Eyes and Derm Flashcards
(168 cards)
1
Q
How does retinal detachment usually present?
A
Usually painless
Can present with flashes of light, floaters and a feeling of dots, cobwebs or a curtain passing over the eye
Visual loss can be sudden or gradual
2
Q
How should suspected retinal detachement be managed?
A
Urgent ophthalmology review (can lead to blindness)
3
Q
How does retinal artery occlusion present? (1 symptom, 1 examination, 1 fundoscopy finding)
A
Sudden painless loss of vision
Pupil poor response to direct light stimulus but normal consensual response
(Cherry red spot on fundoscopy)
4
Q
How does macular degeneration usually present?
A
Often age related, is a painless condition affecting the eyes that usually results in a gradual loss of central vision over time.
5
Q
What is a mucocele and how does it usually present?
A
A mucocoele is a cystic, translucent papulonodule, most often found on the inner surface of the lower lip, and often associated with minor trauma.
6
Q
What is leukoplakia?
A
Oral leukoplakia is the most common premalignant or potentially malignant disorder of the oral mucosa.
- White patch or plaque
- Strongly linked with smoking and alcohol
- Often buccal mucosa
(treat with excision, laser excision etc)
7
Q
What is tinea capitis and how is it treated?
A
Fungal scalp infection, more common in children, causes some hair loss
- Treat oral antifungal (terbinafine)
Can form a kerion if makes an abscess
8
Q
What online resource can be offered to patients regarding eczema care?
A
Eczema care online
(Very good resource, shown to improve eczema control)
9
Q
When prescribing steroids in eczema, when should steroid cream be stopped?
A
Continue until 2 days after flare up resolved
10
Q
What quantity of mositurisor should an average child use per month?
A
500mls tubs
2-4 per month gives good amount
11
Q
What is the role of antihistamines in eczema?
A
Can be used to treat itch in more severe flares
12
Q
How should herpes simplex (cold sore) be managed in patients with atopic ecxema?
A
Oral aciclovir
(Due to risk of eczema herpeticum)
13
Q
Following a diagnosis of scabies and correct first line permethrin 5% treatment inclusing treatment of household contacts a patient is still itchy - how do you manage?
A
Crotamiton cream +/- sedating antihistamine to manage itch
14
Q
A baby comes in with nappy rash - what 3 things could you advise?
A
Barrier cream (Sudocrem, metanium etc)
Keep skin clean and dry
Leave nappies off where possible, make sure fit well
Clean with water, bath daily, use alcohol free wipes but nothing with perfume, soaps or talcum powder as can irritate skin
15
Q
How can you distinguish between scleritis and episcleritis?
A
Scleritis = Red, painful, pain worse on eye movement
Episcleritis = Painless (still red)
16
Q
Name 3 possible symptoms of dry eye disease?
A
Irritation/ itchying discomfort
Eye dryness
Transient blurring vision
Eye watering
17
Q
A patient is found to have a decrease in colour vision when tested with ischiara plates - name 3 opthalmological differentials?
A
Diabetic eye disease
Cateracts
Glaucoma
Age related macular degeneration
18
Q
Differentials for peripheral visual field loss? (4)
A
Glaucoma
Retinal detachement
Retinitis pigmentosa
Branch retinal artery occlusion (usually whole artery would be complete loss)
Stroke
19
Q
What is the most common cause of congenital cateracts?
A
Infection
Rubella (the most common), measles, chickenpox, herpes etc
20
Q
How does Holmes-Adie pupil present and what does it indicate?
A
Mydraiasis (abnormally dilated pupil), slow to react to light
Linked to loss of deep tendon reflexes
- Linked to damage/ infection in cillary region of brain
21
Q
What is hypermetropia and myopia?
A
hypermetropia - Long sighted (Can’t see close up)
Myopia - Near sighted (Can’t see far)
22
Q
What is astigmatism? How might it present?
A
Eye more rugby shaped so light focused in wrong place
- Blurred vision, eye strain, headaches
23
Q
How may thyroid eye disease commonly present? What thyroid condition is it usually associated with?
A
Graves disease (90% of TED)
- Proptosis
- Compressive optic neuropathy (CON)
- Compromised extraocular muscle motility.
