate + ethinylestradiol,) oral retinoids e.g. isoretinoin= last-line, highly teratogenic, S/E= dry skin + lips, photosensitivity to sunlight, suicidal ideation, rarely= SJS and toxic epidermal necrolysis
13
Q
What is mild acne classed as? Moderate acne?
A
<20 comedones, <15 inflammatory lesions, /total lesion count<30
20-100 comedones, 15-50 inflammatory lesions/ total lesion count 30-125
> 5 pseudocysts, total comedo count>100 count, total inflammatory count>50, total lesions count>125
14
Q
What should people with acne be advised of?
A
To avoid over-cleaning the skin, use a non-alkaline synthetic detergent cleansing product x2 daily on acne-prone skin, avoid oil-based comedogenic skin care products, make-up + sunscreens, picking/ scratching can increase scarring risk, tx takes time to work
15
Q
Urgent referral for who with acne? Referral to consultant dermatologist for who?
A
Those with acne fulminans on the same day to the on-call hospital derm team to be assessed within 24 hours
Mild-moderate not responded to 2 completed courses, moderate-severe not responded to previous tx includes oral ABx, acne with scarring/ persistent pigmentary changes, psychological distress/ mental health disorder
16
Q
Epidemiology of eczema/ dermatitis? Aetiology? RFs?
A
Genetically complex, familial with strong maternal influence, up to 40% in their lifetime
Endogenous(atopic)- due to hypersensitivity
Exogenous(contact dermatitis from chemicals, sweat and abrasives)
PP not full understood- damaged filaggrin–> exogenous allergens can invade more easily
Family hx, initial TH2 lymphocyte activation–> inflammation
17
Q
Sx of eczema? Ix?
A
Face + flexure surfaces of limbs, itchy, erythematous, scaly patches on elbows, knees, ankles, wrists and around the neck. increased dryness. infants= often cheeks–> the body, acute may weep/ exude, recurrent s.aureus may be common
Atopic= clinical, 80%= high serum IgE, must have itchy condition in past 6 months + 3/ more of: hx of involvement of skin creases, personal hx of asthma/ hayfever/ family hx, hx dry skin, onset in first 2y of life
18
Q
Tx of eczema?
A
Avoid irritants/ allergens, keep nails short, complete emollient therapy e.g. E45 cream
Occlusive emollients= trap moisture in the skin)eczema= loss of NMF + abnormal lipid bilayer)–> increasing hydration, artificial permeability barrier above stratum corneum preventing water loss between corneocytes
Apply every 4 hours/ 3-4 times per day- x2 at least
250-500g child, 500-750g for adult
19
Q
Topical therapies for eczema?
A
Topical corticosteroids= 1st line
Topical calcineurin inhibitors= 2nd line
Moderate- severe/ non-responsive= oral immune-modulators, oral steroids, ABx, phototherapy with UV A, antihistamines
20
Q
E.g. corticosteroids for eczema?
A
Very potent(only on thick skin)= DERMOVATE (CLOBETASOL PROPIONATE 0.05%,)
Potent= BETNOVATE,
Moderate= EUMOVATE (CLOBETASONE BUTYRATE,)
Mild= HYDROCORTISONE 0.5%, 1% and 2.5%
(HEBDO- oral)
Directly + indirectly inhibit pro-inflammatory cytokines e.g. IL-1, IL-2, -6, TNF- alpha
S/E= skin atrophy, suppression skin barrier homeostasis, telangiectasia, skin thinning, acne, striae
ONLY INFLAMED SKIN
21
Q
E.g. topical calcineurin inhibitors for eczema?
A
Pimecrolimus(mild,) tacrolimus(moderate) ointment
Inhibits calcineurin which induces transcription factors for many interleukins which activate Th cells and induces production of other cytokines- reduce inflammation
(Less effective, less SEs, more useful for sensitive areas, don’t cause skin atrophy- face + eyelid option)
S/E= burning/ stinging following application
22
Q
Oral immune-modulators for eczema? Oral steroids? ABx? Antihistamines?
A
Ciclosporin(calcineurin inhibitor,) azathioprine
Oral prednisolone
Flucloxacillin
Chlorphenamine(sedates the patient so they can sleep)
23
Q
Thin emollient creams for eczema? Thick emollient creams?
A
E45, diprobase cream, oilatum cream, Aveeno, cetraben, epaderm
50:50 ointment, hydromol/ diprobase/ cetraben/ epaderm ointments
24
Q
Most common bacterial infection in eczema? Other viral infection? Tx for bacterial? Sx of eczema herpeticum? Tx?
A
S.aureus–> weeping, crusting, pustules w/ fever or malaise
HSV-1 (eczema herpeticum)
Oral ABx, flucloxacillin, more severe= admission + IV ABx
Widespread, painful, vesicular rash with systemic symptoms e.g. fever, lethargy, irritability + reduced oral intake, lymphadenopathy
Viral swabs–> aciclovir, oral–> IV for mild–> severe
25
Immediate hospital admission for eczema? Consider referral when? Referral to immunologist, paediatrician/ dermatologist when?
Suspected eczema herpeticum
Diagnosis uncertain, not controlled with current treatment, recurrent secondary infection, high risk of comps, tx advice needed
Food allergy trigger suspected, can't manage in primary care
26
Epidemiology of psoriasis? Aetiology/ RFs?
Affects 2% of the UK population, peak prevalence in early adulthood, second peak= 50-60 y/o, equally in men and women
Is polygenic- infection with group A strep, drugs e.g. lithium, UV light, high alcohol use, stress, family hx
27
PP of psoriasis?
T-cell activation--> upregulation of Th1 types cell cytokines e.g. interferon gamma, interleukins, growth factors and adhesion molecules--> increased uncontrolled hyperproliferation of the keratinocytes in the epidermis with increase in epidermal cell turnover rate
28
Sx of psoriasis?
Pitting + onycholysis, chronic plaque psoriasis= most common--> well-demarcated disc-shaped salmon-pink silvery plaques on exterior surface of limbs(elbows + knees,) scalp common, thickened epidermis, new plaques at sites of skin trauma
29
Tx for psoriasis?
Emollients e.g. E45
Topical vitamin D analogues- stimulate keratinocyte differentiation e.g. calcipotriol cream
Topical corticosteroids e.g. hydrocortisone
Topical retinoids e.g. tazarotene gel
UVB
Coal tar
Anti-mitotic e.g. dithranol cream(large plaques)
Extensive plaques= phototherapy with UVA, DMARDs(inhibits folic acid production + DNA replication, GIVE FOLIC ACID SUPPLEMENTS 48 HOURS AFTER TX e.g. oral methotrexate, immunosuppressants e.g. ciclosporin
30
Occurrence of flexural psoriasis? Sx? 1st + 2nd line tx?
Later in life, well-demarcated red, glazed non-scaly plaques, scaling= ABSENT, confined to flexures, mistaken for candida intertrigo
1st line= topical mild-moderate corticosteroids e.g. hydrocortisone/ clobetasol butyrate(short course prevent atrophy)
2nd line= topical vit D analogue e.g. calcipotriol cream
31
Who gets guttate psoriasis? Sx? Tx?
Children + young adults
Trunk, upper arms and legs- small circular/ oval plaques over trunk 2 weeks after strep sore throat
Topical mild-moderate corticosteroids e.g. hydrocortisone/ clobetasol butyrate, UVB, coal tar
32
What is palmoplantar psoriasis? Tx?
