Dermatology

Question 1

features of eczema

Answer 1

defects in the skin barrier lead to inflammation
- redness
- itch
- dry
- FHx
- flexor surfaces common (cheeks in children)

Question 2

endogenous types of eczema

Answer 2

varicose eczema

seborrheic dermatitis

discoid eczema

atopic eczema

Question 3

signs of bacterial infection of eczema

management

Answer 3

weeping, pustules, crusts, atopic eczema failing to respond to therapy, rapidly worsening atopic eczema, fever and malaise)

Fucidin H Cream applied topically if milder

Oral Abx such as fluclox if more severe

Question 4

eczema herpeticum

Answer 4

a viral infection of eczema involving herpes simplex virus 1 or 2

signs:
- areas of rapidly worsening, painful eczema
- clustered blisters consistent with early-stage cold sores
- punched-out erosions
- fever, lethargy or distress.

needs admission and IV aciclovir

Question 5

treatment widespread bacterial infections originating from the skin

Answer 5

systemic antibiotics that are active against staph aureus and steptococcus e..g flucloxacillin

Question 6

localised clinical infection of the skin treatment

Answer 6

Topical antibiotics, including those combined with topical corticosteroids

Question 7

antibiotics to cover staph aureus and strep

Answer 7

flucloxacillin
erythromycin in fluclox allergy/resistance
3 rd line clarithromycin

Question 8

when are Antiseptics such as triclosan or chlorhexidine used in skin infection

Answer 8

Adjunct therapy for decreasing bacterial load in cases of recurrent infected atopic eczema

Question 9

complications of eczema herpeticum if untreated

Answer 9

Encephalitis; particularly if on immunosuppressants
Hepatitis
Pneumonitis

Question 10

what microorgansmism are resident on the skin

Answer 10

mainly gram positive cocci which are aerobic
- staph aureus
- staph epidermis
- strep species

some anaerobic gram positive bacilli

Question 11

main gene involved in eczema

Answer 11

fillagrin gene - loss of function mutations strongly linked to eczema

Question 12

pathology of eczema

Answer 12

breakdown in skin barrier function and inflammation primarily involving Th2 helper cells

Question 13

emollient regime

Answer 13

for eczema; emollient moisturiser, shower gel, bath additive

emollient regimes reduce the need for topical steroids

Question 14

topical corticosteroids in eczema

Answer 14

steroids are second line treatment in atopic eczema not controlled by emollient regime

potency should align with severity i.e. mild potency for mild eczema and increase with severity

shouldn’t be used for longer than 14 days for flares

only mild potency to be used on the face

applied once or twice a day

Question 15

topical calcineurin inhibitors

Answer 15

Tacrolimus and Pimecrolimus are used in eczema as they suppress T-lymphocyte responses, thereby suppressing the synthesis of pro-inflammatory cytokines

used second line after emollients where steroids are wished to be avoided or try after steroids

only in moderate or severe eczema and over 2 years old

side-effect of burning/stinging sensation on initial application

Question 16

stepwise treatment of eczema

Answer 16

1. topical emollient regime
2. topical corticosteroids / immune modulators
3. phototherapy
4. systemic treatments e..g azathioprine, cyclosporin
5. biologic drugs e.g. Dupilumab (injection) and other oral agents which are JAK1 and JAK2 inhibitors

Question 17

macules

Answer 17

flat lesions <5mm

Question 18

papules

Answer 18

raised bumps <1cm

Question 19

pustules

Answer 19

pus filled lesions less than 5mm

Question 20

vesicles

Answer 20

fluid filled lesions less than 5mm

Question 21

plaques

Answer 21

raised lesions greater than 1cm in size

Question 22

features of psoriatic nails

Answer 22

pitting
onychylosis
subungal hyperkeratosis
periungal erythema

Question 23

types of psoriasis

Answer 23

Generalsied pustular psoriasis
Chronic plaque psoriasis
Erythrodermic psoriasis
Guttate psoriasis
Flexural psoriasis

