Skin 2014 Flashcards
(10 cards)
A) small, recent onset, inflamed papule on the distal right forearm. The lesion measured 3 x 2 mm and dermoscopy showed no reticular network but some atypical vessels
were present.
B) red nodule situated in an old melanoma scar - Dermoscopy showed a pale pink area in the centre of the lesion together with regular, well-focused, circumferential hairpin vessels. No peripheral network remnants were evident.
C) non healing ulcer in an 82 yr old - over a prominent hallux valgus on his right foot
D) small swelling lying deep to a small, pale, innocent-looking mole on the left deltoid region. Dermoscopy revealed a featureless naevus with a small area of negative network. A small, indurated, localised area was palpable, lying directly below the naevus, presumably within the dermis.
A) solar keratosis, dermal naevus, hypopigmented common naevus, and amelanotic/ hypomelanotic melanoma (AHM).
B) reddish firm nodule: haemangioma (Campbell de Morgan spot), intraepidermal carcinoma, squamous cell carcinoma, keratoacanthoma, basal cell carcinoma, Merkel cell carcinoma, classical Spitz naevus, pyogenic granuloma, dermal melanoma metastases and AHM.
C) ulcerating non-healing lesion: venous or arterial ulcer, diabetic ulcer, granulating traumatic ulcer, ulcerating squamous cell or basal cell carcinoma and AHM.
D) localised dermal induration: dermatofibroma, neurofibroma, sclerosing basal cell carcinoma, hypertrophic scar and desmoplastic melanoma.
AMH-amelanotic/ hypomelanotic melanoma
AHM are clinically amelanotic but on dermoscopic examination may have some subtle peripheral pigmentation.
It has been proposed that nodular melanomas, including nodular AHM, may originate from dermal stem cells, thereby displaying
a vertical growth phase from the outset.
They demonstrate a more rapid rate of growth, have a more biologically aggressive behaviour, an increased number of mitoses and a propensity to metastasise early, emphasising the importance of early recognition and excision
After the biopsy results are obtained these cases should be referred to a specialist unit for wider excision and, if appropriate, for consideration of a sentinel lymph node biopsy (SLNB) for prognosis and staging.
2) Itchy facial rash - atopic eczema
Atopic eczema (also called atopic dermatitis), which is characterised by itching, is the most common chronic skin condition that affects youngsters. Typically it presents initially in the first 12 months of life. In young children, sleep is often interrupted by itching, which is worsened by overheating in bed. This leads to overtiredness and worsening of daytime behaviour and routines, resulting in poor quality of life for the child and family.1 Note, the words eczema and dermatitis can be used interchangeably as a distinction between the terms is not recognised medically.1 Secondary infection is common in eczema. Infection may be bacterial, viral or fungal in nature.2 There may be pustules or blisters (impetigo). Pustules in crease areas may be due to thrush. The most common cause of secondary infection is Staphylococcus aureus,1,3 and a low grade infection may not be obvious.
Rx plan
An explanation of atopic eczema: many parents think that the eczema is caused by an allergy and that avoidance of the allergen will cure the eczema. Explain that Alice has been born with a genetic predisposition to sensitive skin that is prone to dryness and itch.
Prescribe a topical steroid:1 topical steroids are generally the most effective topical treatment for eczema
Protect the skin: use a moisturiser
Avoid skin irritants: this includes excessive heat
Provide patient information: - written information
Referral
Referral to a dermatologist is recommended if there are problems with the diagnosis, or if topical therapy does not control the eczema, or other therapies such as phototherapy or systematic agents are indicated, or in the case of recurrent secondary infections.
3) Psoriasis
It is sometimes very difficult to differentiate between dermatitis and psoriasis of the hands.Plaque psoriasis may appear anywhere on the body but commonly affected areas include the elbows, knees, lower back (sacrum) and scalp. Flat areas of psoriasis are referred to as plaques and these are usually well delineated and pink with a silvery scale.