24
Q
Name three possible management steps in thyroid eye disease?
A
Stop smoking
Maintain euthyroid
Ocular lubricants
Sleeping propped up
(may use botox, oral steroids or immune suppression in secondary care)
25
How might optic neuritis present? (Hx 2 + Ex 2)
Pain on eye movement
Blurred vision
Impaired colour vision
Exam: Decreased pupil reactions, pale oedematous optic disc, altitudinal visual defect (horizontal half)
26
How might episcleritis present and how should it be managed?
Red eye, gritty sensation
- No pain
Episcleritis is usually self-limiting 7-10days, and is not harmful.
Oral NSAIDS and artificial tears
27
How may anterior uveitis present? (aka iritis)
What's the management?
Red painful eye
- Blurred vision
- Photophobia
- Watering
- Flashes/ floaters
- Unreactive pupil
Same day ophthalmology assessment
28
What is keratitis and what are the categories of problems that can cause it?
Keratitis is inflammation of the cornea
- Can be bacterial, fungal, herpetic (herpes simplex or varicella) or from trauma/ foreign body
Often rapid repair leads to corneal ulcer
29
How may corneal inflammation (keratitis) present? (4)
Pain
Redness
Blurring/ decrease VA
Photophobia
30
Name 5 classical presenting features of acute angle closure glaucoma
Pain
Redness
Blurred vision
Halo's around lights
Headaches
Semi- dilated and fixed pupil
31
Name 1 key feature of chronic glaucoma and an examination finding?
Visual field defect/ loss of peripheries
(progressive, usually asymmetrical)
O/E- cupped optic disc
(usually found from screening with raised IOP, rarely symptomatic)
32
Name three classical symptoms of age related macular degeneration?
Straight lines appear wavy
Loss of central vision
Black/ grey patch in center of vision (Scotoma)
Difficulty adjusting bright to dim lighting
33
Name three classical features of cateracts?
Blurred vision/ reduced VA
Difficulty seeing at night
Sensitivity to light and glare
Halo's around lights
34
Name two conditions that can cause halo's around lights and how you would distinguish between them?
Cataracts - Slowly onset, difficulty seeing at night/ sensitive to light and glare
Acute glaucoma - Acute onset, red, painful eye
35
What are the key presenting features of:
a) Posterior vitreous detachment
b) Retinal detachment
a) PVD - Flashes and floats (no pain or sight loss)
b) RD - Flashes and floaters + blurred vision/ dark shadow or curtain in visual field
36
How may a CRVO present? How does it differ to CRAO?
Loss of vision or blurred vision - often on waking
- Painless
CRAO - More instantaneous, often more complete loss (also painless)
37
What is amaurosis fugax - how may it present and what does it indicate?
Transient loss or vision, usually resolves in seconds - curtain across vision
Suspicious for stroke/ TIA (retinal ischemia)
38
What are the snellen criteria to be diagnosed with severe sight impairment (blind)?
Visual acuity
- < 3/60 with normal visual fields
< 6/60 if very reduced field of vision
(whilst wearing glasses or contacts)
39
What are the snellen criteria to be diagnosed as partially sighted (sight impaired)?
Visual acuity
- Between 3/60 and 6/60 with normal visual field
VA between 6/60 and 6/24 with moderate reduction of field
(whilst wearing glasses or contacts)
40
What is the difference in presentation between a meiboam cyst (Chalazion) and a stye (Hordeolum)?
Stye = Painful (usually last and then break in 3/4 days)
Chalazion = Painless
41
At what age should a child with nasolacrimal duct obstruction be referred?
Ongoing obstruction at 12 months
42
What factor is important when doing lubricant eye drops prescriptions for contact lens wearers?
Preservative free
(Preservatives can cause irritation)
43
A patient on who start amiodarone several months ago has noticed glares around lights - MLD?
Corneal microdeposits
(Caused by amiodarone)
44
How do you distinguish between allergic and irritant contact dermatitis?
Patch testing
45
How is tinea capitis treated?
Oral terbinafine
46
A nine-year-old boy has developed widespread infected atopic eczema over the past three days. He has asthma and is taking salbutamol and beclometasone inhalers, but has no known drug allergies.
