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Dermatology Secondary Care Flashcards

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1
Q

What is bullous pemphigoid?

A

A chronic, autoimmune, subepidermal blistering skin disorder.

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2
Q

How does bullous pemphigoid differ from pemphigus?

A

Pemphigus - intra-epidermal blistering, painful not pruritic

Pemphigoid - sub epidermal blistering, painful and pruritic

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3
Q

What is the median age of onset in bullous pemphigoid?

A

80 years

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4
Q

What is the autoantigen in bullous pemphigoid and what is its function?

A

Type XVII collagen (COL17)

in the basement membrane

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5
Q

What are three risk factors for bullous pemphigoid?

A

Lichen planus/psoriasis
NSAIDS/furosemide/captoptil
Radiotherapy

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6
Q

How does bullous pemphigoid present?

A

Urticarial/erythematous rash on limbs precedes blisters - urticarial prodrome
Blisters/bullae occur in skin flexures, are fluid filled
Post inflammatory hyperpigmentation/milia
Patient is otherwise well

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7
Q

How is bullous pemphigoid diagnosed?

A

Skin biopsy followed by direct immunofluorescence (DIF)

Deposit of IgG and C3 on the epidermis side of the dermal/epidermal junction

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8
Q

What is seen on the histology of a bullous pemphigoid patient?

A

Subepidermal blister with fibrin and inflammatory infiltrate and eosinophilic predominance. Intact epidermis

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9
Q

What is the management of bullous pemphigoid?

A

Urgent referral to secondary care/admission
Dermovate cream
If more severe, PO prednisolone

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10
Q

If systemic steroid treatment lasts more than one month, what is given?

A

PPI and bisphosphonates

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11
Q

What is a complication of bullous pemphigoid?

A

Secondary infection and sepsis

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12
Q

What is pemphigus?

A

A group of autoimmune disorders where there is blistering of the skin and/or mucosal surfaces.

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13
Q

What is the pathophysiology of pemphigus?

A

Circulating IgG autoantibodies bind to antigens (desmosomes) on the surface of keratinocytes leading to acantholysis (keratinocytes separate from each other)

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14
Q

What are some risk factors for pemphigus?

A

Female
Older age
Asian and Ashkenazi Jews
Pregnancy and stress

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15
Q

What are the main three subtypes of pemphigus?

A

Pemphigus vulgaris
Pemphigus foliaceus
Paraneoplastic pemphigus

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16
Q

How does the skin symptoms of pemphigus present?

A

Blisters on normal or erythematous skin and are flaccid
Affected skin is painful but rarely pruritic
Intertriginous areas - granulation and crusting

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17
Q

What are the other symptoms of pemphigus?

A

Nail changes
Burst gingival, buccal, and palatine bullae that are painful and slow healing.
Conjunctivae, oesophagus, and genitalia

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18
Q

How is pemphigus definitively diagnosed?

A

Skin biopsy from the edge of a blister, histology and DIF/IDIF
ELISAs for DSG1 and DSG3 in serum

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19
Q

What are the three phases of management of pemphigus?

A

Control, consolidation, maintenance.

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20
Q

What are the treatment options in the control phase of pemphigus management?

A

PO prednisolone
2nd line: plasmaphresis 3xw w/ azathioprine or cyclophosphamide
3rd line: IVIG

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21
Q

Describe the consolidation and maintenance phases of management of pemphigus.

A

Step down regime and tapering after 80% lesions have healed

Steroid sparing agents sometimes used to further reduce dose

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22
Q

What are the complications of pemphigus?

A

Secondary infection
Effects of corticosteroids
Malignancy immunosuppression

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23
Q

Give four differences between pemphigus and bullous pemphigoid

A

Pemphigus: younger, flaccid epidermal bullae, not pruritic
Pemphigoid: Older, tense subepidermal bullae, pruritic

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24
Q

What is lichen planus?

A

A pruritic, popular eruption characterized by its violaceous colour and polygonal shape.