Question 24

guttate psoriasis

Answer 24

small pink plaques of psoriasis seen on the trunk, often after a streptococcal sore throat

about 1/3 go on to have chronic plaque psoriasis

Question 25

flexural psoriasis

Answer 25

psoriasis affecting the genitalia or axillae Usually the appearance is red (erythematous) and slightly shiny, but there will still be a clearly defined edge between normal and affected skin

Question 26

erythrodermic psoriasis

Answer 26

flare up/inflammation of psoriasis When it covers over 90% of the body surface it is described as erythroderma. The skin is red, feels hot and even painful. There may no longer be clearly defined plaques. Patients can feel unwell and become hypotensive. These patients should be admitted to hospital for treatment.

Question 27

chronic plaque psoriasis

Answer 27

40% of presentations typical distribution: elbows and knees nails scalp genitalia and natal cleft

Question 28

Generalised Pustular Psoriasis

Answer 28

psoriasis can flare, become red, hot, painful and develop pustules within the plaques emergency requiring hospital admission. The trigger is often WITHDRAWAL of use of a superpotent topical or systemic corticosteroids

Question 29

psoriatic arthropathy

Answer 29

Between 5- 20% of patients with psoriasis have arthropathy affecting their joints. Arthropathy can precede (50%) or post-date (15%) the development of skin lesions. The patterns of arthropathy fall into five subtypes: -distal interphalangeal alone -symmetrical polyarthritis (commonest) -asymmetrical oligoarthritis -arthritis mutilans -spondyloarthropathy

Question 30

triggers/risk factors for psoriasis

Answer 30

family history psychological stress medications; antimalarial, NSAIDs, beta blockers, lithium alcohol

Question 31

management of psoriasis stepwise

Answer 31

emollients for all + reduce alcohol and smoking and lose weight 1st line: a potent corticosteroid applied once daily plus vitamin D analogue applied once daily (applied different times of day) 2nd line: if no improvement after 8 weeks a vitamin D analogue twice daily 3rd line: a potent corticosteroid applied twice daily for up to 4 weeks, or a coal tar preparation applied once or twice daily short-acting dithranol can also be used phototherapy and systemic therapy can be considered by secondary care biologics last step

Question 32

cells involved in pathogenesis of psoriasis

Answer 32

Th1 cells increased rate of keratinocyte proliferation inflammatory angiogenesis TNF-a and Psors genes also involved

Question 33

tool to determine severity of skin disease

Answer 33

DLQI (Dermatology of Life Index) is a subjective assessment of the impact of the disease on the patient’s life. The DLQI questionnaire is completed by the patient and is calculated by summing the score of each question resulting in a score between 0 – 30

Question 34

tool to assess psoriasis severity

Answer 34

PASI (Psoriasis Area Severity Index) is an objective measure of the disease severity and is completed by the clinician. It is a numerical score with 0=no disease and 72=maximum disease often used to objectively monitor patients

Question 35

how does phototherapy work for psoriasis

Answer 35

narrow-band UVB or PUVA which slows down the excessive growth of keratinocytes and is considered to be partially immunosuppressive given 2-3 times a week for 10 weeks

Question 36

systemic agents that can be used in psoriasis

Answer 36

ciclosporin methotrexate Acitretin (oral retinoid) Fumaric acid esters Apremilast

Question 37

biologics used in dermatology

Answer 37

TNF inhibitors IL-12/23 inhibitors IL-17 inhibitors

Question 38

acne vulgaris

Answer 38

Acne vulgaris is an inflammatory condition where lesions develop from the sebaceous glands around hair follicles on the skin of the face, chest , back and anogenital region

Question 39

what are open comedones

Answer 39

blackheads

Question 40

APSEA scale

Answer 40

validated tool used to assess psychological impact of acne on work, personal life, relationships confidence etc.

