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MBBS - Year 2 > Dermatology - Eczema, Psoriasis and Infection > Flashcards

Dermatology - Eczema, Psoriasis and Infection Flashcards

1
Q

Main features of eczema

A

Red, itchy, dry

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2
Q

Physical signs in eczema

A 
Erythema 
Scale 
Excoriation 
Exudate 
Crusting 
Hyperkeratosis 
Lichenificaation
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3
Q

Excoriation

A

Scratch marks

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4
Q

Hyperkeratosis

A

Excessive production of epidermis which stays stuck and becomes thick (like on feet)

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5
Q

Lichenification

A

Increased roughened skin markings due to rubbing

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6
Q

Vesicles

A

Raised, clear fluid-filled lesion <0.5cm in diameter

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7
Q

Sub erythroderma vs erythroderma eczema

A 
Sub erythroderma (70-90%)
Erythroderma (>90%)
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8
Q

Exudate

A

Fluid oozing which dries to form crust

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9
Q

Who can atopic eczema affect

A

Adults or children

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10
Q

What are included in atopic disease

A

Eczema
Asthma
Urticaria
Hay fever

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11
Q

What gene abnormality is accosted w/ atopic eczema

A

Fillagrin gene abnormalities

Cross hatching in thenar eminence

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12
Q

How does atopic disease manifest in skin

A

Disruption in barrier function of skin - makes skin ‘leaky’

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13
Q

Typical sites of atopic eczema

A

Flexures

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14
Q

Different strengths of corticosteroids

A

Mild (e.g. 1% hydrocortisone) x4 - face
Medium (e.g. eumovate) x4 - flexures
Potent (e.g. betnovate) x4 - limbs
Very potent (e.g. dermovate) - thicker skin e.g. palms and soles

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15
Q

Difference in strength from mild and very potent steroids

A

64x

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16
Q

Are cushingoid features common w/ topical steroids

A

No

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17
Q

Asteatotic eczema

A

Cuased by lack of oil

Usually seen in older people nursing homes or long stay hosp pts

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18
Q

How much does oil production change per year

A

1% drop with age

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19
Q

Treatment of asteatotic asthma

A

Bathes less often, short and cooler
Use less detergent
Apply oil to skin or emollients
Keep air moist in home

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20
Q

Irritant contact eczema

A

Chemicals will irritate skin cells deepening on exposure and conc
Irritation isn’t same as allergy (due to immune process)

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21
Q

What can irritant contact eczema present as

A

Looks same as atopic eczema - hx is imperative

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22
Q

Allergic contact eczema

A

Comes on a few hrs to 96 hrs after contact

Investigate w/ patch tests

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23
Q

Common skin allergens

A

Nickel
Fragance
Chromate
Formaldehyde

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24
Q

Ix for allergic contact dermatitis

A

Patch tests

Apply patches day 1
Remove day 3
Read days 3 and 5 - redness, itch, scale
Select batteries according to hx and distribution

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25
Q

Why is diagnosing varicose eczema important

A

Commonly breaks down (infection or scratching) to form leg ulcer

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26
Q

Treatment of venous stasis

A 
Lose wt 
Exercise 
Elevate legs 
Avoid standing/ sitting for long periods 
Compression bandages 
VV surgery
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27
Q

Eczema and scratching

A

Scratching causes lichenification long term
Excoriated skin exudes and crust
May become secondarily infected

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28
Q

What type of lichenification can be caused by scratching

A

Lichen simplex

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29
Q

Why are bandages used in eczema

A

Stops scratching and break scratch/ itch cycles

Paste bandages of wet wraps can be used in children

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30
Q

When should bandages not be used for eczema

A

If eczema is infected

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31
Q

Infected eczema (bacterial)

A

Often due to scratching and causes impetiginous change
Commonly due to presence of Staph A
Produces impetiginized eczema

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32
Q

Impetiginized eczema

A

Produces yellow (aureus) crust and/ or blisters of impetigo

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33
Q

Infected eczema (viral)

A

Herpes simples - causes cold sores
Also infects eczema on head and neck
Eczema herpeticum

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34
Q

Eczema herpeticum

A

Erythematous, vesicular, well defined crusted blisters

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35
Q

Discoid

A

Coin shaped

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36
Q

Discoid eczema

A

Variant of bacterial infected eczema

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37
Q

What is discoid eczema often confused with

A

Psoriasis

But has follicular areas, less well defined and lacks psoriasis scale usually

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38
Q

What does discoid eczema often co-exist with

A

W/ areas of follicular eczema

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39
Q

Treatment for discoid eczema

A

Abx and antiseptic/ steroid combi needed

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40
Q

Pompholyx eczema

A

Little blisters down the sides of fingers
Intensely itchy
Episodic

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41
Q

Causes of pompholyx eczema

A

Allergy or endogenous (atopic) or both

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42
Q

What is seborrhoeic eczema sue to

A

Sensitivity to yeast on skin

Not due to yeast in diet

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43
Q

Epidemiology of seborrhaeic eczema

A

Very common (esp in older pts)

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44
Q

What can negatively affect sebborhoeic

A

Made worse by stress

Severe in HIV disease

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45
Q

What does seborrhoeic eczema rash

A

Dandruff

Rash on eyebrows, nose, nasolabial folds and flexures

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46
Q

Treatment of seborrhoeic eczema

A

Treat w/ topical or systemic antifungals +/- corticosteroid creams

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47
Q

General treatment of eczema

A 
Emollients if dry 
Antiseptic soaks if oozing 
Topical steroids depending on degree of infl 
Abx course if infected or discoid 
Antifungals if seborrheic
Antivirals if herpes 
Bandaging if scratching 
Elevation etc in stasis
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48
Q

More aggressive treatments for eczema

A

PUVA
Oral alitretinoin
Oral azathioprine, ciclosporin - broad spectrum immunosuppressants

