Final Derm

Question 1

Which diagnostic factors / characterisitic features are associated with acute [3] subacute [1] and chronic [3] flares of eczema?

Answer 1

Acute:
- Scaling
- Vesicles
- Papules

Subacute:
- Represent an intermediate stage where acute lesions begin to resolve; characterized by erythematous scaling plaques with possible crusting.acacu

Chronic:
- Lichenification
- Hyperpigmentation or hypopigmentation
- Fissures

Papular eczema

Question 2

Describe the characteristics needed for a diagnosis of eczema

Answer 2

An itchy skin condition in the last 12 months

Plus three or more of
* Onset below age 2 years’
* History of flexural involvement’’
* History of generally dry skin
* Personal history of other atopic disease’’’
* Visible flexural dermatitis

‘not used in children under 4 years
‘‘or dermatitis on the cheeks and/or extensor areas in children aged 18 months or under
‘'’In children aged under 4 years, history of atopic disease in a first degree relative may be included

Question 3

Describe the treatment regime for an acute flare of atopic dermatitis / eczema [6]

Answer 3

1. Emollients (warn patients about fire hazard risk)
2. Consider topical steroid cream / ointment. Start on low to medium potency and go up
3. Consider topical calcineurin inhibitor; tacrolimus; pimecrolimus. Useful for long term tx of pruritis without giving steroids for long time
4. Consider Phototherapy: Narrow Band UVB (NB-UVB) small part of the UVB light spectrum is used to tx; where UVA radiation is combined with a chemical called psoralen that increases the effect of UVA on the skin). PUVA (UVA + psoralen)
5. Systemic therapies: methotrexate (1x week medication, given with folic acid); ciclosporin (shorter time for treatment to work; can only use for 1 or 2 years before moving to biologics
6. Biologics: JAK inhibitors - Baricitinib, Upadacitinib; IL-13/4 – Dupilumab, Tralokinumab.

Question 4

State an example of low, mid, high and very high potency corticosteroids used in the tx of eczema

Answer 4

Low-potency: hydrocortisone, desonide

Mid-potency: fluticasone, triamcinolone, fluocinolone

High-potency: mometasone, betamethasone, desoximetasone

Very high-potency: clobetasol, ulobetasol, diflorasone.

Question 5

What are the common side effects of topical calcineurin inhibitors? [4]

Answer 5

About 50% of patients develop some local skin irritation or a burning or itching sensation when these treatments are started, particularly with tacrolimus ointment.

Small increased risk of developing cold sores (herpes simplex infection) on the treated skin during the first few weeks of treatment.

Due to suppressesion of the immune system, one possible consequence of immune suppression is an increased risk of non-melanoma skin cancer and lymphoma.

Question 6

What are triggers for psoriasis? [+]

Answer 6

Infections
- Strep; HIV

Alcohol and stress

Drugs:
- Beta blockers, nicotine and antimalarials
- Lithium
- Antihypertensives (ACEin)

Skin injury: Koebner phenomenon

Endocrine changes
- Puberty
- Pregnancy (generally improves)
- Menopause
- Hypocalcaemia

Ethnicity
- 2x more common in white populations

Question 7

Which investigations do you perform to dx psoriasis? [2]

Answer 7

1. Clinical diagnosis (usually no tests are necessary)
2. Consider skin bx: Intra-epidermal spongiform pustules and Munro neutrophilic microabscess within the stratum corneum
   - parakeratosis, acanthosis, and elongation of the rete ridges.
3. Blood tests
4. Rheumatology Screening:
   - Patients with psoriatic arthritis often present with skin symptoms first
   - Therefore, if joint symptoms are present or if there is a high suspicion of psoriatic arthritis based on clinical judgement, rheumatology screening including serum rheumatoid factor (RF) test and anti-cyclic citrullinated peptide (anti-CCP) antibodies should be considered.

Question 8

Describe the tx algorithm for guttate psoriasis [5]

Answer 8

1. Most cases resolve spontaneously within 2-3 months
2. Phototherapy
3. Ciclosporin
4. Methotrexate
5. Acitretin

Question 9

Which CV complications are linked to psoriasis? [5]

Answer 9

There is a high prevalence of metabolic syndrome among individuals with psoriasis due to shared inflammatory pathways
* DM
* Hyperlipidaemia
* HTN
* High BMI
* History of MI

Question 10

Describe the management plan for a patient with psoriasis

Answer 10

Mild to moderate psoriasis:
- Vitamin D analogues (e.g., calcipotriol) and corticosteroids
- Tar preparations and dithranol may be considered for chronic plaque psoriasis.

