Dermatology Diagnosis+management Flashcards

Question

SCC management

Answer 1

``` Referral of suspicious SCC (urgent 2ww) Excisional biopsy +/- LAPs Curettage and cautery/electrodesiccation Cryotherapy/cryosurgery Pomade/Cream/Gel: Imiquimod cream, Fluorouracil cream, Diclofenac gel Photodynamic therapy (PDT) Electrochemotherapy Radiotherapy Mohs' micrographic surgery ```

Answer 2

Melanocytes found in equal number in black and white skin However in black skin produce much more melanin Results in darker pigmentation; greater UV protections Non-cancerous growth of melanocytes results in MOLES (benign melanocytic naevi) and freckles (ephelides and lentigines)

Answer 3

Malignant melanoma more common in women Much less common than non-melanoma skin cancers (SCC, BCC) Rare in children. Incidence increases with age in box sexes Stages: Stage 0: All melanoma cells confined to epidermis (melanoma in situ); can be cured via excision because has no potential to spread around the body When the cancer has grown through the dermis it is termed an invasive melanoma

Answer 4

Lentigo maligna melanoma: a patch of lentigo maligna, develops a papule or nodule, signalling invasive tumour. Superficial melanoma: a large flat irregularly pigmented lesion which grows laterally, before vertical invasion develops. Superficial spreading melanoma (SSM) is the most common subtype. 3. Nodular melanoma: the most aggressive type. It presents as a rapidly growing pigmented nodule which bleeds or ulcerates. Rarely, they are amelanotic (non-pigmented) and can mimic pyogenic granuloma. Acral lentiginous malignant melanoma: arises as pigmented lesions on the palm, sole or under the nail and it usually presents late.

Answer 5

``` Naevi UV/sun exposure Skin coloud: pale type I/II skin. Fair hair, inability to tan or freckled complexion doubles risk of melanoma Family history Solar keratoses Past pesticide exposure Higher socio-economic group ```

Answer 6

Any pigmented lesion Asymmetrical Irregular border, scalloped or poorly defined edges Uneven or variable colouring Diameter bigger than 6mm Changing size, shape or colour ubungual melanomas: pigmented highly defined stripes under the nail (may just be hyperpigmentation usually in darker skin) but always refer for biopsy to be sure!

Answer 7

``` ABCDE: Asymmetry Border irregular Colour irregularity Diameter greater then 7mm Evolving ``` ``` 7 point checklist: 3+ needs 2ww urgent referral major (2 points each) - change in size - irregular shape - irregular colour Minor (1 pnt each) - >7mm diameter - inflammtion - oozing - change in sensation ```

Answer 8

Androgen driven increase in sebum production Causing obstructed follicles to fill with lipid rich material forming visible open and closed comedones Blockage of sebaceous follicle by keratin and sebum Colonisation of follicle promotes bacterial growth leading to proliferation Propionibacterium acnes (commonly found in large quantities) Inflammation presents in form of papules, pustules, nodules and cysts

Answer 9

Open and closed non inflamed comedones (black and whiteheads; black=oxidised; white=not) Inflamed papules and pustules In severe acne, nodules and pseudocysts (cyst like fluctuant swelling) Post inflammatory erythematous or pigmented macules or scars Adverse social and psychological effects (permanent scarring) Lesions usually present on forehead,nose and chin. More severe cases whole face, upper chest and back may be affected usually with periorbital sparing. *the more widespread the acne the more need to consider systemic ABs/treatment* Whiteheads form when pores are blocked with sebum and dead skin cells. The pore is closed Papules are red, painful with inflammatory evidence; can disappear spontaneous or can develop to become a pustule (squeezy spot) Pustules (AKA pimples) form few days after white blood cells in papule make it to skin surface Develops most commonly in puberty years

Answer 10

Vulgaris means common; most common form of acne Nearly 90% teens suffer Peak incidence 13-16 years May continue to 20-40years 1% men and 5% women have lesions Females with PCOS or those with excess cortisol are prone Differentials: rosacea, folliculitis, perioral dermatitis

Answer 11

Mild: predominantly non-inflamed lesions (open and closed comedones) with few inflammatory lesions, total count <30 Moderate: more widespread with increased number of inflammatory papules and pustules, TLC 30-125 Severe: widespread inflammatory papules, pustules and nodules or cysts. Scarring may be present, TLC >125.

Answer 12

Mild-mod: Topical retinoid - adapalene (DIFFERIN) used alone or with benzoyl peroxide (EPIDUO) in strengths of 2.5%, 5% or 10% (CI in pregnancy and breastfeeding; must be on some form of contraception, apply at NIGHT due to sun sensitivity increase) Topical ab (clindamycin 1%) always prescribed with benzoyl peroxide (antiseptic) apply once at night (DUAC) used at night as makes skin sensitive to the sun Azelaic acid 20% is mildly effective as comedolytic, antibacterial and antiinflammatory agent Treatment for 2-3 months then review and adjust accordingly

Answer 13

If no response/widespread area: Lymecycline or doxycycline for max 3 months Topical retinoid (if no CI) or benzoyl peroxide should always be co-prescribed with oral ABs to reduced risk of AB resistance If no response to two different courses of ABs or if they start to scar; refer to dermatologist for isotretinoin consideration (GP cannot initiate this treatment) Combined oral contraceptives, interfere with androgen production (if not CI) in combo with topical agents should be considered as alternative to systemics ABs in women (PROGESTERONE ONLY CAN WORSEN CONDITION; OTC TOPICAL STEROIDS hydrocortisone 1% CAN ALSO WORSEN) *Topical steroids induce atrophy in skin; worsening acne as will weaken skin barrier and increase likelihood of damage; must be used very carefully for this reason

Answer 14

Severe or nodulocystic acne could benefit from oral isotretinoin Severe social or psychological issues including morbid fear of deformity (dysmorphophobia) Multiple treatments in primary care have failed Laser treatment for acne not covered by NHS

Answer 15

``` Does the pt adhere to the treatment? Possible adverse effects? Progression to more severe acne Use of comedogenic makeup/face creams Trial of alternative formulation or step up in treatment if appropriate (ask these stages first) ```

Answer 16

Chronic relapsing disease of recurrent erythema, telangiectasia, oedema, papules and pustules affecting forehead, cheeks, nose and often the chin Affect fair skinned people relatively commonly accounting for 1% dermatology out pts in britain Occurs in second half of life associated with facial flushing More common in women tends to be more severe in men Ocular changes usually bilateral result in mild blepharitis and conjunctivitis occur in more than 50% pts

Answer 17

Blushing or flushing or persistent erythema Red face and prominent blood vessels (telangiectasia fine, dilated blood vessels) Red papules and pustules on nose, forehead, cheeks sna chin often follow (inflammatory or papulopustular rosacea) rarely trunk and upper limbs may involve Facial skin thickening mostly nose Dry and flaky skin burning stinging sensation Aggravated by sun exposure hot spicy food or drink Sensitive skin burning and stinging esp in makeup reaction sunscreens and facial creams Red sore gritty eyelid margins including blepharitis

Answer 18

Papules and sometimes pustules. Dome shaped rather than pointy like acne and no black/white heads or nodules May also result in red areas (erythematotelangiectatic rosacea), scaling (rosacea dermatitis) and swelling (phymatous rosacea)

Answer 19

``` Acne vulgaris Seborrhoeic dermatitis Steroid rosacea (drug treatment) Flushing from other cause (allergies; malar flush; SLE) Skin ageing ```

Answer 20

Advice: Avoid triggers (heat, certain foods and excessive sun) Never apply topical steroid to rosacea as will increase severity within few weeks Treatment: Topical/oral: ivermectin for 3 months trial reassess 10mg/g cream (SOOLANTRA) OD 8-12wks for mild-moderate papules and /or pustules Brimonidine gel 0.5% reduce facial redness for 3-6hrs OD application. Metronidazole cream or gel 0.75% TD or azelaic acid 15% TD can be used intermittently or long term for mild inflammatory cases in combo with oral ABs for more severe cases Mod-severe papules and/or pustules prescribe combo of topical Ivermectin with oral doxycycline 40mg OD as modified release 8-12wks Systemic ABs: Doxycycline Likely to need many repeat treatments Refer to dermatology if rhinophyma, ocular complications or failure to respond to treatment in GP Urgent referral for if keratitis suspected (eye pain, blurred vision, sensitivity to light) Routine referral for ocular symptoms severe or resistant to max treatment in primary care

Answer 21

Inflamed hair follicles resulting in tender red spot often with surface pustule Can be superficial or deep Affects anywhere Ance and acne variants are also types of folliculitis Bacterial folliculitis usually due to staph. Aureus

Answer 22

Sycosis barbe (beard) Beckhearts impetigo (superficial) Gram -ve folliculitis (following acne treatment due to AB use) Hot tub folliculitis from hot water, spa pool etc Pseudofolliculitis from shaving/razors

Answer 23

Chronic relapsing disease of recurrent erythema, telangiectasia, oedema, papules and pustules affecting forehead, cheeks, nose and often the chin Affect fair skinned people relatively commonly accounting for 1% dermatology out pts in britain Occurs in second half of life associated with facial flushing More common in women tends to be more severe in men Ocular changes usually bilateral result in mild blepharitis and conjunctivitis occur in more than 50% pts

Answer 24

Blushing or flushing or persistent erythema Red face and prominent blood vessels (telangiectasia fine, dilated blood vessels) Red papules and pustules on nose, forehead, cheeks sna chin often follow (inflammatory or papulopustular rosacea) rarely trunk and upper limbs may involve Facial skin thickening mostly nose Dry and flaky skin burning stinging sensation Aggravated by sun exposure hot spicy food or drink Sensitive skin burning and stinging esp in makeup reaction sunscreens and facial creams Red sore gritty eyelid margins including blepharitis

Answer 25

Papules and sometimes pustules. Dome shaped rather than pointy like acne and no black/white heads or nodules May also result in red areas (erythematotelangiectatic rosacea), scaling (rosacea dermatitis) and swelling (phymatous rosacea)

Answer 26

``` Acne vulgaris Seborrhoeic dermatitis Steroid rosacea (drug treatment) Flushing from other cause (allergies; malar flush; SLE) Skin ageing ```

Answer 27

Advice: Avoid triggers (heat, certain foods and excessive sun) Never apply topical steroid to rosacea as will increase severity within few weeks Treatment: Topical/oral: ivermectin for 3 months trial reassess 10mg/g cream (SOOLANTRA) OD 8-12wks for mild-moderate papules and /or pustules Brimonidine gel 0.5% reduce facial redness for 3-6hrs OD application. Metronidazole cream or gel 0.75% TD or azelaic acid 15% TD can be used intermittently or long term for mild inflammatory cases in combo with oral ABs for more severe cases Mod-severe papules and/or pustules prescribe combo of topical Ivermectin with oral doxycycline 40mg OD as modified release 8-12wks Systemic ABs: Doxycycline Likely to need many repeat treatments Refer to dermatology if rhinophyma, ocular complications or failure to respond to treatment in GP Urgent referral for if keratitis suspected (eye pain, blurred vision, sensitivity to light) Routine referral for ocular symptoms severe or resistant to max treatment in primary care

Answer 28

Inflamed hair follicles resulting in tender red spot often with surface pustule Can be superficial or deep Affects anywhere Ance and acne variants are also types of folliculitis Bacterial folliculitis usually due to staph. Aureus

Answer 29

Sycosis barbe (beard) Beckhearts impetigo (superficial) Gram -ve folliculitis (following acne treatment due to AB use) Hot tub folliculitis from hot water, spa pool etc Pseudofolliculitis from shaving/razors

Answer 30

Frequent shaving, waxing, hair removal (pseudofolliculitis) Friction from tight clothes Atopic dermatitis Acne or other follicular skin disorders Use of topical corticosteroids Previous long term antibiotic use Anaemia, obesity, diabetes, HIV/AIDS, viral hepatitis, cancer, other chronic illness Bathing in inadequately cleaned hot tub/pool

Answer 31

Shaving rash No bacteria cause or other organisms present on swabbing In beard areas is known as pseuofolliculitis barbe Common in lower legs in women Frequently itchy Treatment is cessation of hair removal for 3-4 wks until follicles subside To prevent recurrence use more gentle hair removal method

Answer 32

Warm compresses for itch and pain Analgesics and antiinflammatories for pain Antiseptic cleansers (hydrogen peroxide, chlorhexidine) Topical antibiotics such as fusidic acid. To reduce bacterial resistance these should be applied for courses of no more than one wk Incision and drainage of fluctuant lesions and abscesses (deep infection) Systemic AB (oral or IV) flucloxacillin or erythromycin for extensive or severe infections (widespread) 7 day course

Answer 33

``` Deep infection (boils/furuncle) One or more tender red spots, lumps, pustules S aureus cultured from skin lesions Usual course of 10 days Cellulitis and lymphangitis Osteomyelitis Septic arthritis ```

Answer 34

Furuncles: skin abscesses caused by staph infections involving a hair follicle and surrounding tissue Carbuncles: clusters of furuncles connected subcutaneously causing deeper suppuration and scrring. smaller and more superficial than subcutaneous abscesses

Answer 35

Presence of discharge pus and fluctuance Boil initially appear firm and tender, erythematous nodules which after several days enlarge and become painful and fluctuant (wave like feeling on palpation skin overlying fluid filled cavity with non-rigid walls) Check for surrounding cellulitis Check temperature, pulse, BP if clinically indicated (look out for sepsis)

Answer 36

May rupture spontaneously if small, once spontaneous drainage occurs lesion should be covered with sterile dressing They heal over several days/weeks to leave violaceous macule and possible permanent scar Oral AB - flucloxacillin Incision and drainage at primary care (if small) or referral to surgical unit or emergency department according to local protocol Swab lesion if: not responding to treatment; persistent or recurrent; multiple lesions; if pt is immunocompromised; known MRSA; has diabetes as ABs will not help

Answer 37

round shiny lesions filled with fluids often autoimmune related examples: pemphigus vulgaris, pemphigoid and dermatitis herpetiformis

Answer 38

Acquired autoimmune blistering disorder Large tense subepidermal blisters on erythematous base Autoantibodies IgG targeting components of basement memb can be detected Usually disease of elderly rarely presents before 50 years Usually occur on upper arms and thighs may spread to trunk Mucous memb involvement seen in 50% cases Oral lesions in about 1/3rd pts Link to malignancy

Answer 39

Usually self limiting remits within 5years Aim to suppress clinical signs to make disease tolerable for pt Suppress infkammatory process: corticostewrods, BAs (tetracyclines, sulphones) Immunosuppressive treatments: suppress production of pathogenic ABs eg high dose corticosteroids prednisolone 30-60mg /day, azathioprine, methotrexate, cyclophosphamide and cyclosporin

Answer 40

Rare but persistent immunobullous disease linked to coeliac disease Herpetiform (herpes simplex viral blisters) but not actually related to herpes virus Not a viral infection Predominantly affects caucasians aged 15-40 years but may occur in those younger or older and in other races More females under age 20 affected than males Genetic predisposition Some pt have family history of other autoimmune conditions (thyroid disease) at least 75% pts with dermatitis herpetiformis have some degrees of enteropathy (vary from flat mucosa to partial villous atrophy)

Answer 41

Skin biopsy to confirm diagnosis Screen for nutritional deficiencies Offer same blood tests for coeliac disease to screen for nutrition def: FBC; LFTs; serum Ca; iron; zinc; B12; folate; TFTs; IgA anti-endomysial ABs Gluten free diet Sulphonamide AB - dapsone: used for symptomatic relief of rash and itch within a few days starting therapy. Monitor side effects (hemolysis) during treatment

Answer 42

AKA genital warts or anogenital warts Epidermal manifestation caused by HPV (95% by types 6 and 11) Transmitted via sexual contact (60% transmission rate between partners) HPV Types 16 and 18 have higher risk of neoplastic transformation May also have risk of co-infection HPV vaccination program in UK has reduced incidences significantly

Answer 43

Smoking Multiple sexual partners History of other STIs Anoreceptive intercourse. However perianal warts can occur in absence of anal intercourse Manual sexual practices such as fisting and fingering Immunosuppression

Answer 44

Lesion or multiple lesions which may form confluent mass Warts on moist non-hairy skin are usually soft and non-keratinised while those on dry skin are likely to be keratinised and firm Usually painless but can be disfiguring Feel embarrassed Warts can be broad based or pedunculated May be pigmented or not Often found on areas subject to traume during sex Common sites: males; frenulum, corona, glans of penis inner foreskin, urethral meatus, penile shaft and scrotum In females: labia, clitoris, urethral meatus, introitus, vagina and cervix Both sexes: perineum, groin, pubis, perianal area and anal canal

Answer 45