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49
Q

Ddx of eczema

A 
Scabies 
Fungal infection in hands 
Psoriasis 
Drug eruption 
Rarer diseases e.g. bullous pemphigoid, dermatitis herpetiformis, mycosis fungoides
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50
Q

Scabies as ddx of eczema

A

Burrows between the fingers and friends/ family usually affected

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51
Q

Fungal infection in hands as ddx of eczema

A

Often unilateral (one hand, tow feet)

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52
Q

Psoriasis as ddx of eczema

A

Can be itchy but different Physical signs

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53
Q

Tineal (fungal) hand infection

A

Fine, silver scale in creases, lack of cracking and often unilateral
Take fungal scrapings if unsure

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54
Q

Psoriasis and discoid eczema

A

Similar, nail changes can occur in both

But different physical signs, look at scalp

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55
Q

Skin functions

A 
Protective barrier 
Temperature regualtion 
Sensation 
Immunosurveillance 
Appearances/ cosmesis 
Waterproofing
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56
Q

Cell types in epidermis

A

Keratinocytes
Langerhans’ cells
Melanocytes
Merkel cells

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57
Q

Keratinocytes function

A

Protective barrier

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58
Q

Langerhan’s cell function

A

Present antigens and activate T-lymphocytes for immune protection

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59
Q

Melanocytes function

A

Produce melanin, which gives pigment to the skin and protects the cell nuclei from UV radiation-induced DNA damage

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60
Q

Merkel cells

A

Contain specialised nerve endings for sensation

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61
Q

How many layers does the epidermis have

A

4, each representing a different stage of maturation of the keratinocytes

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62
Q

Epidermal layers

A 
Stratum basale (basal cell)
Stratum spinosum (pickle cell layer)
Stratum granulosa (granular cell layer)
Stratum lucidem - found in thicker skin 
Stratum corneum (horny layer)

Come Let’s Get Sun Burnt

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63
Q

Stratum basale

A

Actively dividing cells

Deepest layer of epidermis

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64
Q

What is found in the stratum spinosum

A

Differentiating cells

Cells are bound together by desmosomes

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65
Q

Function of stratum granulosum

A

Secrete lipids in extracellular areas

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66
Q

Stratum corneum

A

Layer of keratin

Most superficial layer of epidermis

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67
Q

Lichen planus

A

C/c autoimmune disorder affecting skin (esp flexor surfaces), mucosa and genitals
Scaliness and itchy skin may be seen

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68
Q

A/c px of lichen planus

A

Affects flexor surfaces
Itchy and can be painful
Distinct, often round, purpuric, raised lesion

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69
Q

Healing of lichen planus lesions

A

Aa the initial lesions heal, leave a small, flat brown discoloured circle

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70
Q

Mx of lichen planus

A

Many cases resolve spontaneously within a yr, can give topical steroids

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71
Q

Epidemiology of granuloma annular

A

Relatively common disorder

Affects children and young adults

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72
Q

Granuloma annulare px

A

Localised ring of beaded papules on the extremities

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73
Q

Mx of granuloma annulare

A

Many cases resolve spontaneously within a year

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74
Q

What does the efficacy of a topical drug depends on

A

Its internet potency and its ability to penetrate skin

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75
Q

Factors affecting penetration of topical drugs

A

Conc of medication
Thickness and integrity of stratum corneum
Frequency of application
Compliance

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76
Q

Factors affecting pharmcokinetics of topical drugs

A

Anatomy/ site
hydration of skin
Type of compound - hydrophilic vs phobic
Age

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77
Q

Common drugs given for derm

A 
Steroids 
Retinoids 
Calcineurin inhibitors 
Topical abx 
Imiquimod 
Sunscreens
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78
Q

Why are steroids given in derm

A

Effective at reducing symptoms tops of infl, but dint address underlying cause of disease

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79
Q

Which dermatoses are most responsive of steroids

A

Psoriasis

Atopic dermatitis

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80
Q

Topical calcineurin inhibitors

A

NSAIDs that reduce pro-infl cytokines responsive for itch and rash of atopic dermatitis

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81
Q

Imiquimod

A

Topical immunotherapy (enhances cell-mediated immune response)

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82
Q

Indications of imiquimod

A

Genital warts
Superficial BCC
Actinic keratosis

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83
Q

Clinically important immune deficiency as a rare cause of skin disease

A

Infections in HIV (cold sore, thrush)
Skin cancer sin organ transplant recipient
Congenital deficiencies e.g. Wiskott-Aldrich syndrome

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84
Q

Allergy vs autoimmunity

A

Both are examples of overactivity/ abnormal regulation of immune system

Allergy - bad clinical reaction to immune system to environmental antigens (allergens)
Autoimmunity - bad clinical reaction by the immune system to self-antigens (auto antigens)

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85
Q

Basis of hypersensitivity reaction in skin

A

Immunological reactions cause disease by promoting infl
Infl leads to diff clinical patterns of disease
A pattern of disease may be caused by more than one type of immunological reaction

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86
Q

What is urticaria characterised by

A

Short-lived swellings caused by plasma leakage from capillary blood vessels in and below skin

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87
Q

Main mediator for plasma leakage in urticaria

A

Histamine - Type I HS or Type V (in response to autoantibodies)

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88
Q

What is histamine released from in Type I HS reaction

A 
Most cells (along w/ other mediators)
Degranulation of mast cells may be triggered by allergens or autoantibodies
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89
Q

