Speciality: Dermatology

Question 1

Patient - Itchy, red, scaly patches on the flexural surfaces. ACF, popliteal fossae.

Answer 1

Eczema

Question 2

Eczema Aetiology

Answer 2

• Genetic FHx
• Atopy
• Hygiene hypothesis
• Climate - heat and cold causes flares.
• Food antigens.

Question 3

Eczema Pathology

Answer 3

• Primary immune dysfunction - IgE sensitisation and allergic inflammation.
• Primary defect of the epithelial layer.

Question 4

Eczema Presentation

Answer 4

• Itchy, red, scaly patches on the flexural surfaces.
• In infants, can start on the face.
• Acute lesion can weep.
• Can become super infected w/ staph aureus.
• Excoriations.
• Eczema herpeticum - super infection with HSV.

Question 5

Eczema Ix

Answer 5

1) Clinical
2) Bloods; eosinophilia and high IgE
3) Skin swabs if super-infection (Black for bacteria and Green for virus)

Question 6

Eczema Rx

Answer 6

1) Education of trigger avoidance
2) Emollients
3) Steroids - topical hydrocortisone.
4) Topical immunomodulators - tacrolimus
5) ABx for superinfection - often flucloxacillin
6) Sedating antihistamines for itch
7) Bandaging
8) Systemic immunosuppression - Ciclosporin

Question 7

Patient - Red, scaly patches w/ silver scales. Extensor surfaces, lower back, scalp, ears.

Answer 7

Psoriasis

Question 8

Psoriasis Aetiology

Answer 8

• Polygenic
• Environmental triggers - cold, stress, alcohol, drugs, infection
• TNF

Question 9

Psoriasis Pathology

Answer 9

• Skin biopsy shows; epidermal acanthosis and parakeratosis.
• Increased skin turnover
• Polymorphonuclear cells present in upper epidermis.

Question 10

Psoriasis Presentation

Answer 10

• Chronic plaque psoriasis
• Flexural psoriasis
• Guttate psoriasis - rain drop like pattern, explosive eruption of small circular/oval plaques on the trunk.
• Nail changes - pitting, separation from the nail bed, yellowing
• Arthropathy

Question 11

Psoriasis Ix

Answer 11

1) Clinical

2) Bloods; CRP & RF (PSa is seronegative)

Question 12

Psoriasis Rx

Answer 12

1) Education around triggers
2) Emollients + skin cleaning and bandaging
3) UV exposure
4) Topical steroids
5) Vitamin D analogues (calcipotriol)
6) Severe = immunomodulators such as MTX ow + folic acid. AZA.
7) Biologics - Etanercept, adalimumab, infliximab.

Question 13

Patient - Teenager w/ blackheads and lots of spots

Answer 13

Acne

Question 14

Acne Aetiology

Answer 14

• Multifactorial
• Follicular epidermal hyper-proliferation.
• Blockage of pilosebaceous units
• Increased sebum production
• Infections w/ Propionibacterium acnes.

Question 15

Acne Presentation

Answer 15

• Infantile acne
• Steroid induced acne
• Oil acne (work)
• acne fulminans - young males, severe necrotic and crusted lesions w/ malaise, pyrexia and arthralgia –> Rx urgently w/ oral pred followed by isotretinoin.
• Presents on the face, back, sternum.
• Open comedones (black) or closed comedones (whiteheads)
• Papules/pustules
• Greasy skin

Question 16

Acne Ix

Answer 16

1) Clinical Dx

2) Skin swab for super-infection.

Question 17

Acne Rx

Answer 17

1) Regular face washing to reduce oils
2) topical agents (kerolytics - benzoyl peroxide) or topical retinoids (tretinoin or isotretinoin) + topical erythromycin or clindamycin.
3) Low dose oral oxytetracycline 500mg Bd
4) Oral isotretinoin (in those w/ scarrin)

Question 18

Patient - facial malar type flushing w/ papules and pustules around the nose, forehead and cheeks. Telangiectasia

Answer 18

• Rosacea

Question 19

Rosacea Aetiology

Answer 19

• UK
• Potential underlying vasomotor instability
• Skin mite demodex
• Associated w/ blepharitis, conjunctivitis and keratitis.

Question 20

Rosacea Presentation

Answer 20

• Often middle aged females
• Facial flushing w/ inflammatory pustules and papules.
• Telangiectasia
• Enlarging of the nose
• Flushing exacerbated by alcohol, sun and heat

Question 21

Rosacea Ix

Answer 21

1) Clinical

Question 22

Rosacea Rx

Answer 22

1) Long term use of topical 0.075% metronidazole or topical azelaic acid
2) 3 month course of oral tetracycline 500mg BD
3) Laser for telangiectasia.