Which is the SINGLE MOST appropriate antibiotic treatment?
Flucloxacillin 1-2 weeks
(Erythromycin if pen allergic)
If widespread infection use systemic treatment
47
In infected eczema how do you decide between topical and systemic antibiotic treatment?
Localised area - topical
Widespread = systemic
48
How does intertrigo present? Name 3 RF's
Area of skin folds
Skin on skin friction
RF: Obesity, diabetes, poor hygeine, hyperhydrosis
49
How is intertrigo treated? What if initial management is unsuccesful?
Topical antifungal and steroid
Further management guided by skin swabs if no response
50
What is Bowen's disease?
Very early squamous cell carinoma
Also called SCC in situ
51
What is Dermatitis herpetiformis? How may it present? (3 features)
Cutaneous manifestation of coeliac disease
Looks like eczema herpeticum (but isn't viral infection)
Very itchy
Usually presents 40's to 50's in patient with gluten enteropathy symptoms
52
NICE recommends the use of the weighted seven-point checklist when assessing skin lesions. Name the major criteria?
Major features (two points each):
Change in size
Irregular shape
Irregular colour
53
NICE recommends the use of the weighted seven-point checklist when assessing skin lesions. Name the minor criteria?
Minor features (one point each):
Inflammation
Altered sensation
Largest diameter 7 mm or more
Oozing of lesion
54
NICE recommends the use of the weighted seven-point checklist when assessing skin lesions. What score indicates referral to dermatology is required?
A score of 3 or more needs 2ww dermatology referral
Major x3 - 2 points each
Minor x4 - 1 point each
(so out of 10)
Can also refer on 2ww if any of major criteria
55
What features in the nail would make you consider a 2ww melenoma diagnosis?
Nail changes, such as:
- A new pigmented line in the nail
- Especially if there is associated damage to the nail
- A lesion growing under the nail.
56
What forms of psoriasis warrant an urgent same day assessment? How may they present?
Pustular psoriasis - Rapidly developing erythema, pustules and 'lakes of pus', systemically unwell
Erythrodermic psoriasis - Diffuse, severe, affects >90% body surface - can be precipitated by infection
57
When considering psoriasis, name 4 criteria that would warrant routine dermatology referral?
Patients presenting under 18
Severe or extensive (>10% body surface area)
Acute guttate psoriasis requiring treatment (>10% BSA)
Nail disease having functional/ cosmetic impact
Disease with major physical, social or pyschological impact
Unclear diagnosis
58
How does guttate psoriasis classcially present? (Skin features + hx)
Small, scattered, round or oval (2 mm to 1 cm in diameter - water drop appearance) scaly papules, which may be pink or red.
Classically after strep infection
59
What are the management options for guttate psoriais?
If >10% body area refer to derm for phototherapy
Otherwise reassure self limiting - 3,/4 months, not infectious
Can use topical emollient +/- potent steroid/ vitamin D combination
60
Name the most common topical vitamin D medication?
Calcipotriol (Dovonex)
Calcipotriol (Non branded)
61
What is first line treatment for erysipelas of the face?
Co-amoxiclav (if near the eyes or nose)
Fluclox for other erysipelas or cellulitis
(Clarithro + metronidazole if pen allergic)
62
What is erysipelas?
Superficial form of cellulitis (only affsects dermis and upper subcut tissues) - cellulitis affects deeper
63
How does erythema toxicum neonatorum (ETN) present?
Day 2-14 life
Well child
Affects 50% term babies
Erythematous macular areas with some pustules and papules
64
How should erythema toxicum neonatorum (ETN) be managed?
Nil
Self limiting 2-3 weeks
Advise on signs unwell child
Alternative name is baby acne - explain to parents very common
65
How might pityriasis rosea classically present?
Classically single patch followed by several scaling patches/ plauques
Often following viral URTI
66
How should pityriasis rosea be managed?
Often self-limiting in 6-12 weeks
Can have phototherapy if extensive or persistent
67
What are the classic risk factors for actinic keratosis?