Bullous pemphigoid

A

Acquired blistering condn of the skin, sometimes mucous membranes

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90
Q

What type of HS is bullies pemphigoid

A

II

Autoantibodies against one or more antigens in the hemidesmosomes

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91
Q

Viral skin infections

A

Herpes simple
Herpes zoster or shingles
Viral warts
Molluscum contagiosum

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92
Q

Pathogen causing Herpes simplex

A

HSV-1 or HSV-2

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93
Q

Features of cold sores

A

Painful (neuropathic - tingling), self-limited

Often seen in recurrent dermatoses

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94
Q

Prevalence of HSV1 and HSV2

A

HSVI - orofacial (80-90%), sometimes genital

HSV2 - genital (70-90%), sometimes orofacial

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95
Q

Transmission of HSV

A

Direct contact at a mucosal surface or on site of abraded skin

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96
Q

Symptoms and signs of herpes simplex

A

Painful (sore) grouped vesicles on erythematous base –> crust + erosions

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97
Q

Dx of HSV

A

Usually clinical
Direct microscopy (Tznack smear)
Viral culture

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98
Q

Treatment of genital herpes simplex

A

Topical acyclovir 5% ointment
SystemicL: aciclovir - 200mg 5x/day for 5/7
Prophylaxis: 200mg TDS for 6/12 - 12/12

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99
Q

Alternative treatments of HSV

A

Famciclovir

Valacyclovir

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100
Q

HSV in immunocomoproimised

A

Lesions can be extensive or c/c

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101
Q

Prognosis of HSV

A

HSV persists in Doral root ganglia for life so tends to reoccur

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102
Q

Compliactions of HSV

A

Erythema multiform
Eczema herpeticum
Affects CNS

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103
Q

Definition of herpes zoster

A

A/c painful dermatomal dermatoses

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104
Q

Prevalence of herpes zoster

A

10-20% of adults have hx of disease

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105
Q

Transmission of herpes zoster

A

Reactivation of latent VZV in a sensory ganglion (previously had chicken pox)

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106
Q

Symptoms and signs of shingles

A

Pain in a demrtaomal or band like pattern

Followed by group of grouped vesicles on erythematous base –> crusting, fever and malaise

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107
Q

Dx of shingles

A

Viral culture
Tzanck smear
DDFA
Serology

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108
Q

Treatment of shingles

A

Analgesics

Aciclovir (effective 24-72hr of disease onset) 800mg 5x/day for 5/7

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109
Q

Prognosis of shingles

A

Symtoms resolve in 2-3/ 52

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110
Q

Complications of shingles

A

Post-herpetic neuralgia
Cranial nerce syndromes e.g. Ramsey hunt syndrome
In immunocompromised: disseminated form

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111
Q

Pathogen causing viral warts

A

HPV

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112
Q

Viral wart definition

A

Benign epithelial growth (premalignant on genitals and immunosuppressed - 16-18 subtypes )

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113
Q

Prevalence of viral warts

A

5% of population

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114
Q

Transmission of viral warts

A

Skin to skin contact

Sexually (condyloma acuminatum)

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115
Q

Symptoms of viral warts

A

Hyperkeratotic, flesh-coloured papule and/or plaque studded w/ small dots (thromboses capillaries)

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116
Q

Dx of viral warts

A

Clinical appearance

Histology if any doubt

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117
Q

Treatment of viral warts

A

No treatment
Topical salicylic acid
Cryosurgery

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118
Q

Prognosis of viral warts

A

Remove spontaneously within yrs

In immunocompromised; warts are resistant

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119
Q

Complications of viral warts

A

SCC genitals e.g. 16-18 subtypes

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120
Q

Pathogen causing molluscs contagious

A

Molluscum contagious virus (MCV) (poxvirus)

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121
Q

Definition of molluscum contagiousm

A

Benign self-limited papular eruption

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122
Q

Prevalence of molluscum contagiousum

A

Common in children and sexually active adults

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123
Q

Transmission in mollucsum contagiosum

A

Skin to skin contact

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124
Q

Symptoms in mollucscum contagiousm

A

Smooth flesh-coloured, dome-shaped, umbilicate papules contain keratotic (cheesy) plug

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125
Q

Dx of MCV

A

Clinical appearance

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126
Q

Prognosis of MCV

A

Spontaneous resolution

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127
Q

Treatment of MCV

A

May not be necessary
Cryotherpay
Curettage
May use topical immunomodulator drugs

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128
Q

Bacterial skin infections

A 
Impetigo 
Folliculitis, furunculosis, carbunculosis 
Ecthyma 
Erysipelas and cellulitis
Necrotizing fasciitis
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129
Q

Pathogen causing impetigo

A

Staph A > Strep pyogenes

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130
Q

Impetigo

A

Superficial skin infection

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131
Q

Prevalence of impetigo

A

1%

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132
Q

Transmission of impetigo

A

S. aureus and S. pyogenes are infrequent resident flora of skin

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133
Q

Symptoms of non-bullous impetigo

A

Vesicles or pustules or erythemautos skin –> erosions –> golden-yellow crust

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134
Q

Symptoms of bullous impetigo

A

Flaccid bullae w/ clear, yellow fluid (S. aureus) –> erosions —> golden-yellow crust

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135
Q

Dx of bullous impetigo

A

Clinical px

Confirmation by culture

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136
Q

Treatment of bullous impetigo

A

Topical aciclovir and/ or systemic abx e.g. topical mupirocin TDS for 7-10days or systemic beta lactams

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137
Q

Pathogens causing infection of hair follicles

A

Staph A
Psuedomonas aeruginosa

Folliculitis, furunculosis, carbunculosis

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138
Q

Transmission of infection of hair follicles

A

S. aureus is infrequent resident flora of skin

Exposure to P. aeruginosa in hot tubs or swimming pools

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139
Q

Different infections of fair follicles

A

Folliculitis - most superficial
Furunculosis
Carbunculsosis - deepest

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140
Q

Dx of infection of hair follicles

A

Clinical px

Conformation by culture

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141
Q

Treatment of infections of hair follicles

A

Topical treatments w/ 1% clindamycin or 2% erythromycin

Systemic antistpah abx, incision and drainage

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142
Q

Symptoms in folliculitis

A

Generally asymptomatic

But may be pruiritis and painful

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143
Q

Furunculosis

A

Tender, erythematous, fluctuant nodules that rupture w/ purulent discharge

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144
Q

Carbunculosis

A

Larger & deeper infl nodules often w/ purulent drainage

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145
Q

Ecthyma

A

Deep infection of the skin (down to epidermis) that causes a shallow, round, punched out ulcer