Question 23

SCC Aetiology

Answer 23

• Pre-malignant form = Solar keratoses. Silver-scalp papules or patches w/ conical surface and red base.
• Bowen’s disease = Intraepidermal Carcinoma in situ. Looks like psoriasis.

Question 24

SCC Presentation

Answer 24

• Asymptomatic
• Lesions are keratotic, ill-defined nodules which can ulcerate.
• Can grow fast and metastasize.

Question 25

SCC Ix

Answer 25

1) Clinical | 2) Confirmed w/ biopsy and pathology

Question 26

SCC Rx

Answer 26

1) Solar keratoses = Cryo or topical 5-FU cream | 2) SCC = WLE, radio.

Question 27

BCC Aetiology

Answer 27

- Sun exposure - Genetics - Gorlin's syndrome - Immunosuppression.

Question 28

BCC Presentation

Answer 28

- Common on sun exposed sites (not ear) - Slow growing papule or nodule - Roled pearly edge - Telangiectasia.

Question 29

BCC Ix

Answer 29

- Clinical

Question 30

BCC Rx

Answer 30

1) Surgical excision w/ controlled borders. Mohs procedure for sensitive areas. 2) Cryotherapy 3) Radio

Question 31

MM Aetiology

Answer 31

- Excessive sunlight - RF's = pale skin, lots of moles, immunosuppression, Lentigo maligna. - Oncogenes; CDK4, PTEN.

Question 32

MM Presentation

Answer 32

1) Lentigo maligna melanoma - patch of lentigo maligna develops a papule or nodule. 2) Superficial spreading MM - Large flat irregularly pigmented lesion growing laterally. 3) Nodular MM - Most aggressive, rapidly growing pigmented nodule which bleed and ulcerates.