Over 50
Fiar skin
Blue eyes/ blond hair
Lots of sun exposure/ tanning beds
Working outdoors (construction, farmers)
68
What is the chance of actinic keratosis becoming SCC?
If 7-8 actinic keratosis about a 10% chance one will become SCC over 10 year period
69
What is Actinic cheilitis and how should it be managed?
Actinic keratosis on the lip
Urgent dermatology referral as risk of SCC on lip much greater
70
You have decided to watch and wait to see what happens with a lesion you suspect to be an actinic keratosis, what should the patient be advised?
Medical advice should be sought again if there are any changes to the appearance or if it becomes tender. A moisturising (emollient) cream might be advised to help soften the skin around the actinic keratosis.
71
What are the treatment options in actinic keratosis? (name 5)
Refer (excision, curettage)
Topical diclofenac 3% (Solaraze)
Efudix cream (5-fluorouracil)
Imiquod cream (Aldara)
CruotherpayW
72
What is Morphoea? Who does it affect and where?
Localised scleroderma
Thicken areas of skin
Usually affects middle aged women in skin folds (groin, armpit, breast)
- Can follow tick bites, pregnancy, autoimmune diseases
73
Among the immunocompetent, who should receive aciclovir for chicken pox?
Immunocompetent who present over age 14 within 24 hours of rash
74
What is the adult dose of aciclovir for chicken pox?
Aciclovir 800 mg orally five times a day
(IV if systemically unwell)
75
What should patients be advised regarding the infectious period of a chicken pox rash?
Advise that the most infectious period is from 24 hours before the rash appears, but infectivity continues until all the lesions have crusted over (commonly about 5 days after the onset of the rash):
76
How do you manage exposure to chicken pox in:
a) Pregnant women
b) Neonates
c) The immunocompromised
(Assuming no confirmed hx of chickenpox or varicella vaccine)
a) Test for VZIG - if not immune contact specialist to consider prophylaxis
b) Urgent advice needed
c) Seek same day testing and advice
(But likely all will get oral aciclovir)
77
A lady who is 20weeks pregnant attends as her older child (4) has chicken pox. She checked with her mum and she definitely had chicken pox when she was a child, what should you advise regarding her risk of chicken pox?
If the woman has a definite history of chickenpox or shingles or two doses of a varicella containing vaccine, and is not immunocompromised, reassure her that she is not at risk of chickenpox because immunity can be assumed.
78
What is vitiligo, how does it present and what are the risk factors (2)?
Loss of skin pigmentation
- Skin patches gradually turn completely white
RF: Fhx of vitiligo or PHx/ FHx of other autoimmune disorders
79
What is Wallace rule of 9's?
% Body surface area in adults:
- Head/ R arm/ L arm = 9% each
- R leg/ L leg = 18% each
- Anterior trunk/ posterior trunk = 18% each
80
What are some of the classical features of hereditary haemorrhagic telangiectasia? (3)
Spontaneous recurrent nosebleeds (90%)
Multiple telangiectasia on skin/ mucus membranes
Involvement of internal organs - may show as IDA
Affected parent child or sibling
(Need specialist referral)
81
What is Pityriasis alba and how does it present? How is it managed?
White patch on skin - usually most noticed in summer
Can be post inflammatory/ infectious
No treatment needed, patches fade and disappear over months but can take years
82
What is a spitz naevus and how does it present? What is the management?
Type of neavi
Common in children, rarely in 30
Rapid growth for several months
Maximum at 6 months
Can be pigmented
Note although benign can mimic melanoma so all need 2ww referral to exclude melanoma
83
How should a spider naevus be managed?
Check spider naevus (blanches with pressure, refils from centre)
If just a one or a few - no action needed
If associated with pregnancy - dissapear within 6-7 months
If worried about other conditions, consider LFT's but rarely needed
84
What conditions are spider naevi associated with?
Pregnancy
Alcoholic cirrhosis
Hepatitic cirrhosis
Hepato-pulmonary syndrome
(Anything that increases oestrogen levels)
85
How should pityriasis versicolor be managed?
Ketoconazole shampoo
Clotrimazole cream if localized, fluconazole oral if widespread
Note not contagious
86
Which investigations should be performed before starting isotretinoin? When should the be repeated?