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25
What are the five Ps of lichen planus?
``` Purple Pruritic Polyangular Planus (flat-topped) Papules ```
26
Where is the rash of lichen planus found?
Flexor surfaces of extremities, upper>lower Genitalia Mucous membranes
27
What are some characteristic signs of lichen planus?
Lacy white lesions on mucous membranes | Intensely itchy 2-5mm red/violet shiny flat-topped papular with Wickham's Striae
28
What occurs when papules clear in lichen planus?
They are replaced by brown discolouration
29
What are the nail and scalp changes seen in lichen planus?
Longitudinal ridges | Scarring alopecia
30
What are the potential causes of lichen planus?
T-cell mediated Kobner's phenomenon RF: hepatitis C, PBC, female
31
What are the variations of lichen sclerosis?
``` Hypertrophic Atrophic Erosive/ulcerative Follicular Vesicular/bullous ```
32
What is seen on skin biopsy and histology in lichen planus?
Saw tooth pattern of epidermal hyperplasia and vacuolar alteration of the epidermis T lymphohistioctic infiltration Reduced melanocytes - Wickham's striae Globular deposits of IgM
33
What is the treatment of lichen planus?
Symptomatic itch treatment - potent corticosteroids and topical antifungals Psoralen and PUVA radiation treatment Systemic steroids
34
What is lichen simplex chronicus?
Localized area of skin becomes thickened and leathery due to chronic rubbing
35
What is the treatment of lichen simplex chronicus?
Superpotent corticosteroid ointment | Less potent if genital skin
36
50% of melanomas result following which mutation?
BRAF V600 on C7q34
37
What are five risk factors for malignant melanoma?
``` Previous history of melanoma More than 100 naevi Sun exposure Skin type 1 or 2 Solar keratoses ```
38
Name three subtypes of malignant melanoma.
Lentigo maligna melanoma Superficial melanoma Nodular melanoma
39
What is the weighed 7 point checklist for suspicious moles?
Major features (2 pts): - Change in size - Irregular shape - Irregular colour Minor features (1pt): - Largest diameter>7mm - Inflammation - Oozing - Change in sensation
40
What score on the weighted 7 point checklist for moles indicates a 2ww referral?
3 or more
41
How is malignant melanoma diagnosed?
Full thickness excisional biopsy with lateral excision margin of 2mm normal skin Sentinel lymph node biopsy CT and MRI
42
What is the primary treatment of malignant melanoma?
Wide local excision
43
What are some other treatments in malignant melanoma?
Vitamin D supplementation Topical imiquimod Lymhadenectomy Adjuvant radiotherapy
44
What biologic therapies can be used to treat BRAF V600 positive malignant melanoma?
Dabrafenib and vemurafenib
45
What is the Breslow thickness?
Depth of invasion of melanoma at diagnosis | Strongly correlates with survival
46
Where do squamous cell carcinomas arise from?
Keratinizing cells of the epidermis
47
What are the risk factors for SCC and BCC of the skin?
Chronic UVR exposure, skin types 1 and 2, previous history. immune deficiency
48
Name two pre-malignant conditions which may lead to SCCs.
Bowen's disease | Solar keratoses
49
How do squamous cell carcinomas present?
Indurated nodular keratinizing or crusted tumour that may ulcerate Mostly head and neck Tumour may bleed
50
How is squamous cell carcinoma diagnosed?
Excisional biopsy with wide margins | If in a cosmetically sensitive area, can be incisional/punch biopsy
51
How are SCCs managed?
Curettage and cautery Cryotherapy Electrochemotherapy
52
What are the topical treatments of superficial SCC or pre cancerous lesions?
Imiquimod 5% cream Fluorouracil (Efudix 5%) cream Diclofenac gel
53
What is the name of the technique where excision of the skin lesion is carried out in stages and each stage checked histologically?
Moh's micrography
54
Which cancer is Mohs' micrography used more often for?
Basal cell carcinomas
55
What are basal cell carcinomas?
Slow growing locally invasive malignant epidermal skin tumours that are thought to arise from hair follicles
56
What are the features of Gorlin's syndrome?
``` Basal cell naevus and multiple BCCS Cataracts Jaw cysts Pitting of the hands and soles Calcification of the falx cerebri ```
57
What do early lesions of BCCs look for?
Small Translucent or pearly May have a raised area with telangiectasia
58
What is a rodent ulcer?
A large nodular BCC with a necrotic centre
59
What are the 5 subtypes of BCCs?