Question 33

MM Ix

Answer 33

``` 1) Clinical A- asymmetry B- Border irregularity C - Colour variation D - Diameter >6mm E - Elevated 2) Dermatoscope 3) Excise then histology ```

Question 34

MM Rx

Answer 34

1) Surgery - WLE 2) Sentinel node biopsy 3) Mets = chemo/radio

Question 35

Impetigo Aetiology

Answer 35

- Staphylococcus or GAS | - Abnormal skin flora imbalance

Question 36

Impetigo Presentation

Answer 36

- Weeping exudative areas w/ a honey crusted surface. | - Often around the face/mouth.

Question 37

Impetigo Ix

Answer 37

1) Clinical | 2) Skin swab + MC&S

Question 38

Impetigo Rx

Answer 38

1) Prevention w. good hygiene 2) Topical fusidic acid. 3) Oral Fluclox for Saureus 500mg 4xdaily or phenoxymethylpenicillin 500mg 4xdaily for GAS.

Question 39

HSV Aetiology

Answer 39

- Most facial cold sores = HSV 1 - Immunosuppression. - Colds and illness. - Can superinfect eczema.

Question 40

HSV Presentation

Answer 40

- Clusters of painful blisters on the face. - Painful gingivalstomatitis - Cold sore

Question 41

HSV Ix

Answer 41

1) Clinical | 2) Skin swab + PCR

Question 42

HSV Rx

Answer 42

1) Oral valaciclovir (500mg BD 5 days) for primary and painful HSV 2) Topical acyclovir for cold sores.

Question 43

Athletes foots. 1. Causes 2. Presentation 3. Ix 4. Rx

Answer 43

1. Fungal - Trichophyton 2. Scaling, flaking, itching between toes. 3. Clinical - Swab - Toenail clippings 4. Topical miconazole.

Question 44

Dermatitis herpetiformis 1. Causes 2. Presentation 3. Ix 4. Rx

Answer 44

1. Autoimmune associated with Coeliac disease. - Deposition of IgA in the dermis. 2. Itchy, vesicular rash on the extensor surfaces; elbows, knees, arse 3. Skin biopsy + direct immunofluorescence shows IgA in the dermis. 4. Gluten free diet. - Dapsone

Question 45

Pyoderma gangrenosum 1. Causes 2. Presentation 3. Ix 4. Rx

Answer 45

1. Idiopathic - IBD - RA/SLE - Lymphoma - PBC 2. Lower limbs - Initially a small red papule which develops into a red, necrotic ulcer with a violaceous border. - Systemic Sx. 3. Bloods - infection and inflammation - Autoantibodies (p-ANCA) - Swabs and MC&S - Biopsy. 4. Oral steroids as first line. - Difficult cases = cyclosporin or infliximab

Question 46

Lichen Sclerosus 1. Causes 2. Presentation 3. Ix 4. Rx

Answer 46

1. Inflammatory condition which effects the pussy or the penis. - More common in women. - Atrophy of the epidermis. 2. Itch - White plaques 3. Clinical - Biopsy if atypical or suspicious of VIN. 4. Increased risk of Ca - Vulval Ca in women - Rx with topical steroids and emollients.

Question 47

Acanthosis nigerians associated conditions

Answer 47

- GI cancer - DM - Fatness - PCOS - Acromegaly - Cushing's - Hypothyroidism

Question 48

Venous ulcers 1. Causes 2. Presentation 3. Ix 4. Rx

Answer 48

1. Venous blood flow return insufficiency 2. Ulcer above the medial malleolus. 3. ABPI - normal = 0.9-1.2 and indicate lack of arterial disease. - Values below 0.9 or above 1.3 indicate arterial disease. 4. Compression bandaging, 4 layers. - Little evidence for much else. - Keep clean and prevent infection.

Question 49

Scabies 1. Causes 2. Presentation 3. Ix 4. Rx

Answer 49

1. Mite = Sarcoptes scabiei - Spread via skin contact. - Mite burrows into the skin and lays eggs in the stratum corneum. 2. Itching - Linear burrows on the side of the fingers. - Worse at night - Secondary features of scratching and infection. 3. Clinical 4. Permethrin 5% first line - Malathion 05% is second line.

Question 50

Hereditary haemorrhagic telangiectasia 1. Causes 2. Presentation 3. Ix 4. Rx

Answer 50

1. AD inherited. 2. Multiple telangiectasia over the skin and mucous membranes. - diagnostic criteria = a) Epistaxis - spontaneous and recurrent b) Telangiectasia - lips, fingers, nose and oral cavity c) FHx 3. Capillary microscopy. - CT/MRI for lesion identification - Often clinical 4. Acute haemorrhage w/ empirical Rx such as blood Tx etc. - Surgical or laser ablation of telangiectasia. - Septoplasty of the nose

Question 51

Lichen Planus

Answer 51

Purple, pruritic, papular, polygonal rash on the flexor surfaces.

Question 52

Granuloma annulare

Answer 52

- Papular lesion - Hyperpigmented - Central depression - occur on the arm and legs. - Associated w/ DM

Question 53

Side effects of Isotretinoin

Answer 53

- Teratogenicity - Dry skin, lips and eyes - Low mood - Raised triglycerides - Nose bleeds

Question 54

Hirsutism 1. Causes 2. Presentation 3. Ix 4. Rx

Answer 54

1. PCOS - Cushing's - CAH - Androgen therapy - Obesity - Adrenal tumour - Drugs 2. Increased hair growth - Male pattern hair growth - Ferrimen-gallwey scoring system; 9 areas. 3. Clinical - Testing for causes listed above. 4. Cosmetic techniques; waxing etc. - Use of COCP

Question 55

Pityriasis Versicolour 1. Causes 2. Presentation 3. Ix 4. Rx

Answer 55

1. Fungal skin infection - Malassezia furfur - RF's = immunosuppression, malnutrition and cushing's 2. Commonly affects the trunk - Hypopigmented patches; pink or lighter brown. - Scale - Itch 3. Clinical - Skin scraping for MC&S 4. Topical antifungal - ketoconazole shampoo

Question 56

Erythema Nodosum 1. Causes 2. Presentation 3. Ix 4. Rx

Answer 56

1. Inflammation of Subcut fat - Sarcoidosis - IBD - Infection (TB) - Drugs; penicillin's, COCP. 2. Tender, red, nodular lesion - Often on the shin - Heals w/o scarring. 3. Throat swab for strep. - CSR for sarcoidosis - Serum ACE - Look for cause. 4. Self-limiting - Symptom relief only - NSAID's can help. - Bed rest w/ foot elevation.

Question 57

Tinea (ring worm) 1. Causes 2. Presentation 3. Ix 4. Rx

Answer 57

1. Fungal - dermatophytes 2. Well defined, annular with central clearing. - Red lesions w/ pustules and papules 3. clinical 4. Oral fluconazole

Question 58

Erythroderma 1. Causes 2. Presentation 3. Ix 4. Rx

Answer 58

1. When 95% of the body is covered in a rash - Eczema - Psoriasis - Lymphoma - idiopathic - Drug reaction. 2. Widespread erythema of the skin. - Scaling - excoriation - itching. 3. Clinical 4. Monitor as inpatient - Complications include; dehydration, infection and HF - bed rest - Emollients and wet dressings. - Nutritional support. - Steroids or ciclosporin and infliximab