Flashcards in Session 4 Deck (39)
• Presenting complaint - • Nature (e.g. rash vs lesion)
• History of presenting complaint - • Initial appearance and evolution*
• Symptoms (particularly itch and pain)
• Aggravating and relieving factors (“triggers”)
• Previous and current treatments (effective or not)
* Indicates points more important with lesions as presenting complaint
• Past medical history -• Systemic diseases
• History of atopy (asthma, hay fever, eczema)
• History of skin cancer or pre-cancer*
• History of sunburn/sunbathing/sun-bed use*
• Skin type*
• Family history - • Family history of skin disease*
• Family history of atopy
• Family history of autoimmune disease
• Social history - • Occupation
• Sun exposure*
• Improvement in PC when away from work
• Drug history and allergies - • Regular and recent
• Systemic and topical
• Get specific with topical treatments!
• How much?
• How long for?
• Impact on quality of life / ICE• Impact of skin complaint on life
• Expectations- • Impact of skin complaint on life
What are the different skin types?
EXAMINING THE SKIN and description of physical findings
systemic check - whole skin, hair, nails, mucous membranes
How to describe a skin condition?
• S - Site, distribution (rash)
• or Size and Shape (lesion)
• C - Colour (and Configuration)
• A - Associated changes e.g. surface features
• M - Morphology
ABCD FOR PIGMENTED LESIONS
• Border (irregular or blurred)
How to describe Site & Distribution of a skin condition
How to describe Configuration of a skin condtion
How to describe the colour of a skin condition
How to describe the Surface Features of a skin condition
How to describe the hair findings in a skin condition
How to describe nail findings?
• A 42 year old man with a background of chronic plaque psoriasis has presented to Accident Emergency feeling unwell.
• Describe the rash?
• Describe which functions of the skin are impaired in this patient?
• What is the name of this clinical presentation?
Functions of the skin
• Protective barrier against environmental insults
• Temperature regulation
• Vitamin D synthesis
Erythroderma and its complications
• >90% of body surface area affected, erythematous and exfoliatitive
• Causes: psoriasis, eczema, drugs, cutaneous T cell lymphoma
• Symptoms: pruritus, fatigue, anorexia, feeling cold
• Signs: erythematous, thickened, inflamed, scaly, no sparing
• ‘Total skin failure’
• Hypothermia (loss of thermoregulation)
• Infection (loss of protective barrier)
• Renal failure (insensible losses)
• High output cardiac failure (dilated skin vessels)
• Protein malnutrition (high turnover of skin)
Cells of the Epidermis
• 4 major cell types each with individual function
• Keratinocytes - protective barrier
• Langerhan cells- antigen presenting cells
• Melanocytes- produce melanin which provides pigment to the skin and protects cell nuclei from UV DNA damage
• Merkel Cells - contain specialised nerve endings for sensation
Layers of the epidermis
• 4 layers of the epidermis
• Each layer represents a different stage of maturation of the keratinocyte
• Average epidermal turnover time is about 30 days
• The 4 layers of the epidermis include: stratum basale (basal layer), stratum spinosum, stratum granulosum, stratum corneum (horny layer- most superficial)
• Stratum lucidum found in areas of thicker skin such as palms and soles
How might pathology affect the epidermis
• a) Change in epidermal turnover
• b) Change in surface of the skin
• c) Changes in pigmentation of the skin
• Composed of collagen, elastin and glycosaminoglycans
• Provides strength and elasticity
• Also contains immune cells, nerve cells, skin appendages, lymphatics and blood vessels
• Produce sebum through hair follicles (pilosebaceous unit)
• Secrete sebum on to skin which lubricates skin
• Active after puberty
• Stimulated by conversion of androgen to dihydrotestosterone
• Increased sebum production and bacterial colonisation in conditions such as acne vulagris
Eccrine and Apocrine glands
• Regulate body temperature
• Innervated by sympathetic system
• Two types: Eccrine and Apocrine
• Eccrine are widespread
• Apocrine are active following puberty and are found in axillae, areolae, genitalia and anus.
• Each hair consists of modified keratin and is divided into hair shaft and hair bulb
• 3 main types of hair: lanugo hair, vellum hair (short hair all over body), terminal hair (coarse long hair)
• Each hair follicle enters a growth cycle which has 3 main phases: anagen, catagen, telogen
• Consists of a nail plate which arises from the nail matrix at the posterior nail fold and rests on the nail bed.
• Nail bed contains blood capillaries
⦁ Learn the history and key presenting features of Atopic Eczema
GENERALISED SYMMETRICAL rash consisting of ERYTHEMATOUS, SCALY, ILL DEFINED, PATCHES, EROSIONS
•Endogenous vs Exogenous •Acute vs chronic •Epithelial disruption-vesicles, bullae, papules •Pruritus +++ •Clinical diagnosis- personal or family history of atopy(inc.hay fever and asthma) •Complications include heavy bacterial colonization, eczema herpeticum, superimposed contact allergy, reduced quality of life
•Education-National Eczema society •Avoidance of exacerbating factors and use of soap substitute •Generous use of non-perfumed emollient (500g/week) •Topical steroids/calcineurininhibitors •Phototherapy •Systemic therapies
⦁ Learn the history and key presenting features of psoriasis
Extensor surfaces with Scaly, well defined, Plaques and nail pitting
• Overactive maturation of keratinocytes driven by inflammation • Autoimmune driven- genetic and environmental factors • Made worse by stress, infection and cold weather (improved by sun light) • Patients can also have nail findings and psoriatic arthritis • Management: Steroid creams, Vitamin D3 analogues, UV light therapy and immunosuppressant therapy
⦁ Learn the history and key presenting features of Acne Vulgaris
Generalised, Erythematous, maculopapular vesciles, pustules and comedones with crusting and excoriation
• Occur when dead skin cells and oil (sebum) clog hair follicles • Often more common in adolescents due to pubertal effects on sebum production • Genetics plays a large role in incidence • Can also be affected by diet, stress and infections • Usually managed in community but if resistant or scarring present then dermatology input advised • Treatment involves lifestyle changes, antibacterial facewash, antibiotics and hormonal therapy
Macules and Patches
Macules are nonpalpable lesions <1 cm that vary in pigmentation from the surrounding skin. Patches are nonpalpable lesions >1 cm. These lesions are flush with the surrounding skin.
Papules are palpable, discrete lesions measuring <1 cm in diameter. They may be isolated or grouped
Plaques are elevated lesions that are >1 cm in diameter. Plaques may be formed by a confluence of papules
Nodules are palpable, solid or cystic, discrete lesions measuring 1-2cm in diameter.
Pustules are small, circumscribed skin papules containing purulent material