LFT's
Lipid levels
Before treatment, at 1 month and 3 months
87
Name 3 common side effects of isotretinoin? (3)
Severe dry skin/ mucinous membranes
Nosebleeds
Joint pains
Raised lipids
88
What is first line management for chronic urticaria?
Non sedating antihistamines
89
You are investigating a patient for hirsutism and the testerone level comes back as 6.5. How should you manage?
Refer urgently (2ww) to endocrine
- If testerone above 6 risk of underlying adrenal or ovarian neoplasm
Also need to consider if very rapid hair growth, or signs such as voice deepening, increased muscle bulk etc
90
What are the management options for hirsutism in pre-menopausal women where referral is not required? (4)
Weight loss
Methods of hair reduction/ removal
Topical eflornithine (takes 4-8 weeks to work)
COCP (Dianette) is the only one licensed for mod/ severe hirsutism
91
Name three other conditions that have a greater incidence in those who have psoriasis? (3)
Depression
Cardiovascular disease
Venous thromboembolism
Lymphoma
Non melanoma skin cancer
92
How may a pyogenic granuloma be managed?
In GP:
Imiquimod cream 5%, timolol gel 0.5%
If needing to escalate:
Cryotherapy or steroid injection
93
You are asked to prescribe a leave-on emollient as a regular moisturiser for a four-year-old girl with widespread eczema of her arms and legs.
Which SINGLE ONE of the following is the LEAST suitable?
Aqueous cream, doublebase gel, E45 cream, epaderm ointment, hydrous ointment
Aqueous cream is unsuitable as a leave-on emollient because it is associated with an increased risk of skin reactions. It is used as a soap substitute.
94
Which eye condition is linked with sarcoidosis?
Anterior uveitis
95
What is hutchinson's sign?
Rash on tip of nose - increased likelihood occular involvement in herpes zoster opthalmicus (4x increased risk)
NOTE all opthalmic herpes - all should be referred same day
96
What are the classic features of central rentinal vein occlusion?
Visual reduction (not always complete loss)
Flame haemorrhages on fundoscopy
CV risk factors (HTN)
97
How long after starting new psoriasis treatment should you arrange to see a patient?
4 weeks
(And then thereafter judged on need)
98
What factors may affect your decision between prescribing cream/ ointment/ lotion or gel?
Red and inflammed = cream (water evaporation cools)
Dry and not inflammed = ointment works better
Lotions, solutions, gels are best for hair bearing areas
99
According to NICE guidance what is the first line psoriasis treatment?
Topical emoillient
+
Topical potent steroid AND topical Vit D (both once daily but applied at different times)
100
How long should you treat an area of Psoriasis for at intital treatment step?
Initial 4 weeks topical steroid + vit D
- Can continue to 8 weeks if no response
After 8 weeks if no response go to step 2 (top vitD alone BD for 8 weeks)
101
A patient has had poor response to 8 weeks of OD steroid + vitD for psoriasis. Next step?
Do 8 weeks of topical vitD alone twice daily
102
A patient has had poor response to 8 weeks of OD steroid + vitD for psoriasis. They then tried a further 8 weeks of only vitD but BD. Next step?
Potent steroid BD for further up to 4 weeks
OR
coal tar applied OD/BD
103
Steroid should be used topically in one area up to a maximum of 8 weeks. How long break should you have in that area before another course?
4 weeks before any more steroid in that area
104
How should nail psoriasis be managed in primary care?
Usually refractory to topical treatment
- If mild no action
- If mod/ severe then refer to derm
Advise to keep nails short, avoid manicures
105
How is management of flexural or genital psoriasis different to chronic plaque psoriasis?
No role for vitamin D
Go straight to moderate (not potent) steroid OD or BD for up to 2 weeks initially
106
To whom/ what body locations should potent or very potent steroids not be prescribed?
Face, flexures, genital areas
Do not prescribe potent to children under 12months
Do not prescribe very potent to any age child without specialist advice
107
Give an example of 2 moderate, a potent and a very potent topical steroid?