Thickening of palms and soles
Emollients, keratolytic agents e.g. salicylic acid, potent topical corticosteroids e.g. flucinonide, phototherapy with UVA, oral retinoid e.g. oral acitretin= anti-proliferative, alongside phototherapy, S/E= dry lips, eyes and mucosa, hyperlipidaemia, disturbed liver functions, TERATOGENIC
IF SYSTEMIC THERAPY FAILED= anti-TNF biologics e.g. IV infliximab, IV etanercept/ IV adalimumab
33
Types of psoriasis is an emergency?
Pustular- pustules form under areas of erythematous skin(not infectious)
Erythrodermic= extensive red inflamed areas covering most of the surface of the skin- comes away in large patches--> raw + exposed
34
Specific signs of psoriasis?
Auspitz sign- small points of bleeding when plaques are scraped off
Koebner phenomenon= psoriatic lesions affected by trauma
Residual pigmentation after lesions resolve
35
What is a venous ulcer defined as?
Loss of skin below the knee on the leg/ foot that takes more than 2 weeks to heal from sustained HTN in the superficial veins
36
Epidemiology and aetiology of venous ulcers?
Most in developed world, common in later, most on lower leg in triangle above the ankles
Incompetent valves in deep/ perforating veins, previous DVT, atherosclerosis, vasculitis
Varicose veins/ DVT
37
PP of venous ulcers? Sx?
Increased pressure--> extravasation of fibrinogen through capillary walls--> perivascular fibrin deposition--> poor oxygenation of surrounding skin
Sloping + gradual edges, ulcer= large, superficial, irregular and exudative, oedema of lower leg, venous eczema, brown pigment from haemosiderin, less painful than arterial- relieved by elevation
38
Ix of venous ulcers? Tx?
ABPI= normal, Doppler USS exclude arterial disease
High compression 4 layered bandage, leg elevation, ABx for infection, analgesia- ibuprofen/ morphine, support stockings for life
39
Epidem and RFs for arterial ulcers? Sx?
Claudication, HTN, angina/ smoking, arterial disease, hypercholesterolaemia, diabetes
Punched out, painful ulcers higher up leg/ on feet, intense pain worse on elevation + at night, leg= cold, pale, shiny skin, loss of hair, absent peripheral pulses, arterial bruits, NO OEDEMA
40
Ix and tx for arterial ulcers?
Doppler USS, ABPI= arterial insufficiency
Keep clean + covered, analgesia, vascular reconstruction, never use compression bandaging
41
Score used for estimating a patient's risk of developing a pressure ulcer?
Waterlow Score
42
Sx of neuropathic ulcers? Tx?
Often painless, over pressure areas of the feet, common in diabetes + neurological disease, leprosy= common cause in developing countries, variable size, may be surrounded by callus, warm skin + normal pulses
Keep ulcer clean, remove pressure/ trauma from area, correctly fitting shoes + specialist podiatrist for diabetes
43
Most common cutaneous vasculitis? Usually appears where? Causes? Sx? Tx?
Leucocytoclastic vasculitis/ angiitis
On lower legs as symmetrical palpable purpura
Idiopathic, drugs, infection, inflammatory/ malignant disease
Haemorrhagic papules, pustules, nodules, plaques, DON'T BLANCH with glass slide pressure, pyrexia + arthralgia
Analgesia, support stockings, dapsone(antibiotic)// prednisolone
44
Things to ask in a skin cancer hx?
Sunlight/ sun exposure, occupation, foreign travel, radiation exposure, burn easily/ sun protection, smoking, family hx- benign/ malignant, genetic, PMH- immunosuppression?, previous skin cancer, moles, growing, bleeding, itching
45
Examination for a skin lesion/ ulcer?
Look, feel, move, regional lymphatic drainage, special tests
Look: single/ multiple, size, site, shape, margin, edge, floor, discharge, surrounding skin, whole limb(if limb,) consider dermatoscope
Feel: tenderness, temp, edge-induration, bleeding?
Move: tethering?
Regional lymphatic drainage: lesion in lower limb, trunk, upper limb, head + neck
Special tests: peripheral pulses, light touch and pressure sensation, bony involvement, relevant examinations if systemic features
46
Epidemiology and RFs for melanoma? 5 year survival rate?
Excessive sun exposure + sunburn in childhood, more affluent people, heavy alcohol drinking(alcohol carcinogenic to melanocytes,) red hair, high density freckles, skin type 1: tends to burn and not tan, atypical moles, multiple melanocytic naevi, sun sensitivity, immunosuppression, family hx, pale skin
90%
47
Sx of melanoma?
Men= back/ chest, women= lower legs, more in younger people
>95%= dark colour, black/ almost black
ABCDE: asymmetrical, border irregular, colour irregular, diameter>6mm, elevation/ evolution
48
Major features for a lesion scoring 2 points? Minor scoring 1? Lesions above/= to what are suspicious and need referring?
Change in size, shape, border/ colour
Largest diameter 7mm/ more, inflammation, oozing/ crusting of the lesion, change in sensation- itching
3, low suspicion= monitor over 8 weeks
49
Most common type of melanoma? Most aggressive?
1)Superficial spreading(SSMM)- trunk in males, legs in females
2) Nodular- most common= trunk, head and neck
3) Lentigo: common= face, more common in elderly
4) Acral: palms/ soles, most common in darker skin types, often presents late, worse prognosis
50
DDx for melanoma? Tx? Prognosis?
Benign pigmented naevus, seborrheic wart, pyogenic granuloma- small warty lesion bleeds easily, non-pigmented- minor trauma, benign lesion grows quickly
51
Tx? Prognosis of melanoma?
2WW
Surgical= curative in early cases, metastatic= remove lymph nodes, isolated limb perfusion, radiotherapy, immunotherapy and chemo
Distant= commonest to lung, liver, CNS
Diagnostic excision of the pigmented skin lesion with a 2mm peripheral margin
Wide local excision - margins dependent on staging
Thin lesions<1mm- Breslow= best, >60= <5y survival, female advantage, ulceration= late sign, poor= trunk vs limbs
52
What is dermoscopy useful for? 3-point checklist?
Distinguishing between benign and malignant pigmented lesions
Asymmetry of colour/ structure, atypical pigment network, blue-white structures
53
What are pre-malignant keratinocyte tumours which can turn into SCC? RFs for non-melanocytic skin cancer?
Actinic keratosis and Bowen's disease
UV exposure, Fitzpatrick skin types I-II, increasing age, immune suppression, ionising radiation, chronic wounds, smoking, HPV, genetics
54
Sx of actinic keratosis? Tx?
Develops over years, sun exposed sites, no hx of rapid growth/ pain/ bleeding/ ulceration, base not raised
Field change= topical treatments(5- flurouracil, imiquimoid, diclofenac,) PDT
Discrete lesions= cryotherapy, C&C, topical treatments
55
Sx of Bowen's disease(in situ SCC confined to the epidermis)? Tx?
Develops over years, sun exposed sites, no hx of rapid growth/ pain/ bleeding/ ulceration, base not raised
5- flurouracil, cryotherapy, C&C, PDT
56
What is a SCC? Sx?
Locally invasive malignant tumour of the squamal keratinocytes, more aggressive than BCC, higher met potential- part to lymph nodes
Sun-exposed sites in later-life, keratotic, ill-defined nodules may ulcerate, grow very rapidly, raised base, may be painful, ulcerates lesions on lower lip/ ear= often more aggressive
57
Tx of SCC? DDx for SCC?