Moderate to severe disease not responding to topical treatments:
- Narrowband UVB therapy (psoralen plus UVA (PUVA) therapy may be utilised if narrowband UVB is ineffective or contraindicated)
- Methotrexate, ciclosporin or acitretin can be considered in patients with severe disease or when topical treatments and phototherapy have failed

Severe disease who have failed traditional systemic therapies:
- etanercept (TNF-inhibitors)
- ustekinumab (interleukin-12/23 inhibitors)
- secukinumab (interleukin-17 inhibitors)

Question 11

Answer 11

ACE inhibitors

The following factors may exacerbate psoriasis:
* trauma
* alcohol
* drugs: beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab
* withdrawal of systemic steroids

Question 12

Management of psoriatic arthritis should be holistic, addressing symptoms, disease progression and potential complications and disability.

Describe the treatment regime of PsA

Answer 12

NSAIDs - First line symptomatic relief
Intra-articular corticosteroid injections - may be used alone or in combination with oral medication

DMARDs:
- if there is a failure of response to initial medical treatment or if there is severe disease at diagnosis
- 1st line: standard DMARDs (methotrexate, leflunomide or sulfasalazine)
- 2nd line: biological agents (etanercept, infliximab, apremilast)

Question 13

Describe the clinical presentation of PsA [+]

Answer 13

Joint pain
- The most common joints involved are the spine, sacroiliac joints (SIJ) and the small joints of the hands.
- Enthesitis: inflammation at the insertion of tendons and ligaments (most commonly the Achilles tendon)
- Asymmetric oligoarthritis: less than four joints affected in an asymmetrical pattern - common

Dactylitis

Morning stiffness: greater than 30 minutes and improves over the course of the day

Constitutional symptoms: fatigue, malaise and low-grade fevers

TOM TIP: Psoriatic arthritis tends to affect the distal interphalangeal (DIP) joints and axial skeleton, whereas rheumatoid arthritis tends not to affect these joints. This can help you distinguish them.

Question 14

Describe clinical imaging of PsA?

Answer 14

X-ray of affected joints:
- may show erosion of the small joints. Classic findings are erosions of the DIP with periarticular bone formation (osteophytes). In advanced disease, there may be “pencil in cup deformity” at the DIP

X-ray of the sacroiliac joints (SIJ):
- usually normal in the initial stages, but it is important to obtain a baseline radiograph for assessing disease progression
- Periostitis (inflammation of the periosteum, causing a thickened and irregular outline of the bone)

MRI of SIJ:
- looking for joint oedema (not routinely performed due to low specificity)

TOMTIP: The classic x-ray finding in the digits is a “pencil-in-cup” appearance.

Question 15

What is this? [1]

Answer 15

Naevus spillus

Question 16

Describe what is meant by acne fulminans [1]

Answer 16

Acne fulminans
- severe form of acne conglobata with systemic features such a fever, arthralgia and lymphadenopathy.
- Hospital admission is often required and the condition usually responds to oral steroids

Question 17

Alternative to repeated courses of isotretinoin = ? [2]

Answer 17

oral contraceptives e.g. microgynon

antiandrogens e.g. spironolactone, cyproterone acetate

Question 18

Perioral dermatitis presents as small papules and pustules around the mouth area. This condition can be mistaken for acne vulgaris due to similar lesion types; however, it differs which ways?

Answer 18

Limited to the perioral area (around the mouth), periocular area (around the eyes) or nasolabial folds, whereas acne vulgaris commonly affects the face, chest and back.

No comedones

Perioral dermatitis may appear scaly or dry, unlike acne vulgaris.

Question 19

Describe the mangement of mild, moderate and severe acne vulgaris [+]

Answer 19

Mild: 12 week topical combination of any of the following:
* a fixed combination of topical adapalene with topical benzoyl peroxide
* a fixed combination of topical tretinoin with topical clindamycin
* a fixed combination of topical benzoyl peroxide with topical clindamycin

Moderate to severe acne: a 12-week course of one of the following options:
* a fixed combination of topical adapalene with topical benzoyl peroxide
* a fixed combination of topical tretinoin with topical clindamycin
* a fixed combination of topical adapalene with topical benzoyl peroxide + either oral lymecycline or oral doxycycline
* a topical azelaic acid + either oral lymecycline or oral doxycycline

Severe - not responding to treament
- Oral isotretinoin (derived from vitamin A and is a powerful anti-inflammatory agent)

Question 20

NICE guideline 198 (June 2021) advises considering oral isotretinoin use in those over the age of 12 who have failed treatment with topical therapies and systemic antibiotics.