Question 41

grading clinical severity of acne

Answer 41

The Leeds Scoring system counts and categorises lesions into inflammatory and non-inflammatory ranging from 0 for mild acne to 12 for the severest form (nodules, cysts, scars

Question 42

indications for treatment with oral retinoids (isotretoin) for acne

Answer 42

- Moderate acne, unresponsive to conventional therapy or relapsing after conventional therapy - Severe acne - Acne scarring - Psychological effects resulting from acne and scarring - Unusual form of acne

Question 43

different types of drugs for acne (how they work)

Answer 43

drugs that inhibit sebaceous gland function - anti-androgens - oestrogens - isotretinion drugs that normalise pattern of follicular keratinisation - topical retinoids drugs with anti-inflammatory/anti-bacterial effects - antibiotics - benzoyl peroxide

Question 44

acne pathophysiology

Answer 44

blockage and inflammation of the pilosebaceous unit (the hair follicle, hair shaft and sebaceous gland). It presents with lesions which can be non-inflammatory (comedones), inflammatory (papules, pustules and nodules) or a mixture of both.

Question 45

treatment of acne

Answer 45

first line 12 week course of one of: - topical adapalene with topical benzoyl peroxide - topical tretinoin with topical clindamycin - topical benzoyl peroxide with topical clindamycin if moderate to severe consider oral antibiotics and Topical azelaic acid as other first line options single antibitoic should be used for 12 weeks to assess response combined oral contraceptives may be considered in women as treatment

Question 46

what is acne fulminans

Answer 46

Acne fulminans is a sudden severe inflammatory reaction that precipitates deep ulcerations and erosions, sometimes with systemic effects (such as fever and arthralgia).

Question 47

risk factors for BCC compared to SCC

Answer 47

both - chronic UV exposure - skin types I and II - chemicals - immunosuppressants SCC also cigarette smoking and chronic ulcers

Question 48

Fitzpatrick skin types

Answer 48

Type I - always burns never tans very pale Type II - usually burns tans poorly pale Type III - tans after initial burn darker white Type IV - tans easily burns minimally light brown Type V - tans darker brown skin Type VI - always tans darker never burns dark brown/black skin

Question 49

squamous cell carcinoma - what is it - does it spread?

Answer 49

malignant tumour arising from keratinocytes of the epidermis can invade locally and has metastatic potential

Question 50

how does an SCC present

Answer 50

fast growing and can be painful often on face, scalp and hands rare under 60 years unless immunosuppressed indurated nodular lesions often have crusted or hyperkeratotic surfaces can develop de novo or from precursor leisons

Question 51

pathophysiology of SCC

Answer 51

malignant transformation of normal keratinocytes by apoptotic resistance via loss of TP53

Question 52

what lesions can be precursors to SCC

Answer 52

actinic/solar keratoses - multiple lesions often head and neck non painful. dysplastic keratinocytes Bowen's disease - single plaque of epidermal dysplasia. can be managed with cryotherapy

Question 53

poor prognostic features SCC

Answer 53

tumours >2cm lesions on lip or ear immunosuppression

Question 54

what options may be used to manage a BCC

Answer 54

- imiquimod cream 5% - radiotherapy - photodynamic therapy - surgical excision; can be done as a day case - watchful waiting

Question 55

how can actinic keratosis be managed

Answer 55

5% 5-FU (efudix) cream

Question 56

how is prognosis of SCC determined

Answer 56

depth invasion of the skin

Question 57

high risk BCCs

Answer 57

lesions on eyelid margins, ear, lip perineurial invasion on histology recurrent lesion lesions in immunocompromised

Question 58

BCC presentation

Answer 58

slow growing typical features; telangiectasia, pearly translucent nodule

Question 59

types of moles

Answer 59

junctional naevus - brown and flat intradermal naevus - skin coloured and raised compound naevus - brown and raised

Question 60

what are the criteria for 2WW referral

Answer 60

- new mole quickly growing in an adult - long standing mole changing in shape and colour - a mole with 3 or more colours or lost its symmetry - any new nodule growing and pigmented or vascular - new pigmented line in a nail or something growing under the nail