``` Nodular Superficial Morphoeic/sclerosing Pigmented Basosquamous ```
60
What is the cause of psoriasis?
Skin is inflamed and proliferates at 10x the normal rate | T-lymphocyte driven disorder
61
What are the genetic components of psoriasis?
PSORS1-9 genetic loci
62
What are the trigger factors of psoriasis?
``` They activate the APC-dendritic or Langerhans cell. Trauma UV light Beta blockers Infection Smoking/alcohol ```
63
What is the most common type of psoriasis?
Chronic plaque
64
How does Kobner Phenomenon feature in psoriasis?
New plaques at the site of trauma
65
When does flexural psoriasis present?
In later life
66
What are the features of guttate psoriasis?
Raindrop like plaques on trunk Children 2 weeks post strep throat
67
What is the name of the most severe form of psoriasis?
Erythrodermic and pustular
68
What are the systemic features of erythrodermic/pustular psoriasis?
Malaise Pyrexia Circulatory disturbance
69
What are the associated nail features of erythrodermic/pustular psoriasis?
Nail pitting Onycholysis Subungal hyperkeratosis
70
7% of psoriasis patients develop a seronegative arthropathy. What are the different forms?
``` Mono/oligoarthritis Psoriatic spondylitis Asymmetrical polyarthritis Rheumatoid like polyarthritis Arthritis mutilans ```
71
What is the first line treatment of psoriasis?
Potent corticosteroid OF and Vit D analogue OD e.g. betamethasone and calcitrol Applied separately - one in the morning and one in evening
72
What is the second line treatment of psoriasis?
As above but Vit D analogue BD
73
What is the third line treatment of psoriasis?
Potent corticosteroid BD and vit D analogue BD | OR add coal tar to the above
74
What are the indications for referral in psoriasis?
Child or young person Psoriasis is severe or covers 10% of body Uncontrolled Acute guttate psoriasis - requires phototherapy
75
What are some other treatments of psoriasis that can be initiated in secondary care?
Phototherapy (narrow band ultraviolent B (UVB) therapy) Methotrexate Infliximab/adalimumab/Certolizumab pegol
76
Name five conditions which can cause alopecia.
``` Seborrheic dermatitis Lichen planus Discoid SLE Iron deficiency Thyroid disease ```
77
What are some possible over the counter or private treatments for androgenetic alopecia in males?
Minoxidil topical | Finasteride PO
78
What is alopecia areata?
A chronic inflammatory disease which affects hair follicles and sometimes nails
79
What is pathognomic of alopecia areata?
Exclamation mark hairs
80
How is alopecia areata managed?
Spontaneous self resolution in 80% Topical potent/very potent steroid Some dermatologists may consider topical immunotherapy or minoxidil, or PUVA therapy
81
What is telogen effluvium?
Hair loss caused by physiological or hormonal stress | Hair is triggered to move into the telogen (dormant) phase
82
Give three causes of telogen effluvium.
Childbirth Crash dieting/anorexia Severe infection
83
What is the treatment of telogen effluvium?
Treat the cause and hair will return in a matter of months
84
What is the name of the condition where hair production is arrested in the anagen phase, caused by chemotherapy or radiotherapy?
Anagen effluvium
85
What is the management of burns?
IV fluid if burns>15% body surface area (10% if child) Analgesia and urinary catheter Escharotomy if circumferential burns Excision and skin grafting
86
What are some complications of burns?
``` Curling's stress ulcer Rhabdomyolysis Compartment syndrome DIC Respiratory failure ```
87
What does dermatitis herpetiformis look like?
Itchy, vesicular lesions on the extensor surfaces e.g. elbows, knees, buttocks
88
How is dermatitis herpetiformis diagnosed?
Skin biopsy: DIF showed deposition of IgA in the upper dermis
89
How is dermatitis herpetiformis managed?
Dapsone | Gluten free diet (Coeliac's)
90
What is acne rosacea?
Chronic skin disease of erythema, papules, and pustules, on the nose, cheeks, and forehead Rhinophyma
91
What is the treatment of acne rosacea?
Topical metronidazole | Severe: oral tetracycline
92
What is the treatment of actinic keratoses?
Fluorouracil cream Topical diclofenac Topical imiquimod
93
What are the causes of erythema nodosum?
Sarcoidosis Pregnancy Drugs IBD
94
What are the symptoms of hereditary haemorrhagic telangiectasia?
Pulmonary, hepatic, cerebral, and spinal AVMs Nosebleeds, haemoptysis and dyspnoea, anaemia

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