Examples include [4]

Answer 20

Nodulocystic acne
Acne conglobata
Acne fulminans
Acne at risk of permanent scarring

Question 21

What risks occur with isotretinoin prescription? [5]

Answer 21

Teratogenicity
hyperlipidaemia
hepatotoxicity
Sexual side effects: erectile disfunction, loss of libido, vaginal dryness
Photosensitivity
Depression & ? suicide ideation

Question 22

Name this type of melanoma [1]

Characteristics? [+]

Answer 22

Amelanotic Melanoma
- no melanin
- firm
- grow fast
- look harmless

Question 23

What does the Breslow thickness (mm) of a MM mean? [1]

What does the Clark level (I-V) refer to? [1]

What thickness inidcates a thin [1] and thick melanoma [1]

Answer 23

Breslow thickness (BT) is based on the vertical thickness of the tumour in millimetres.

Clark level (I-V) is a histological classification with estimated prognosis based upon the anatomical level of invasion into the skin.

Breslow Thickness and Clark level
Thin melanoma: < 0.8mm
Thick melanoma: >0.8mm

Question 24

Which genetic conditions are a risk factor for BCC? [2]

Answer 24

Genetic disease:
* Gorlin syndrome
* Xeroderma pigmentosum

Question 25

Describe this type of BCC [1]

Answer 25

**Morphoeic BCC** - sclerotic (scarred)

Question 26

Describe the characteristics of SCC [+]

Answer 26

* **Enlarging scaly/crusted lump**s * Grow **rapidly** over weeks * May **ulcerate** * Often **tender**/painful/bleed (except in IC ptx) * Usually arise within **pre-existing actinic keratosis** or intraepidermal carcinoma * Commonly **face, lips, ears, hands and limps** * **Rarely metastasises** * Often have **hyperkerotic horn** / no rolled border

Question 27

Dx? [1] Describe this [1]

Answer 27

**Actinic Keratoses** - **hyperkeratotic papules on a background of sun-damaged skin** - Actinic keratosis involves the formation of **precancerous scaly lesions on the skin** - Actinic keratoses have around a **10% risk of developing into an SCC,** therefore monitoring and treatment are important

Question 28

Name and describe this type of skin condition [3]

Answer 28

**Junctional Naevi** * Mole * Flat * Pigmented * Regular, symmetrical, static appearance | GO over

Question 29

Name and describe this type of skin condition [3]

Answer 29

* **Compound Naevi** Mole **Central raised area** Surrounded by flat pigmentation

Question 30

Name and describe this type of skin condition [1]

Answer 30

**Naevus Spilus** - Nevus spilus, also known as speckled lentiginous nevus, is a light brown or tan birth mark, speckled with small, dark spots or small bumps. - **Malignant change very rare**

Question 31

What are risk factors for malignant melanoma? [5]

Answer 31

**UV Radiation** - UVB causes direct DNA damage **Skin Type** - (Fitzpatrick Skin types I & II) **Melanocytic naevi** - **multiple (>100) or giant (>20 cm) naevi** - **Congenital melanocytic naevi** (moles present from birth, or that develop within the first few months after birth, are called congenital melanocytic nevi) - **Atypical mole syndrome** (AMS): >1 pigmented lesions on the iris; >1 naevi on buttocks or instep naevi on anterior scalp; ≥2 atypical naevi; >100 naevi **Genetics** - CDK4, xeroderma pigmentosum, melanocortin 1 receptor **Previous skin cancer** - Previous melanoma **Immunosuppression** - HIV/AIDS - Organ transplant recipient - Lymphoproliferative disease - Anti-TNF treatment

Question 32

Which is the most common place to get MM in women? Skin of lower limb Skin of trunk Skin of upper limb Head or neck

Answer 32

Which is the most common place to get MM in women? **Skin of lower limb** Skin of trunk Skin of upper limb Head or neck

Question 33

Histologically, melanomas are divided into five major subtypes. What are they? [5]

Answer 33

Superficial spreading (70%) Nodular (15%) Lentigo maligna (10%) Acral lentiginous (< 5%) Desmoplastic melanoma (< 1%)

Question 34

**[]** occurs in the elderly on chronically sun-exposed sites. Superficial spreading Nodular Lentigo maligna Acral lentiginous Desmoplastic melanoma