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146
Q

Pathogens causing ecthyma

A

Staph A
Strep pyogenes

Botha re infrequent resident flora of skin

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147
Q

Symptoms of ecthyma

A

Vesicles and bullae that progress to punched out ulcerations w/ adherent crust, which heals w/ scarring

148
Q

Dx of ecthyma

A

Clinical px

Confirmation by culture

149
Q

Treatment of ecthyma

A

Oral staphylococcal abx

150
Q

Erysipelas and cellulitis

A

Erysipelas - super infection of skin, involves upper dermis and superficial lymphatics
Cellulitis - Deeper infection of skin, involving deep dermis and s/c tissue

151
Q

Pathogens causing erysipelas;as and cellulitis

A

Staph A and strep pyogene

152
Q

Symptoms of erysipelas

A

Tender, well-defined, erythematous patch

153
Q

Symptoms of cellulitis

A

Ill-defined erythematous and oedematous patch

154
Q

Dx of erysipelas and cellulitis

A

Clinical px

155
Q

Treatment of erysipelas and cellulitis

A

Beta lactams - e.g. fluclox/ amoxi or erythromycin

156
Q

Pathogens causing necrotising fasciitis

A 
Strep pyogenes 
Gp B and C strep
Vibrio vulnifics 
Clostridium perfigens 
Bacteroides fragilis (mixed infection)
157
Q

Necrotizing fasciitis

A

Life threatening infection of s/c tissue and fascia

158
Q

Causes of necrotising fasciitis

A

Idiopathic
After surgery/ trauma - cutaneous portal of entry
IVDU

159
Q

Symptoms seen in necrotising fasciitis

A

Erythema and severe pain extending to deep to underlying fascia
Skin becomes dusky and bullae form

160
Q

Progression of symptoms in necrotising fasciitis

A

Severe pain, erythema and oedema followed by necrosis, gangrene
Fever, systemic toxicity, organ failure, shock, death

161
Q

Dx of necrotising fasciitis

A

Bx for histology

Gram stain and culture for identifying causative pathogen

162
Q

Treatment of necrotising fasciitis

A

Surgical debridment or amputation

Abx (gentamicin, clindamycin)

163
Q

Parasitic skin infections

A

Scabies
Cutaneous and mucocutaneous leishmaniasis
Cutaneous larva migrans

164
Q

Scabies

A

Infective disease of the skin caused by S. scabiei burrowing into the epidermis

165
Q

Transmission of scabies

A

Skin to skin contact

166
Q

Symptoms of scabies

A

Intense itching, esp at night

Burrows, vesicles, papule and pustules

167
Q

Location of scabies lesions

A 
Finger webs 
Around wrists Elbows
Armpits 
Waist 
Thigh 
Genitals, nipples, breast and lower buttocks
168
Q

Dx of scabies

A

Looking for mites

Eggs under microscopes (skin scrapings)

169
Q

Treatment for scabies

A

Skin lotions contain permethrin
All family members, all over body
Repeat treatment in 7/7

170
Q

Pathogen causing cutaneous and mucocutaneous leishmaniasis

A

Leishmania tropica (cutaneous)
L. brazilenis (mucocutaneous)
L mexican, L. aethiopia (diffuse cutaneous)

Originate from sand fly

171
Q

Symptoms in cutaneous leishmanias

A

Skin lesions w/ erythema, infl and ulceration

172
Q

Symptoms in mucocutaneous leishmaniasis

A

Lesions of mnasal and/ oral mucosa

173
Q

Symptoms of diffuse cutaneous leishmaniasis

A

Multiple, deep skin lesions

174
Q

Mucocutaneous leishmaniasis

A

Infections disease of skin caused by Leishmania spp, growing and destroying epidermis and mucosae

175
Q

Transmission of leishmaniasis

A

Bites of infected sandflies

176
Q

Ddx of leishmaniasis

A

Appearance of lesions

Culture of parasite

177
Q

Treatment of leishmaniasis infections

A

CL: self-healing, abx

MCL, DCL - pentavalent antimonial , amphotericin B

178
Q

Pathogen causing cutaneous larva migrans

A

Larvae of dog and cat hookworm

179
Q

Cutaneous larva migrans (creeping eruption)

A

Cutaneous eruption usually confined onto the skin of the feet, arms, or buttocks caused by migrating larva

180
Q

Transmission of cutaneous larva migrans

A

Active penetration of the skin by larva

181
Q

Symptoms of cutaneous larva migrans

A

Erythematous, pruritic, serpiginous lesions that advance severe mm/day
Allergic immune response

182
Q

Dx of cutaneous larva migrans

A

Classical clinical appearance of the eruption

183
Q

Tx of cutaneous larva migrans

A 
Thiabendazole (topical or oral)
Albendazole
Mebendazole 
Ivermectin 
Abx
184
Q

Fungal infections of the ksin

A 
Tinea corporis (body)
Tinea capitis (head)
Tinea pedis (feet)
Tinea cruris (groin)
Candida intertrigo
Piyriasis versicolour
185
Q

Tinea

A

Infectious disease of the skin caused by fungi

Most common organisms are tines verrucosum, Tinea rubrum, micorposrum canis

186
Q

Dx of tinea infections

A

Skin scrapings by direct microscopy - branching hyphae may be seen
Woods light reveals green flurosence

187
Q

Symptoms of tinea infections

A

Itch

Usually peripheral scaling, discoid lesions

188
Q

Tx of tinea infections

A

Imiadozales (miconozale or clotrimazole) or the allylamines e.g. terbinafine
Systemic antifungals for nails, scalp or widespread, also give. for c/c fungal infections of skin

189
Q

Systemic antifingals for c/c/ infections

A

Griseofulvin
Terbinafine
Itraconazole

190
Q

Pathogen causing candidal intertrigo

A

Yeast - candida albicans

191
Q

Candidal intertrigo

A

Superficial, mycotic infection of skin

Erythematous, macerated patch w/ satellite macule or pustules extending beyond the flexures