Surgical excision with minimal margin of 5mm, radiotherapy if non-resectable
Keratocathoma- may shrink, tx surgically, solid core filled with keratin, arise from hair follicle skin cells
58
Most common malignant skin cancer? Sx?
BCC< metastatic + aggressive than SCC
Border= raised with pearly appearance, slowly enlarging shiny nodule on head and neck which bleeds following minor trauma, local destruction if not tx
59
BCC tx?
Surgical excision with wide borders + histology to ensure margins
Superficial= cryotherapy, photodynamic therapy, radiotherapy if can't tolerate surgery
60
What is the thick skin found over the palms, soles of the feet and flexor surfaces of the fingers that is free from hair called? Hair follicles and sebaceous glands combine to form what? They release their glandular secretions via what mechanism into the hair follicle shaft? The hair follicle is associated with what?
Glabrous skin
Pilosebaceous unit
Holocrine mechanism
Arrector pili- contract to cause the follicle to stand upright
61
2 types of sweat glands? Eccrine glands release a clear odourless substance comprised mainly of what? Involved in what? Location of apocrine glands? These can be broken down by what producing what? Layer that's a major body store of adipose tissue?
Eccrine and apocrine
NaCl + water- thermoregulation
Axillary and genital regions
Cutaneous microbes--> body odour
Hypodermis
62
Cellulitis preferentially involves what area? Aetiology? RFs?
Lower extremities
Group A Beta-haemolytic strep e.g. s.pyogenes= most common, s.aureus, sometimes MRSA
Lymphoedema, leg ulcers, immunosuppression, traumatic wounds, athletes, leg oedema, obesity
63
PP and presentation of cellulitis? DDx?
Lower leg/ arm and spreads proximally, also abdomen, perianal and periorbital areas- can affect just one side of face
Local inflammation- proximally spreading, hot erythema in affected area, poorly demarcated margins, swelling, warmth and tenderness, occasionally will blister if oedema is prominent, systemically unwell with pyrexia
DVT, septic arthritis, acute gout, ruptured Baker's cyst
64
Ix and tx of cellulitis?
Clinical, skin swabs= negative unless from broken skin, serological testing to confirm a strep infection e.g. antistreptolysin O titre(ASOT)
ABx: oral phenoxymethylpenicillin/ oral flucloxacillin, oral erythromycin if penicillin allergic
If widespread- then IV for 3-5 days followed by at least 2 weeks of oral therapy
Recurrent--> prophylaxis low-dose ABx e.g. oral phenoxymethylpenicillin x2 daily
65
What is necrotising fasciitis? 2 forms? RFs?
Deep-seated infection of SC tissue--> fulminant and spreading destruction of fascia and fat- initially spares the skin, high mortality
Type 1: caused by mixture of aerobic and anaerobic bacteria following abdominal surgery/ diabetics
Type 2: from group A beta-haemolytic strep e.g. s.pyogenes- most common cause, arises in previously healthy patients
Abdominal surgery, immunosuppression
66
Presentation of necrotising fasciitis?
Severe pain out of proportion to skin findings at initial site of infection rapidly followed by tissue necrosis, infection track rapidly along the tissue planes causing spreading erythema, pain and sometimes crepitus
Suspect in those with fever, toxicity and pain out of proportion to the skin findings
Multi-organ failure= common, mortality= high
67
Ix and tx of necrotising fasciitis?
Soft tissue gas on XR, raised CRP, very raised white cell count, treat aggressively and promptly
For confirmed group A strep: Type 2= IV benzylpenicillin + clindamycin
Unknown aetiology e.g. Type 1= broad spec IV ABx with inclusion of IV metronidazole
Urgent surgical exploration with extensive debridement/ amputation if necessary
68
Eron classification for cellulitis: class 1, 2, 3, 4? Admit for IV ABx if what class or what?
No systemic toxicity/ comorbidity, systemic toxicity/ comorbidity, significant systemic toxicity/ significant comorbidity, sepsis/ life-threatening
Class 3 or 4, frail, very young or immunocompromised
69
Example of diffuse non-scarring hair loss? Responds to what orally, but what happens? Other causes? Causes of localised non-scarring hair loss? Scarring?
Male pattern baldness- topical minoxidil and 1mg finasteride orally- returns as soon as it's stopped(not available on NHS prescription)
Hypothyroidism; iron deficiency; malnutrition; hypopituitarism; hypoadrenalism; drug-induced
Alopecia areata; ringworm, traumatic, hair pulling, traction; SLE; secondary syphilis
Burns; radiation; shingles; tertiary syphilis; lupus erythematosus; morphoea; lichen planus
70
Example of diffuse non-scarring hair loss? Responds to what orally, but what happens? Other causes? Causes of localised non-scarring hair loss? Scarring?
Male pattern baldness- topical minoxidil and 1mg finasteride orally- returns as soon as it's stopped(not available on NHS prescription)
Hypothyroidism; iron deficiency; malnutrition; hypopituitarism; hypoadrenalism; drug-induced
Alopecia areata; ringworm, traumatic, hair pulling, traction; SLE; secondary syphilis
Burns; radiation; shingles; tertiary syphilis; lupus erythematosus; morphoea; lichen planus
71
What is alopecia areata? % with a family hx? Alternative diagnosis of what if scales/ erythema are present? Tx?
Chronic inflammatory disease affecting the hair follicles +/- nails, patches of hair loss usually on the scalp
20%
Tinea capitis
Reassure and monitor hair loss; refer more severe cases, topical/ locally injected/ systemic steroids +/- contact immunotherapy
72
If skin lesions are present with itch, search for what? Exceptions are patch testing for what and skin biopsy for what? Causes when skin lesions are present?
Unexcoriated lesions, contact dermatitis and dermatitis herpetiformis
Urticaria, infections, contact dermatitis and allergies, prickly heat, skin infestations e.g. scabies, pediculosis, insect bites, dermatitis herpetiformis, lichen planus, senile atrophy, psychological causes
73
Look for what when skin lesions are absent with itch? Consider what Ix? If still undiagnosed do what? Causes?
Pallor, jaundice, weight loss, LN enlargement, abdominal organomegaly
Urinalysis- dipstick + MSU, FBC, ESR/ CRP, serum ferritin, LFTs, U&Es, Cr and eGFR, glucose, serum Ca2+, TFTs and CXR
Refer
Hepatic- obstructive jaundice, pregnancy, endocrine= DM, thyrotoxicosis, hypothyroidism, hyperparathyroidism, renal= chronic renal failure, haem= polycythaemia vera, iron deficiency, leukaemia, Hodgkin's disease, malignancy- any carcinoma, drug allergies, psych= obsessive states, schizophrenia, rare= diabetes insipidus, roundworm infection
74
Causes of subcorneal blisters? Intraepidermal? Subepidermal? Other?
Bullous impetigo, pustular psoriasis
Eczema, HSV, VZ- chickenpox/ shingles, pemphigus, friction
Cold/ heat injury, pemphigoid, dermatitis herpetiformis, linear IgA disease
Insect bites
75
What is bullous pemphigoid? Ddx?