``` Taking history on: Urethral or vaginal discharge Pelvic or scrotal pain Sexual activity in preceding 3 months Contraceptive and condom use Pregnancy possibility HIV risk activities Investigations: Diagnosed usually by clinical presentation Can take biopsy or viral typing in uncertain or recurrent cases or those with atypical features or high risk HPV malignancy Be suspicious of any pt >35 years or those with new symptoms Screen for other STI’s if appropriate ```

Answer 46

Cervical cancer Vaginal, vulval and penile cancer Anal cancers Oral and oropharyngeal cancers

Answer 47

Pt education on condition and implications of long term health for them and their partners (reinforce with written info) Advise use of condoms until lesions have resolved (protect against warts but not necessarily HPV) Refer for counselling PRN Screen and treat for other STIs if needed Current partners and those in the previous 6 months should be assessed and educated with regards to STI prevention Smoking cessation (evidence shows better response to treatment) One third of warts regress spontaneously within 6 months Podophyllotoxin for soft non-keratinised external warts. 0.15% cream or 0.5% solution TD for 3 days; four days rest. Can be repeated in weekly intervals PRN. Solution better for penile; cream better for vulval and anal lesions Imiquimod 5% cream for keratinised lesions and non-keratinised external lesions. Thin application 3x wkly at night until lesions resolve for max 16 wks Trichloroacetic acid less used due to corrosive action on skin but occasionally used in hospitals by specialists (pregnancy or indurated pts) Ablation Cryotherapy Excision Electrocautery or laser *only surgical approaches have near 100% non-recurrence rate *all treatments are associated with itching, pain, burning and erosions *referral needed for cervical warts, intra-anal and pregnancy *children showing genital warts raises safeguarding concerns however can be transmitted during birth or via non-sexual transmission from household members *follow ups to assess response and side effects and check for new lesions regularly

Answer 48

Characterised by hyperpigmentation and thickening (hyperkeratosis) of skin Occurs mainly in folds of skin like axilla, groin, back of neck Cause is unknown but appears related to insulin resistance Has also been associated with benign and malignant conditions

Answer 49

``` Obesity associated (most common): may occur at any age but more common in adulthood and is associated with insulin resistance Syndromic acanthosis nigricans: defined as being associated with a syndrome such as hyperinsulinemia, Cushing’s, PCOS, total lipodystrophy, Crouzon syndrome Benign: AKA acral acanthotic anomaly. Thick lesion most prominent over the upper surface of hands and feet in pt who are otherwise healthy. Most common in darker skin types Drug induced: uncommon but medications include nicotinic acid, insulin, systemic corticosteroids and hormonal treatments Hereditary benign: autosomal dominant trait. Lesions may manifest at any age Malignant: associated with internal malignancy. Most common cancer is tumour of the gut (90% cases) esp. Stomach cancer. In 25-50% cases lesions are present in mouth on tongue and lips Mixed type: patients with one type acanthosis nigricans may develop new lesions of different cause eg obesity type then develops malignant type. ```

Answer 50

Thickened brown textures patches In folds of axilla and neck most commonly Papillomatosis (finger like growth) common on cutaneous and mucosal surfaces (oral cavity, nasal and laryngeal mucosa and oesophagus) Itchy Abrupt development of lesions in middle aged may indicate malignancy Investigations: Tests for underlying tumours or risk factors and refer immediately PRN

Answer 51

Correct hyperinsulinemia with diet/mediations Lose weight with obesity associated type Excise or treat underlying tumour Stop offending medicines in drug induced type Hereditary type may spontaneously resolve eventually

Answer 52

Mild: hydrocortisone: used on face, neck and infants Moderate: clobetasone (Eumovate), betamethasone 0.025% (betonvate RD): used on infants for max 3 days, children and body Potent: betamethasone (betnovate 0.1%), mometasone (Elocon): use on body Very potent: clobetasol (dermovate): use on hands and feet

Answer 53

Clean area Rinse with water Apply emollient thin layer gently to skin in direction of hair growth Wait 15-30mins before applying steroid creams also in direction of hair growth * fingertip method: use finger to measure volume of cream needed per application! full tip of finger length = adult; half FTU = half fingertip length and so on

Answer 54

Characterised by papules and vesicles on erythematous base Atopic is most common type of eczema Usually develops in childhood and resolves during teen years (may recur) 80% cases before age 5 20% prevalence in <12 years in UK Subtypes: Intrinsic: atopic, seborrhoeic, pompholyx, discoid, venous Extrinsic: contact allergic dermatitis, contact irritant dermatitis

Answer 55

Family history of atopic eczema, allergic rhinitis, asthma Primary genetic defect in skin barrier function appears to underlie cause but no one really knows Exacerbating factors such as heat, allergens, infections, sweating and severe stress can trigger/cause

Answer 56

Itchy Erythematous dry scaly patches More common on face, hands, extensor aspects of limb (infants) and flexor aspects in children and adults Acute lesions are erythematous, vesicular and weepy (exudate) Chronic scratching/rubbing can lead to excoriations and lichenification May show nail pitting and ridging

Answer 57

if it doesn’t itch; it’s probably not eczema! Itchy skin + 3 more of the following: History of itchy skin creases such as folds of elbows or knees (or cheeks in <18months) History of asthma, hay fever or atopic disease in first degree relative in children under age 4 General dry skin in preceding year Visible flexural eczema Onset in first two years of life (genetic factors; not acquired)

Answer 58

Visual analogue scales (0-10) capturing the child/parent/carer's assessment of severity, itch and sleep loss over the previous three days and nights. Patient-oriented Eczema Measure (POEM). Children's Dermatology Life Quality Index (CDLQI). Infants' Dermatitis Quality of Life Index (IDQOL). Dermatitis Family Impact (DFI) Questionnaire.

Answer 59

``` Psoriasis Contact dermatitis Seborrhoeic dermatitis Fungal infections Lichen simplex chronicus Scabies ```

Answer 60

Clinical examination and history IgE and specific radioallergosorbent tests (RASTs) only to confirm atopic nature Swabs for bacteriology if not responding to treatment to identify MRSA strain or detect addition strep. Infection

Answer 61

Mild: emollients: mild potency topical corticosteroids Moderate: emollients; moderate potency topicalcorticosteroids; topical calcineurin inhibitors (tacrolimus or pimecrolimus) and bandages (prescribed by specialists usually) severe: emollients; potent topical corticosteroids; topical calcineurin inhibitors (tacrolimus or pimecrolimus); bandages; phototherapy; oral corticosteroids (prescribed by specialists usually) Tacrolimus recommended for 2+ years Pimecrolimus for ages 2-16 in moderate cases

Answer 62

results from repeated scratching; initially treated with potent steroid, bandages containing ichthammol paste etc. can be applied over steroid. Coal tar and ichthammol can be used in chronic cases

Answer 63

initial potent steroid. Infection may also be present and need ABs. potassium permanganate solution can be used in exudative eczema for antiseptic and astringent effects

Answer 64

specialist referral and care. May need phototherapy, systemic steroids or other drugs on the immune system (ciclosporin etc). Alitretinoin recommended for adults with severe chronic hand eczema not responding to potent topical steroids with Dermatology Life Quality Index score >15

Answer 65

Topical corticosteroids Treat any associated infections (mod-severe usually 14 day course flucloxacillin) Urgently refer or admit severe unresponsive disease or with suspected infection with herpes simplex virus Frequent flare ups: Change emollient to higher lipid content Advise application more often and more quantity each time Review factors provoking flares

Answer 66

Incidence 0.5-1%; hsa decreased in recent years likely due to greater awareness of problems from topical steroid use long term Predominantly affects women aged 15-45 years Male incidence increasing probably due to cosmetic use change

Answer 67

Underlying cause not found in all pts. And exact cause is unknown Topical steroid preparations. No clear correlation exists between risk of condition and strength of steroid or duration of use Cosmetics High factor sun protection creams Fluoridated toothpaste Physical factors: UV, heat, wind Candidiasis Hormonal factors suspected: premenstrual deterioration also oral contraceptives potentially

Answer 68

Skin lesions grouped follicular reddish purple, vesicles and pustules on an erythematous base around the mouth, nasolabial folds and cheeks Pale area adjacent to border of mouth is characteristic (sparing of lip margins) Occasionally the eruption can be more widespread (affecting eyelids and forehead) Often sensation of burning and tension; itching is rare Lupoid perioral dermatitis is severe variant with yellow granulomatous infiltrates Complications mostly emotional and scarring related (with lupoid form)

Answer 69

Evaluate pt for underlying factors Reassurance and education of condition; potential triggers (avoid alcohol and spicy foods, cosmetics, cleansers and moisturisers); time course of disease; wash hands after applying steroid cream Topical antibiotics (clindamycin, erythromycin or metronidazole) can be used for mild cases Mod-severe cases need systemic antibiotic for 4-6wks (oxytetracycline 500mg TD, lymecycline 408mg OD, erythromycin 500mg TD) or modified release doxycycline capsules 40mg OD If unresponsive and granulomatous; oral isotretinoin may be considered Pimecrolimus cream if other treatments fail may help Photodynamic therapy may be effective (no large studies to evaluate this) *with treatment there can be initial worsening of symptoms before they improve esp if steroids are withdrawn* *in cases of long term topical steroid misuse, gradual withdrawal with low dose 0.1-0.5% hydrocortisone cream can be initially trialed*

Answer 70

Women more affected 4-7% dermatology app. Are for this Hands affected in 75% contact and 90% occupational dermatitis Prevalence lower in children but increasing Pts in contact with chemicals may also be at risk of: contact urticaria, acne, folliculitis, skin infections, pigmentary disorders, mechanical skin disease (repetitive trauma), skin cancers

Answer 71

``` Florists hairdressers/ barbers Cooks Beauticians and related occupations Metal working machine operatives Chemical, rubber, glass and ceramic process operatives Dental practitioners and dental nurses ```

Answer 72

Allergic contact dermatitis: type IV hypersensitivity reaction occurs after sensitisation and subsequent re-exposure to allergen Irritant contact dermatitis: inflammatory response occurs after damage to skin usually by chemicals. Not allergy and can occur in anyone significantly exposed to irritants. May be acute or chronic/cumulative

Answer 73

``` common irritants and allergens (non-exhaustive list) Water (hard, chalky or heavily chlorinated) Detergents and soaps Solvents and abrasives Machining oils Acids and alkalis, including cement Reducing agents and oxidising agents including sodium hypochlorite Powders, dust and soil Plants Cosmetics Metals Topical medications Textiles Epoxy resin adhesives ```

Answer 74

``` Red skin Vesicles or papules on affected area Crusting and scaling skin Itching Fissures (chronic exposure) Hyperpigmentation (chronic) Pain or burning sensation from affected area Hands affected in 75% contact and 90% occupational dermatitis ```

Answer 75

Secondary bacterial infections Occupational skin disorders may impact quality of life and may need change of occupation Investigations: Full history including: job, materials involved, amount and duration of exposure, location of rash and distribution, timing of rash with relation to work and weather skin clears inbetween Specialist patch testing (GOLD STANDARD)

Answer 76

Avoid irritants Hand hygiene/protective equipment wearing Severe or chronic forms may benefit from topical corticosteroid cream, strength and period of use being adjusted according to severity Short course oral steroid may be used for acute severe episodes Second line agents (psoralen combined with UV A - PUVA) treatment, ciclosporin and azathioprine may be used in specialist setting for chronic resistant dermatitis

Answer 77

1-5% population globally Incidence increased in immunocompromised pts (34-83%) Suggested early marker of HIV/AIDs infection Often severe condition More common in males Thought to be due to androgen effect on sebum production Cause unclear but thought to be inflammatory reaction to yeast called malassezia spp Aggravated by psychological and physical stressors

Answer 78

Face: inflamed, greasy areas with fine scaling (nasolabial folds, nose bridge, eyelashes and eyebrows, blepharitis, ear particularly behind skin folds) Scalp: dandruff flaking, ill-defined pink patches dry with yellowish or white bran like scale Chest: usually greasy scaly papules; less commonly macules and papules similar to extensive pityriasis rosea Sternum and upper back may show fine scaling Flexures may have erythematous patches, papules or plaques presenting as intertrigo

Answer 79

Secondary bacterial infection | Severe SD or generalised seborrhoeic erythroderma is rare. May occur with immunosuppression or cardiac failure

Answer 80

Regular antifungal medication with intermittent topical steroids. Calcineurin inhibitors Scalp: First remove thick crusts or scales with olive oil or keratolytic prep such as salicylic acid or coal tar. Leave olive oil on affected areas for several hrs before washing off with normal coal tar shampoo Medicated shampoos: containing ketoconazole 2% (nizoral) with sulfide shampoo (selsun) Use at least 2x weekly for at least a month after which frequency may be reduced Also used in beard Steroid scalp applications reduce itching. Intermittent use for few consecutive days may be helpful (not in beard) Face, ears, chest and back Clean skin but avoiding soap Ketoconazole or antifungal cream used OD for 2-4wks. Repeat PRN; reduce frequency when symptoms are controlled. Can use antifungal shampoos in addition 1% hydrocortisone cream applied once or twice daily for 1-2wks. Intermittent use may be needed if chronic (avoid long term) Topical calcineurin inhibitors (pimecrolimus cream or tacrolimus ointment) may help (may allow sparing use of steroid creams) For eyelids consider hygiene methods Other treatments: Oral antifungal medication - azoles (ketoconazole or itraconazole) Oral tetracyclines used (off label) for antiinflammatory effects Oral isotretinoin (off label) UV light treatment *often responds well to treatment; often relapses so maintenance or intermittent treatment be be needed*

Answer 81

Medical emergency! Rare widespread HSV infection occurs in atopic eczema patients (most often children) Characterised by fever and clusters of itchy blisters or punched out erosions Often seen as complication of atopic dermatitis Repeated episodes of this condition are unusual More commonly seen in infants and children with atopic eczema

Answer 82

Herpes simplex virus type 1 or type 2 May also complicate recurrent herpes When break down of skin barrier is not caused by atopic eczema is termed kaposi varicelliform eruption, can be due to: thermal burns, pemphigus vulgaris, darier disease, benign familial pemphigus, cutaneous T cell lymphoma and ichthyosis Other virus’ can be due to coxsackivirus A16 (foot and mouth disease) causing similar eruptions (eczema coxsackium)

Answer 83

Clusters of painful itchy blisters Most often on face and neck but can affect anywhere New patches form and spread over 7-10 days Monomorphic blisters may be filled with yellow pus Often blood stained New Blisters have central dimples (umbilication) May weep or bleed Older blisters crust over foring sores (erosions) Lesions heals over 2-6 wks In severe cases small white scars may persist where skin has been destroyed

Answer 84

Diagnosed clinically when pt has known atopic dermatitis and presents with acute painful blisters, fever and malaise Viral culture Direct fluorescent antibody scan PCR sequencing Tzank smear (showing epithelial multinucleated giant cells and acantholysis; cell separation)

Answer 85

Considered a dermatological emergency Prompt treatment with antiviral medications may eliminate need for hospitalisation Oral aciclovir 400-800 mg 5xdaily; valaciclovir 1g TD for 10-14 days or until lesions heal IV aciclovir if pt too sick to take tablets or infection deteriorates further Secondary bacterial infections treated with systemic antibiotics Topical steroids not generally recommended but may be needed to treat active atopic dermatitis Consult ophthalmologist when eyelid or eye is involved

Answer 86

Chronic dermatitis causing skin to become itchy, swollen, cracked in circular or oval patches Cause: Unknown although thought to be related to dry skin History of atopic disease does NOT seem to be relevant to this condition May be triggered by insect bites, burns, infections like Hep C, drugs (statins, TNF-alpha blockers) or weather changes

Answer 87

Distinct oval or circular patches of eczema Can affect any part of body although usually NOT face or scalp First signs usually small group of spots or bumps on skin These join up to form larger patches ranging from few mm to several cm large Lighter skin will show red or pink patches Darker skin will show dark brown or slightly palmers than normal surrounding skin Dry, crusty Swollen and blistered May ooze fluid Centre of patch may become clear leaving ring of discolouration which may be mistaken for ringworm If infected: malaise, nausea, chills, fever

Answer 88

Emollients and avoiding triggers Topical corticosteroids Antihistamines to reduce itching Antibiotics for secondary infections

Answer 89

Chronic inflammatory skin disease due to hyperproliferation of keratinocytes and inflammatory cell infiltration Chronic plaque psoriasis most common type Other types include guttate (raindrop lesions), seborrhoeic (nasolabial and retroauricular), flexural, pustular (palmer-planter), and erythrodermic (total body redness) Affects about 2% of population in UK; Onset 30-50s Increased prevalence increasing distance from equator Pathophysiology: Activated t cells infiltrate epidermis Hyperproliferation of keratinocytes in epidermis Increased epidermal cell turnover rate

Answer 90