192
Q

Where does candidate interior tend to affect

A

Tends to affect moist, occluded skin folds

193
Q

Dx of candidate intertrigo

A

Skin scrapings or swab (black) - culture

194
Q

What should you check if a pt presents w/ widespread candidal intertrigo

A

DM (fasting glucose, urinalysis)
HIV

These condns make them predisposed to candidiasis

195
Q

Symptoms of candidal intertrigo

A

Itch, maybe pain

196
Q

Tx for candidal intertrigo

A

Clotrimazole, terbinafine or antifungals w/ weak steroids e.g. daktacort
Keep area drug - powder anti fungal, loose clothing, wt loss if obese
Severe cases po fluconazole

197
Q

Pathogen causing pityriasis versicolor

A

Yeast - malassezia furfur

198
Q

Pityriasis veriscolor

A

Superficial mycotic infections of skin

Confluent, fine scale, well-dermacted, hypo/hyperpigented plaques

199
Q

Dx of pityriasis verisocolor

A

Skin scrapings or swab (black)

200
Q

Tx for pityriasis versicolor

A

Selenium sulphide shampoo (2.5%)
Ketoconazole shampoo
Topical anti fungals

201
Q

Features of c/c plaque psoriasis

A

Well defined
Erythematous patches
Scaly
Seen in extensor surfaces - elbow, knees, scalp, hands and feet

202
Q

Features of guttate psoriasis

A

AKA ‘rain drop’ psoriasis
Common in children
Lesion often erupts after an URTI (strep infetion)
Small scaly plaques

203
Q

What does guttate psoriasis respond well to

A

Phototherapy

204
Q

Features of pustular psoriasis

A

Generalised painful erythematous and sterile pustules
A/c px - pyrexia and ill pts
Can be life threatening

205
Q

Complications of pustular psoriasis

A

2’ infection
Disturbed protein and electrolyte imbalance
Renal and liver impairment

206
Q

Types of pustular psoriasis

A

Generalised pustular psoriasis
Palmoplantar pustolosis
Acrodermatitis continua of Hallopeau

207
Q

Features of palmoplantar pustulosis

A

Localised to palms and soles
Sterile yellowish and brownish pustules
May have c/c plaque psoriasis elsewhere

208
Q

Features of acrodermatitis continue of Hallopeau

A

Very rare
Pustules on distal portion of finger and sometimes toes
Shedding of nail can occur if involved

209
Q

Features of flexural psoriasis

A

Inverse psoriasis
Localised to skin fold (flexures), genitals
Shunt and smooth
Fungal and bacterial trigger may exist

210
Q

Features of scalp psoriasis

A

Common site in c/c plaque psoriasis
Well defined clay plaques
Can extend from hairline to neck
Hair loss usually transient

211
Q

Features of nail psoriasis

A

Niall pitting
Onycholysis (loosening of nail)
Subungual hyperkeratosis

212
Q

Types of psoriasis

A

C/c plaque
Guttate
Pustular
Localised forms

213
Q

Localised forms of psoriasis

A

Scalp
Nail
Flexural
Oral mucosa

214
Q

Epidemiology of psoriasis

A

Infl skin disease affecting 2% population
M=F
Two peak: 10-20yrs and 50-60yrs

215
Q

Predisposing factors for psoriasis

A 
Genetic 
Infection - strep, HIV
Stress 
Drugs 
Autoimmune - T cell 
Trauma - Koebner phenomena
216
Q

Drugs predisposing psoriasis

A

Lithium
BB
Anti-malarial
Tapering down systemic steroids

217
Q

Koebner phenomenon

A

Formation of new lesions in otherwise healthy skin after cutaneous injury
Lesions are same as preexisting dermatoses

218
Q

Psoriasis as the marker of underlying systemic disease

A

Psoriasis pts at greater riskier mI, metabolic syndrome
Directly correlates w/ psoriasis severity
Increase mortality in severe psoriasis

219
Q

Metabolic syndrome

A

Multiplex risk factor that arises from insulin resistance accompanying abnormal adipose deposition and function

220
Q

Topical treatments for psoriasis

A 
Vit D3 analogues 
Corticosteroids 
Dithranol 
Retinoids 
Coal tar 
Salicylic acid
221
Q

An example of vit D3 analogue

A

Calcipotriol

222
Q

MOA of vit D3 analogues

A

Inhibit epidermal proliferation and infl cell function

223
Q

Indication of vit D3 analogues

A

Mild to moderate psoriasis

Some not appropriator face and genitalia

224
Q

Adverse effect of vitamin D3 analogues

A

Irritation

Hypercalcaemia

225
Q

Indications for corticosteroids

A

Mild to moderate psoriasis

226
Q

Adverse effects of corticosteroids for psoriasis

A

Skin atrophy
Peri-oral dermatitis and steroid rosacea
Allergic contact dermatitis
Suppression of pituitary adrenal axis

Short term use is best

227
Q

Properties of coal tar and wood tars

A

Anti infl and anti-pruritic

228
Q

Adverse effects of coal tar and wood tars

A

Unpleasant smell

Messy formulation - staining

229
Q

Keratolytics for psoriasis

A

E.g. salicylic acid
Reduces scales –> enhances penetration of topical medications
Risk of systemic intoxication if applied on widespread areas

230
Q

Example of topical retinoid

A

Tazarotene

231
Q

Topical retinoids for psoriasis

A

Decrease epidermal proliferation and inhibits differentiation
Not very effective

232
Q

Adverse effects of topical retinoids

A

Irritation
Pruritus
Burning sensation
Dryness

233
Q

Indications for dithranol

A

Mild to severe psoriasis

234
Q

Dithranol for psoriasis

A

Short contact (out-pt)
24 hrs application schedule (in-pt)
Concand application time gradually increased

235
Q

Adverse effects of dithranol

A

Irritation

Staining of clothes and skin

236
Q

Phototherpay for psoriasis

A

Topical PUVA: psoralen baths or topical application
Systemic PUVA: ingestion of psoralen
Narrow band UVB: most optimal option