Usually affecting the elderly, urticarial reaction may precede onset of blistering
Large, tense blisters on red/ normal skin on limbs, trunk and flexures, oral in 20-30%, may be localised
Pemphigus, dermatitis herpetiformis, linear IgA disease
76
What does cicatricial pemphigoid affect? Pemphigoid gestationis?
Mucous membranes in the eyes/ mouth, scarring--> visual loss, refer to ophthalmology
Ass w/ pregnancy- remits after delivery, often recurs in subsequent pregnancies
77
Refer for what? Tx for pemphigoid?
To derm for skin biopsy
Oral steroids pred 30-60mg daily initially- reducing as symptoms improve, Abx, nicotinamide, azathioprine, other immunosuppressants
78
What is pemphigus? Presentation and tx?
Uncommon AI disorder affecting skin + mucous membranes, peak= 30-70 y/o, 90%= circulating autoantibodies, ass with other AI disorders e.g. MG
50%= oral lesions, mucocutaneous erosions/ blisters, flaccid superficial then appear- sometimes months later- over scalp, face, back, chest and flexures, may present as crusted erosions
Refer to derm- high-dose systemic steroids/ other immunosuppressive agents
79
Peak age for dermatitis herpetiformis? Presentation? Closely related to what? DDx? Tx?
3rd/4th decade, itchy vesicular rash on elbows, knees, buttocks, and scalp, often broken by scratching to leave excoriations
Coeliac disease- classic sx uncommon
Scabies, eczema, linear IgA disease
Refer to derm for skin biopsy- responds to withdrawal of gluten, may take up to 1 year, controlled with dapson or sulfapyridine
80
What is epidermolysis bullosa?
Group of genetically inherited diseases characterised by blistering on minimal trauma, most common= simple (AD,) blistering= from friction, mild and limited to hands and feet, advised to avoid trauma
81
What is linear IgA disease?
Rare condition of blisters and urticarial lesions on the back and extensor surfaces- refer to derm, responds to dapsone
82
What is contact dermatitis precipitated by? DDx? Presentation? Tx?
Irritants- water, abrasives, chemicals, detergent/ allergens e.g. nickel chrome; rubber
Endogenous eczema, psoriasis, fungal infection
Affects hands most commonly- acute= itchy erythema + skin oedema +/- papules, vesicles, or blisters, chronic= lichenification, scaling and fissuring
Identify the agent- consider referral for patch testing, exclusion from the environment, hand care, emollients, topical steroids, exclude/ tx secondary infection
83
What is urticaria? What does angio-oedema commonly affect?
Superficial itchy swellings of the skin/ weals
Deeper longer-lasting; painful> itchy= eyes, lips, genitalia, hands and/ or feet, may affect bowel/ airway, consider anaphylaxis if airway compromise
84
Fraction of urticarial lesions present with urticaria alone? Angio-oedema alone?
Half
1 in 10
85
Tx of acute urticaria?
Antihistamines for itch- non-sedating for daytime
Topical menthol 1% cream= alternative/ adjunct to antihistamines
Severe= short-course steroids e.g. pred 40mg OD for 3-5 days
86
Tx of chronic urticaria?
Check FBC, ESR and TFTs
Assess severity and impact- identify causes, avoid, NSAIDs if aspirin-sensitive
Antihistamines for itch, others= H2 receptor antagonists + anti-leukotrienes
87
Tx of angio-oedema?
Adrenaline if anaphylaxis is suspected, admit if airway compromise, otherwise same as acute urticaria, if not taking ACE-i, refer to allergy clinic/ immunology, if taking- stop, refer if sx continue/ recur after >3 months
88
Who does urticaria pigmentosa appear in? Sx and tx?
In infancy, usually <2 weeks, dark freckle-like lesions on the face, limbs or trunk become urticarial when the skin is rubbed
No tx is needed- clears spontaneously
89
Sx of urticarial vasculitis? Other features? Ix? Specialist tx?
Burning/ painful rather than itchy and/ or lesions leave scaling, bruising, purpura/ petechial haemorrhages, suspect if relentless
Joint pains, fever, and/ or malaise, refer
Skin biopsy
Steroids and/ or other immunosuppressive agents
90
What is hereditary angio-oedema caused by? inheritance? Emergency tx? Maintenance therapy for who?
C1 esterase inhibitor deficiency- autosomal dominant, usually presents in puberty with episodes of angio-oedema without weals- low C4 level suggests the diagnosis
Hospital admission for C1 inhibitor concentrate infusion
For patients with symptomatic recurring angio-oedema or related abdominal pain
91
Causes of pallor?
Anaemia, shock, Stokes-Adams attack, vasovagal faint, myxoedema, hypopituitarism, and albinism
92
What is lichen planus?
Very itchy polygonal, flat-topped papular lesions 2-5mm diameter affecting flexor surfaces, palms/ soles, mucous membranes and genitalia in a symmetrical pattern, Koebner phenomenon- papules may have white lines (Wickham's striae)
Initially papules= red, but become violaceous, flatten over a few months to leave pigmentation or occasionally become hypertrophic
93
Peak age of lichen planus? Cause? Variants? Ddx?
30-60 y/o, unknown
Annular- commonly on glands penis
Atrophic- ass w/ hypertrophic lesions
Bullous- blistering= rare
Follicular- may just affect the scalp
Hypertrophic- may persist for years
Mucous membrane- alone/ with skin changes
Lichenoid drug eruption; psoriasis
94
Tx for lichen planus?
Emollients and moderate/ high potency topical steroids = symptomatic relief, sedating antihistamines may be useful if sleep disturbed, oral lesions= hydrocortisone pellets
95
What is pityriasis rosea? What may relieve itch? Fades spontaneously in how long?
Acute self-limiting disorder most commonly affecting teenagers and young adults
Generalised eruption preceded by herald patch- single, large oval lesion 2-5cm diameter, several days later= rash many smaller lesions mainly on trunk, also upper arms and thighs
Lesions= oval, pink and delicate collarette of scale, may be asymptomatic/ cause mild/ moderate itch
Tx= doesn't speed clearance, topical steroid- in 4-8 weeks
96
What is pityriasis (tinea) versicolor? Tx?
Chronic often asymptomatic, fungal infection of the skin, common in humid/ tropical conditions, UK= often affects young adults and teenagers
On untanned, white skin= pinkish-brown, oval, or round patches with a fine superficial scale, tanned/ darker skin= patchy hypo-pigmentation, trunk +/- proximal limbs
Topical imidazole antifungal/ selenium sulfide shampoo to all affected areas at night, washed off following morning and repeated x2 at weekly intervals
Resistant= systemic antifungal e.g. itraconazole 200mg OD for 1 week
97
Sx of pityriasis alba? Affects who? Associated with what? Tx?
Finely scaled white patches on face or arms- children/ young adults
Atopy
None- resolves spontaneously over months or years, severe= topical steroids and/ or PUVA
98
Seborrheic warts are common in who? Often what and where? Cause? Features on dermoscopy and tx?
In >60 y/o
Often multiple, most commonly on trunk
Warty nodules, usually pigmented, 1-6cm diameter with a stuck-on appearance, pieces can be picked off
Unknown
'Fat fingers,' irregular crypts, light brown fingerprint-like parallel structures, milia-like cysts- 2 types: tiny, white starry and larger yellowish cloudy
Reassurance- removal required= cryotherapy, curettage, shave biopsy, excision biopsy are all effective
99
What is actinic (solar) keratosis? Tx?