Answer 34

**[]** occurs in the elderly on chronically sun-exposed sites. Superficial spreading Nodular **Lentigo maligna** Acral lentiginous Desmoplastic melanoma

Question 35

How do you investigate for MM? [1]

Answer 35

All patients require a **careful skin** and **lymph node examination.** - ALWAYS send for histology - Suspicious lesions should be excised with a **narrow (2mm) margin** - **NEVER** shave or curette a suspected melanoma

Question 36

Management is complex and guided by the **Melanoma Multidisciplinary Team (MDT)**. Describe the different treatment options

Answer 36

**Surgical**: - **WLE** represents the standard treatment for primary melanoma. Involves removal of the biopsy scar with a surrounding margin of ‘healthy’ skin, with fat, down to muscular fascia. This margin is determined by the Breslow thickness. - **Sentinel Lymph Node Biopsy (SLNB)** - **Electrochemotherapy** is a relatively new therapy for patients with locally advanced melanoma. **Medical** (typically adjuvant therapy) - Chemotherapy - Radiotherapy - Immunotherapy

Question 37

Which factors determine if a MM prognosis? [5]

Answer 37

**Breslow thickness** **Clark level** **Ulceration** - . It is suggestive of an aggressive tumour phenotype with greater likelihood for invasion and metastasis. **Mitotic index** (an indicator of cell turnover) is also an important histological finding.

Question 38

Types of BCC: **[]** and **[]** BCCs are considered low-risk, whereas **[]** is high-risk due to their extensive local spread and high recurrence rate.

Answer 38

**Nodular** and **superficial** BCCs are considered **low-risk**, whereas **morpheaform** is **high-risk** due to their extensive local spread and high recurrence rate.

Question 39

Describe the different treatment options for low and high risk BCC [+]

Answer 39

The main goal of treatment is the **complete** **removal** of the **tumour** with **preservation** of the **function** and **cosmesis** of the **affected area.** The type of treatment depends on whether the BCC is **low or high risk** **Low risk:** - **complete** **surgical** **removal** or **electrodesiccation** and **curettage** **(ED&C)** - **Superficial BCCs** – 5-flourouracil or imiquimod cream **High risk** - **Mohs micrographic surgery** is a specialist removal method for non-melanoma skin cancers with high recurrence risk - As an alternative for high-risk lesions, **simple resection with adjunct radiotherapy** has been recommended

Question 40

Describe what is meant by Bowen's disease [1]

Answer 40

**Bowen’s disease** (also known as SCC in situ) occurs when the cancerous cells are c**onfined to the epidermis**.15 It can also progress into **invasive SCC,** so it is important to monitor and treat Bowen’s disease promptly.

Question 41

Describe the management of squamous cell skin cancer [3]

Answer 41

**Surgical excision** with **4mm** **margins** if lesion **< 20mm** in diameter. If tumour **>20mm** then margins should be **6mm.** **Mohs micrographic surgery** may be used in **high-risk patients** and in **cosmetically important sites.**

Question 42

Describe the differences in a good and bad prognosis for squamous skin cell cancer [4]

Answer 42

**High-risk features include:** Size: >2mm deep or >20mm wide Site: face, ear, genitals, hands, feet Recurrence Immunosuppressed individual Poor differentiation (histologically) Perineural invasion (histologically) High tumour budding *Geeky medics^*

Question 43

Tx for serborrheic keratoses? [2]

Answer 43

* **reassurance** about the benign nature of the lesion is an option * options for removal include **curettage, cryosurgery and shave biopsy**

Question 44

Name and describe this type of skin condition [3]

Answer 44

**Intradermal Naevi** * Protrude from the skin surface * Pigmented or flesh coloured

Question 45

Name and describe this type of skin condition [1]

Answer 45

**Blue Naevi** - solitary, bluish, smooth surfaced macule, papule or plaque. They are generally round or oval in shape.

Question 46

Describe the management options for Actinic Keratoses [4]

Answer 46

**Management options include**: - prevention of further risk: e.g. sun avoidance, sun cream - **fluorouracil cream**: typically a 2 to 3 week course. The skin will become red and inflamed - **sometimes topical hydrocortisone** is given following fluorouracil to help settle the inflammation - **topical diclofenac**: may be used for **mild AKs**. Moderate efficacy but much fewer side-effects - **Imiquimod** can be used for lesions on the face and scalp when cryotherapy or other topical treatments cannot be used.