237
Q

Adverse effects of phototherpay

A

Skin burn
Increases risk of skin cancer
Cataracts w/ PUVA-ingested

238
Q

MTX indication in psoriasis

A

Severe psoriasis - reduced lymphocyte proliferation

239
Q

Admin of MTX for psoriasis

A

Once weekly dose (IM, SC or po)

Folic acid added on another day

240
Q

Blood monitoring for MTX

A

FBC
LFTS
U&Es

241
Q

Adverse effects of MTX

A 
Nausea 
Pancytopenia 
Oral erosions 
Opportunistic infections 
Hepatic and cirrhosis
Interstitial pneumonitis
242
Q

Ciclosporin indication for psoriasis

A

Sever psoriasis - decreases T-cell in epidermis

243
Q

Monitoring for cyclosporin

A

BP
U&Es
LFTs
Lipids

244
Q

Adverse effects of cyclosporin

A 
HTN 
Renal failure 
Carcinogeneisis 
Opportunistic infections 
Hyperlipidaemia
245
Q

Systemic retinoids

A

E.g. acitretin
Derived from vit A
Inhibit epidermal proliferation and the activation of polymorphic leukocytes

246
Q

Monitoring of systemic retinoids

A

LFTs

Fasting lipids

247
Q

Side effects of systemic retinoids

A 
Teratogenic 
Dryness of skin and mucosal membranes 
Hepatic toxicity 
Hyperlipidaemia 
Depression and suicidal ideation
248
Q

NICE pathway for psoriasis treatment options

A
  1. Topical therapy
  2. Phototherapy
  3. Specialist referral - for systemic therapy, non-biologics before biologics
249
Q

NICE indications for biological therapy for psoriasis

A

Moderate to severe plaque psoriasis in adults to fill to repost/ intolerant/ have contraindications to other systemic therapies

250
Q

What is severe psoriasis defined at

A

PASI > 10

DLQI > 10

251
Q

Biologics given for psoriasis

A 
Adalimumab - anti-TNF
Etanercept - anti-TNF
Ustekinumab - blocks IL-12 7 IL-23
Ixekizumab - blocks IL-17
Secukinumab - blocks IL-17a
252
Q

When is infliximab indicated in psoriasis

A

PASI of 20

DLQI > 18

253
Q

Adverse effects of biologic therapy in psoriasis

A 
Infections (TB) and malignancy
Demylinating disease 
Heart failure 
Allergic reaction 
Lupus-like syndromes 
Rarely, sever hepatitis
254
Q

PASI

A

Psoriasis Area Severity Index
Assess severity of psoriasis in 4 body areas
Range from 0 (no disease) to 72 (maximal disease)
Physician-peformed assessment

255
Q

Social effect of psoriasis

A

Psoriasis affects QoL
Disabling (psoriasi to palms and soles)
Affects social and personal life
Low self esteem

256
Q

DLQI

A

Dermatology Life Quality Index (DLQI)
A simple, practical pt-focused technique
10 question validated questionnaire
Used to assess impact of skin disease o pt

257
Q

Allergy risk factors

A 
First born 
Atopic parents (genes)
C-section delivery 
Bottle-fed 
Early abx
258
Q

Types of food hypersensitivity

A

Food allergy - IgE -mediated food allergy, non-IgE mediated food allergy e.g. coeliac
Non-allergic food HS (formerly food intolerance)

259
Q

What is psoriasis

A

C/c infl skin condn due to hyperproliferation of keratinocytes and infl cell infiltrations

260
Q

Where does seborrheic psoriasis px

A

Nasolabial folds

Retro - auricular

261
Q

Auspitz sign

A

Seen in psoriasis

Scratch and gentle removal of scales cause capillary bleeding

262
Q

Complications of psoriasis

A

Erythroderma

263
Q

Erythema vs purpura

A

Erythema - redness (due to infl or vasodilation) that DOES blanch w/ pressure
Purpura - red/ purple (bleeding into skin or mucous membrane) that DOES NOT blanch w/ pressure

264
Q

Petechiae

A

Small pin-point macule

265
Q

Ecchymoses

A

Larger, flat-like bruises

266
Q

Mx of mild plaque psoriasis

A

Topical treatments e.g. hydrocortisone, tazarotene

267
Q

Mx of moderate to severe psoriasis

A

PUVA
MTX
Ciclosporin retinoids
Biologics

268
Q

Mx of gutatte psoriasis

A

PUVA
Ciclosporin
MTX

269
Q

Mx of pustular psoriasis

A

Supportive care
PUVA
Systemic agents e.g. cyclosporin, MTX

270
Q

Mx of urticaria

A

Fexofenadine (antihistamine)

Sometimes oral steroids are used

271
Q

Macule

A

Flat area of altered colour

272
Q

Patch

A

Larger, flat area of altered colour or texture

273
Q

Papule vs nodules

A

Papule - solid raised lesion <0.5cm in diameter

Nodule - solid raised lesion >0.5cm in diameter, w/ a deeper component

274
Q

Plaque

A

Palpable scaling raised lesion >0.5cm in diameter

275
Q

Vesicle vs bulla

A

Raised clear, fluid-filled lesion <0.5cm (vesicle)/ >0.5 (bulla) in diameter

276
Q

Pustules

A

Pus-containing lesion <0.5cm in diameter

277
Q

Abcess

A

Localised accumulation of pus in dermis of s/c tissue

278
Q

Wheal

A

transient raised lesion due to dermal oedema

279
Q

Excoriation

A

Loss of epidermis following trauma e.g. scratching

280
Q

How do the different Th cells manifest in disease

A

Th1 - involve in autoimmune diseases

Th2 - involved in allergic disease

281
Q

Examples of atopic diseases

A 
Asthma 
Eczema 
Rhinitis 
Dermatitis 
Food allergy - anaphylaxis, diarrhoea, abdominal pain, FTT
282
Q

