Rash clinical cases

Question 1

How should any rash be assessed?

Answer 1

Detailed history, examination (distribution/site affected, morphology, secondary features)

Question 2

How common is psoriasis?

Answer 2

Occurs in 2% of adults

Question 3

Is psoriasis curable?

Answer 3

No-has chronic course

Question 4

What is the most common form of psoriasis?

Answer 4

Chronic plaque psoriasis (psoriasis vulgaris)

Question 5

What are some features of chronic plaque psoriasis?

Answer 5

Symmetrical, commonly extensors (elbow/knee), scalp, sacrum, hands, feet, trunk and nails, sharply demarcated, scaly, erythematous plaques

Question 6

What is the Koebner phenomenon?

Answer 6

Psoriasis develops in areas of skin trauma

Question 7

What is the Auspitz sign?

Answer 7

Removal of psoriasis surface scale reveals tiny bleeding points (dilated capillaries in elongated dermal papillae)

Question 8

What are some forms of psoriasis?

Answer 8

Guttate, palmoplantar pustular, erythrodermic or widespread pustular (rare)

Question 9

What are some sign of psoriatic nail disease?

Answer 9

Nail pitting, subungal hyperkeratosis, dystrophy, onycholysis

Question 10

What are some systemic effects of psoriasis, and what are some of the co-morbidities?

Answer 10

Biomarkers of systemic inflammation are raised; psoriatic arthritis, obesity, hypertension, diabetes, lipid abnormalities, Crohn’s, depression, cancer, uveitis

Question 11

What is the life expectancy for patients with severe psoriasis?

Answer 11

About 4 years due to increased CV risk (3 x more at risk of MI)

Question 12

Who controls the topical therapies for psoriasis?

Answer 12

GPs

Question 13

What are some topical therapies for psoriasis?

Answer 13

Vitamin D analogues, Calcipotriol (Dovonex-for localised plaques), Calcitriol (Silkis-for flexures, less irritating), coal tar, dithranol, steroid ointments, emollients

Question 14

When is dithranol used to treat psoriasis?

Answer 14

If few localised plaques and short contact

Question 15

What is the risk of using steroid ointments to treat psoriasis?

Answer 15

Can cause rebound if potent

Question 16

What are some specialised treatments for psoriasis?

Answer 16

Phototherapy (narrowband UVB and PUVA), immunosuppression (methotrexate), immune modulation

Question 17

What is acne vulgaris?

Answer 17

Chronic inflammation of the pilosebaceous unit

Question 18

What is the typical age range of acne sufferers?

Answer 18

14-17 years old in females, 16-19 old years in males

Question 19

What is the pathogenesis of acne?

Answer 19

Portal occlusion, bacterial colonisation of duct, dermal inflammation, increased sebum production

Question 20

What does the distribution of acne reflect?

Answer 20

Sebaceous gland distribution (face, upper back, anterior chest)

Question 21

What is the primary lesion in acne?

Answer 21

Comedones = open (blackheads), closed (whiteheads)

Question 22

What are some of the skin changes that can form in acne?

Answer 22

Pustules and papules, cysts, erythema

Question 23

What kinds of scarring can occur in acne?

Answer 23

Atrophic, ice-pick, texture changes, hypertrophic

Question 24

How is acne graded?

Answer 24

Mild = scattered papules and pustules, comedones
Moderate = numerous papules, pustules and mild atrophic scarring
Severe = cysts, nodules and significant scarring

Question 25

What are some topical acne treatments?

Answer 25

Benzoyl peroxide (keratolytic, antibacterial), vitamin A derivatives (retinoids = drying effect), antibiotics (antibacterial and anti-inflammatory)

Question 26

How long should antibiotic treatment of acne last for?

Answer 26

At least six months

Question 27

What does Isotretinon do?

Answer 27

Oral systemic retinoid = effect on sebaceous gland activity

Question 28

What is an issue with systemic treatment of acne?

Answer 28

Lots of side effects including initial aggravation of acne

Question 29

Where does rosacea tend to affect?

Answer 29

Nose, chin and forehead

Question 30

What age group does rosacea tend to occur in?

