Dermatology Flashcards

Question

Name a mild steroid and a very potent steroid

Answer 1

Very potent - dermovate aka clobetasol propionate 0.05% Mild - hydrocortisone 1%

Answer 2

> Chronic relapsing and remitting scaling skin disease > May appear at any age and affect any part of the skin > Prevalence 1.5-3%, age onset often 2 peaks 20-30y or 50-60y > Cause >> T cell mediated autoimmune disease >> Abnormal infiltration of T cells >>> Release of inflammatory cytokines including interferon, interleukins & TNF >>> Increased keratinocyte proliferation >> Environmental and genetic factors >>>PSORS genes e.g. PSORS1, chromosome 6 and HLA – Cw0602 associated in certain subtypes > Linked to >> Psoriatic arthritis >> Metabolic syndrome >> Liver disease / alcohol misuse >> Depression

Answer 3

- Plaque - Guttate (teardrop/raindrop) - Pustular - Erythrodermic (more inflammatory) - Flexural / inverse - Palmar / plantar pustulosis - Psoriasis at sites of trauma/scars: Koebner phenomenon > Not Auspitz: pinpoint bleeding after scratching psoriasis scale

Answer 4

Well-defined Hyperkeratosis >If significant, plaque appears white Characteristic sites: nape of neck, back, extensor surfaces of elbows/knees Symmetrical distribution Nails: pitting

Answer 5

> Depends on severity, patient wishes, presence of arthropathy > Scoring systems – >> DLQI (Disease Life Quality Index) - impact on patients >> PASI – psoriasis area severity index; clinician index >> PEST – psoriasis epidemiology scoring tool; marker of psoriatic arthritis > 20% of patients with psoriasis develop arthritis Treatments for psoriasis > In order of increasing effectiveness (and toxicity) > Topical creams and ointments >> Moisturisers – help reduce dryness, flaking >> Steroids – reduce autoimmune response, redness, itching, inflammation >> Salicylic acid – dissolve thick dead skin > Slow down keratinocyte proliferation >> Vitamin D analogues >> Coal tar >> Dithranol > Phototherapy light treatment >> Uses UV-B commonly – non-specific immunosuppressant therapy >>> UV-A with psoralen photosensitiser >> Encourages vitamin D and reduces skin turnover >> Risks: short-term - burning; longer term - cancer > Systemic drugs/immunosuppressants >> Immunosuppressants: methotrexate, ciclosporin >> Acitretin (oral retinoid / vitamin A) >> Dimethyl fumarate >> Apremilast: anti-phosphodiesterase inhibitor > Biologic therapies >> Adalimumab – anti-TNF >> Ustekinumab – anti-IL12/23

Answer 6

> Moles > Fibroepithelial polyps aka skin tags > Seborrheic warts / keratosis >> Elderly patients >> Raised, rough lesions >> Found in back commonly >> Well-defined >> Cauliflower like appearance > Viral warts (verrucae) > Vascular spots

Answer 7

At least 2 distinct pathways interact or converge to cause skin cancer Direct action of UV on target cells (keratinocytes) for neoplastic transformation via DNA damage Effects of UV on the host's immune system – immune suppressant (indirect effect)

Answer 8

Most common type of skin cancer Process of creating new skin cells is controlled by a basal cell's DNA PTCH gene mutation may predispose (rare) Commonly found on head and neck / UV exposed sites Rarely metastasises or kills – unless neglected/untreated Appearance > Pearly rolled margin with a shoulder > Dipped centre which may ulcerate > Telangiectasia – lightning bolt blood vessels

Answer 9

Nodular > Most common > Raised lesion - shiny "pearly" > Telangiectasia > Often ulcerated centrally Superficial > Tiny thread like rolled shoulder > Lightning bolt blood vessels > Crusting - suggests ulceration > Flatter > Often on neglected areas i.e. back Pigmented > May be confused with melanoma or seborrhoeic warts > Same features just pigmented - more melanin deposited in basal cell Morphoeic / sclerotic > Barely visible, usually extends further below surface

Answer 10

> Gold standard – surgical excision 3-4mm margin > Curettage and cautery >> Circular scalpel used to scrape away damaged tissue >> Usually used in diagnostics > Cryotherapy >> If surgery not suitable >> High recurrence rate > Photodynamic therapy >> Immune based treatment >> Apply a photosensitiser which provokes an immune reaction when you shine LED light on it >> Preferentially taken up by tumour cells – high recurrence rate – painful (burns skin) > Topical imiquimod / 5-fluorouracil cream >> Immune triggers to provoke immune system to kill cancer cells >> Inflammatory burn reaction in area applied to > Mohs micrographic surgery >> Pathology technician ensures all tumour is removed (histological checking) >> Saucer-like sections taken around tumour >> Time-consuming, only used when tissue sparing would be useful e.g. morphoeic tumour where margin is unclear