Conditions and their associated risk of developing asthma

A

Eczema - 50%
Eczema + allergy - 90%
Rhinitis - 50%

283
Q

Emergency plan for allergens contact

A 
Avoidnaces 
Antihistamines asap - may need bronchodilator
Repeat histamine
Adrenaline (Epipen or anapen) 
Seek medical help
284
Q

Systemic signs that might hint at a skin infection

A

Fever
HR
RR
BP

285
Q

Lab testing for skin infections

A 
Swabs 
Scrapes 
Bx 
Aspirates 
Bloods - cultures, serology, FBC, CRP
286
Q

Toxin mediated skin infections

A

Staph A - scalded skin syndrome, TSS

Strep pyogenes - scarlet

287
Q

Tips for describing skin infection lesions

A 
Pustules or vesicles 
Raised or flat 
Crusted or non-crusted 
Pus inside dermis or deeper 
Ulceration and scarring 
Discharge 0 exudate 
Progression 
Palpation - rough, smooth, indurated
288
Q

Production of macule

A

Local infl
Immune response
Infiltrating leukocytes

289
Q

Production of papule

A

More marked infl

Invasion of neighbouring tissues

290
Q

Production of vesicles

A

Microbe invades epithelium - HSC, VZV

291
Q

Production of ulcer

A

Epithelium ruptures

Microbe discharged - HSV, VZV

292
Q

Production of papilloma

A

Microbe grows in epithelium, which proliferates, microbe shed w/ epithelial cells (warts)

293
Q

Factors affecting microbial load on skin

A 
Limited amount of moisture presents 
Acid pH of normal skin 
Surface temp 
Slaty sweat 
Exerted chemicals e.g. sebum, fatty acids
294
Q

Exotoxins

A

Produced mostly by Gram+ve bacteria

Released into surroundings

295
Q

Endotoxins

A

Exists as part of outer portion of cell wall of Gram-ve

Freed when cell dies and cell wall breaks

296
Q

Ddx of cellulitis

A

Stasis ulcer
Impetigo
Stasis dermatitis

297
Q

What is erysipelas confined to

A

Dermis
Well detracted
Typically in cheeks, face and nose

298
Q

Palpation of erysipelas

A

Warm
Tender
Smooth

299
Q

Mx of abscess

A

Incise and rain areas
Hosp admission
Abx
IV

300
Q

Ecthyma vs impetigo

A

Ecthyma is a deep infection than impetigo (invasion of demris)
Unlike impetigo, ecthyma heals w/ scarring (eschar)

301
Q

Pathogen causing ecthyma gangrenous

A

Pseudomonas aeruginosa

302
Q

Skin manifestation of systemic infections

A

Petechial rash of meningocoaal septicaemia
Ecthyma gangrenosum of pseudomonas in blood stream
Splinter haemorrhage of endocarditis
Rash as part of systemic infection (e.g. chicken pox, measles)
Primary site of herpes simplex infection
Toxin mediated skin disease

303
Q

Features of TSS

A 
High fever 
Rash that resembles sunburn followed by desquamation 
D+V
Hypotension
Multiorgan failure
304
Q

What can TSS be caused by

A

Use of tampons

305
Q

What is Scalded Skin Syndrome (SSS)

A

Flaccid blisters and superficial denudation/ desquamation

AKA Ritter’s disease

306
Q

Desquamation

A

Peeling of skin

Skin cels are created, clogged away and replaced

307
Q

Who does SSS affect

A

Children <5

Immunocompromised adults

308
Q

PVL

A

Panton-Valentine-Lecocidin
A toxin produced by staph A that kills leucocytes
Has been proven to cause recurrent, persistent skin infections e.g. abcesses

309
Q

Why is PVL screened for in hospitals

A

Necrotising infections - risk of fatal pneumonia

310
Q

How is MRSA killed before pts go to surgery

A

Nasal decontamination w/ mupirocin wash

311
Q

Streptococcal toxinoses

A

Streptococcal skin infections are caused by Strep. Pyogenese (Gp A strep)
Strep impetigo develops independently of strep URTI

312
Q

Streptococcal toxins

A

Pyrogenic toxins - causes of rash seen in scarlet fever and streptococcal TSS
Streptolysins O and S: dame mammalian cells
Streptokinase: plasminogen –> plasmin, lysis of clots
Hyaluronidase: disrupts ground substance

313
Q

A/c glomerulonephritis and skin infections

A

Occurs more often after skin infections then throat infections

314
Q

Meningococcal petechiae

A

Endotoxin causing endothelial damage
Increased permeability and capillary leakage (micro haemorrhage)
Activation of coagulation cascade –> microvascular thrombosis
NB non blanching ‘tumbler test’

315
Q

Initial lesion causing necrotising fasciitis

A

Can be trivial e..g minor abrasion, insect bite, injection (IVDU) and visible skin lesion

316
Q

Initial px of necrotising fasciitis

A

That pf cellulitis (v hard and indurated) - can advance rapidly or slowly
As it progresses there’s systemic toxicity - high temp, disorientation, lethargy

317
Q

Examination of local sites of necrotising lesion

A

Typically reveals cutaneous infl, oedema and and discolouration or gangrene and anaesthesia

318
Q

Fournier’s gangrene

A

Associated w/ DM, this is an extensive necrotising infection of the genitals, perianal, scrotum and perineal region and groins
Life threatening - surgery within 1hr

319
Q

Causative organisms of Fournier’s gangrene

A

Gram -ve
GpA strep
Anaerobes

320
Q

Epidemiology of Fournier’s gangrene

A

M > F

321
Q

Anaerobic/ clostridial gangrene

A

Traumatic or surgical wounds can be come infected w/ Clostridum species

322
Q

How does C. tetani causes clostridial gangrene

A

Gains access to the tissues through of the ski, but the disease it produces of the powerful exotoxin