Single/ multiple, discrete, scaly, discrete, hyperkeratotic, rough-surfaced areas over sun-exposed areas e.g. dorsum of hands; head, neck, occasionally= on lower lip, more common in fairer skin types, may regress spontaneously or be pre-malignant
Removal by cryotherapy, curettage, excision biopsy or topical:
Ingenol mebutate gel 150mcg/g OD for 3 days to scalp/ face or 500 mcg/g OD to trunk/ extremities for 2d
Fluorouracil cream- thinly OD/ BD for 3-4 weeks
Diclofenac gel- BD for 2-3 months
Imiquod cream
Advise sunblock daily; avoid sun exposure by covering up, wear a hat with a brim
100
What is a naevus? Ddx?
Benign proliferation of >/=1 normal constituent of the skin, most common= melanocytic naevus/ 'mole', most develop in childhood + adolescence
Freckle, lentigo, seborrheic wart, haemangioma, dermatofibroma, pigmented BCC, malignant melanoma
101
Features of naevi?
Congenital at birth in 1% Caucasians, usually >1cm diameter, large ones= high risk of malignancy, junctional: flat, round/ oval, brown/ black, 2-10mm diameter, common= soles, palms, genitalia
Intradermal= dome-shaped papule/ nodule commonly on the face or neck, may be pigmented
Compound<10mm diameter, smooth surface, variable pigmentation
Blue= blue-coloured solitary naevus found on extremities- especially hands and feet
Halo= common in children/ adolescents, white halo of depigmentation surrounds the naevus= then disappears, ass w/ vitiligo
102
Tx of naevi? Reasons for excision biopsy? Refer when?
Patients usually present worried about a mole- any change merits attention
Concern about malignancy, increased risk of malignant change, recurrent trauma/ inflammation, cosmetic reasons
For urgent derm assessment if malignancy is suspected
103
What are skin tags? How can cosmetic removal be achieved?
Small pedunculated polyps found in the axillae, groin, neck/ on the eyelids
Snipping across the skin tag with scissors, cryotherapy, or diathermy
104
What are sebaceous cysts? What is curative?
Round/ oval keratin-filled firm cysts 1-3cm in diameter within the skin, usually a punctum is seen on the surface- reassure
Tx any complicating bacterial infection with oral ABx e.g. flucloxacillin 500mg QDS
Excision
105
What is a dermatofibroma? Tx?
Firm nodule 5-10mm in diameter may occur following an insect bite or minor trauma, most common site= lower legs
Excision biopsy of symptomatic/ diagnostically doubtful lesions
106
What is a keratocanthoma? DDx? Tx?
Rapidly growing nodular tumour of sun-exposed skin of face/ arms, central keratin plug may fall out leave a crater, heals spontaneously over several months leaving a scar
SCC
Excision biopsy to exclude SCC or curettage and cautery
107
What is a Keloid scar? Tx?
Proliferation of connective tissue presenting as firm smooth nodules/ plaques in response to trauma
Changes limited to the scar= hypertrophic, keloid if extends beyond limit of original injury
Most common sites= upper back, chest, ear lobes, more common in negroid races(2nd-4th decades)
Consider steroid injection into scar, ineffective--> dermatologist/ plastic surgeon
108
What is a pyogenic granuloma? Tx? Other common cause of benign tumour?
Bright red/ blood-crusted nodule that bleeds easily, typically at trauma site, enlarges rapidly over 2-3 weeks, usually in children/ young adults, most common= finger, DDx= malignant melanoma
Pregnant= may disappear spontaneously after delivery, other= exclusion biopsy to exclude malignancy
Lipoma- often on trunk, neck, upper extremities, removal by excision= rarely needed
109
What is a Campbell de Morgan spot(cherry angioma)?
Small bright red papules on the trunk in middle-aged/ elderly patients, usually no tx required
110
What is impetigo? DDx? Avoid what? Localised/ widespread tx?
Superficial skin infection due to s.aureus, very common in childhood, thin-walled blister ruptures easily--> yellow crusted lesion, may occur anywhere, most common on face
HSV, fungal infection
Spreading to other children- no sharing towels, face flannels
Topical ABx e.g. fusidic acid cream, oral flucloxacillin/ clarithromycin
111
What is erysipelas? Sx? DDx?
Acute infection of the dermis
Often preceded by fever/ flu-like sx- usually affects face/ lower leg- painful, tender reddened area with a well-defined
Often the area is swollen and may blister, may be an obvious entry wound
Angio-oedema, contact dermatitis, gout
112
Tx for severe erysipelas? If systemically well? For facial infection? Recurrent infections?
Admit for IV ABx
Mark the area before starting flucloxacillin 500mg QDS/ clarithromycin 500mg BD for 7-14 days- advise to seek help if infection is spreading or becoming systemically unwell
Penicillin 500mg QDS- fluclox 500mg QDS/ clarithromycin 500mg BD
May need prophylactic long-term penicillin w/ attention to skin care and management of any lymphoedema
113
What is a boil(furuncle)? Sx? Predisposing factors? Carbuncle?
Acute infection of a hair follicle usually with s.aureus- hard, tender red nodule surrounding a hair follicle becomes larger and fluctuant after several days, occasionally ass w/ fever +/- malaise, later may discharge pus and a central 'core' before healing may leave a scar- DM, HIV, obesity, blood dyscrasias, immunosuppressive drugs
Swollen painful area discharging pus from several points, group of hair follicles become deeply infected, usually with s.aureus, may be ass w/ fever+/- malaise- malnutrition, cardiac failure, drug addiction, severe generalised dermatosis, prolonged steroid therapy, DM
114
Tx of boils// carbuncles if non-fluctuant lesions? Fever/ surrounding cellulitis/ lesion on the face? Large, but localised, painful and fluctuant?
Apply moist heat to relieve discomfort, help localise infection, and promote drainage
Oral ABx e.g. flucloxacillin 500mg QDS for 7 days- clarithromycin 500mg BD alternative
Consider incision and drainage, admission may be needed if young/ uncooperative child
Admit if not sensitive
Recurrent/ chronic take swabs for culture- advise improved hygiene
115
What is folliculitis? RFs? DDx? Tx?
Superficial infection of the hair follicles usually from s.aureus usually presents as pustules in hair-bearing areas e.g. legs, beard
Obesity, DM, occlusion from clothing, topical steroid use
Pityrosporum folliculitis
Exclude DM; tx with topical antiseptic, not clearing- topical/ systemic ABx, recurrent/ chronic= tx as recurrent boils
116
What is acute paronychia? Tx?
Infection of skin and soft tissue of proximal and lateral nail fold- most commonly s.aureus- often from break in the skin or cuticle as a result of minor trauma e.g. nail biting
Skin + soft tissue= red, hot and tender, nail may be discoloured/ distorted- tx same as a boil
117
What is staphylococcal whitlow(felon)? Sx? DDx?
Infection involving bulbous distal pulp of the finger following trauma/ extension from acute paronychia, onset of pain= rapid, there is swelling of the entire finger
Herpetic whitlow
118
Tx for felon if fluctuant? Non-fluctuant?
Admit for drainage and Abx
Elevate, apply moist heat e.g. soak in hot water, and tx with oral ABx- fails--> incision and drainage
119
RFs for wound infection? Sx?