``` Genetic (40% family history) PSORS1 locus within major MHC on chromosome 6p21 (location of HLA genes) Obesity Smoking Alcohol Stress Infections ```

Answer 91

Causes: Complex interaction between genetic, immunological and environmental factors Precipitating factors include: trauma (may produce Koebner phenomenon), infection (tonsillitis), drugs, stress and alcohol Complications: Erythroderma Psychological and social effects

Answer 92

Well- demarcated erythematous scaly plaques Lesions can be itchy, painful or burning Common on extensor surfaces and scalp Auspitz sign (scratch and gentle removal of scales causes capillary bleeding) 50% associated with nail changes (pitting, onycholysis) 5-8% suffer from associated psoriatic arthropathy - symmetrical polyarthritis, asymmetrical oligomonoarthritis, lone distal interphalangeal disease, psoriatic spondylosis and arthritis mutilans

Answer 93

``` Plaque Palmo-plantar (feet and palms) Nail Scalp Inverse Guttate (small widespread plaques) ```

Answer 94

``` General measures to avoid known precipitating factors and emollients to reduce scaling Topical therapies (localised and mild cases): vit D analogues, topical corticosteroids, coal tar preparations, dithranol, topical retinoids, keratolytics and scalp preparations Phototherapy (extensive disease): UVB and photochemotherapy Oral therapies (extensive and severe or with systemic involvement): methotrexate, retinoids, ciclosporin, mycophenolate mofetil, fumaric acid esters and biological agents ```

Answer 95

Aim is eversion of wound edges not inversion! Move knots to the same side (don’t leave in the centre) Place sutures to line up irregular wound edges first then suture between for full closure Principles are: To support tissues until healing process restores tensile strength To minimise risk of bleeding and infection To close dead space by approximating wound edges ensuring functional and aesthetically pleasing result

Answer 96

``` Incision: sharp straight deep cut Punture: deep and narrow Abrasion: top layer of skin scraped off Laceration: irregular cut from tearing Avulsion: part of skin is loose/torn Amputation: part of body detached Burn: thermal electrical or chemical injury to skin Crush injury: body part subjected to high degree of force or pressure, usually after being squeezed between two heavy objects Bite: human/animal ```

Answer 97

* injuries involving glass, dog bites etc. should be X Rayed to check for residual foriegn body and fractures * puncture wounds are deep and difficult to clear; cover with broad spectrum antibiotics * hand wounds are most likely to get infected * Sun exposure can cause hyperpigmentation and scarring - keep wound covered * Small amount of foriegn body to remain is potentially normal/OK

Answer 98

Typically for cuts or wounds which aren’t too severe or minor surgery Help heal wounds by pulling two sides of skin together without making contact with actual wound; reducing chance of introducing bacteria or other substances into cut Sometimes a better option than stitches as they don’t need to be sewn into skin and are easily removable (good for children esp.)

Answer 99

Are wound edges straight? Steris are best for shallow cuts with straight clean edges Is bleeding light and measurable? Use sterile cloth to put pressure on the wound for 5mins at least. Don’t use strips if it’s still bleeding after this Is the wound less than 5cm in length? Steris aren’t recommended for anything larger than this! Is it in an area where skin doesn’t move a lot? Steri’s might not work as well on joints or other areas where it may have trouble staying in place Using steri’s: Make sure wound and surrounding area stays clean Make sure steris area is kept dry for at least 24-48hrs once applied; special care when bathing or showering (cover with bandages etc) Trim away edges of steris that come loose using scissors Inspect wound every day to ensure no sign of infection Don’t pull on loose steri ends (can reopen wound) Don’t rub or pick the area (could introduce bacteria into or open wound again)

Answer 100

Medical glue used to close wounds Can be used on it’s own or with stitches or adhesive tape Forms protective waterproof covering over the wound Mainly used for cuts that are minor, up to 5cm long, have straight edges and are easily pulled together Can also close wounds on the face, head, some parts of arms and legs, trunk Is not always suitable for joints as can move about too much Will slough off within 5-10days

Answer 101

Should not be put inside wounds Hold skin together and put glue over the top of skin Avoid touching for 24hrs Keep wound dry for at least 5 days Scar should take around 6months to fade Pat dry if it’s wet, do not rub! Don’t put plasters, creams, clothing, don’t brush hair in glued area, don’t pick glued area for first 5 days

Answer 102

Face/lip: 6-0 monofilament, non-absorbable remove in 3-5 days Scalp: 3-0, 4-0: Monofilament, non-absorbable remove in 7-10 days Chest/abdomen/back: 3-0, 4-0 monofilament may be absorbable or not. remove in 10-14 days if non-absorbable Limbs: 3-0 to 5-0: monofilament may be non or absorbable; remove in 10-14 days if needed Hands: 4-0 or 5-0: monofilament usually non-absorbable remove in 10-14 days

Answer 103

Max dose 1% is 3mg.kg 1% lidocaine (10mg per ml = 100mg in 10ml) Usually comes in 5ml vial (5ml x 10mg = 50mg per vial) Average 70kg person (3 x 70 = 210mg max) 210/50 = 4 vials max If you have 0.25% = 2.5mg per 1ml (5 x 2.5 = 10mg per vial) 210/10 = 21 vials max Warm liquid in hands by rubbing hands together: is rather acidic so can sting a bit when being given

Answer 104

Check all bones for tenderness (move face; jaw etc.) Infraorbital nerve: sensation and eye movements Can touch gums to test sensation Mouth injuries: any wound crossing vermillion border should be referred to maxfax for closure. Same for any cosmetically concerning cases Nose injuries: NO nose XR for suspected fractures as unlikely to show up (unless very complex; then discuss with ENT before discharge). Have follow up with ENT Drs in around 7 days time; then will decide if they need imaging (less swelling; easier to see on XR). But still very important to rule out septal haematoma for nose injuries; look in nostrils (must be documented as can go on to cause significant infection!!)

Answer 105

Injecting drug users are high risk (particularly if SC or IM routes) Any wound including burn is potent tetanus risk: always ensure there is sufficient tetanus protection (vaccinated) Wounds most at risk are contaminated wounds (saliva, soil, dirt etc) Standard active immunisation involved initial course of 3 IM doses of 0.5mL tetanus toxin given at 2,3,4 months old followed by boosters at 4 and 14 years Full course of all 5 is considered to give lifelong immunity Inadequate immunisation is likely in immigrants, elderly, patients with reduced immunity and those who refused vaccinations

Answer 106

Need for immunisation after injury depends on pts immunity status and weather the wound is ‘clean’ or ‘tetanus prone’ such as: Heavily contaminated (esp. With soil or faeces) Devitalized tissue Infection or wound >6hrs old Puncture wounds and animal bites If the pt receives full 5 dose vaccine: no need to give further vaccine Consider giving anti-tetanus immunoglobulin (HATI) only if the risk is especially high (wound contaminated with manure etc.) If immunisation status is unknown/uncertain then give dose of combined tetanus/diphtheria/polio vaccine and refer to GP for further doses if needed For tetanus prone wounds also give one dose of HATI (250-500 units IM) at a different injection site

Answer 107

Most wounds won’t need antibiotics They are frequently used for wounds >6hrs old, complex oral wounds and in high risk workers (gardeners, farmers, fishermen etc) Antibiotics are indicated for penetrating injuries which cannot be properly cleaned

Answer 108

Can cause contaminated puncture wounds, contaminated crush injuries or both All carry high infection risk (bacterial, viral, rabies etc) Bacterial infection is likley in: punctures (cats/human bites), hand wounds, wounds older >24hrs, immunocompromised, alcoholics and diabetics Bacterial organisms most likely to infect: streptococci, staph. Aureus, clostridium tetani, pasteurella multocida (cat bite or scratch), bactericides, Eikenella corrodes (human bites)

Answer 109

Establish what animal How long ago Where bite occurred (surroundings) XR if fracture suspicion, joint involvement (look for air), or radio-opaque foreign body (tooth)

Answer 110

Clean: explore fresh bite wounds with appropriate anaesthetic, debride and clean with normal saline or washing with tap water Refer significant facial wounds or involving tendons or joint to specialist (usually plastics team) Cosmetic considerations usually outweighs risk of infection for most facial wounds so aim for primary closure Do not close puncture wounds that can’t be satisfactorily irrigated Whether to give ABs prophylaxis for bite is controversial, consider for: punctures, crush injuries with devitalized tissues, bites to hands, wrist or genitals, primarily closed bites, human, cats and rat bites, bitten individuals who are immunocompromised Co-amoxiclav is for broad spectrum cover (doxycycline and metronidazole or ceftriaxone alone for penicillin allergy) Do not use erythromycin or flucloxacillin alone as prophylaxis

Answer 111

Most occur >24hrs after injury and are due to staphylococci or anaerobes Pain, inflammation and swelling +/- regional lymphadenopathy within 24hr suggests P. multocida infections Take swab of all infected wounds Treat with cleaning, elevation, analgesia and antibiotics (guided by micro results) Oral Co-amoxiclav and outpt review at approx 36hr is appropriate for localised infections with no systemic involvement and no suspected underlying joint involvement Refer pts with spreading infection for IV antibiotics and admission

Answer 112

Many human bites occur ‘in reverse’ when an individual punches another in the mouth, causing wounds on the dorsum of the hand over the MCPs Underlying joint involvement is common and may progress to septic arthritis unless treated aggressively with exploration, irrigation and antibiotic —> refer all such patients Consider Hep B, C and HIV, give appropriate prophylaxis

Answer 113

Minor local reactions are common Treat with ice, rest, elevate, analgesia and antihistamine (chlorphenamine 4mg TDS or non-sedating alternative such as loratadine PO 10mg OD)

Answer 114

This is a severe soft tissue infection caused by a variety of bacteria including Clostridium an d Streptococcus that can lead to tissue loss and sepsis.

Answer 115

This is an infection of your skin that’s not in immediate contact with the wound. Red hot, swollen and painful +/- systemic symptoms (fever, anorexia, nausea and vomiting. Treat with ABs according to local guidelines (Flucloxacillin 250mg-500mg QDS 1wk; usually 500, can go up to 1g PRN). Mark the area of infection to monitor spreading.

Answer 116

Bacterial infection in a large joint. Reduced range of movement; red, hot and swollen. Aspirate joint to test synovial fluid in the lab to check WCC/bacterial organism. Give IV antibiotics to treat (before results come back) may also go to theatres for drain and washout to avoid infection spreading to the bone.

Answer 117

Caused by thermal, chemical, electrical or radiation energy Scald is burn caused by hot liquid or steam Consider NAI (non-accidental injury) Highest rates seen in children under age of 5 and elderly over age 75 About 50% burns and scalds occur in kitchen Infants and toddlers are at high risk of scalds from pouring hot beverages over themselves and at particular risk of burns from touching hot items

Answer 118

Palmar surface of pts hand, including fingers, represents approx 1% of pts body surface The adult body is divided into anatomical regions that represent 9%, or multiples of 9%, of the total body surface. Therefore, 9% each for the head and each upper limb. 18% each for each lower limb, front of trunk and back of trunk. The palmar surface of the patient's hand, including the fingers, represents approximately 1% of the patient's body surface. Body surface area differs considerably for children - the Lund and Browder chart takes into account changes in body surface area with age and growth.

Answer 119

Superficial and partial thickness Red, glistening, pain, absence of blisters and brisk capillary refill Not life threatening Normally heal within a week without scarring

Answer 120

Pale pink or mottled with associated swelling and small blisters. Surface may be weeping, wet and extremely hypersensitive Brisk capillary refill Heal within 2-3wks with minimal scarring and full functional recovery

Answer 121

Blistering, dry, blotchy cherry red, doesn’t blanch, no capillary refill and reduced or absent sensation 3-8 wks healing with scarring May need surgery for best functional recovery

Answer 122

Dry, white or black, no blisters, absent capillary refill and absent sensation Needs surgical repair and grafting

Answer 123

Includes subcutaneous fat, muscle and perhaps bone | Needs reconstruction and often amputation

Answer 124

Remove all clothing: adherent synthetic clothing and tar should be actively cooled with water and left for formal debridement Dry chemical powers carefully brushed from wound Rinse involved surface area with copious amounts of water Cool burn with running water from cold tap for at least 20mins but avoid using ice or refrigerated water as this can cause further vasoconstriction and tissue damage Great care needed to avoid hypothermia especially in children and those with extensive burns as this worsens shock Remove constrictive clothing and jewellery before covering pt with warn, clean and dry linens to prevent hypothermia

Answer 125

Clean with soap and water or dilute water based disinfectant to remove loose skin Blisters smaller than 1cm diameter (or pts little finger nail) should be left intact to minimalism risk of infection Debride larger blisters (remains controversial) Examine dressings at 48hrs to reassess burn, including depth Dressings on superficial partial thickness burns can be changed after 3-5 days in absence of infection If infection occurs then daily inspection and dressing change is needed and prescribe 7 days flucloxacillin (1st line) or erythromycin. Clarithromycin for intolerance Ensure adequate analgesia and assess need for tetanus prophylaxis

Answer 126

Initial treatment needs to include: direct thermal injury producing upper airway oedema/obstruction, inhalation of products of combustion(carbon particles) and toxic fumes leading to chemical tracheobronchitis, oedema and pneumonia, CO poisoning Prompt irrigation with running cool tap water for at least 20 minutes (but no more than one hour) provides appropriate cooling. Very cold water, ice and objects from a freezer to cool the area should be avoided as these cause vasoconstriction and may worsen tissue ischaemia and local oedema. Chemical burns may need longer periods of irrigation, but irrigation should last no longer than one hour as a maximum period. Dressings help to relieve pain and keep the area clean but avoid circumferential wrapping, as this can cause constriction.The choice of dressing used can vary between specialist units. However, some studies have suggested that paraffin gauze dressings are a valuable option in superficial burns, while silver-based dressings are preferable in deeper burns. All patients with facial burns or burns in an enclosed environment should be assessed by an anaesthetist for early intubation. For full-thickness circumferential burns, escharotomy may be required to avoid respiratory distress or reduced circulation to the limbs as a result of constriction.

Answer 127

above the glottis is very susceptible to obstruction because of exposure to heat. The clinical presentation of inhalation injury may be subtle and often does not appear in the first 24 hours. Inhalation injury: face +/- neck burns, carbon deposits + acute inflammatory changes to oropharynx carbon particles in sputum hoarseness explosion with burns to head and torso carboxyhemoglobin level greater than 10% if the pt is involved in a fire

Answer 128

Arterial blood gas determinations should be obtained as a baselinebutarterialPO2 doesnotreliablypredictCO poisoning. Therefore, baseline carboxyhaemoglobin levels should be obtained and 100% oxygen should be administered. Elevation of the head and chest by 20-30° reduces neck and chest wall oedema. If a full-thickness burn of the chest wall leads to severe restriction of the chest wall motion, chest wall escharotomy (burn incised into subcutaneous fat and underlying soft tissue; no anaesthetic is required due to loss of sensation anyway) may be required. CO poisoning: has a much greater affinity than oxygen for haemoglobin and so displaces oxygen: Assume CO exposure in patients burned in enclosed areas. Diagnosis of CO poisoning is made primarily from a history of exposure. Patients with CO levels of less than 20% usually have no physical symptoms. Higher CO levels may result in headache and nausea, confusion, coma and death. CO dissociates very slowly but this is increased by breathing high-flow oxygen via a non-rebreathing mask.

Answer 129

Burns >15% total body surface (disregard superficial burns) or child with more than 10% requires fluid replacement Needed in first 24hrs from time of injury (0.5-1ml/kg adults; 1-2ml/kg children) Aim to keep good urine output Adults for partial and full thickness burns or those with associated inhalation injury, use 4ml Hartmanns solution/kg/% burn discarding superficial. HALF of this given over first 8 hrs and other half given over following 16 hr Children: replace fluids as above plus maintenance of 0.45% saline with 5% dextrose should be titrated against nasogastric feeds or oral intake: 100ml/kg first 10kg body weight plus 50ml/kg for next 10kg body weight plus 20ml/kg each extra kg Ensure analgesia using strong opiates Prevent hypothermia

Answer 130

Need reassessment in first 24-72hrs as are very dynamic Depth can increase as result of inadequate treatment or superadded infection Burns can be superficial in some areas but deeper in others Circumferential extremity burns: assess status of distal circulations, checking for cyanosis, imapried cap refill or progressive neurological signs Assessment of peripheral pulses in burns in best performed with doppler ultrasound

Answer 131

Respiratory distress from smoke inhalation or a severe chest burn. Fluid loss, hypovolaemia and shock. Infection (SEPSIS is massive risk and can recur endlessly in some pts) Increased metabolic rate leading to acute weight loss. Increased plasma viscosity and thrombosis. Vascular insufficiency and distal ischaemia from a circumferential burn of limb or digit. Muscle damage from an electrical burn may be severe even with minimal skin injury; rhabdomyolysis may cause acute kidney failure. Poisoning from inhalation of noxious gases released by burning (eg, cyanide poisoning due to smouldering plastics). Haemoglobinuria and renal damage. Scarring and possible psychological consequences. Hypertrophic scarring is more common following deeper burns treated by surgery and skin grafting than with superficial burns.

Answer 132

All complex injuries preferably referred Age under 5 and over 60 years Site of injury: face, hands, perineum, flexure surface, circumferential dermal burns or full thickness limb, torso or neck burn Inhalation injury Mechanism of injury: chemical affecting >5% body surface (>1% for hydrofluoric acid burns), ionising radiation burns, high pressure steam or high tension electrical injury Suspected non-accidental in child Large affected area: age under 26 (>5% total area) over 16 years (10% total surface burned) Co-existing conditions, pregnancy or associated fracture, head injury or crush injury

Answer 133

Can result from exposure to acidic, alkaline or petroleum products. Alkali burns tend to be deeper and more serious than acid burns. Immediately flush away the chemical with large amounts of water for at least 20 to 30 minutes (longer for alkali burns). Alkali burns to the eye require continuous irrigation during the first eight hours after the burn. If dry powder is still present on the skin, brush it away before irrigation with water.

Answer 134

Are often more serious than they appear on the surface. Rhabdomyolysis results in myoglobin release, which can cause acute kidney injury. If the urine is dark, start therapy for myoglobinuria immediately. Fluid administration should be increased to ensure a urinary output of at least 100 ml/hour in the adult. Metabolic acidosis should be corrected by maintaining adequate perfusion and adding sodium bicarbonate.

Answer 135

Superficial burn which may be partial thickness in severe cases Risk factors: duration of sun exposure, height of sun, types of UV (UVB more potent than UVA), increasing altitude, environmental reflection, lighter skin pigmentation, moist skin, limb skin, areas of vitiligo and alopecia, photosensitivity (SLE, porphyria, ance topical creams), sunbed/lamp overuse

Answer 136

skin is red, hot, blanches on pressure. Painful and tender may be some oedema. Erythema usually occurs 2-6 hrs after exposure peaking at 12-24hrs. Resolves over 4-7 days usually with peeling and skin scaling. More severe shows vesicles and bullae may form. Systemic symptoms can accompany (headache, chills, malaise, nausea and vomiting).

Answer 137

severity and area covered. Examine colouring, blistering, cap refill. Degree of pain, dehydration, heat exhaustion or heat stroke signs (high body temp, fatigue, weakness, dizziness, syncope, headache, nausea, vomiting, rapid pulse, myalgia, altered behaviour). Children; consider neglect or non-accidental injury. Assess for co-existing injuries or contributing medical conditions

Answer 138

(mild-mod): educate on sun safety and prevention. spontaneously resolve; maintain hydration, cool shower or compresses, simple analgesics, emollients Moderate: treat dehydration and heatstroke; symptom relief as above; if there are blisters, wound care and dressings needed Severe: treat as severe burn referrals: all deep dermal and full thickness burns. All circumferential burns, superficial covering >3% age 16+, >2% under age 16, superficial dermal burns involving face, hands, feet, perineum, genitalia or flexures, suspicious of dehydration, heatstroke, shock or sepsis. Wound not healed for >14 days, co-existing medical conditions, uncertainty of burn depth or severity, age <5 or >60.

Answer 139

heatstroke, secondary infection, exacerbation of dermatological conditions, premature ageing, skin cancers, photosensitivity reactions

Answer 140

Specialised puncture wound Principal risks are hep B, C and HIV in practice Risk of Hep B estimated at 2-40% Risk of Hep C 3-10% HIV risk estimated at 0.2-0.5% but may be higher if significant volumes ejected Approx 0.03% risk of HIV transmission after mucocutaneous exposure (cuts, abrasions, mucous membranes including the eye) Small risk of HIV following needle stick from person with known HIV may be reduced by post exposure prophylaxis

Answer 141

Squeeze out blood excess Wash with soap and water Ensure tetanus coverage Ensure hep B cover (start cover if not previously covered) Check antibody titres if immunised and give booster if low If very low give immunoglobulin and start vaccine course Many local needlestick policies advise obtaining informed consent from source pt, prior to taking bloods to check hep and HIV status In practice, identify source of pt is not always clear: do not withhold hep B prophylaxis if there is any doubt If source of pt is known or suspected being HIV +ve: follow local guidelines to discuss PEP (post exposure prophylaxis) and follow up 245mg tenofovir OD +200mg emtricitabine OD + 400mg lopinavir BD + 100mg ritonavir BD Most effective if started within 1 hr exposure but consider in <72hrs Side effects include diarrhoea Advise pt to use barrier contraceptives and not to donate blood until subsequent HIV ruled out Take baseline bloods for storing (serology for possible future testing) and in case of possible HIV source pt also take FBC, U+Es, LFT + amylase If occurred in hospital report to occupational health

Answer 142