323
Q

Causes of gas gangrene/ clostridia gangrene

A

Several species of clostridia - C. pefringens is the most common

324
Q

Diabetic foot ulcers causeative organisms

A

Can be caused by Staph A, Strep, anaerobes, E. coli, proteus, polymicrobial - infections
These can all become necrotic

325
Q

Gram +ve cocci - aerobic

A

Pairs, tetrads: staph

Chains: strep, enterococcus sp

326
Q

Gram-ve rods - aerobic

A

E. coli
Preoteus
Pseudomonas

327
Q

Gram +ve/-ve bacteia - anaerobes

A

Peptostreptococcus

Clostridum

328
Q

ZN stain

A

+ve for mycobacteria

329
Q

Systemic viral infections seen in skin

A 
Measles 
VZV 
Erythrovirus (aka parvovirus)
HHV-6
Rubella
330
Q

Nail changes in psoriasis vs infections

A

Fungal - single nail, infl at nail bed, darker colour (brown discolouration)
Bacterial - green (pseudomonas)
Psoriasis - more symmetrical, more nails involved

331
Q

What does the PASI score look at

A

% of body involvement
Redness
Induration

332
Q

What might cause a flare up of psoriases

A 
Stress
Medications
Infections e.g. step & guttate
Smoking
Drinking
Steroids - tapering down & pustular
Koebner
333
Q

Drugs that may cause a flare of psoriases

A

BB
NSAIDs
Anti-malarial
Lithium

334
Q

What group of syndromes are psoriasis associated with

A

Metabolic syndrome e.g. DM , increased insulin resistance, HTN, abdominal obesity

335
Q

Treatment of mild atopic eczema

A

Emollients

Mild potency topical steroids

336
Q

Prescription of emollients

A

250g to 500g for children, 500g+ for adults

Prescribe two containers for children - one available at school, nursery

337
Q

Treatment of moderate atopic eczema

A

Emollients
Moderate potency topical steroids
Topical calcineurin inhibitors - tacrolimus
Bandages

338
Q

Treatment of severe atopic eczema

A 
Emollients 
Moderate potency topical steroids 
Topical calcineurin inhibitors - tacrolimus
Bandages
Phototherapy 
Systemic treatments
339
Q

How should emollients be applied

A

In downwards motion to avoid plugging follicles

Folliculitis - avoid excessive rubbing in of any topical if there’s a possibility of histamine release

340
Q

Skin barrier defect as cause of atopic eczema

A

Inherited abnormalities in fillagrin expression

Water is lost
Irritants and allergens may penetrate skin barrier

341
Q

Th2 response as a cause of atopic eczema

A

Infl induced by Th2 response exacerbates barrier defect

Ceramides reduced 
Fillagrin reduced 
Antimicrobial peptides reduced 
Bacteria colonise and infect skin 
Infections harder to control
342
Q

Why is urticaria described as transient

A

Usually doe not last more than 24hrs in same place

343
Q

Distinctive feature of anaphylaxis vs angiodema

A

Anaphylaxis is characterised by circulatory shock e.g. hypotension
Angiodema is just swelling

344
Q

Types of urticaria

A

Ordinary E.g. physical - clothing. Can be a/c, c/c, or episodic
Mechanical
Aquagenic
Solar

345
Q

Dx of urticaria/ angiodema

A

Hx is typically sufficient
Examination - distribution, morphology and size of wheals
Further ix may be needed e.g. urticarial vasculitis (ESR, autoimmune screen), skin prick test

346
Q

Dermatographism

A

Exaggerated wheal and flare response that occurs within minutes of skin being touched
Most common form of physical or c/c inducible urticaria

347
Q

Treatment of urticaria/ angiodema

A

Stop offending drug
Avoid trigger
Give non-sedative antihistamine op to qid - fexofenadine
Short course of pred
Stronger agents - anti-IgE, cyclosporin, calcineurin inhibitors,

348
Q

Paronychia

A

Infection AROUND nail caused by staph or strep

349
Q

Treatment of paronychia

A

Incision and drainage using local anaesthetic

Follow up w/ po abx

350
Q

What is the stream basale bound to

A

Basement membrane by hemidesmosomes

351
Q

What IL are involved in the pathogenesis of psoriasis

A

IL-17 and IL-23

352
Q

Why are oral steroids contraindicated in psoriasis

A

Treats psoriasis initially but causes very bad flare once stooped

353
Q

How many session can be given for narrow band UVB in psoriasis

A

Max 30-36

354
Q

When is narrow band UVB contraindicated in psoriasis

A

If pt has several moles

355
Q

Different retinoids and their indications

A

Isotet for acne
Alitret for hand eczema
Acitret for psoriasis

356
Q

What viral infections should be screened before starting ciclosporin

A

HPV

357
Q

Causes of erythema nodusum

A

NODUSUM

NO - no cause
D - drugs E.g. dapsone, sulphonamides 
O - OCP
S - sarcoidosis
U - ulcerative colitis/ Crohn’s
M - micro e.g. TB, strep, toxoplasmosis
358
Q

Mx of SSS

A

IV abx
Topical fusidic acid
Supportive treatment

359
Q

When is Nikolsky’s sign positive

A

SSS
TEN
Pemphigus vulgaris

360
Q

What can you get get SSS secondary to

A

Initial impetigo

361
Q

Abx of choice to treating TSS

A

IV clindamycin and meropenem

362
Q

Treatment of severe TEN

A

IVIg +/- plasmapheresis

363
Q

Treatment of scarlet fever

A

Oral penicillin V

364
Q

Algorithm for topical treatment of psoriasis

A

All pts need to use emollients
1st line - potent steroid (betnovate) and Vit D (Dovonex) applied at diff times
2nd line - stop steroid, use Vit D BD
3rd line - stop Vit D, use potent steroid BD

Dithranol and coal tar are alternatives

365
Q

Side effects of ciclosporin

A 
Hypertrophy of gums 
Hypertrichosis 
HTN
Hyperkalaemia
Hyperglycaemia

MBBS - Year 2 (20 decks)

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