Moderate:
- Betamethasone 0.25% (betnovate RD)
- Clobetasone 0.05% (Eumovate)
Potent:
- Betamethasone 0.1% (Betnovate)
Very potent:
- Clobestasol 0.05% (Dermovate)
108
How should you advise a patient to manage a blister or blood blister?
Resolves itself within a week
Don't pop, peck at skin
Cover with a dressing, once popped allow to drain before covering with a plaster
109
How do you assess the severity of hyperhidrosis?
validated hyperhidrosis disease severity scale (HDSS):
1-2 = Mild
3-4 = Moderate/ severe
110
What is the diagnostic criteria for primary focal hyperhidrosis?
Has lasted at last 6 months
No other cause
At least two of:
- Started under 25
- Postive fhx
- Bilateral/ symetrical
- Interfers activities
- At least once a week
- Stops during sleep
111
A patient presents with excessive sweating. You suspect primary hyperhidrosis, what ix do you do to rule out other causes? (5)
FBC/ CRP/ U+E/ LFT's
HbA1c/ TFT's
HIV
24 hour urine for catecholamines
CXR
112
What is first line management for primary hyperhidrosis?
1) Lifestyle measures (antipersprant, clothing choices)
2) Aluminium salts in antiperspirants
- Apply just before sleep
- wash off in the morning
Access for treatment beound this may need individual funding request
113
What is the natural history of a haemangioma (strawberry naevi)
Appear shortly after birth (1/3 by birth), most 4-6 weeks after
Grow for first 6-12 months
Usually gone by age 7 but can be up to 12
114
What is the natual history of blue/ grey (mongolian blue) spots?
Present from birth
Usually go away by age 4
Do not need treatment, no association with other conditions
115
What is the natural history of a port-wine stain in a newborn?
Present from birth
Darkens through life
Will be present for life
Needs early derm referral, can be associated with other health conditions
116
When and how would you treat an infantile haemangioma?
If head and neck
If concerning to parents
Treat with topical timolol (beta blocker)
117
What should you advise patients to care for wounds to reduce scaring?
Keep dry
Can use moisturisor like vasline
Keep clean
118
How long would you expect it to take for a c-section scar to heal?
6 weeks
Redness then fades with time
119
What is seborrhoeic dermatitis and how does it present?
A type of eczema
- Areas of high sebaceous activity (Beard, ears, eyebrows, scalp)
120
You have treated psoriasis with good response to a moderate steroid - how should you stop the steroid (It was previously OD?)
Never suddenly in psoriasis
- Reduce to every other day
- Then twice weekly
- Then stop
121
What criteria would warrant a referral for eczema?
- Management not working (one-two flares per month)
- Severe or infected eczema which hasn't responded to topical treatment within 1 week (urgent - see in 2 weeks)
- Contact allergic dermatitis is suspected
- Recurrent secondary infection
122
Name the 4 brand names of steroid creams in the steroid ladder?
Mild: Hydrocortisone
Mod: Eumovate
Potent: Betnovate
V. Potent: Dermovate
123
A patient with eczema is struggling with severe itch and urticaria - what are your prescribing options?
If struggling with sleep - Sedating antihistamine (chlorphenamine)
If no sleep issue - Cetirizine, loratidine or fexofenadine
124
How should infected eczema be managed?
If systemically well do not routinely give topical or PO ABx. If they are needed:
Topical: Fucidic acid 2% (5-7 days) (localised)
PO: Fluclox (widespread), clarithromycin if pen allergic
125
How might eczema herpeticum present?
Grouped vesicles, may bleed, may also have some bacterial looking areas
Fever, lymphadenopathy and malaise are common
Urgent same day admission needed
126
What topical steroid prescriptions are available OTC?
Hydrocortisone 1% is available over-the-counter for the treatment of mild-to-moderate eczema not involving the face or genitals.
127
How should seborrhoeic dermatitis be managed in infants? When does it resolve?
Topical emoillients + topical antifungal (clotrimazole 1% 2-3x daily for up to 4 weeks)
Consider adding short course mild steroid for up to 2 weeks if no response
Usually resolves spontaneously in a few months
128
How should seborrhoeic dermatitis be managed in adults within the scalp or face/ beard area? When does it resolve?