``` Inspect generally: Observation Number and sizes of lesions Patterns of distribution and configuration if multiple Describe: SCAM Size Colour Associated secondary change Morphology and margin In presence of pigmentation: ABCD: these are red flags! Asymmetry Irregular borders Colouration (2 or more) Diameter >6mm Palpate: Surface Consistency Mobility Tenderness Temperature Systemic check: Nails, scalp, hair, mucus membranes, General inspection of all systems ```

Answer 143

Age (most common conditions for age range) Distribution + colour (localised/sensitive area? Periocular, perioral?) Other symptoms (itchy, discharge, bleeding) Response to treatment (always check those tried prior to consultation) Allergies (history of known allergies and irritants; new shampoos/body wash/washing up liquid/detergents) etc Occupation and exposure to potential triggers/causes

Answer 144

Distribution and colour (localised/sensitive areas, widespread?) If widespread: symmetrical? Central, peripheral? Does it involve flexures? Limited to sun-exposed sites? Regional (groin or axilla?) Does it follow a dermatome (nerve root distribution) pattern? Eg in shingles

Answer 145

Refers to tendency to develop allergic diseases like asthma, eczema and hay fever Mostly inherited (hyperreactive immunity, skin barrier dysfunction) as well as environmental factors Characterised by overactive immune response to environmental factors Same factors have no effect on skin of non-atopic

Answer 146

Patch containing suspected allergen; place on pt and see response on skin Used in complexes cases (severe eczema) Used if recurrent cases with unsure of triggers and cause

Answer 147

Benzoyl peroxide can be purchased in strengths of 2.5%, 5% or 10%. Its primary mechanism of action is bactericidal activity against C. acnes, but it also somewhat prevents sebum production and has keratolytic effects. •Start with low strength and increase •Counselling points: can bleach fabric, use as directed and reduce or cease if skin reactions, also stay out of sunlight when in use

Answer 148

Single topical treatment (retinoid eg adapalene: CI pregnancy and breastfeeding is tetraogenic) used alone or in combo with benzoyl peroxide Topical antibiotic (eg clindamycin 1%) Azelaic acid 0% (chemical exfoliator also kills C. acnes

Answer 149

Oral tetracycline (mx 3 months) commonly lymecycline, doxycycline etc. Erythromycin in pregnancy No improvement = change antibiotic No improvement after 2 antibiotic 3 month courses (6mths) refer to dermatologist Topical retinoid or benzoyl peroxide should always be co-prescribed to reduce risk of resistance Combined oral contraceptives (NOT progesterone only as this worsens acne) Isotretinoin (oral retinoid) shrinks sebaceous glands and reduces sebum production. Doses 0.6-1mg/kg/day show 90% reduction sebum production within 6 wks. Usually initiated by specialist. MONITORING: LFTs and lipids before, 1mth post and then every 3mths. Side effects: skin reactions (severe dryness), alopecia and skin fragility (psychotic disorders also but rare) Highly teratogenic (CI in pregger and BF) must be on some form of contraception unless infertile. COUNCIL POINTS: regular moisturising (cetaphil), hair removal not allowed, joint pain is common side effect,any psychological symptoms must speak to GP

Answer 150

Spreading bacterial skin infection Involves deep subcutaneous tissue Erysipelas is an acute superficial form of cellulitis and involves the dermis and upper subcut tissue. It’s distinguished from cellulitis by a well-defined, red raised border ``` Causes: Streptococcal pyogenes Staph. Aureus Risk factors: Immunosuppression Wounds Leg ulcers Toeweb intertrigo Minor skin surgery ```

Answer 151

Most common in lower limbs Local signs of infection: swelling, erythema (rubor), warmth, pain, may be associated with lymphangitis Blisters and bullus may form Systemically unwell: fever, malaise or rigors, particularly with erysipelas

Answer 152

Investigations: Swab of site Usually made by clinical exam and history ``` Differentials: DVT Erysipelas Septic arthritis Acute gout Ruptured Baker’s cyst ```

Answer 153

Flucloxacillin (500mg-1g QDS for 5-7 days) or benxylpenicillin Clarithromycin 500mg TD 5-7 days if penicillin allergy Supportive care: rest, leg elevation, sterile dressings and analgesia Complications: Local necrosis Abscesses Persistent leg ulceration Septicemia

Answer 154

Most often affects children Streptococcal form more common in warmer and more humid climates Risk factors: Poor hygiene Skin conditions leading to break in skin (atopic eczema, bites, skin trauma, scabies, chickenpox, burns and contact dermatitis)

Answer 155

``` Non-bullous: Start as tiny pustules or vesicles evolve rapidly into honey coloured crusted plaques Tend to be <2cm diameter Usually on the face (mouth and nose) May also be on extremities where bites, abrasions etc. have occurred Spreads rapidly little/no erythema or oedema Regional lymph nodes often enlarged ```

Answer 156

Thin roof of skin tend to rupture easily/spontaneously Usually on the face, trunk, extremities, buttocks or perineal regions More likely to occur on top of other diseases like atopic eczema Little/no erythema and usually no regional lymphadenopathy More common in neonates Painful Associated with malaise symptoms

Answer 157

Begins as non-bullous impetigo but ulcerates and becomes necrotic Deeper and may occur with lymphadenitis

Answer 158

Investigations Diagnosis by clinical exam Swab for culture and sensitivity if it’s extensive or severe, MRSA suspected or is recurrent impetigo to exclude nasal staphylococcal colonisation ``` Differentials: Cellulitis Scabies Contact dermatitis Chickenpox Intertrigo Burns ```

Answer 159

``` Avoid contact with infected individuals Keep wounds clean Good personal hygiene Treat pre-existing skin conditions Naseptin or Mupirocin TD for five days applied to each nostril to reduce nasal colonisation in S.aureus household member carries ```

Answer 160

Good hygiene methods Mupirocin and fusidic acid topical/oral antibiotics Extensive infection: systemic ABs 7 day course flucloxacillin 500-1000mg first line; clarithromycin or erythromycin 2nd line for penicillin allergy/pregnancy (bullous infections usually need oral ABs Localised non-bullous: Hydrogen peroxide 1% cream for those systemically well with little risk of complications; short course topical antibiotic if not suitable (fusidic acid 2% first line) Wide-spread non-bullous: short course topical/oral antibiotic if not systemically unwell or at risk of complications (flucloxacillin) Recurs frequently: swab for micro testing and review AB choice with results Refer to hospital or specialist if: more serious illness suggested, widespread infection in immunocompromised individual, bullous form particularly in <1 years, recurs frequently, at high risk of complications

Answer 161

If causative group A beta-haemolytic streptococcus can have rare complications such as scarlet fever or glomerulonephritis Cellulitis Staphylococcal scalded skin syndrome Suppurative lymphadenitis Lymphangitis *mortality in infants with staph. Scalded skin syndrome is low but can be as high as 63% in adults.

Answer 162

Difficult to diagnose; often clinically mimics other conditions Female scabies mite is typically 0.4mm long; male around half this size After mating on the skin, male dies and female tunnels into the epidermis, depositing eggs in burrow Development from egg to adult takes around 10-15 days Adult mites return to skin surface to begin cycle again (die in around 4-6 wks) The average host harbours 10-12 mites but this can be much more in immunocompromised individuals Usually requires skin to skin contact for 10-15 minutes for mites to pass from one host to another Classical scabies usually only transmitted via direct skin contact Crusted scabies (more severe) can also be transmitted via bedding, towels, clothes and furniture There is a period of asymptomatic infection (can still transmit), pruritus develops as allergic reaction to infection at about 4-6 wks post-infestation

Answer 163

``` Overcrowding Poverty, poor nutrition Homeless Poor hygiene Institutions (care homes, refugee camps) Dementia Sexual contact Children esp in developing countries Immune suppression ```

Answer 164

signs and symptoms develop after 3-4 wks Widespread itching Worse at night or when warm History of family members suffering itch suggestive of scabies Skin changes very: lesions may be papules, vesicles, pustules and nodules. Erythematous papular or vesicular lesions usually seen in sites of burrows More widespread, symmetrical and itchy papular eruption is not in areas of burrow or obvious mite activity (most commonly seens around axillae, periareolar region in women, abdomen, buttocks, thighs) Excoriation marks are common and may be more marked than underlying rash Burrows may be visible as fine, wavy, greyish, dark or silvery lines 2-15mm long sometimes with minute speck (mite) at closed end Most often seen on interdigital web spaces of hands, flexor surfaces of wrists and elbows, axillae, ankles, feet, buttock areas, male genitalia and periareolar area (women) ‘Wake sign’ specific to scabies: V burrow pattern Nodules can develop particularly at elbows, anterior axillary folds, penis and scrotum. Firm, dull, red or brown and may be very itchy. May persist for wks/months after treatment (doesn’t necessarily mean active infection) Usually spares soles of feet and thick skin areas as they’re more resistant Burrows often obliterated during bathing

Answer 165

Hyperinfestation with thousands of mites present in exfoliating scales due to hosts insufficient immune response Hyperkeratotic crusted lesions typically affect hands, feet, ails, scalp and ears but all areas but all areas of skin, including scalp and trunk may be involved Crusted scabies resembles psoriasis sometimes May present with generalised lymphadenopathy and can be associated with eosinophilia Often becomes secondarily infected (itching prone to bacterial infection) Very contagious and far more difficult to eradicate than classical form

Answer 166

``` Differentials: Insect bites Tinea Atopic eczema Impetigo Contact dermatitis Investigations: Largely clinical diagnosis Ink burrow test: ink rubbed over burrow then wiped off with alcohol swab. Ink will track in the burrow and outline it Diagnosis can be confirmed by skin scraping from affected area and placing material on glass slide with drop of 10% potassium hydroxide and seeing if adult mite, egg or eggshell is under light microscopy (low sensitivity) ```