The symptoms of psoriatic arthritis are transitory but the condition is life-long and can eventually result in significant damage to joints
-atigue, eye inflammation (iritis), mouth ulcers and nail changes
enthesopathy
thickening and subungual hyperkeratosis and/or separation of the nail from the nail bed (onycholysis) or nail pitting (psoriatic nail dystrophy).
psoriasis has been associated with a number of conditions that may impact on mortality and morbidity, such as cardiovascular disease, diabetes, renal disease and rheumatological disease
4) fungal nail infection onychomycosis and
onycholysis
Trichophyton rubrum (T rubrum), T. interdigitale – the infection is also known as tinea unguium), yeasts (e.g. Candida albicans) and moulds (e.g. Scopulariopsis brevicaulis, Fusarium).
oncholysis, which is the separation of a nail from the nail bed, in the right toenail. Oncholysis most often starts at the tip of the nail and progresses back
Oncholysis may also be caused
by infection or medications (e.g. tetracyclines, fluoroquinolone antibiotics, chlorpromazine, oral contraceptives and some anti-cancer treatments)
associated with underlying disease
(e.g. multiple myeloma, anaemia, diabetes, erythropoietic porphyria, hyperthyroidism, hypothyroidism, impaired peripheral circulation, Reiter syndrome, sarcoidosis, scleroderma, yellow nail syndrome due to chronic lung, or sinus disease)
DD- bacterial infection, psoriasis, onychogryphosis (nail thickening)
diagnosis
clippings of the affected nail, including scrapings from the discoloured surface of the nail, and
debris from under the nail where feasible.1, 5 Microscopy and culture are positive in about 80% of onychomycosis cases.
Rx
Three options could be considered. These include topical therapy, oral therapy and/or non-pharmacological approaches
Topical therapy is usually combined with oral therapy, which increases success rates,duration of treatment is in excess of 6 months. It may take up to 9 months
for substantial nail dystrophy to grow out
Oral therpy and SECurrent guidelines recommend the use of terbinafine as first-line treatment, prescribed at 250 mg daily for 12 weeks (or longer) for toenails.Reduce in renal impairment. baseline liver function tests should be performed, and liver function and blood count should be monitored where planned treatment will be longer than 6 weeks.
Laser therapy is a relatively new therapy for the treatment of nail fungal infections, but all infectious agents can be treated with heat,18 which is the basis of laser therapy. It is well tolerated and has been shown to be very effective and to have high cure rates in a limited number of studies.It is also a cost-effective treatment, as prolonged treatment with oral and topical agents is expensive
5) warts
Plantar warts (verruca valgaris) involve HPV subtypes 1–4, 27, 29 and 57 Plantar warts have a characteristic appearance and clinical examination usually identifies the warts.
indications for treatment of warts include pain, interference with function, cosmetic embarrassment and risk of malignancy.
Recommended first-line treatment for common warts and plantar warts includes topical keratolytics (e.g. salicylic acid) or antivirals (podophyllum resin), with or without occlusion. salicylic acid might be more efficacious for treating warts on hands than feet
Where topical therapy has failed, cryotherapy may be used to freeze warts using liquid nitrogen as the cryogen of choice. single or double freeze of warts for 15–20 seconds every 3–4 weeks
electrosurgery (curettage and cautery), topical or oral retinoids, fluorouracil cream, bleomycin injections, as well as immune-based treatment approaches, for example, imiquimod cream.
Lastly, laser vaporisation or pulse dye laser destruction of feeding blood vessels could be considered.cure rates of 75–82% have been reported. Pain and discomfort are minimal. Mosaic warts are more resistant to therapy and may require multiple treatments clinical clearance occurs after 2–3 treatments
Transmission of warts is facilitated by direct and indirect means avoid sharing socks, shoes and towels with others, keep feet dry and change socks daily, use an antiseptic spray, and avoid scratching the lesions