Malnutrition, carcinomatosis, infection near the incision site, DM, steroid therapy, contamination of the wound
Painful, look for swelling, wound tenderness +/- pus
120
Ix for wound infection? If indurated and infection localised to the wound suspect what and tx? If cellulitis around wound suspect what and tx? If foul smell, suspect what and tx?
Swab for M,C&S
Staph- flucloxacillin 500mg QDS/ clarithromycin 500mg BD
Strep- penicillin V 500mg QDS/ clarithromycin 500mg BD
Anaerobes- metronidazole 400mg TDS
121
Other name for a verucca? Plane warts most common on what? May show what?
Plantar warts
Face/ backs of hands- smooth flat-topped papules often slightly brown in colour, usually>1- Koebner phenomenon
122
Tx of common, plantar and plane warts?
Refer immunocompromised for specialist advice- tx usually unnecessary
123
Sx of primary HSV stomatitis?
After prodromal period<6 hours of tingling, discomfort, or itching, small tense vesicles appear on erythematous base, burst to form multiple, small painful mouth ulcers, infection may be accompanied by systemic sx- may be asymptomatic
124
Tx of primary HSV stomatitis?
Symptomatic relief- analgesic mouthwashes e.g. benzydamine- healing in 8-12 days, <48h= oral antivirals e.g. aciclovir 200mg 5x/d for 5 days- if cannot take fluids--> admit for IV fluids
125
What is molluscum contagiosum? Tx?
DNA pox virus spread by contact- including towels- discrete pearly pink umbilicated papules, 1-3mm in diameter, squeezed--> cheesy material
Lesions= multiple + grouped usually on trunk, face or neck, untreated= resolve spontaneously after 12-18 months
Older child= expressing the contents with forceps, curettage or cryotherapy is possible- usually unnecessary
126
What is an orf? Cause? Complications?
Solitary red rapidly growing papule often on hand, evolves into painful purple pustule, usually hx of close contact with sheep
Parapox virus- incubation period= 6 days, resolves spontaneously in 2-4 weeks
COMPS= secondary infection; erythema multiforme, lymphangitis- tx with topical/ systemic ABx
127
Sx of thrush? Intertrigo?
Itchy, sore vulvovaginitis +/- white plaques on mucous membranes and cheesy discharge, men= similar
Reddened, moist glazed area in submammary, inguinal/ axillary folds, wet workers= may be between digits, patients may present with skin changes and/ or itch
128
Sx of oral thrush? Who does systemic candidiasis occur in?
Sore mouth, poor feeding in infants, most common in babies, patients with poor oral hygiene, or elderly with false teeth, white plaques on buccal mucosa which can be wiped off +/- angular stomatitis
Immunosuppressed e.g. HIV/ malignancy, red nodules may appear on skin
129
RFs for candidiasis?
Moist, opposing skin folds, obesity, DM, neonates, pregnancy, poor hygiene, humid environment, wet work occupation, use of broad spec ABx
130
Tinea denotes what infection type? Dermatophyte infection affects what? What may confirm diagnosis?
Fungal infection
Skin, hair or nails
Skin scrapings or nail clippings
131
Topical tx for fungal infections? Genital lesions? Nail infections? Skin lesions?
Remove tongue deposits with a toothbrush by brushing 2x/ day, treat with oral suspensions or gels
False teeth= imidazole gel on the teeth before insertion and sterilise overnight with dilute hypochlorite solution e.g. Milton
Imidazole cream/ pessaries
Edge/ 1 or 2 nails= use a lacquer or paint e.g. amorolfine 1-2x/week after filing/ cleansing for 6 months(fingernails) or 9-12 months (toenails)- avoid nail varnish/ artificial nails during treatment
Imidazole cream, spray or powder; terbafine cream
132
Use systemic tx for what with fungal skin infections? Warn about what?
For oral, mucocutaneous or systemic candidiasis= oral fluconazole 50mg OD for 1-2 weeks- higher doses/ prolonged therapy if immunosuppressed
Genital= single oral dose of 150-200mg fluconazole
Tinea pedis/ manuum= oral terbinafine 250mg OD for 2-6 weeks or itraconazole 100mg OD for 30d/ 200mg BD for 7 days
Tinea cruris= oral terbinafine
Nail infection= consider if topical tx unsuccessful/ proximal or >2 nails= involved, confirm with nail clipping mycology before tx with oral terbinafine
Scalp- if kerion suspected= refer to derm, otherwise oral terbinafine/ griseofulvin(''= teratogenic)
133
Sx and location of ringworm? DDx?
Single/ multiple plaques with scaling and erythema, especially at the edges, lesions enlarge slowly and clear centrally- trunk/ limbs, discoid eczema/ psoriasis/ pityriasis rosea
134
Sx and location of cruris-'jock itch'? DDx?
Ass w/ tinea pedis, involves upper thigh + scrotum rarely, red plaque with scaling- groin(common in athletes,) intertrigo, candidiasis, erythrasma
135
Sx and location of pedis? DDx?
Itchy maceration between the toes, RFs= swimming, occlusive footwear; hot weather- feet, young>old, contact dermatitis, psoriasis, pompholyx
136
Sx and location of capitis? DDx?
Defined inflamed scaly areas +/- alopecia with broken hair shafts- hair + scalp, alopecia areata, psoriasis, seborrheic eczema
137
Sx and location of unguium? DDx?
Begins at distal nail edge and progresses proximally to involve the whole nail, eventually results in thickening, yellowing, and crumbling of the nail plate, tinea pedis often co-exists, nails- prevalence increases with age; rare in children, toenails> fingernails, psoriasis/ trauma/ candidiasis
138
Headlice most common in who? Only what is contagious? Spread how? S+Sx? Detected how? 'Nits,' eggs or deadlice indicate what?
Children aged 4-11 y/o
Adults
Close head to head contact
Normally asymptomatic- contact tracing, occasionally itchy scalp
Past infection
139
Detection of lice? Treat all household contacts how? Tx?
After washing hair, apply conditioner and comb with fine-tooth detector comb, in at-risk groups= repeat weekly, lice removed by a comb and seen trapped in teeth
Simultaneously
Dimeticone lotion or spray coats lice and interferes with their water balance by preventing excretion of water(advise rubbing into dry hair and scalp in the evening, allow to dry naturally, then shampoo off next morning, repeat after 7 days)
Insecticides: malathion, phenothrin, permethrin(OTC,) carbaryl=3rd line(2 applications 7 days apart, check wet, conditioned hair with a detector comb before the first application, then every 2d until 2-3d after the second application
Mechanical clearance- wet-comb conditioned hair with fine-tooth comb until all lice removed, repeat at 3-4d intervals for 2 weeks
Electric combs, aromatherapy, herbal txs
140
3 reasons for reinfestation/ resistance to headlice tx?
Reinfestation- lice found= large adults only, ask patient to check close contacts again, re-treat with different insecticide
Incorrect use insecticide/ mechanical clearance- repeat with different insecticide
Resistance to insecticide- re-treat with another product
141
RFs for scabies? Spread how? Sx? O/E?
Immunodeficiency, children, institutional, overcrowding, winter months
Skin-skin contact
Itch++, webbing between fingers, palms, wrists
Inflammatory, erythematous papules, crusting, vesicles, urticaria
142
What are scabies? Can take up to how long for sx/ rash to appear after initial infestation? Sx?