Answer 167

All household members, sexual partners and close contacts within last month should be treated simultaneously (must apply treatment on same day to reduce risk of re-infection) Wash all clothes, towels, bed linen etc. to prevent reinfestation Topical application of parasiticidal preparation overnight to whole body from head to toe then repeated 1 wk later: apply esp between fingers, toes, behind ears etc. should not be applied after a hot bath (increases systemic absorption risk). Reapply if hands are washed etc. First line is permethrin 5% dermal cream; those with crusty form may need 2-3 applications on consecutive days to ensure enough penetrates hyperkeratotic areas Second line: malathion 0.5% liquid Third: crotamiton 10% cream: fourth: oral ivermectin single dose 200mcg/kg Antihistamines for itch Low dose steroid creams or emollients may also ease itch *Seek specialist advice for <2months age, breastfeeding or pregnant women *Suspect treatment has failed when itching persists for >6wks or non-compliance suspected with applications Complications: Eczema or psoriasis Secondary bacterial infection (staph. Aureus or strep pyogenes most severe) Nodules may need corticosteroid injection for complete resolution

Answer 168

Due to loss of functioning melanocytes from epidermis Cause remains unknown: autoimmune destruction? Neurochemical destruction? Autocytotoxic? Biochemical? Genetic predisposition? risk factors: Family history Personal of family history of other autoimmune diseases (particularly thyroid), pernicious anaemia, addison’s disease, diabetes History of melanoma and cutaneous T cell lymphoma Possible triggers: stress, childbirth, skin trauma or injury, exposure to certain chemicals

Answer 169

Non-segmental vitiligo (NSV): Subtypes are focal, mucosal, acrofacial, generalised, universal White patches often bilateral and symmetrical Overlaps with other conditions Segmental vitiligo (SV): Subtypes are focal, mucosal, uni/bilateral, pluri-segmental Rapid onset Unilateral Distribution may approx. match a dermatome Involves hair follicle depigmentation Mixed vitiligo (NSV+SV): Rare Unclassified: Allows for period of time of observation, after which definitive classification can be made

Answer 170

Presents at any age but often noticed before 20 years Can be itching at onset of new lesions but mostly asymptomatic Psychological impact Lesions are flat and non-scaly Often bilateral and symmetrical At first show few clearly defined lesions but as they increase in size and number will merge into large patches covering whole body Most often found on fingers and wrists, neck, nipples, navel and genitalia and skin around eyes and mouth as well as body folds like axilla Hair may be white or grey usually in patches on scalp but can be generalised Other body hair may also be affected (leukotrichia)

Answer 171

Trichrome (area of partial depigmentation as well as depigmented and normal skin - 3 colours seen) Marginal inflammatory where raised red periphery occurs either at onset or up to 1 year later Blue vitiligo may occur with post-inflammatory hyperpigmentation that proceeds condition

Answer 172

Investigation: Clinical diagnosis Evidence of associated disease (diabetes etc) Wood’s light to exclude fungal infections Assess impact on quality of life Differentials: Tinea versicolor Piebaldism Idiopathic guttate hypomelanosis

Answer 173

Response varies between patients Protect against sun exposure (white patches only burn) Minimise skin injury as this causes increased likelihood of white patches Monitor for other autoimmune diseases Assess impact on quality of life and presence of psychosis problems Cosmetic camouflage options available on NHS if endorsed ACBS: refer to changing faces (patient education) and self tanning creams Topical corticosteroids in people with less than 10% body affected for max 2 months Topical calcineurin inhibitors (tacrolimus and pimecrolimus creams for head and neck regions; initial use is 6 months but can be extended if ineffective Phototherapy for widespread cases (15-20%+) or in combination treatments or in those with significant impact on quality of life Oral corticosteroids and other immunosuppressants: side effects often outweigh benefits Surgeries: top layer of skin removed by shaving, dermabrasion or laser and replaced with pigmented skin Depigmentation therapy - remove all pigment only leaves white skin

Answer 174

Seen in all age groups but usually first appear between 40-60 years Solitary lipomas are more common in women Lipomatosis (multiple) more common in men Estimated incidence 1 in per 1000 of the population Congenital lipomas have been seen in children

Answer 175

Familial: autosomal dominant condition most frequently in men, characterised by widespread symmetrical lipomas most often over extremities and trunk Gardner’s syndrome: lipomatosis may also be associated with Gardner's syndrome; autosomal dominant condition involving intestinal polyposis, cysts and osteomas Dercum’s disease: aka adiposis dolorosa. Rare and characterised by presence of irregular painful lipomas, more often found on the trunk, shoulders, arms, forearms and legs. At least 5 x more common in women often found in middle age. Also has asthenia and psychiatric disturbances as other prominent features Madelung's disease: aka benign symmetric lipomatosis. Involves the head, neck, shoulders and proximal upper extremities. Often presents in men who drink excess alcohol and may present with ‘horse collar’ cervical appearance/ rarely experience dysphagia, respiratory obstruction and sudden death Post traumatic lipomas: following blunt trauma, thought it may be partly due to herniation of fat through torn fascia. Resulting swelling referred to as pseudo-lipoma Liposarcoma

Answer 176

Soft or firm nodule 0.5-10cm Smooth normal surface and skin coloured 80% <5cm diameter, some can reach up to 20cm Large lipomas on the back are usually situated deep in a fatty layer with normal skin overlying. Round or irregular shaped Single or multiple Usually non-painful, mobile masses with soft doughy feel Most are asymptomatic but can compress nerves causing pain

Answer 177

``` Investigations: Clinical exam/appearance Ultrasound MRI CT scan Biopsy (FNA) ``` Differentials: Epidermoid cyst Subcutaneous tumours Nodular fasciitis

Answer 178

Can be left untreated and size usually plateaus after initial growth May be removed for cosmetics, nerve compression or uncertain diagnosis (usually can be shelled out easily with excision due to non-infiltration) Segmental extraction - small stab incision and blind dissection of lipoma can leave minimal scarring Non-excisional treatment includes steroid injections and liposuction

Answer 179

malignancy is rare but can be found in a lesion with clinical appearance of a lipoma. Liposarcoma presents in similar fashion to lipoma. More common in retroperitoneum, shoulder and lower extremities. Some recommend complete excision of a lipoma to exclude a possible liposarcoma esp in fast growing lesions. Pre-op radiography may be suitable. Ultrasound and MRI may be able to differentiate between lesions not 100% reliable. FNA can be used for suspicious lesions. Concern if: >5cm diameter, located in extremities, retroperitoneally, in groin, scrotum or abdominal wall. Deep lesions or exhibiting other malignant behaviours (rapid growth, invasion into nerve or bone).

Answer 180

AKA hives Itchy red blotchy rash resulting from swelling of superficial part of skin Can be localised or widespread Angio-oedema occurs when deeper tissues are involved and also become swollen Acute is more common than chronic More common in women particular ages 30-60 More common in individuals with atopy

Answer 181

Due to activation of mast cells in skin resulting is histamine release and other mediators Cause capillary leak, causing swelling of skin and vasodilation causing erythematous reaction Often the triggers for this are unknown, particular in chronic cases but thought autoimmune reactions may be involved Acute triggers: foods, bites, viral infections, nettles, latex, medications, friction,pressure, heat or cold Chronic triggers: sun exposure, contact with hot/cold water, exercise or emotion, friction or minor trauma, pressure, vibration

Answer 182

Acute: develop quickly but resolve quickly often within 48 hrs Chronic: rash persists for more than 6 wks: divided into subtypes Chronic spontaneous: triggers include medication, stress and infections Autoimmune urticaria: may account for over half of all chronic cases and may be associated with other autoimmune conditions Inducible urticaria: triggers similar to acute

Answer 183

Itchy White papule or plaque Swelling of surface of skin (weal or wheal) Surrounded by erythematous flare Lesions vary in size and shape May be associated with swelling of soft tissues of eyelids, lips and tongue (agio-oedema) Individual lesions are typically transient coming and going within minutes-hours

Answer 184

``` Differentials: Erythema multiforme Dermatitis herpetiformis Pemphigoid Erysipelas ``` Investigations: Clinical exam and history Bloods: FBC, ESR, CRP Physical challenge: cold provocation testing (ice cube), heat test, pressure, UV light, exercise, hot bath etc. for cholinergic urticaria Elicit dermatographism (firm rubbing) Patch testing/prick testing for contact urticarias IgE test for specific allergens Thyroid autoantibodies Exclusion of suspected medication or food Tests for infectious diseases Skin biopsy (urticaria vasculitis)

Answer 185

Identify and treat cause Nonspecific aggravating factors should be minimised such as overheating, stress, alcohol, caffeine and medication likely to cause urticaria (NSAIDs and ACEi) Topical antipruritic agents such as calamine lotion or topical menthol 1% cream may ease symptoms Antihistamines (cetirizine, loratadine) up to 4 x daily (avoid in pregnancy) Severe symptoms: short course oral steroids (prednisolone 40mg daily 7 days) Second line can include montelukast, omalizumab (anti-IgE) monthly injections, Ciclosporine for immunosuppression

Answer 186

Uncontrolled symptoms If antihistamines needed continuously >6wks If painful and persistent suspect vasculitic urticaria Urgent hospital admission indicated if acute rapidly developing into angio-oedema or anaphylactic shock

Answer 187

``` Common mild infections of superficial layers of skin, nails, hair Can be severe in immunocompromised pts. Causes: Dermatophytes: tinea/ringworm Yeasts: candidiasis, malassezia etc. Moulds: eg aspergillus ```

Answer 188

Establish correct diagnosis by KOH preparation of skin scrapings, hair, nail clippings (dermatophytes), skin swabs (for yeasts) if needed. Treat known precipitating factors and educate pt to: keep skin dry, avoid trainers, wear clean and loose fitting underwear Topical antifungal agents (eg terbinafine cream) or imidazoles are main first lines; often need at least 4 wks treatment and should continue for 1-2 wks after lesions have healed. Most commonly use clotrimazole or ketoconazole Oral antifungal agents (itraconazole) for severe, widespread, nail infections around 1-2 months treatment Avoid use of topical steroids - can lead to tinea incognito Correct predisposing factors where possible (eg moist environment, underlying immunosuppression)

Answer 189

Most often due to trichophyton rubrum and T. interdigitale. Increased prevalence with age and spreads from tinea pedis or less often, tinea manum May affect one or more toenails and/or fingernails and most often involved great or little toenail Often confused with non-infected nail dystrophy due to skin disease, particularly psoriasis (also dermatitis, lichen planus, viral warts, ageing changes)

Answer 190

Lateral onychomycosis: White or yellow opaque streak appears at one side of nail Subungual hyperkeratosis: scaling occurs under nail Distal onycholysis: end of nail lifts up and free edge often crumbles Superficial white onychomycosis: flaky white patches and pits appear on top of nail plate Proximal onychomycosis: yellow spots appear in half moon (lunula) Complete nail destruction

Answer 191

Nail clippings taken from crumbling tissue at end of infected nail Discoloured surface can be scraped off Debris can be scooped out under nails Always take samples before treatment as this can affect fungal growth in cultures To confirm diagnosis: antifungal treatment will not be successful if there is another explanation

Answer 192

Mild infections affecting less than 80% of one/two nails may respond to topical antifungal medications but cure usually needs oral antifungal medications. Fingernails usually cured faster and more effectively Topical antifungals used twice weekly for 6-12 months for nail plate infections (amorolfine ‘Loceryl’ and ciclopirox ‘Batrafen’) Azole oral antifungals (prescribed by specialists) are avoided in pregnancy. Duration 6-12 weeks (fingers) or 3-6 months (toes): Terbinafine ‘Lamisil’ and itraconazole ‘Sporanox’ Removal of nail (rarely needed): unpleasant and painful Chemical evulsion can be performed by applying urea paste under occlusion and repeating every few days as needed. May take months for nail to regrow

Answer 193

AKA whitlow Inflammation of skin around a finger or toenail Acute (<6wks) or chronic (>6wks) May be associated with felon (infection of pulp of fingertip) Acute is more likely to follow a break in the skin esp. Between proximal nail fold/cuticle and nail plate eg: bitten nails, sucking finger/thumb, manicuring, ingrown toenails etc. Chronic mainly occurs in people with hand dermatitis or those with constantly cold and wet hands such as: dairy farmers, fishermen, bartenders, cleaners, poor circulation etc. Tend to be more frequent and aggressive in diabetic or chronic debility or that are immune suppressed

Answer 194

Acute usually due to bacterial infection with staph. Areus, strep. Pyogenes, pseudomonas or other pathogens. Can also be due to cold sore virus herpes simplex and yeast candida albicans Chronic cause is not fully understood but many cases are due to dermatitis of nail fold. Often several different organisms can be cultures particularly candida albicans and gram -ve bacilli, pseudomonas

Answer 195

Develops rapidly over few hours, usually affects single nail fold Painful Red Swollen If caused by herpes simplex virus, multiple tender vesicles may be seen. Sometimes yellow pus appears under the cuticle and can evolve into abscess. Nail plate may life up (onycholysis) Caused by S. pyogenes may be seen with fever, lymphangitis and tender lymphadenopathy Acute candida more commonly infects proximal nail fold

Answer 196

Gradual process May start in one nail fold particularly proximal nail fold but often spreads laterally to several other fingers May be red and tender occasionally Each affected nail is swollen and lifted off nail plate Sometimes may have white/yellow/green pus under cuticle Nail plate thickens and is distorted often with transverse ridges

Answer 197

Complications: Acute can spread to cause serious hand infections (cellulitis) may involve underlying tendons (infectious tendonitis) Nail dystrophy ``` Investigations: Clinical diagnosis Gram stain microscopy for bacteria Bacterial culture Viral swabs Tzanck smears Nail clippings for mycology ```

Answer 198

Soak affected digit in warm water, several x daily Topical antiseptic for localised minor infections Oral antibiotics for severe or prolonged bacterial infection; doxycycline Aciclovir for severe herpes simplex infection Surgical incision and drainage of abscess followed by irrigation and gauze packing Rarely; remove nail to drain pus

Answer 199

Attend to predisposing factors: keep hands warm and dry, avoid wet work, clean fingernails etc. Dermatitis: topical corticosteroid for 2-4 wks, tacrolimus ointment, intralesional steroid injections for resistant cases Antiseptics r antifungal lotions or solutions for several months Oral antifungal agent (itraconazole or fluconazole) if C. albicans confirmed Monitor diabetics and vascular disease for signs of cellulitis Surgical excision of proximal nail PRN Eponychial marsupialisation - remove narrow strip of skin next to nail to reduce infection risk Swiss roll technique retains nail plate and gives quicker recovery

Answer 200

Venous Arterial Neuropathic Vasculitic (purpuritic, punched out lesions) Infected (purulent discharge may have systemic signs) Malignancy (SCC)

Answer 201

History Often painful Worse on standing History of venous disease eg varicose veins, DVT ``` Common sites Malleolar area (more common on medial than lateral) Lesion Large, shallow irregular Exudate and granulating base ``` Associated features Warm skin Normal peripheral pulses Leg oedema, hemosiderin and melatonin deposition (brown pigment) Lipodermatoscleorsis and atrophie blanche (white scarring with dilated capillaries) ``` Investigations Normal ABPI (0.8-1) ``` Management Compression bandaging After excluding arterial insufficiency

Answer 202

History: Painful esp at night and when legs elevated History of arterial disease (atherosclerosis) Common sites: Pressure and trauma sites eg pretibial And at distal points eg toes Lesions: Small Sharply defined deep ulcer Necrotic base ``` Associated symptoms: Cold skin Weak or absent peripheral pulses Shiny pale skin Loss of hair ``` Investigations: ABPI <0.8 - presence of arterial insufficiency Doppler flow and angiography Management: Vascular reconstruction Compression bandaging is contraindicated

Answer 203

History: Often painless Abnormal sensation History of diabetes or neurological disease Pressure sites eg soles, heel, toes, metatarsal heads Common sites: pressure sites eg soles, toes, metatarsal heads Lesions: Variable depth and size Granulating base May be surrounded by/underneath hyperkeratotic lesion (eg callus) Associated features: Warm skin Normal peripheral pulses (cold/weak/absent pulses if neuroischaemic ulcer) Peripheral neuropathy Investigations: ABPI <0.8 implies neuroischaemic ulcer XR to exclude osteomyelitis Management: Wound debridement Regular repositioning, appropriate footwear and good nutrition

Answer 204

Chronic or recurrent suppurative disease of unknown cause occurring in apocrine follicles Usually affects the groin and axillae and other apocrine bearing sites (breast, perineum and buttocks) Follicular occlusion may lead to chronic replasping inflammation, mucopurulent discharge and progressive scarring Induration, ulceration and sinus and fistula formation may occur More common in women: submammary, axillary and inguinal more in females with males more perineal involvement common Does not start before puberty (hormones thought to play role)

Answer 205