Chronic condition, often long term maintainance needed
1) Ketoconazole 2% shampoo (twice weekly for up to 4 weeks then once a week for maintainance)
2) If severe inflammation consider topical steroid (potent if scalp, mild if beard)- for up to two weeks)
129
Which antifungal creams can be used in children, what is the usual dose?
Clotrimazole 1% (2-3x daily for 2-4 weeks)
OR
Miconazole (2x daily) for 2-4 weeks
Ketoconazole is not licenced for us in children
130
What are the key features of acne rosacea (major and minor)?
Maj: Flushing and transient erythema, papules and pustles, telangiectasia, eye symptoms (ocular rosacea)
Min: Skin burning/ stinging/ dryness/ oedema
131
How should acne rosacea be managed?
Trigger avoidance (suncream, skincare etc)
Redness: Topical brimonidine 0.5%
Palpule/ pustules: Topical ivermectin OD 8-12wks
Severe papules/ pustules: Oral doxycycline 40mg OD for 8-12wks
132
When should acne rosacea be referred to a dermatologist?
Persistent erythema/ papules/ pustules not responded to primary care management
Severe telangiectasia not responded to management advice
133
What is pemphigoid? How does it present?
Blistering disease of older people, usually starts blistering and urticaria like rash
Later large tense blisters
134
How is bullous pemphygoid managed?
Most need secondary care unless very localised (systemic steroids, immunosuppresion etc)
Localised - dermovate, wound care +/- oral Abx
135
What is pemphigus vulgaris? How does it present?
Autoimmune condition causing blistering of mouth and skin
136
How is pemphigus vulgaris managed?
Blistering of mouth and skin
Mx: Oral steroids, immunosuppresion (aziothioprine, methotrexate etc)
137
What is stephen johnson syndrome and how does it present?
SJS and toxic epidermal necrolysis (TEN) are characterised by detachment of the epidermis and mucus membranes
Starts URTI develops to severe ulcers and lesions
Usually (but not always) caused by drugs
138
Name 3 common drugs that can cause stephen johnson syndrome?
Carbamazepine
Sulfonamides (trimethoprim)
Alloupurinol
Anticonvulsants (Sodium valproate/ lamotrigine)
Sertraline
Aspirin
139
What scoring system is used to assess severity of stephen johnson syndrome?
SCORTEN
(Score for toxic epidermal necorylisis system)
140
What is hidradenitis suppurativa and how does it present?
Reccurent disease of apocrine follicles (usually axilla or groin)
Nodules which become pustules, painful and itchy
(eventually get chronic sinus formation etc)
141
How is hidradenitis supportiva managed?
Mild - Clindamycin 2% topical BD for 3 months
Moderate - Systemic (lymecycline 408mg OD) for 3 months
Secondary care: Adalimbumab or surgery
142
What is acanthosis nigricans and how does it present?
Dry, dark patches of skin (hyperpigmentation) that can appear in the armpits, neck or groin
143
What are the main causes of acanthosis nigricans? How do you distinguish between them?
Obesity (most common)
Hereditary
Drugs (steroids)
Malignancy (normally gastric adenocarinoma)
Usually asymptomatic other than in malignancy when abrupt presentation and itch/ irritation
144
What is lichen simplex, how does it present and how is it managed?
Eczematous problem characterised by small number (or single) very itchy lichenified (thickened) plaques
Treatment with potent/ v.potent steroid (or refer for intralesional steroid)
145
What is lichen planus? How does it present?
Common, itchy, non infecious bumpy (lichen) flat (planus) topped lumps
Management with potent/ v.potent topical steroid
146
What is lichen sclerosus and how does it present? How should it be managed?
Uncommon, white sclerotic macules/ patches which mainly affect genitals and perianal skin.
- Very itch and sore
Commonly associated with SCC so look for this
If no SCC features
- Topical very potent steroid
147
How might erythema nodosum present? How is it managed?
Ages 20-40 most common
Fever, aching and arthralgia
Followed by painful rash - red, tender nodules
Most self limiting - just need analgesia
148
What conditions is erythema nodusum commonly associated with? (Name 3)
70% no cause found
Common: Strep infection, TB, drug reactions, sarcoidosis, IBD
149
What is erythema multiforme and how does it usually present?