Sarcoptes scabiei burrow under the skin causing infection and intense itching, lay eggs in the skin--> infection + sx
8 weeks
Itchy small red spots possibly track marks where mites have burrowed- classic= finger webs, can spread to whole body
143
What is crusted (Norwegian) scabies? Scabies complications? Ix? DDx?
Hyperinfestation with thousands or millions of mites present in exfoliating scales of skin- affects debilitated/ immunosuppressed patients, typically not itchy but presents with crusted skin rash often misdiagnosed as psoriasis- resistant cases= ivermectin + isolation
Secondary bacterial infection--> cellulitis, folliculitis, boils, impetigo or lymphangitis
Hx and examination, hx from family + close contacts, skin scraping microscopy can be used to confirm diagnosis
Lichen planus, dermatitis herpetiformis, papular urticaria, eczema
144
Tx for scabies?
Permethrin cream 5%/ malathion lotion, tx close contacts simultaneously- whole body, scalp, neck, face and ears, finger/ toe webs, reapply after 1 week and hands alone if washed with soap<8h after application
Launder all worn clothing and bedding after application
Chilled crotamiton lotion and/ or sedating oral antihistamines for symptomatic relief of itch up to 4 weeks after tx
Oral ivermectin as single dose can be repeated week later for difficult to treat/ crusted scabies
145
Skin changes in Addison's disease? Cushing's disease?
Pigmentation, vitiligo
Pigmentation, hirsutism, striae, acne, truncal obesity, moon facies, buffalo hump
146
Skin changes in diabetes?
Diabetic dermopathy- depressed pigmented scars on the shins
Necrobiosis lipoidica- shiny, atrophic yellowish-red plaques on the shins, <1%, limited to those with DM/ later develop DM
Granuloma annulare- palpable annular lesions on hands, feet or face, rare, fades spontaneously <12 months, differentiated from ringworm
Xanthoma
Fungal infection
Vascular and neuropathic ulcers
147
Skin changes from drugs (drug eruptions)?
Withdrawal usually results in clearance in <2 weeks, simple emollients +/- topical steroids may ease sx in interim, occasionally severe reactions require admission
SJS(erythema multiforme)
148
Skin changes in hyperlipidaemia?
Xanthoma- yellowish lipid deposits in the skin- may be eruptive, tendinous, plane, tuberous
Xanthelasma- yellowish plaques on the eyelids, not always ass w/ hyperlipidaemia
149
Skin changes in IBD?
Crohn's- perianal abscess, sinuses or fistulae; erythema nodosum, Sweet's disease, clubbing
UC= pyoderma gangrenosum, erythema nodosum, Sweet's disease, clubbing
150
Skin changes in liver disease? Malabsorption?
Pruritus, spider naevi, erythema, white nails, pigmentation, xanthomas
Dry itchy skin, ichthyosis, eczema, oedema, dermatitis herpetiformis
151
Skin changes in malignancy?
Acanthosis nigricans- epidermal thickening and pigmentation in flexures and neck, ass w/ GI malignancy
Mycosis fungoides- lymphoma in skin, systemic only in terminal stages, may resemble psoriasis/ eczema
Paget's disease of the nipple, skin secondaries- most commonly breast, GI, ovary, lung/ haem, lymphoedema
152
Skin changes in malnutrition?
Iron= alopecia, koilonychia, itching
Scurvy= vit C deficiency- bleeding gums, woody oedema, perifollicular oedema
Protein= pigmentation, dry skin, oedema, pale brown/ orange hair
Pellagra- nicotinic acid deficiency
153
Skin changes in neurofibromatosis?
NF1/ von Recklinghausen's disease= >/= 6 cafe-au-lait patches >5mm pre-pubertal or >15mm post-pubertal
>/=2 neurofibromas: dermal= small violaceous skin nodules appear after puberty, nodular= SC, firm nodules arising from nerve trunks/ plexiform neurofibroma appears as a large SC swelling
>/=2 Lisch nodules- nodules of the Iris only visible with a slit lamp
Distinctive bony abnormality specific to NF1 e.g. sphenoid dysplasia
1st degree relative with NF1
154
Complications of NF1? (affects 1 in 3 patients)
Mild learning disability, short stature, macrocephaly, nerve root compression, GI bleeding/ obstruction, cystic bone lesion, scoliosis, pseudoarthrosis, high BP due to RAS/ phaeochromocytoma, malignancy, epilepsy
155
Skin changes in pregnancy?
Pigmentation, spider naevi, abdominal striae, pruritus, pruritic urticarial papules and plaques of pregnancy(PUPPP,) pemphigoid gestationis
156
Skin changes in sarcoidosis?
Nodules, plaques, erythema nodosum, dactylitis, lupus pernio (dusky-red infiltrated plaques on nose +/- fingers)
157
Skin changes in thyroid disease?
Hypothyroidism: alopecia, coarse hair, dry, puffy brownish yellow skin
Thyrotoxicosis: pink, soft skin, hyperhydrosis, alopecia, pigmentation, onycholysis, clubbing, pretibial myxoedema
158
Skin changes in tuberous sclerosis?
Adenoma sebaceum= red/ yellow fibromatous plaques usually around the nose
Periungual fibroma= pink, fibrous projections under nailfolds
Ash-leaf macules= white, oval macules best seen under Wood's light
Shagreen patches= yellowish naevi with cobblestone surface found on the back
159
Examples of emollients? Indications? Mechanism? Adverse effects/ CI?
Aqueous cream, liquid paraffin, E45
Topical tx for dry and scaling skin disorders e.g. psoriasis- alone/ in combination with topical corticosteroids in tx of eczema, can reduce dryness and cracking in psoriasis
Help to replace water content in dry skin, oils/ paraffin based products help to soften the skin by protecting against evaporation, can be used as a soap substitute/ moisturiser
Main tolerability issue= cause greasiness of the skin and can exacerbate acne on the face
160
Examples of keratolytics? Indications? Mechanism? Adverse effects/ CI?
Salicylic acid, lactic acid, allantoin
Removal of warts and other lesions of excess skin growth, tx of dry skin + acne
Thins the skin on and around the lesion and causes the outer layer of skin to loosen and shed
Can also soften keratin in the skin improving the skin's moisture binding capacity
Acne= epidermal cells shed more rapidly opening clogged pores and neutralises bacteria within, produces anti-inflammatory effects by suppressing cyclo-oxygenase
High concs--> chemical burns, hypersensitivity, use sun protection too
161
Examples of retinoids? Indications? Mechanism? Adverse effects/ CI?
Acitretin, tazarotene
Used in range of conditions, also in skin cancers
Shown to induce apoptosis in various cells especially sebaceous gland cells, may amplify production of certain skin proteins that reduce sebum production and exhibit antimicrobial effect
Transient worsening of acne, dry and fragile skin, increased susceptibility to sunburn and anaemia, rare= myalgia, headache and severe depression, TERATOGEN
162
How to apply topical corticosteroids? Cautions and CI?
Least potent prep that is effective, thin layer to affected areas>30 minutes prior to emollients once or twice daily
Not in urticaria, rosacea, acne, may worsen ulcerated/ secondarily infected lesions, pruritus- only if inflammation is causing itch, not long-term/ on the face/ for children
Perioral lesions= hydrocortisone 1% for
163
What is erythroderma? Typical patient? Other sx? What appears 2-6 days later? Action? Causes?