``` Smoking Obesity Lithium therapy Possible diabetics and PCOS Hormonal factors: improves in pregnancy and with combined oral contraceptive and may remit after menopause Genetic factors (fam history 30%) ```

Answer 206

Usually starts at puberty but can present any time after this until middle age Predominantly in axilla, groin, perineum, buttocks, scrotum and submammary regions (mostly axilla and groin) Early lesions are solitary, painful and pruritic nodules and multiple sites may be affected at once May persist for wks/months Any subcutaneous extension appears as indurated plaques Episodes of cellulitis may occur Nodules develop into pustules and eventually rupture with discharge of purulent material Healing occurs with dense fibrosis so scarring is common Tend to recur in same regions leading to chronic sinus formation with intermittent release of serous, purulent or bloodstained discharge Sinus formation and rupture may occur internally into adjacent structures as well as externally Regional lymphadenopathy usually absent

Answer 207

``` Differentials: Acne Abscess Lymphogranuloma venereum Cutaneous crohn's disease ``` Investigations: Clinical exam and history Bloods: FBC, BG Swabs for micro cultures

Answer 208

``` Cystic acne Pilonidal sinus Crohn’s disease Down’s syndrome Metabolic syndrome ```

Answer 209

Stage 1: Abscess formation, single or multiple without sinus tracts and scarring stage 2: Recurrent abscess with single tracts and scarring, single or multiple widely separated lesions Stage 3: Diffuse /almost diffuse involvement or multiple interconnected tracts and abscesses

Answer 210

Referral for pts with frequent exacerbations causing stress and those with active disease and scarring in at least one site (hurley’s stage 2) LIFESTYLE: Good hygiene; advise weight loss and good diet PRN; smoking cessation; assess psychological impact Topical antibiotic (clinamycin 2% TD for 3 months first line mild disease) Systemic AB (lymecycline 408mg OD; Doxycycline 100mg OD etc.) for 3 month trial. If ineffective trial clindamycin 300mg TD with rifampicin 600mg OD or 300 mg TD Anti-TNF therapies: adalimumab for mod-severe cases Anti-andeogens ‘Dianette’ often used in women Dapsone Retinoids (isotretinoin and acitretin) Ciclosporin Surgical intervention: remove surrounding scars. Should be performed in a quiescent phase. May be extremely complex in extensive disease. STEEP is a more limited surgical option of deroofing and skin tissue saving excision. Incision and drainage of boils not as effective Radial excision may give small relief but disease may recur in surrounding areas CO2 laser has some success

Answer 211

Fistula Chronic infection leading to anaemia, hypoproteinaemia or amyloidosis Chronic malaise, reduced quality of life Scarring may lead to lymphatic obstruction SCC in areas of chronic lesions

Answer 212

Merocrine: sweat directly onto skin surface via sweat pore. In superficial hypodermisl smallest gland type. Salivary glands, sweat glands and pancreas. Apocrine: secretes substance into pillory canal of hair follicle without opening directly onto skin. medium sized glands.Present at junction of dermis and subcut fat. Sweat glands in axilla, pubic area, mammary glands, eyelids. Holocrine (sebaceous): secretes sebum. Largest glands.

Answer 213

Caused by allergic reactions, ACEi, hereditary or idiopathic Most often caused by allergy In hereditary angioedema, can occur spontaneously or triggered by: injury/infection, surgery, stress, pregnancy, medications such as contraceptive pill Idiopathic triggers: stress, minor infections, hot/cold temperatures, strenuous exercise

Answer 214

Characterised by sudden skin swelling over hours, usually lasting days Most often affects the feet, hands, around the eyes, lips and tongue and genitals In severe cases the throat can be affected causing breathing difficulties May cause abdominal pain, dizziness, diarrhoea, syncope if very severe Often occurs with urticaria

Answer 215

Clinical exam and history (known allergies, medications, ACEi etc.) Allergy tests: skin prick test, bloods Management: Depends the on type of angioedema Allergic and idiopathic usually treated by avoiding triggers and preventing further cases Antihistamines for swelling Adrenaline auto-injectors for serious allergies (anaphylaxis) Drug induced angioedema: taper/change medications if possible Hereditary: avoid triggers, danazol/oxandrolone can reduce chance of swelling occurring (side effects weight gain, hirsutism, HTN) Icatibant injection can ease swelling; C1 esterase inhibitor replacement injection can also help reduce swelling risk in hereditary cases

Answer 216

With treatment rash should go within 2-6 wks Risk of eye damage Secondary bacterial infections causing sepsis and death Immunocompromised or neonates can be fatal. In immunocompromised cutaneous lesions may spread to adjacent sites such as oesophagus or lungs. Neonatal HSV infection may occur in skin or eyes causing encephalitis or disseminated spread with high rates of morbidity and mortality All IC and neonates must be referred to specialist

Answer 217

50-100 hairs shed/day Each hair is on an individual cycle; not synchronized together! Seasonal and gender dependent Shaving and trimming DO NOT affect the hair growth cycle Plucking, waxing etc. DO Anagen or growth phase on the scalp lasts between three and five years and the hair grows at approximately 1 cm a month. The duration of the anagen phase varies from person to person and it determines how long hair will grow if not cut. Usually about 85% is in anagen phase. Catagen phase follows the anagen phase and is an involutional stage that lasts around two weeks. Telogen, or dormant, phase lasts about three months. The hair remains in the follicle but does not grow. At the end of the telogen phase the follicle starts production of new anagen hair which displaces the old one from the follicle, with the old one being shed. In some animals this is synchronised to produce moults but in humans it is unsynchronised and around 50 to 100 hairs drop out each day, mostly unnoticed. Sometimes people go through a period of more predominantly telogen phase and they lose a lot of hair in brushes and combs, causing much anxiety; however, baldness does not develop.

Answer 218

Androgenic (male/female pattern baldness) Alopecia areata: autoimmune condition causing bald patches (oval/round) on scalp or other body hair (beard, eyebrows etc) types include patchy, totalis, universalis, barbae, diffuse and ophiasis. Telogen effluvium: More hairs than usual move into the telogen phase and shed more. Often caused by physical or psychological triggers and often resolves spontaneously Anagen effluvium: chemotherapy induced alopecia. Hair falls out after treatment as side effect of medications Trichotillomania: Psychological condition where you can’t stop pulling out hair leading to hair loss. Most commonly places include scalp, eyebrows and eyelashes Traction alopecia: hair falls out due to being pulled in the same way for a long time. Caused by tight hairstyles, relaxers or extensions Alopecia related to/caused by skin conditions or systemic illness including: seborrheic dermatitis, lichen planus and discoid lupus erythematosus, tinea capitis, impetigo, secondary syphilis, thyroid disease, iron deficiency

Answer 219

AKA male pattern baldness Most common non-scarring hair loss disorder Affects 50% men over 50 and more than 40% of women by age 70 (increasingly common with age) Characterised by increased sensitivity to androgens in susceptible people Often shows familial traits Dihydrotestosterone shortens the anagen phase and minimises follicles on the vertex of the scalp Androgenic hair (beards) dependent on dihydrotestosterone for growth

Answer 220

Genetics: increased sensitivity to dihydrotestosterone Hair follicles become smaller over time Terminal hairs replaced by thinner hairs Spend less time in anagen phase resulting in shorter hairs Telogen hair more loosely attached and fall out more easily Increased time between telogen shedding and anagen phase

Answer 221

In men may present shortly after puberty while women affected later in life (usually around menopause) In younger women may show acne, hirsutism, menstrual disturbances (PCOS) Women often present with more diffuse pattern of hair thinning Investigations: If history suggests ferritin issues: Iron studies and TFTs Scalp biopsy for unclear diagnosis

Answer 222

Reassure total baldness is unlikely, educate on condition, offer support counselling Around 1/3rd pts won’t respond to treatment (not available on NHS) Men: Minoxidil 2% or 5%: topical application BD, available OTC or private prescription. 5% may be more effective but can cause irritation. More likely to be useful in early stages. At least 6 months treatment to assess response; if successful then used indefinitely Finasteride: 1 mg daily PO. Only private prescription. A 6 month trial at least to determine effectiveness (more likely 12 months) continued indefinitely if successful. Small risk of adverse sexual side effects (decreased libido). Must not be handled by pregnant women. Women: Minoxidil 2%: apply TD indefinitely. Has limited response and side effects include unwanted facial hair growth. Other options: Spironolactone (little evidence) Hair pieces/wigs Surgical transplantation

Answer 223

Causing grey/brown patches to develop Usually in adults (particularly pregnancy women up to 50%) More common in people of colour and those who tan quickly Exact pathogenesis is unknown but there is an increase in melanin content of keratinocytes and melanocytes Can be linked to taking hormonal contraceptives, cosmetics, isotretinoin and anticonvulsants Not associated with malignancies

Answer 224

Tinea faciei: occurs outside of the beard area on the face often as a result of extension from the beard, scalp or body. Tinea barbae: occurs within the bearded area. Insidious onset, may have folliculitis like appearance and may be itchy.

Answer 225

Tinea corporis (ringworm): infection of trunk and limbs. Itchy, circular or annular lesions with clearly defined, raised and scaly edges are typical. Usually manifests as isolated lesions with subsequent development of satellite lesions. Needs terbinafine or griseofulvin topical treatment

Answer 226

Tinea pedis: athletes foot, extremely common. Moist scaling and fissuring in toewebs, spreading to sole and dorsal aspects. Can flare in hot weather, infection starting in interdigital spaces of toewebs. Pruitis is common and feels intense when shoes/socks are removed. Might present with red, scaly plaques and blisters to areas of maceration between digits

Answer 227

Tinea manuum: infection of hand. Scaling and dryness in palmar creases. Usually occurs alongside tinea pedis and can be mistaken for other dermatosis (always check if pedis is on feet to to help diagnosis)

Answer 228

Tinea capitis: scalp ringworm. Patches of broken hair, scaling and inflammation. Most common in young children. Appearance varies and some may suffer hair loss appearing as bald, scaly patches with broken hairs. Others may just look like dandruff. Might result in kerion (large boggy abscess) due to infection. Cervical adenopathy may be present. Can be passed between people in close proximity.

Answer 229

``` Progressive hyperpigmentation Not associated with any other symptoms (bleeding, scales etc) Usually on sun exposed areas Improves in winter Common on face Irregular macules (flat, distinct coloured areas <1cm) Bilateral Light or dark brown colour Confluent or speckled Sharply defined margins Resolution may occur over several months ```

Answer 230

Investigations Clinical diagnosis Wood lamp Management: For pregnant women; reassure condition will likely improve postpartum without treatment Avoid sun exposure: year round sun protection blocking UVA and UVB Cosmetic camouflage Review of potential causative medications such as hormonal contraceptives Topical therapies (specialist referral) Skin lightening agents: hydroquinone sometimes in combination with other treatments Chemical peels Laser treatment

Answer 231

Tinea infection is caused by malassezia furfur organisms that transform from yeast cells to pathogenic mycelial form. Then begins to produce azelaic acid causing inflammatory process and dysregulation of melanin production (increased = darker; decreased = lighter macules) Actually caused by lipophilic yeast infection, malassezia so is not a ‘true’ tinea Organisms are part of normal skin flora therefore not a contagious condition Commonly affects young adults and causes widespread lesions, small and circular macules of varying pigmentation Macules appear lighter or darker than surrounding unaffected skin

Answer 232

``` Summer months Hyperhidrosis Tropical locations Chronic steroid use Cushing's syndrome/disease Immunosuppression Use of topical skin oils ```

Answer 233

Often asymptomatic Hypopigmented, hyperpigmented or erythematous lesions Mostly seen in the UK in the summer months Often flat macules but can be raised in some plaques Macular lesions often start on the trunk and spread out to neck, upper arms, abdomen Lesions most commonly found on trunk but children may present with facial liaisons Rash is seen around areas where sweat glands are Some superficial scaling may be present where skin is slightly stretched

Answer 234

Diagnosis: Clinical exam and history KOH preparation if need confirmation Management: Topical imidazoles: ketoconazole shampoo 1st line used as body wash for 5 days. Lathered onto affected areas and left for up to 5 minutes and washed off. Can take several months for skin to return to normal and recurrence is common. Pts should be advised hypopigmentation will fade but may take long time Ciclopirox; Terbinafine ; Selenium sulfide; Pyrithione zinc are other long term topical treatments Recurrence may consider systemic antifungal treatments

Answer 235

Common self limiting condition Not yet understood cause Affects mostly those age 10-35 More common in women

Answer 236

Herald patch precedes main rash Generally larger lesion than the others Overall shape of rash forms ‘christmas tree’ distribution Usually self resolving within 6 wks healing completely

Answer 237

Diagnosis: Clinical Management: Usually none needed as resolves within around 6 wks Emollient can be given with particularly itchy rash

Answer 238

Most common yeast infection Varies from benign local mucosal membrane infection to disseminated disease Caused by candid (yeast like fungi) over 20 different forms can cause disease in humans Candida albicans is most common; commensal in GIT and vagina but can also infect foreskin, glans penis and scrotum in men Nappy rash is an infection due to irritated skin on the nappy area causing candidiasis infection: needs canesten treatment cream (clotrimazole) Skin folds like inner thigh, axillae, breast folds or nappy area in babies are most at risk

Answer 239

Pseudomembranous candidiasis: those with weakened immune systems (most common in young infants/elderly/suppressed etc.) shows white cottage cheese lesions which can be scraped away easily leaving red patches which may bleed. Thrush is usually this kind in the mouth and nappy region. Vulvovaginitis: pain while urinating, discharge as well as potential rash Erythematous candidiasis: change in microbial competition on body leading to spread of growth. Increases blood flow to tissues with infection causing red painful lesions Serious invasive infections (immunocompromised, diabetics etc) caused by central venous catheter insertion, affects many organs like heart, liver causing more severe complications including eye complications Red, Inflamed, glistening surface Peeling edge May have few pustules Sometimes is few small satellite lesions look like red spots Candida albicans is most common; commensal in GIT and vagina but can also infect foreskin, glans penis and scrotum in men Skin folds like inner thigh, axillae, breast folds or nappy area in babies are most at risk

Answer 240

Diagnosis: Clinical Swabs/tissue biopsies for uncertainty Blood cultures (gold standard) Management: Topical imidazole creams to affected area 2-3 x daily (oral thrush treated with oral nystatin suspension) Mild steroid cream for severe inflammation or itch If ineffective or immunocompromised or widespread infection; oral fluconazole may be given (50mg/daily for 2-4wks ALWAYS REVIEW AT 2 WKS) Predisposing factors such as diabetes should be excluded and treated alongside this Severe infections can be treated with amphotericin, azole antifungals, echinocandins (micafungin) Non-pharmacological measures such as keeping skin uncovered and dry, washing with emollients and avoiding obesity to minimise skin folds should be advised

Answer 241

Translated as: ‘Tree moss’ ‘flat’ as rash resembles tree moss pattern and has flat topped lesions Papular skin eruption found over flexor surfaces of limbs, genitalia and mucus membranes Chronic inflammatory, intensely itchy skin disease Believed to be autoimmune: healthy keratinocytes begin expressing antigens on MHC I triggering T cell response (kill cells) causing damage to the keratinocyte layers Possibly triggered by virus or precipitated by trauma (Kobner’s phenomenon) Oral lichen planus: affecting oral mucosa Cutaneous lichen planus: affecting skin Often both are present at the same time

Answer 242

Hypertrophic: causes very itchy lesions usually on extensor surfaces of extremities especially ankles. Can last for long time and leave residual scarring and pigmentation Atrophic: few lesions are present which often resolving angular or hypertrophic lesions Erosive/ulcerative: found on mucosal surfaces and develop from sites where lichen planus have previously developed Follicular: AKA lichen planopilaris. Keratotic papules that may merge into plaques. More common in women and often involved mucous membrane and nails. Scarring alopecia sometimes develops Annular: pureple annular lesions (rare). Papules with atrophic centre may develop on male genitalia or buccal mucosa Vesicular and bullous: usually develop from existing areas of lichen planus. Lower limbs and mouth most commonly. Rarely a combo of lichen planus and bullous pemphigoid can develop called lichen planus pemphigoides Actinic: seen in subtropical areas such as africa, middle east and india. Typically appears as nummular patches with hyperpigmented centre surrounded by hypopigmented area. Condition is mildly itchy often spares the nails, scalp, mucous membrane and covered areas Lichen planus pigmentosus: more commonly affects darker skin. Resembles erythema dyschromicum perstans (ashy dermatosis). Some authorities maintain it is the same condition. Relatively rare