Answer 11

May occur in normal skin or skin that has been injured (burns) or chronically inflamed – damaged skin (UV or other) Originates from keratinocytes Pre-malignant variants > Actinic keratoses >> Patches of skin damage > Bowen's disease >> SCC in situ Most SCC occur on skin that is regularly exposed to sunlight or other ultraviolet radiation Risk of metastasis from a high-risk SCC is 10-30% High risk sites > Ears, lips Appearance > Slight central dip > Centre heavily keratinised – crust > Tumour lumps > On very damaged skin i.e. skin damage

Answer 12

Gold standard – surgical excision 4mm margin Curettage and cautery (frail & elderly) Pre-malignant: squamous cell carcinoma in situ > Topical imiquimod / 5-fluorouracil cream > Cryotherapy > Photodynamic therapy – also used in Bowen's disease

Answer 13

Malignant tumour of melanocytes Higher risk of metastasis and recurrence Most common in skin but can be found in bowel or eye DNA damage – mainly UV, rarely genetic Radial growth phase then vertical growth downwards (more aggressive) Depth of presentation determines prognosis Spread via lymphatics (also via blood vessels) Goes into subcutaneous fat, spreads to distant sites i.e. lungs and liver via lymph nodes

Answer 14

- Superficial spreading melanoma - Nodular melanoma - Acral melanoma > Poorer prognosis > Found late, quite hidden > Very dark, satellite drifting > More common in darker skin types - Subungal melanoma - Amelanotic melanoma > Red nodule (very rare) - does not look like melanoma

Answer 15

- Lentigo maligna > Premalignant precursor > Usually unique to very sun damaged head and neck skin (usually elderly) - Lentigo maligna melanoma - Melanoma in situ

Answer 16

Breslow thickness - how deeply tumour cells have invaded Measured from most superficial aspect of granular cell layer (or from base of ulcer) to deepest point of invasion Important for prognosis > Also mitotic rate, ulceration & extent of metastatic disease > Lymphatic or vascular invasion, perineural infiltration > Family history > Sun exposure, tanning beds > Molecular mutational gene expression (immunogenetics) Clark level - staging system that describes the depth of melanoma as it grows in the skin

Answer 17

Surgical excision > Breslow < 1mm : 1cm margin > Breslow > 1 mm : 2 cm margin Immunotherapy – ipilimumab, nivolumab Immune checkpoint / MEK inhibitors – trametinib Biologic antibodies – BRAF genetic defects (debrafanib) involved in predisposition to melanoma > Can reduce risk of recurrence Imaging / scanning CT / MRI / PET > Staging from head to pelvis, brain scan Long-term follow up up to 5 years – to look for metastatic spread Assessment for lymph node or organ spread > Clinically, US or CT Genetic testing in families, multiple primary melanomas > Multiple melanomas at a young age > CKDN2 genetics

Answer 18

Gorlin's syndrome > Multiple BCCs, jaw cysts, risk of breast cancer Brook Spiegler syndrome > Multiple BCCs, trichoepitheliomas Gardner syndrome > Soft tissue tumours, polyps, bowel cancer Cowden's syndrome > Multiple hamartomas (benign or malignant), thyroid, breast cancer

Answer 19

- Corticosteroids - Lithium - Vitamin B12 - Thyroid hormones - Iodine-containing drugs - Antibiotics e.g. tetracyclines, streptomycin

Answer 20

Dry skin – hypothyroidism Thyroid dermopathy – pretibial myxoedema > Grave's disease > Velvety texture, exaggerated skin markings Thyroid acropachy – Grave's disease > Soft tissue swelling of distal digits and around nail resulting in bowing or "clubbing"

Answer 21

Necrobiosis lipoidica > Waxy yellow appearance surrounded by erythema > Bilateral appearance on shins > Occasionally ulcerates and scars Diabetic dermopathy > Inflammatory papules and patches > Mild itch healing with hyperpigmentation > Affects lower legs Scleredema > Woody inflammatory infiltrate in skin > Warm to touch – cannot squeeze skin due to lack of elasticity > Often affects upper back Leg ulcers > Pressure calluses > Venous ulcers Granuloma annulare > Round plaques > Granulomatous histological appearance > Appear on dorsum of hands & feet usually

Answer 22

- Acne - Striae - Erythema - Gynaecomastia

Answer 23

Hyperpigmentation - Addison's disease > Mucosal surfaces > Bronzing of skin > Acanthosis nigricans