How would you manage?
Hypersensitivity reaction, usually to infection (herpes most common)
Presents with classic target lesions
Supportive management, usually self resolves
150
Name 3 classic dermatological manifestations of lupus?
Photosensativity rash
Butterfly/ malar rash
Discoid lupus erythematosus
151
What is a seborrheic kertatosis and what are the clinical features?
"Stuck on wart" appearance
Largely asymptomatic
Usually come with age
Benign - no management needed, no malignant potential (although if uncertainty in diagnosis needs 2ww)
152
What are the 3 most common types of melanoma?
Superficial spreading melanoma (70%) - increases age, peak in 70's
Nodular melanoma (20%) - Presents atypically, often ulcer/ bleed, rapid depth - peak 40/50's
Lentigo maligna melanoma (10%) - Especiallly on sun damaged skin, grows from brown plaque (slow)
153
How should suspected SCC or suspected BCC be referred?
SCC - Two week wait
BCC- Routine referral
154
What are the typical features of a basal cell carcinoma?
Ulcer with a raised rolled edge; prominent fine blood vessels around a lesion;
or a nodule on the skin (particularly pearly or waxy nodules).
155
What is a keratocanthoma and how would it typically present/ how are they managed?
Rapidly growing (weeks to months) squamous proliferative lesions which then spontaneously resolve after around 6 months
(Usually over 60's in sun exposed areas)
They are benign lesions - however because intially they appear so similar to SCC will need 2ww
156
What are the classical clinical features of an SCC? (3)
Non healing ulcer or growth in high risk sun exposed areas, mostly head and neck
Usually small nodule > enlarges > centre sloughy with hard raised edges
Any suspicious for this need 2ww
157
How should a cutaneous horn be managed?
Can come from warts, seborrhoeic keratosis or actinic keratosis
- But 15% from SCC - therefore need 2ww
158
What are the typical features of a venous ulcer?
Venous (70%) - Gaiter area (medial ankle to mid-calf) + signs venous disease (varicose veins, varicose eczema)
Slow onset, pain in legs, worse in morning, throbbing, aching - improves with elevation and rest
Large, shallow and irregular in shape with poorly defined edges and slough
159
What are the typical features of an arterial ulcer?
Usually foot or lateral aspect leg
Punched out appearanced with well defined edges
Small, deep and very painful
Arterial compromise (pallor, loss of nail, cold, pulses weak, low cap refil)
160
What are the typical clinical features of a neuropathic ulcer?
Develop over pressure areas (sole of foot, ball of toes)
- Irregular shape and shape of pressure point
Edge often clean and deep - may see tendon/ bone
161
How should a venous ulcer be managed?
Usually by DN/ tissue viability nurse
ABPI in both legs performed first to exlude arterial insufficiency
Offer strongest compression stockings that can be tolderated
Review weekly for 2 weeks, then start to extend this
162
What are the result categories of ABPI?
< 0.5 = Severe arterial disease
0.5-0.8 - Arterial or mixed disease
0.8-13 = No evidence of arterial disease
> 1.3 = Likely arterial calcification
163
What is the definition of a leg ulcer?
Ulcer of skin below knee which takes more than 2 weeks to heal
164
Namme 3 risk factors for venous ulcers?
Varicose veins
Phelbitis
Previous DVT
Previous fravture, or surgery
Symptoms venous insufficiency (leg pain/ heavyness, aching, itching, swelling, pigmentation, eczema)
165
In what circumstances should an ulcer be referred?
Arterial ulcer/ ABPI <0.8/ >1.3- refer to vascular (manage as PAD)
Diabetic - refer to diabetic ulcer clinic
Unclear diagnosis/ possible skin lesion/ rapid changes or worsening - refer derm
166
What is first choice antibiotic in leg ulcers?
Flucloxacillin
(if pen allergic clarithro/ erythro/ doxy)
167
A patient attends with a history consistent with subacute angle closure glaucoma - where should they be referred?
Symptomatic - same day opthalmology assessment
Currently asymptomatic - urgent optician assessment
168
When does NICE advice use of preservative free eye drops?
If any history of allergy or irritation with the preservative