Answer 243

Usually acute onset Typical lesion is 2-5mm red or violet shiny flat topped papules. Blisters can occur occasionally Eruption usually starts on flexures of wrists, forearms or lower legs and can remain localised or may spread to other regions Lesions on genitalia, anus, larynx and rarely tympanic membrane or oesophagus Approx. 50% cases have mucosal involvement; usually asymptomatic but can be very painful and difficult to treat Rash is purple ish colour papules and polygonal plaques that are shiny, flat topped and firm Plaques are crossed by fine white lines called Wickham striae Plaques resolve after some months leaving greyish brown macules that can take years to go away Usually the scalp is sparred, but lichen planus affecting the scalp may cause permanent scarring alopecia

Answer 244

``` Purple Planar Pruritic (itchy) Polygonal Papules Plaques ```

Answer 245

``` Differentials: Drug eruption Eczema Psoriasis Candidiasis ``` Diagnosis Clinical Biopsy for definitive diagnosis in atypical cases (sawtooth shape at dermo-epidermal junction)

Answer 246

Management: Not always needed; may resolve spontaneously within 1 year (65%) although mucous membrane more persistent and resistant to treatment Moderate potent topical steroids for itching as well as sedating antihistamines Inform pts lesions take a long time to resolve. Complications: Very small risk of SCC Hypertrophic lesions can leave residual hyperpigmentation

Answer 247

Hypersensitivity reaction/inflammatory condition Unknown aetiology Acute self limiting condition usually resolves without complications Triggered most commonly by herpes simplex virus Characterised by target lesions Most often affects 20-40years Males most commonly Genetic tendency

Answer 248

HSV infection Herpes labialis (cold sore on lip) and less often genital herpes HSV type 1 more common than type 2 HSV infection usually precedes skin eruption by 3-14 days Mycoplasma pneumonia is next most common trigger 50% cases idiopathic Can also be triggered by streptococcal, hep B infections as well as drugs (penicillin, sulfonamide, barbiturate, saids, SLE, pregnancy and malignancy

Answer 249

Few to hundreds of lesions erupt within 24 hr period First seen on backs of hands and/or tops of feet then spreads down limbs towards the trunk Tupper limbs more commonly affected than lower Palms and soles may be involved Face, neck and trunk are common Skin lesions are often grouped on elbows and knees May be associated mild itch or burning sensation Initial lesions are sharply demarcated, round, red/pink and flat (macules), which becomes raised (papules/palpable) and gradually enlarge to form plaques (flat raised patches) up to several cm in diameter Centre of papule/plaque darkens in colour and develops surface (epidermal) changes such as blistering or crusting Usually evolve over 72 hrs Typical target lesions (AKA iris lesions) have sharp margin, regular round shape and 3 concentric colour zones: dark red blister or crusted centre, paler pink raised (oedema) ring then outer layer is bright red (erythematous)

Answer 250

Diagnosis: Clinical Management: None needed; self limiting will settle within a few wks Supportive treatments of antihistamines, topical steroids, analgesia and soothing ointments if needed

Answer 251

Rare acute condition classed as medical emergency Skin reaction almost always caused by medications Mucocutaneous necrosis with at least 2 mucosal sites involved SJS and TEN are variants of the same condition Spontaneously occurs (while on medications) Slightly more common in females 100 x more common in association with HIV More than 200 medications have been reported in association with SJS/TEN mostly antibiotics but others include: sulfonamides, penicillins, cephalosporins, anticonvulsants, allopurinol paracetamol, NSAIDs SJS/TEN usually develops within the first week of antibiotic therapy but up to 2 months after starting an anticonvulsant. For most drugs the onset is within a few days up to 1 months

Answer 252

``` Allopurinol Carbamazepine Trimethoprim Antivirals Anticonvulsants NSAIDs Salicylates Sertraline ```

Answer 253

Unpredictable reaction to medication Often starts with nonspecific URTI may be associated with fever, sore throat, chills, headache, arthralgia, vomiting and diarrhoea and malaise Tachycardia; hypotension; altered consciousness; seizures and coma With mucosal involvement can see erythema, oedema, sloughing, blistering, ulceration and necrolysis. Mucocutaneous lesions develop suddenly and clusters of outbreaks last from 2-4 wks Lesions usually non-pruritic Mouth may have severe oromucosal ulceration Respiratory involvement can cause cough producing thick purulent sputum Pt. with genitourinary involvement may complain of dysuria or inability to pass urine Ocular symptoms can be painful red eye, purulent conjunctivitis, photophobia, blepharitis Genital signs may show erosive vulvovaginitis or balanitis

Answer 254

Lesions can appear anywhere but most often the palms, soles, dorsum of hands and extensor surfaces May be confined to any one area of the body; most often the trunk Can begin as macules developing into papules, vesicles, bullae, urticarial plaques or confluent erythema Centre of lesions may be vesicular, purpuric or necrotic Typical lesion has appearance of target which is considered pathognomonic Lesions may become bullous and later rupture and Skin become susceptible to infection Urticarial lesions usually not pururitic

Answer 255

Nikolsky sign is +ve (mechanical pressure to skin leading to blistering within min-hrs) Bloods (not diagnostic but used to ensure fluid and vital nutrients have been replaced and to identify complications) can show: anamia (most cases), leucopenia esp. Lymphopenia (90% cases), neutropenia (poor prognosis sign), mildly raised LFTs (30% cases) and 10% pts develop hepatitis. Mild proteinuria in 50% cases. Kidney function changes also occur in majority of cases

Answer 256

Can be fatal from complications in acute phase (mortality rate 10% for SJS and 30% for TEN) Dehydration and acute malnutrition Infection of skin, mucous membranes, pneumonia, septicaemia ARDS: respiratory failure Gastrointestinal ulceration, perforation and intussusception Shock and multiple organ failure including kidney failure Thromboembolism and disseminated intravascular coagulopathy

Answer 257

MDT of eyes, mucous membranes (GIT, mouth, gynae) helps improve prognosis and reduce adverse sequelae Acute phase: identify and remove causative drug or underlying cause Rapid assessment using SCORTEN Supportive care: airway, haemodynamic stability, fluid/electrolyte corrections, pain control, Skin lesions treated same way as burns mouthwashes, topical anaesthetics for pain allowing intake of fluids Eye care: frequent assessment and eye drops including antibiotic and steroid when needed Treat secondary infections: immunomodulation, steroids (controversial), ciclosporin, cyclophosphamide, anti-TNF alpha, plasmapheresis, haemodialysis in acute phase (none considered standard treatment)

Answer 258

More than 50% of those surviving will experience long term sequelae Skin: hyperhidrosis, xeroderma, reversible hair loss, heat and cold sensitivity, scarring and irregular pigmentation, nail dystrophy Mucous membranes: vaginal, urethral and anal strictures. Persistent mucosal erosions Ocular: xerophthalmia, photophobia, symblepharon, synechiae, entropion, meibomian gland dysfunction and sight impairment Overall mortality is up to 10% for SJS and at least 30% for TEN (correlates with SCORTEN score >90% with score of 5 or more). High mortality rate results primarily from development of complications in form of systemic infection and multiple organ failure

Answer 259

``` severity assessment to determine mortality rate in SJS and TEN. one point given for each of seven criteria present at time of admission. Pts with score >3 need intensive care monitoring: >40 year Malignancy HR >120 Initial % epidermal detachment >10% Serum bicarbonate <20mmol/L Serum urea >10mmol/L Serum glucose >14mmol/L ```

Answer 260

``` Bacterial superficial infection in upper layer of skin (epidermis + upper dermal layers) Similar to (is an acute form of) cellulitis and also treated similarly Distinguished from cellulitis by the well defined red raised border Both conditions can overlap so it’s not always possible to make a definitive diagnosis between the two Almost all erysipelas are caused by Group A beta-haemolytic streptococci (pyogenes), staphylococcus aureus including MRSA strains. Strep pneumoniae, Klebsiella pneumoniae and haemophilus influenzae also rarely found to cause (unlike cellulitis which is caused by wider range of organisms) ```

Answer 261

Predominantly in skin of lower limbs When it involves the face can have characteristic butterfly distribution on cheeks and across bridge of nose Affected skin has very sharp raised border Bright red, firm and swollen. May be dimpled (like orange skin) May be blistered and in severe cases can become necrotic Bleeding into skin may cause purpura Cellulitis does not usually exhibit such marked swelling but shares other features with erysipelas, such as pain and increased warmth of affected skin In infants it often occurs in umbilicus or nappy region Bullous erysipelas can be due to strep infection or coinfection with staphylococcus aureus (including MRSA)

Answer 262

Antibiotics (flucloxacillin 500mg QTD) | Usually improves within a few days and resolves in a few weeks

Answer 263

classical are a group of highly contagious diseases caused by viruses, usually affecting children. Exanthem is a rash and is usually accompanied by non-specific prodromal illness with fever, headache and malaise. There are now only 4 viral exanthems (previously 6) Scarlet fever and Dukes disease were previously thought to be the 2nd and 4th viral exanthems however they have now been classified as disease caused by streptococcus bacterial infection.

Answer 264

AKA 1st disease or rubeola Caused by RNA virus which binds to and enters cells changing RNA transcription Transmitted through airborne droplets: extremely contagious (if 1 person has it; 90% non-immune people nearby will get it) Infects respiratory epithelium and spreads to skin and other organs Incubation roughy 10-14 days 2 distinct phases: Prodrome (2-4 days) or exanthem (7-10 days) Once infected/immunised have life long immunity

Answer 265

Prodrome phase: fever, rhinorrhoea, cough, conjunctivitis, Kopliks spots Exanthem: maculopapular rash starting behind the ears then spreading to forehead, neck, face, trunk, upper limbs, buttocks and lower limbs. Fever peaks with rash then decreases over 4-5 days Cough may remain post infection in recovery period In immunocompromised pts. They may not present with enanthem (Koplik spots) or exanthem (rash) but show higher rates of pneumonia and encephalitis meaning they have higher mortality rates

Answer 266

Prodrome phase: fever, rhinorrhoea, cough, conjunctivitis, Kopliks spots Exanthem: maculopapular rash starting behind the ears then spreading to forehead, neck, face, trunk, upper limbs, buttocks and lower limbs. Fever peaks with rash then decreases over 4-5 days Cough may remain post infection in recovery period In immunocompromised pts. They may not present with enanthem (Koplik spots) or exanthem (rash) but show higher rates of pneumonia and encephalitis meaning they have higher mortality rates

Answer 267

Diagnosis: Clinical exam and history IgM measles specific swab or serum sample to confirm diagnosis Complications Associated with miscarriage and premature delivery in pregnant women Post measles encephalomyelitis within 2 weeks onset of rash in immunocompromised children (poor prognosis - autoimmune reaction) Suppresses immunity for up to 6 wks: Bacterial superinfections: Otitis media or bacterial pneumonia (mostly in young infants) <2 years: subacute sclerosing panencephalitis (can occur up to 10 years later): caused by persistent measles infection due to abnormal immune response or mutated viral strain leading to inflammation of the entire brain. Symptoms initially subtle like mood changes but lead to seizures, coma, death.

Answer 268

Management: Supportive treatment; disease is usually self limiting Human immunoglobulin may be given within 5 days following exposure to unimmunised children (<3years), immunocompromised and pregnant women Vaccinate other household members PRN Vitamin A for young children and severely malnourished pts may decrease complication risk and boost antibody response Notifiable disease: inform local health protection teams of suspected cases Prevention: Vaccine given as MMR Given at 12-15 months then again at 4-6 years 95% efficacy rate Mothers give transplacental antibodies lasting until 9 months old roughly

Answer 269

``` AKA 3rd disease or rubella Generally mild disease in childhood Caused by RNA virus Transmission via droplets Mainly common in spring and summer months Can cause severe foetal damage in vitro in pregnant women: causes foetal cell cytolysis through vasculitis and immune-mediated inflammation Is part of MMR vaccine for this purpose Incubation 14-21 days ```

Answer 270

Prodrome: malaise, fever, coryza, cough, lymphadenopathy Rash after 1-5 days (may be absent in young children): blotchy, red/pink macular eruptions on the face and neck spreading to the trunk and limbs Rash usually fades after 1-2 days and rarely persists beyond 3 days Diagnosis: Clinical history and exam (difficult as rash is fleeting and mimics any viral rash) Rubella testing kit confirms diagnosis

Answer 271

self limiting disease Notify local health teams Keep children from school for at least 4 days after rash has gone to limit spread to others Ask about any contact with pregnant women ``` Complications: Thrombocytopenia Encephalitis Purpura Arthritis ```

Answer 272

Classic triad of cataract, cardiac deformities and deafness (microcephaly) Maternal viremia with rubella infections during pregnancy may result in infection of the placenta and foetus causing these developmental defects Growth cells in foetus are reduced and some reduced after birth Prevented with effective immunisation Few cases people develop ear encephalitis: treated with rest, tylenol or non-aspirin pain relief for fever Congenital rubella has poor prognosis and many children die from heart problems; those who survive need lifelong treatment for deafness, learning disabilities and other congenital problems etc.

Answer 273

AKA 5th disease or slapped cheek Characteristic facial rash over cheeks and nose, perioral and periorbital regions Caused by parvovirus B19 a single stranded DNA virus (can cause other syndromes but this is most common) Transmission is via respiratory droplets, infected blood transfusion and placenta Enters erythroid progenitor cells and alters DNA to replicate virus eventually promoting cell apoptosis of healthy cells before bursting open and releasing virus into blood where immune cells begin to remove pathogen Mild disease in children but adults often affected by self-limiting but moderately severe polyarthropathy

Answer 274

Flu like symptoms in viremia stage facial rash over cheeks and nose, perioral and periorbital regions Children: Bright red maxillary rash Fever (low grade) ``` Adults: Reticular Non-itchy Maculopapular rash ‘Lace’ like appearance May also occur on trunk Arthritis and arthralgias are common (usually in small joints of hands, feet etc.) as well as fever ```

Answer 275

Diagnosis: Clinical examination Blood tests for atypical IgM or IgG No tests needed unless concerned about about exposure to pregnant women Prevention: Hygiene No vaccine!

Answer 276

Supportive treatment as usually self-limiting Those with haemolytic anaemias or women in 1st or 2nd trimester of pregnancy may be given immunoglobulin treatments Treat complications: anaemias may need transfusion, NSAIDs for joint pains and swelling, transfusions at birth for severe anaemia in foetus’ or immunoglobulin IV therapy for chronic infection

Answer 277

Can cause transient aplastic crisis in pt. With haemolytic anaemia or in foetus (causing hydrops fetalis, fluid in soft tissues, or miscarriage) as they already have low RBC Severe anaemia Pure RBC aplasia: chronic severe anaemia Chronic viral infection in immunocompromised pts.