Answer 24

Testosterone > Symptoms >> Acne >> Hirsutism > Causes >> Polycystic ovarian syndrome >> Testicular tumours >> Testosterone drug therapy Progesterone > Symptoms >> Acne >> Dermatitis > Causes >> Congenital adrenal hyperplasia >> Contraceptive treatment

Answer 25

Excessive production of cortisol in the body leads to > Increased central adiposity > Moon faces and buffalo hump > Global skin atrophy, epidermal and dermal components > Striae on abdominal flanks, arms, thighs > Purpura with minor trauma – reduced connective tissue

Answer 26

Necrolytic migratory erythema Aka glucagonoma syndrome Very rare Erythematous, scaly plaques on acral, intertriginous and periorificial areas Association with islet cell tumour of the pancreas Other signs > Hyperglycaemia > Diarrhoea > Weight loss > Glossitis

Answer 27

Rare Very distinctive skin disease Reddened concentric bands whorled woodgrain pattern Severe pruritus and peripheral eosinophilia Strong association with lung cancer Also breast, cervical, GI cancers Treatment of underlying malignancy treats skin disease

Answer 28

Smooth, velvet-like hyperkeratotic plaques in intertriginous areas (groin, axillae, neck) 3 types >Type I >> Associated with malignancy >> Adenocarcinoma, especially gastric >> Sudden onset and more extensive > Type II >> Familial type – AD >> Very rare >> Appears at birth – no malignancy > Type III >> Associated with obesity and insulin resistance >> Most common type

Answer 29

Affects head and neck Juicy, infiltrated, red, inflammatory (sometimes ulcerated) plaques and nodules Associated with haematological malignancy

Answer 30

Sister Mary Joseph Nodule

Answer 31

B6 – pyridoxine >Dermatitis B12 – cobalamin >Angular cheilitis B3 – niacin >Pellagra – dementia, dermatitis, diarrhoea, death

Answer 32

Acrodermatitis enteropathica > Inherited or acquired > Results in pustules, bullae, scaling (acral and perioral distribution) > Inherited – mutation in SLC39A – encodes an intestinal zinc transporter > In infants – deficiency can follow breastfeeding when breastmilk contains low levels of zinc > In adults, disease can occur after total parenteral nutrition without zinc supplementation >> Alcoholism >> Malabsorption states >> Inflammatory bowel disease >> Bowel surgery

Answer 33

Scurvy > Punctate purpura / bruising > Corkscrew spiral curly hairs > Patchy hyperpigmentation > Dry skin > Dry hair > Non-healing wounds > Inflamed gums

Answer 34

Causes > Streptococcal infection > Pregnancy / oral contraceptive > Sarcoidosis > Drug-induced > Bacterial / viral infection > Others Distribution – lower legs Deep red/purple bruise-like discolouration Patient will be extremely uncomfortable and cannot tolerate touch

Answer 35

Deep ulcer with purple overhanging edge Treating underlying disorder leads to improvement 50% idiopathic Autoimmune – responds to immunosuppression Linked to > Inflammatory Bowel disease > Crohn's disease > Ulcerative colitis > Rheumatoid arthritis > Myeloma

Answer 36

Alopecia areata

Answer 37

B12 deficiency Iron deficiency Lupus Hypothyroidism

Answer 38

Scleroderma and dermatomyositis

Answer 39

Maculopapular > Areas of flat colour change with small papules Urticaria > Nettle like rash Morbilliform > Measle like rash Papulosquamous > Raised areas with dry flakiness Phototoxic > Exposed skin in response to UV light > Areas covered from sun spared – T shirt distribution > Can be caused by bendroflumethiazide or quinine > Chronic phototoxic rash Pustular Lichenoid (like lichen planus) Fixed drug rash Bullous Itch – no rash

Answer 40

Antibiotics e.g. penicillins, trimethoprim NSAIDs: urticaria, angioedema Chemotherapeutic agents Pyschotropic – chlorpromazine, alanzapine, risperidone Anti-epileptic – lamotrigine, carbamazepine Cardiac drugs – BB, ACE, anticoagulant

Answer 41

Inflammation of blood vessels Triggers > Infection > Drugs > Connective tissue disease e.g. RA, SLE Investigations – systemic vasculitis > Renal BP > Urinalysis Localised, not rapidly progressive Less unwell than in meningococcal rash

Answer 42

Psorasis-like Well demarcated pink erythema with scale Sudden onset, no family history Lithium, beta blockers