Widespread erythema>90% BSA, suberytheroderma if 70-90% BSA
Middle-aged elderly
Patchy--> universal<48 hours- fever, shivering, malaise, skin= red, hot, itchy, dry, thickened, feels thick, may be oedema/ oozing, hair and nails may shed
Scaling
Admit as acute medical emergency
Eczema, psoriasis, lymphoma, drug eruption, other skin disease, unknown, immunobullous disease, HIV, idiopathic
164
Complications of erythroderma and tx?
Fluid status, hypothermia, infection, HF, pneumonia, hypoalbuminaemia, oedema, pigment changes
Supportive care, ABx, emollients, wet wraps
165
Causes of palmar erythema?
Generalised reddening of the palms ass w/ pregnancy, liver disease and polycythaemia
166
What is erythema nodosum? Resolves when? Tx? Associations?
Tender erythematous nodules 1-5cm diameter on extensor surfaces of limbs- especially shins +/- ankle and wrist arthritis +/- fever
<8 weeks, non-scarring
No tx needed- analgesia and mild compression may ease sx, elevate leg
Strep infection, drugs e.g. oral contraceptives, acute sarcoidosis, IBD, malignancy, TB
167
What is erythema multiforme? Causes? Sx? DDx? Tx?
Immune-mediated disease characterised by target lesions on hands and feet
Idiopathic, infective- strep, HSV, hep B, mycoplasma, drugs- penicillin, sulfonamide, barbiturate, other- SLE, pregnancy, malignancy
Target lesions on hands and feet, new lesions= for 2-3 weeks
Toxic erythema, toxic epidermal necrolysis, Sweet's disease, urticaria, pemphigoid
Mild= resolve spontaneously, admit if extensive involvement
168
What is rosacea? Most common in who? Cause? Sx? Aggravating factors?
Relapsing-remitting chronic inflammatory facial dermatosis characterised by erythema and pustules
30-50 y/o, unknown, possible ass w/ face mite, h.pylori and migraines
Earliest= flushing, erythema, telangiectasia, papules, pustules +/- lymphoedema affects cheeks, nose, forehead and chin
Sunlight, topical steroids, stress, hot weather, alcohol, spicy foods, exercise, cold weather/ wind, hot baths/ drinks, cosmetics/ skin products
169
Comps, DDx and tx of rosacea?
Rhinophyma (bulbous appearance of nose,) blepharitis, dry eye and conjunctivitis
Acne, contact dermatitis, SLE, photosensitive eruptions, seborrheic dermatitis
Avoid triggers, ABx- repeated tx usually needed over many years with prolonged courses of topical/ systemic ABx e.g. metronidazole gel BD/ topical azelaic acid BD for 3-4 months, refer to derm if rhinophyma, ocular comps, or failure to respond to tx in GP
170
What is toxic epidermal necrolysis? Sx? Causes?
Acute-onset, life-threatening idiosyncratic mucocutaneous reaction usually occurring after commencement of a new medication
Prodromal phase for 2-3 days of URTI sx--> ill-defined red burning/ painful macular or papular rash spreading from face/ upper trunk, bullae form + coalesce, increase in number over 3-4 days, epidermis can then slough in sheets, may be hyperpyrexia/ hypotension/ tachycardia, Nikolsky's sign may be +ve(top layers away from bottom when rubbed)
80%= drugs(allopurinol, phenytoin, carbamazepine, lamotrigine, NSAIDs,) infections, vaccinations
171
How does SJS compare to TEN? Comps? Prognosis? Management?
Less epidermis sloughs off in SJS, >30% SA is affected in TEN
Fluid status, infection, thermoregulation, multiple organ failure, VTE, DIC, ARDS
SCORTEN predictor used to predict mortality
Supportive care ABCDE, analgesia, ABx, emollients, debridement of necrotic skin, GCSF if neutropenic
172
Who gets venous eczema? Early and later signs? Tx?
Middle-aged/ elderly
Capillary veins and haemosiderin deposition around ankles and over prominent varicose veins, eczema +/- lipodermatosclerosis +/- ulceration
Emollients +/- mild moderate steroid ointment + compression hosiery- tx venous disease/ ulceration, avoid prolonged standing, vascular surgery
173
What is pruritus vulvae? Causes? Comps?
Itching of the vulvae- dermatological, infections, neoplastic, hormonal, GI disease, urinary incontinence and systemic causes
Small risk SCC those with lichen sclerosus and lichen planus, psych issues, sleep issues, architectural damage, lichen simplex, secondary bacterial infection- s.aureus
174
Those with pruritus vulvae should be advised to do what and to avoid what? Tx?
Shower rather than bath, clean x1 a day with soap sub, gently dab dry/ washing with water only or soap, contact with shampoo etc, tight-fitting garments, fabric conditioner/ biological washing powder
Emollient + mildly anxiolytic antihistamine, short trial low potency topical corticosteroids, combine with antibacterial/ antifungal
175
What is pruritus ani? Most common cause? Secondary causes? Tx?
Perianal itching/ burning
Primary: functional- irritant to perianal tissues
Dermatitis, psoriasis, infections, scabies, colorectal and anal pathologies, cancer, diabetes, anaemia, drugs, food and drinks
Manage causes, lifestyle advice, ensure stools are regular and firmed, topical= bismuth subgallate or zinc oxide/ mildly potent topical corticosteroid and/ or sedating antihistamine
176
What is seborrheic dermatitis? Sx? Cause? Ix?
Inflammatory skin condition occurring in areas rich in sebaceous glands-scalp, nasolabial folds, eyebrows and chest, infants= mostly the scalp-'cradle cap'
Erythematous patches with scale which may be white or yellow, oily or dry
Not understood
Clinical
177
Infantile seborrheic dermatitis resolves by what age? Tx?
4 months of age
Softening of scales with emollients, gentle brushing + washing of the scalp with baby shampoo, ineffective--> imidazole cream, >4 weeks sx--> specialist advice
178
Tx of seborrheic dermatitis of the scalp and beard? Face and body?
Ketocanazole 2% shampoo, selenium sulfide shampoo/ OTC anti-dandruff shampoo, severe itching of scalp= potent topical corticosteroid scalp application for 4 weeks
Ketonazole 2% cream/ other topical imidazoles, ketonazole shampoo 2% as body wash
Mild topical corticosteroid cream such as hydrocortisone 1% for flares to settle inflammation
179
Tx of severe/ widespread seborrheic dermatitis? Referral to derm if what?
Consider alternative ix e.g. psoriasis, SLE/ infected eczema, immunocompromised, referral to derm whilst person is waiting
Diagnostic uncertainty, failure to respond to routine tx, severe/ widespread, eyelid involvement
180
What drugs can cause photosensitive skin reactions?
Amiodarone, chlorpropamide, furosemide, griseofulvin, phenothiazines, sulfonamides, tetracyclines, thiazides, nalidixic acid, coal tar, plant-derived psoralens
181
Epidemiology of SLE? Sx? Ix?
F>M, 15-45 y/o, malar butterfly rash, photosensitivity, mucosal ulcers, neurological/ psych issues, blood disorders, arthritis, pleurisy, pericarditis/ pericardial effusions, GN, tiredness, hair loss/ thinning
ANA, dsDNA, complement, clinical features
182
Tx for lupus?
Sun protection, smoking cessation, topical steroids, systemic steroids, hydroxychloroquine- methotrexate, immunosuppressives- azathioprine, ciclosporin, cyclophosphamide, NSAIDs, steroids if symptoms are severe to reduce inflammation, check for APS