Answer 278

AKA exanthem subitum or 6th disease Benign febrile illness Causes maculopapular erythematous rash and high fever Caused by human herpesvirus 6 (HHV6); double stranded DNA virus; attaches to dendritic cells and then other immune cells like monocytes. Can remain latet in monocytes which may cause encephalitis in immunocompromised pts. Transmission via contact with oral secretions Common cause of febrile convulsions Incubation 5-15 days

Answer 279

Incubation 1-2 wks After incubation shows high fever for 3-5 days Febrile stage: periorbital oedema, acute otitis media, rhinorrhea, cough, vomiting, diarrhoea, bulging fontanelle, cervical/occipital or postauricular lymphadenopathy, nagayama spots (red spots on soft palate or uvula) After fever: maculopapular rash for 1-2 days which may go away within 48 hrs

Answer 280

Child develops high fever lasting 3-5 days Associated with rhinorrhoea, irritability and fatigue Faint pink maculopapular rash appears within 48 hrs over the face, neck, trunk, arms and legs Typically fades within 48 hrs

Answer 281

Diagnosis: Clinical exam and history PCR from bloods, CSF or respiratory secretions Management: Supportive only as self limiting disease Severe cases give antivirals

Answer 282

AKA 2nd disease Not actually viral exanthem is a bacterial disease from streptococcus infection from upper resp. Tract or skin. Has been accepted to be the same as Dukes disease (previously the 4th disease) Bacteria produce erythrogenic toxins causing rash on the skin and tongue Incubation 2-5 days

Answer 283

Rash on skin and tongue Circumoral pallor 2-4 days post infection (usually pharyngeal) a sandpaper like rash appears over the trunk, neck and extremities Face may be flushed but usually spared Tongue appears red and swollen (strawberry tongue) After around 5 days, desquamation of skin occurs

Answer 284

Diagnosis: Clinically Throat swabs to confirm Management: Penicillin (or azithromycin for allergy) full 10 day course

Answer 285

Varicella zoster virus (VZV) infects respiratory cells and liver and spleen in the primary viremia stage; then to the T cells in secondary viremia at around 2 weeks post-infection. T cells release pathogens to skin causing skin lesions as keratinocytes etc are infected. Common illness manifesting as general vesicular rash Extremely contagious spread by respiratory droplets (in unvaccinated population 90% would become infected) Predominant age of infection is 5-10 years Infectious period begins 2 days prior to symptom onset and lasts until all lesions have crusted Incubation period around 9-21 days

Answer 286

Brief prodromal period with fever, chills, headache and malaise Lesions start to appear over head and trunk, spreading to peripheries Often very itchy New lesions generally stop appearing after day 4

Answer 287

Diagnosis: Clinical diagnosis Lesion scraping to confirm if needed Prevention: Vaccine for unexposed individuals working in healthcare but no national vaccine as of yet

Answer 288

Management: Self- limiting disease supportive care given Paracetamol, antihistamines Avoid contact with pregnant women, neonates, immunocompromised If pt is immunocompromised then specialist advice needed as may need IV acyclovir (antiviral) ``` Complications: Secondary bacterial infections leading to necrotising fascitis or toxic shock syndrome Viral pneumonia Encephalitis Aseptic meningitis Vasculitis Osteomyelitis Otitis media Sepsis ```

Answer 289

AKA herpes zoster Acute self limiting vesicular eruption occurs alongside a dermatome Caused by reactivation of latent VZV in people who have previously had chickenpox After primary VZV infection the virus lays dormant in the sensory root ganglion of the spinal cord. When reactivated it replicates and migrates along nerve to skin Usually occurs in older adults, immunocompromised people or children who had chicken pox under age 1

Answer 290

Most common site is thoracic nerves and ophthalmic division of trigeminal nerve Pre-eruptive phase: pain, tenderness and paraesthesia over the dermatome region precedes the skin manifestation by 3-5 days Malaise, myalgia, headache and fever may be present Eruptive phase: acute neuropathic pain, erythema and grouped vesicles of varying size in clusters become pustular, scab and fall off over period of 3 wks As the rash is dermatomal it DOES NOT cross the midline Lesions shed VZV virus and can cause chickenpox in previously unexposed individuals

Answer 291

Diagnosis: Clinical exam and history Prevention: Shingles vaccine for >70 years which may help to prevent or lessen symptoms if contracted

Answer 292

``` Management: Oral antivirals shorten duration of symptoms, should be started within 72 hrs of rash appearing in anyone >50 years, with non-truncal involvement, ophthalmic involvement, immunocompromised (may need IV acyclovir) Acyclovir 800mg 5 x daily for 7-10 days Valacyclovir 1g TDS for 7 days Strong analgesia may be needed ```

Answer 293

Complications: Ophthalmic disease may result in corneal ulcers, optic neuritis, uveitis and keratitis. Any pt with suspected optic disease needs to be referred for ophthalmological review Post herpetic neuralgia - lasting nerve pain in area previously affected by shingles (sharp, stabbing, burning, shooting, aching or throbbing Ramsay Hunt syndrome: involvement of facial nerve resulting in paralysis and hearing loss as nerve becomes inflamed and irritated. Short course of high dose steroids may be beneficial

Answer 294

Often asymptomatic and can move through population ‘silently’ Types 1 + 2 are DNA viruses causing very common self limiting vesicular eruptions Highly contagious, spreads via direct contact with infected individuals Virus penetrates epidermis or epithelium and replicates within cells After primary infection the virus remains latent within dorsal root ganglion where it can later reactive, invade skin and cause lesion outbreak Virus sets in trigeminal ganglia or sacral ganglia for life: lesions wil; develop on the ipsilateral side to that of the ganglia they invade! HSV1 typically affects the face, non-genital regions (cold sores) ABOVE WAIST HSV2 typically causes gential lesions although this is not absolute BELOW WAIST

Answer 295

Most common site is vermillion border of lips (HSV1, penile shaft or glans penis in men and labia in women (HSV2) but can also be found on buttocks, trunk and fingertips (herpetic whitlow) Once on fingers is easily spread to other areas (autoinoculation) In children in primary infection can show sores on gums, palate, tongue, lip and facial area Primary infection: symptoms start 3-7 days after contact and include low grade fever, myalgias, lymphadenopathy, pain, burning, itching, tingling which may last several hrs Grouped vesicles appear, uniform size with surrounding erythema and ulceration or crust within 48 hrs Lesions last 2-6 wks Recurrent infection: caused by alteration of immune system: stress, fatigue, local trauma, exposure to sunlight etc. Prodromal symptoms of fatigue, burning, itching of skin lasting 12-24hrs Cluster of lesions evolve within 24 hrs transitioning from macule to papule and then vesicles Vesicles rupture forming crusts in 1-2 days which shed and resolve in 7-10 days

Answer 296

Clinical exam and history PCR Antibody response to virus Viral culture if needed (limited due to short period of viral shedding and low number of viral particles present in samples)

Answer 297

Cold sores usually mild and self limiting Avoid touching lesion, good hand hygiene, don’t share lip products, avoid kissing or oral sex until lesions heal Simple analgesia for pain. Chlorine salicylate or lidocaine gel Topical antivirals (small benefit) need to be administered before vesicles appear (aciclovir 5% for 4-5 days) Oral antivirals for severe episodes do not eradicate virus only ease symptoms: aciclovir 200mg 5 x daily for 5 days Genital herpes: refer to sexual health clinic for accurate diagnosis and treatment as well as screening for other STIs Simple analgesia and topical lidocaine gel 5% for pain Topical antivirals not recommended Orla antivirals (aciclovir 400mg TDS for 5 days; valaciclovir 500mg BD 5 days) Condoms are NOT reliably protective

Answer 298

Eye infection: Keratoconjunctivitis (inflammation of cornea and conjunctiva causing pain, redness, tearing, blurry vision, classic herpes signs Eczema herpetium in atopic eczema pts (esp young children) Meningitis - often during reactivation Encephalitis (temporal lobe affected most commonly) often due to reactivation Can be transmitted to baby from mother during birth: causing skin, eye, mucus membrane infections (lesions pop up few wks post delivery) CNS infections causing seizures wks after delivery diagnosed via lumbar puncture, ECG, MRI Immunocompromised pt can have lesions in lungs and more widespread lesions etc

Answer 299

Caused by human papilloma viruses Benign epidermal neoplasms Common in children and young people Infection more likely in immunocompromised Spread via direct contact Over 100 subtypes of HPV and different subtypes associated with different clinical lesions

Answer 300

Common warts: dome shape nodules, common on hands, may have fine digit like projections caused by HPV 2, 27 and 57 Plane warts: smooth, flat topped papules common on the face, may have brownish colour and caused by HPV 3 and 10 Plantar warts: found on soles of feet, can be painful and scaly, may have dark punctate spots caused by HPV 1, 2, 4, 27 and 57 Anogenital warts: occur on genitals and spread through sexual contact. May be small or coalesce into larger lesions called condylomata acuminata caused by HPV 6 and 11 Filiform warts: eye or face typically have fingerlike projections Epidermodysplasia verruciformis: rare genetic condition of chronic cutaneous infection starting out as flat warts then developing into skin cancer

Answer 301

Infections of mucous membranes like URT can cause respiratory papillomatosis causing voice changes and high pitched breath sounds if the larynx is infected Anal and genital infections tend to be skin coloured, range in size and have califlower like surface. Typically painless, can be itchy, burning local pain or bleeding

Answer 302

Clinical exam and history Mucous membrane infections may need endoscopy (if URT suspected) or regular pap or acetic acid tests of cervix after 21 years old even if symptoms are subclinical Cervical smears detect HPV virus after 25 years old every 3 years until age 50 when becomes every 5 years Definite diagnosis needs biopsy microscopy confirmation

Answer 303

Prevention: HPV vaccine nationally against HPV 16 and 18 Now switched to protect against HPV 16, 18, 6 and 11 so is also protective against genital warts Management: Most resolve without treatment: watch and wait if not painful Topical salicylic acid first line: pared down wart prior to application then daily treatment for at least 12 weeks Cryotherapy: 2 wkly liquid nitrogen given by clinician. May be painful and cause bleeding. Avoid in young children Anogenital: may resolve spontaneously, remain same or increase in size. Need to be referred to sexual health clinic for diagnosis, STI screening and management. There is a very long latent period of HPV so reassure pt it does not mean infidelity Podophyllotoxin cream/solution self application for soft, non-keratinised external warts for 3 days BD Imiquimod 5% for keratinised lesions and non-keratinised external lesions apply 3 x weekly until resolution or for up to 4 months Surgical removal All treatments cause burning, itch and pain Condoms not reliably protective 95% genital warts not associated with high risk neoplasm transformation however types 16 and 18 are high risk of anogenital cancers

Answer 304

Caused by DNA pox virus Causes smelly pearly umbilicated papules Spread by direct contact and mainly affects children and young people If squeezed, punctum releases cheesy material that carries the virus May be single or in clusters Common in children and should raise concern of autoimmune deficiency in adults

Answer 305

Diagnosis: Clinical exam and history Management: Generally self limiting within 8 months lesions disappear Autoinoculation causing new lesions parents often request treatment for children Avoid scratching, cover lesions with clothing or bandages, sharing towels, refer to sexual health clinic if presenting with anogenital area spread Cryotherapy Imiquimod cream Curettage

Answer 306

Occurs mainly in elderly Lower legs become pale red then darker red to brown coloured Skin becomes thicker and bumpier May be painful or not or itchy or not Improves when legs are elevated Due to pooling of blood irritating skin causing dermatitis Cause: Pressure increases in deep veins due to leaky valves Backflow of blood increases Fluid leaks out of veins and under skin setting off inflammation causing skin to harden over time and discolour

Answer 307

Cool shiny skin Rusty red/brown coloured skin Skin feels hard or tight around ankles especially Blisters may be present Generally begins around the calf above ankle Some skin may break down forming ulcerations Investigations: Clinical diagnosis Patch testing for cases resistant to treatment to check if contact dermatitis has developed

Answer 308

Leg elevation (best to have feet above heart level) Try to avoid skin injury Keep active where possible to improve circulation Avoid standing still for lengths of time Keep skin moisturised and hydrated to reduce eczema symptoms and reduce risk of ulceration Topical steroids for eczema flares Compression stocking Antibiotics for infections

Answer 309

Dermatitis or unknown aetiology Characterised by itchy vesicular eruption of hands, fingers, soles of feet Can be acute, recurrent or chronic Difficult to treat effectively More common in spring and summer and in warmer climates Term dyshidrosis indicates sweating abnormality but histology reveals no evidence or eccrine gland involvement Hyperhidrosis (sweating problem) is associated in 40% of cases however Cause: Complex immunological process involving myeloperoxidase (lysosomal protein) Triggers include stress, allergic contact dermatitis and allergens such as chromate, neomycin or nickel Association with atopy and tinea pedis More likely to occur with sweaty feet

Answer 310

80% hands involved 12% feet and 8% both areas Affects palms or soles Usually symmetrical Several hours of burning or itching then eruptions develop Tiny vesicles 1-2mm in diameter erupt along lateral aspects of fingers and then palms or soles Later in the course there may be unroofed vesicles with inflamed bases possibly with peeling or rings of scale or lichenification Transverse furrows can develop on nail when eruptions occur in periungual area or nail matrix Vesicles may break out in waves Usually persists for 3-4 wks then resolves

Answer 311

Investigations: Clinical history and exam Cultures and sensitivity tests for resistant eruptions Serology of HTLV-1 to rule out adult T cell leukaemia or lymphoma which presents in a similar rash Management: Self limiting condition but symptomatic treatment given for itch Burow’s solution for oozing lesions (drying solution) Large blisters can be drained Antibiotics for secondary infections Strong topical steroids for itch control and cold compresses Oral steroids for resistant outbreaks Immunosuppressants for severe cases

Answer 312

Presents as localised demarcated plaque usually scaling, excoriation and lichenification (increased skin markings and thickened skin) Particularly itchy lesions Common sites are calf, elbow, shin, behind neck and genitalia (vulva or scrotum) Plaques usually >5cm diameter Highest prevalence between 30-50 years Darker skin types tend to develop more pigmented changes cause Common initial cause is eczema. Intense pruritus lead to persistent scratching and area becomes lichenified (thick and leathery) Other common causes include insect bites, scars and venous insufficiency

Answer 313

Investigations: IgE level and patch testing to exclude atopy and allergy Mucolytic studies Biopsy Management: Once lesion is covered over and pt cannot scratch the lesion usually resolves (apply firm occlusive dressing) Potent steroid creams for itch relief Tar or ichthyol preparations for anti-pruritic effect Antihisamines/ sedative antihistamines Antibiotics for secondary bacterial infections

Answer 314

Head lice/nits Public lice: usually on pubic hair, passed on by close contact such as sex, treatment involves insecticide, symptoms are itching, should be tested for other STIs Body lice: also passed on by close contact. Mostly occur in colder climates and overcrowded areas with poor sanitation and high poverty rates. Being unable to regularly wash body/clothes increases chance of body lice. grey/brown insects that cling to hair and feed off the scalp. Lay eggs which hatch within 7-10 days. Takes 7-10 days after for these lice to grow and begin to lay eggs also. Nits are they empty yellow/white eggshells which are left when they hatch. Look similar to dandruff but are not easily brushed out (unlike dandruff) Transmission is close to hair to hair contact: they soon die on bedding or clothes but can occasionally be passed on via hair brushes, hats etc. Very common in children mostly girls due to longer hair

Answer 315

Symptoms: Itchy (most of the time) Rarely causes scalp rash from scratching and occasionally an infection from this also White dandruff that is difficult to brush out of the hair Diagnosis: Seeing live louse on head (clinical exam and history) Nit detection comb STI screen for pubic lice if found

Answer 316

hair lice: Lotion treatments Wet combing Most insecticides need to be used twice and combing needs to be done several times over at least 2 wks To help prevent, tying hair back and detection combing often (once a week) will allow early detection and treatment Public lice: Malathion lotion and permethrin 5% cream (not suitable for all and permethrin not used for under 18s) Use cream and lotion all over body including scalp as may spread to here also Sexual partners within last 3 months must be notified and examined also so they can be treated if needed Body lice: Main treatment directed at destroying nits and lice in clothing and bedding. Wash in hot water, iron with hot iron and hot dryers Insecticide may be needed for body if many lice present People in close contact should also be examined and treated if needed

Answer 317

Idiopathic (45-55%) Infection (15-20%) eg Henoch-Schonlein purpura, septic vasculitis, URT flares of granulomatosis with polyangiitis (GPA), polyarteritis nodosa (PAN) Inflammatory diseases (10-15%) eg SLE, rheumatoid arthritis, Crohn’s disease and ulcerative colitis. Drug induced (10-15%) eg sulfonamides, beta-lactams, quinolones, NSAIDs, oral contraceptives, thiazides, anti-influenza vaccines Neoplastic (<5%) eg as result of paraproteinemia or lymphoproliferative disorder

Answer 318

very wide range of symptoms: Small vessel/hypersensitive: alpable purpura 1-3 mm (may join to form plaques ± ulcer), Tiny papules, Splinter haemorrhages, Urticaria, Vesicles, Livedo reticularis (rare) Medium sized vessel vasculitis: Ulcers, Digital infarcts, Nodules, Livedo reticularis, Papulo-necrotic lesions, Hypertension (damage to the renal vessels) Large vessel vasculitis: End-organ ischaemia (TIA/CVE), HTN, aneurysms, dissection +/- haemorrhage or rupture

Dermatology Diagnosis+management Flashcards

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