Answer 43

Same area, same drug, e.g. paracetamol

Answer 44

Steven Johnson Syndrome (SJS) > Can be drug induced or viral (HSV) > Causes blistering and ulceration around mouth and mucosal surfaces > Up to 30% skin involvement Toxic epidermal necrolysis (TEN) > Dermatological emergency > Majority drug-induced Disease spectrum from SJS to TEN > Most severe mucous membrane involvement > Stop suspect drug > Top of the full thickness of the epidermis sloughs off In-patient management > Derm > ITU > Burns > Analgesia > Fluid balance SCORTEN severity scale > Special mattress, sheets > Infection control, prophylaxis > Non-adherent dressings > Urology, gynae, ophthalmology inputs >50% mortality rate

Answer 45

Bullous pemphigoid > Rare autoimmune skin condition that affects mainly older people > Starts with an itchy raised rash > As it develops large tense fluid-filled blisters can form > Tend to be stable as lesions are subepidermal and unlikely to erode > Lesions most commonly on flexures Pemphigus vulgaris > Mucosal erosions are an early sign often preceding the cutaneous > Cutaneous lesions typically affect chest, back and scalp > Erythematous macules appear first later evolving into flaccid blisters > Blisters are intraepidermal so are weak and rupture easily resulting in painful erosions

Answer 46

Flexural folds first Younger patients Toxin from Staph aureus infection causes rash Treatment is antibiotics for underlying infection

Answer 47

> Self-limiting allergic reaction > HSV, EBV, occasionally drug > No or mild prodrome > Target lesions > Never to TEN

Answer 48

- Bullous pemphigoid - Pemphigus vulgaris -

Answer 49

Skin rash associated with coeliac disease Tiny vesicle blisters in very distinctive sites Treatment > Topical steroids > Gluten free diet > Oral dapsone

Answer 50

Reduce autoimmune reaction – topical / oral corticosteroids Steroid sparing agents e.g. azathioprine, anti-inflammatories, tetracyclines Burst any blisters Dressing and infection control Check for oral / mucosal involvement Consider screen for underlying malignancy

Answer 51

Itchy, wheals (hives) Lesions last <24 h Non-scarring, common skin disorder to present to A&E Acute < 6 weeks, chronic > 6 weeks Can have angioedema but no anaphylaxis

Answer 52

Immune-mediated > Type 1 IgE response Non-immune mediated > Direct mast cell degranulation e.g. opiates, antibiotics, contrast media, NSAIDs Investigations > Often none > Not normally allergy driven > Don't do allergy testing, no patch testing Treatment > Antihistamines > Steroids > Phototherapy > Immunosuppression > Omalizumab Causes > Unknown > Viral infections > Medication – NSAIDs, aspirin, ACE > Foods & food additives > Parasitic infections > Physical stimulants – colds, pressure, solar, cholinergic, aquagenic

Answer 53

> 80-90% involvement, erythema - Associated with exfoliation – skin peeling off in scales or layers - Intense itch - Temperature dysregulation - Fluid loss - Oedema Causes > Psoriasis > Eczema > Drug reaction > Cutaneous lymphoma > Others Treatment > Treat underlying skin disorder > Supportive > Fluid / temperature balance important

Answer 54

Rare disease that causes muscle weakness and skin rash Symptoms > Red or purple rash on sun exposed skin and eyelids > Calcium deposits under the skin > Muscle weakness > Trouble talking or swallowing

Answer 55

Acute febrile pustular eruption on erythematous background > 90% drug induced (other causes – HS to mercury, enteroviral infection) Short time between drug and eruption <2- 4/7 Clinical features - High fever, usually onset same day as rash - Numerous small, non-follicular, sterile pustules arising within large areas of oedematous erythema +/- burning, pruritus - Lesions start face and arimpits & groins then disseminate over a few hours Drugs causing AGEP: “BAD FACE”-mostly penicillins and macrolides - Bactrim - Antibiotics and antifungals(Vanc/Penicillins/Cephalosporins/Macrolides/terbinafine/itraconazole) - Diltiazem - Frusemide - Allopurinol/antimalarials - Cimetidine - Epileptics Treatment > Stop offending drug > Supportive – rest, bland emollients, topical steroids

Answer 56

Psoriaform e.g. psoriasis > Histology >> Hyperkeratosis: thickened keratin layer >> Parakeratosis: nuclei within keratin layer >> Acanthosis: thickened epidermis Spongiotic e.g. eczema > Space between epidermal keratinocytes due to increase in fluid between cells > Scattering of eosinophils in dermis Lichenoid e.g. Lichen planus, lupus Vesiculobullous e.g. pemphigus Granulomatous e.g. Tuberculosis, sarcoidosis Vasculopathic e.g. Leukocytoclastic vasculitis Drug rashes

Dermatology Flashcards

(80 cards)