Question 61

looking for evidence of metastasis in melanoma

Answer 61

localised: cutaneous/subcutaneous nodules around the lesions regional: lymphadenopathy distant: hepatomegaly +/- splenomegaly

Question 62

treatment of suspected melanoma

Answer 62

excision with a margin of normal skin same day or same week after excision follow up 3 monthly for a year immune and targeted therapies are also now used improving survival

Question 63

melanoma presentation

Answer 63

50% from existing moles normally asymptomatic but occasionally bleeding and itching reported existing or new mole than changes rapidly, irregular, different shades, larger, reddish outline

Question 64

what are dysplastic naevi

Answer 64

moles that are on a continuum from benign naves to melanoma some people have several in a genetic condition and this predisposes to melanoma

Question 65

types of melanomas

Answer 65

superficial spreading nodular lentigo maligna aural lentiginous melanoma

Question 66

risk factors melanoma

Answer 66

UV exposure +++ sunburns people with many typical moles immunosuppression family history link to IBD

Question 67

what is Breslow thickness

Answer 67

distance in mm from the granular layer in the epidermis to the deepest level of invasion major prognostic indicator TNM based on this + some other features (mitotic index, ulceration, LN involvement and metastasis)

Question 68

chronic pruritus

Answer 68

chronic pruritus is > 6 weeks which can lead to characteristic skin lesions including excoriations, lichenification and hyperpigmentation pr hypopigmentation

Question 69

itching without skin change/rash (pruritus)

Answer 69

unlikely to be dermatological if itch came first - malignancy and haematological (NHL, leukaemia, metastasis of solid tumours) - multisystem inflammatory (dermatomyositis, scleroderma) or infectious (HIV, Hep C) - psychogenic - metabolic (hyperT, CKD, diabetes) - GI cholestasis - drugs

Question 70

bullous pemphigoid

Answer 70

autoimmune condition causing sub-epidermal blistering of the skin oral corticosteroids are mainstay of treatment

Question 71

contact dermatitis

Answer 71

two main types: - irritant contact dermatitis - allergic contact dermatitis; type IV hypersensitivity reaction. needs topical potent steroid

Question 72

Dermatitis herpetiformis

Answer 72

autoimmune blistering skin disorder associated with coeliac disease caused by deposition if IgA in the dermis

Question 73

Erythema multiforme

Answer 73

hypersensitivity reaction that is most commonly triggered by viruses but also bacteria and drugs in its most severe form can involve mucosa such as mouth

Question 74

erythema nodosum

Answer 74

inflammation of subcutaneous fat causing tender, erythematous, nodular lesions usually on the shins many causes including infection, sarcoid, malignancy, drugs and pregnancy

Question 75

lichen planus

Answer 75

itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms oral involvement in 50% needs potent topical steroids

Question 76

Lichen sclerosus

Answer 76

condition of white patches typically affecting the genitalia of elderly females managed with topical steroids and emollients note increased risk of vulval cancer

Question 77

examples of topical steroids and potency

Answer 77

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%)

Question 78

psoriasis Treatment options

Answer 78

Topical steroids Topical vitamin D analogues (calcipotriol) Topical dithranol Topical calcineurin inhibitors (tacrolimus) are usually only used in adults Phototherapy with narrow band ultraviolet B light is particularly useful in extensive guttate psoriasis

Question 79

isotretinoin side effects

Answer 79

teratogenic - need effective contraception Dry skin and lips 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

Question 80

scabies presentation and treatment

Answer 80

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. treatment is with permethrin cream which should be left on for 8-12 hours all over for

Question 81

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)

Answer 81

spectrum of the same pathology of epidermal necrosis due to an immune response caused by medications or infections needs admission, good supportive care as well as medical management including steroids, immunoglobulins and immunosuppressant can lead to eye damage, permanent skin damage and secondary infection