Answer 30

Age 30-60

Question 31

What are some features of rosacea?

Answer 31

Papules, pustules, erythema, prominent facial flushing, enlarged/unshapely nose (rhinophyma), conjunctival/gritty eyes

Question 32

Why does rosacea not cause comedones?

Answer 32

It isn't a disease of the pilosebaceous units

Question 33

What are some triggers of rosacea?

Answer 33

Sudden temperature change, alcohol, spicy food

Question 34

What are some ways to avoid the aggravating factors of rosacea?

Answer 34

Wear high factor sunscreens, avoid spicy foods and topical steroids

Question 35

What are some topical therapies for rosacea?

Answer 35

Metronidazole, ivermectin (for demodex mite)

Question 36

What are some oral therapies for rosacea?

Answer 36

tetracycline (long term), isotretinoin (low dose if severe)

Question 37

What are some additional treatments for rosacea?

Answer 37

Vascular laser for telangiectasia, surgery/ laser shaving for rhinophyma

Question 38

What characterises lichenoid eruptions?

Answer 38

Damage and infiltration between the epidermis and dermis

Question 39

What are two examples of lichenoid eruptions?

Answer 39

Lichen planus, lichenoid drug eruptions

Question 40

What age group commonly gets lichen planus?

Answer 40

Middle aged patients

Question 41

What occurs in lichen planus?

Answer 41

T cell mediated inflammation targeting an unknown protein within the skin and mucosal keratinocytes

Question 42

What is the skin manifestation of lichen planus?

Answer 42

Viloaceous (purple/pink) flat-topped shiny papules, intensely itchy

Question 43

Where does lichen planus typically affect?

Answer 43

The volar wrists/forearms, shins and ankles

Question 44

What is Wickhams striae as a sign of lichen planus?

Answer 44

Fine lace like pattern on surface of papules and buccal mucosa (often asymptomatic)

Question 45

How long does lichen planus typically last before burning out?

Answer 45

12-18months

Question 46

What is the management of lichen planus?

Answer 46

Check if possible drug precipitant, emollients, treat symptomatically (potent/very potent topical steroids, oral steroids if extensive), UVB phototherapy or PUVA

Question 47

What are bullous disorders?

Answer 47

Autoimmune diseases where damage to adhesion mechanisms in the skin results in blistering at various levels

Question 48

What are the main bullous disorders?

Answer 48

Bullous pemphigoid (split is deeper, through DEJ), pemphigus (split more superficial, intra-epidermal), dermatitis herpetiformis

Question 49

What are the features of dermatitis herpetiformis?

Answer 49

Associated with Coeliac, intensely itchy, vesicles removed by scratching leaving erosions, symmetrical on scalp, shoulders, elbows, knees and buttocks

Question 50

What is Nikolsky's sign?

Answer 50

Top layers of skin slip away from the lower layers when slightly rubbed, indicates plane of cleavage within the epidermis

Question 51

What are the features of bullous pemphigoid?

Answer 51

Elderly patients, localised to one area/widespread on the trunk and proximal limbs, non-scarring, mucosal lesions unlikely, Nikolsky's sign negative, itchy erythematous plaques and papules may be the presenting feature

Question 52

What are the features of Pemphigus vulgaris?

Answer 52

Typically affects scalp, face, axilla and groin, flaccid vesicles/bullae (thin roofed), lesions rupture and leave raw areas (increased infection risk), Nikolsky's sign positive, mucosal involvement very common (eyes, genitals

Question 53

What is the prognosis of bullous disorders?

Answer 53

Chronic self-limiting course, duration varies from months to years, most patients achieve remission within 3-6 months, pemphigus has high mortality if left untreated, bullous pemphigoid has much lower risk

Question 54

What are the investigations for bullous disorders?

Answer 54

Skin biopsy with direct immunofluorescence, indirect immunofluorescence

Question 55

What is the general treatment for bullous disorders?

Answer 55

Systemic steroids and other immunosuppressive agents

Question 56

What is the treatment for pemphigus?

Answer 56

Tetracycline

Question 57

What topical treatments are used for bullous disorders?

Answer 57

Emollients, topical steroids, topical antiseptics/hygiene measures