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149 Cards in this Set

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What aspects of the history needs to be taken for a rash?
- How long?
- When did it start?
- Where is it now?
- Is it spreading?
- Is it changing?
- Size, shape, colour.
- Is it getting worse (more intense)?
- Pain?
- Itchy?
- Blistering?
- Bleeding?
- Treatments previously tried?
On examination, what general observations need to be made for a patient presenting with a rash?
- Distribution: Generalised or localised?
- Distinct pattern? (e.g. dermatomal).
On examination, what specific observations of a rash need to be made for a patient presenting with a rash?
- Same morphology?
- Size?
- Shape?
- Colour?
- Raised or flat?
- Border distinct or blurred?
When taking a history of a dermatology patient, what environmental exposures do you need to elicit?
- Medications.
- Non-prescribed drugs (legal and illegal).
- Contact with others (family, friends, workmates, school, daycare).
- Contact with environmental agents.
- Organic chemicals e.g. petrochemicals, detergents, dyes, etc.
- Inorganic chemicals - e.g. heavy metals, exposures.
- Biological materials - plants, insects, animals.
- Sunlight.
- Employment.
- Hobbies.
A vascular cause may result in localised skin lesion, generalised skin lesion or both?
Localised only.
A bacterial cause may result in localised skin lesion, generalised skin lesion or both?
Localised +

Generalised -(+)
A viral cause may result in localised skin lesion, generalised skin lesion or both?
Localised +/-

Generalised +
A fungal cause may result in localised skin lesion, generalised skin lesion or both?
Localised only.
A parasitic cause may result in localised skin lesion, generalised skin lesion or both?
Localised +

Generalised -(+)
An inflammatory cause may result in localised skin lesion, generalised skin lesion or both?
Localised +

Generalised -(+)
A neoplastic cause may result in localised skin lesion, generalised skin lesion or both?
Localised only.
A degenerative cause may result in localised skin lesion, generalised skin lesion or both?
Generalised only.
A congenital cause may result in localised skin lesion, generalised skin lesion or both?
Localised only.
An allergic cause may result in localised skin lesion, generalised skin lesion or both?
Localised +/- (+)

Generalised +
An autoimmune cause may result in localised skin lesion, generalised skin lesion or both?
Generalised only.
A traumatic cause may result in localised skin lesion, generalised skin lesion or both?
Localised only.
An endocrine/metabolic cause may result in localised skin lesion, generalised skin lesion or both?
Generalised only.
What points on history taking can elicit high risk to skin cancer?
- Blistering sunburns.
- Occupational and recreational exposure to solar radiation.
- Family or personal history of melanoma or multiple atypical (dysplastic) naevi.
- Family history or personal history of non-melanoma skin cancer.
- Immunosuppression.
- Exposure to arsenic.
- A history of change or symptomatology for any lesion.
The highest rates of non-melanoma skin cancer are found on what parts of the body?
Face:
- Nasolabial fold.
- Eyelid.
- Nonmucosal skin of the lips.
- Ears.
- Nose.
- Cheeks.

Men: Neck, back and shoulders.
Women: Neck, shoulders and outer arms.
Scars should be checked and re-examined for recurrence of excised lesions. What type of lesion may develop within longstanding scars and ulcers?
BCCs.
When should a lesion biopsy (punch or shave) be done?
- If a firm clinical diagnosis cannot be made.
- If treatment choice may be dicated by tumour type or pattern of growth.
Follow-up after excision of a skin cancer is required for what reasons?
- Detection of further primary tumours.
- Detecting local persistence of previously treated tumours.
- Early detection of metastatic disease.
Why does the face require extra care in managing skin cancers?
For cosmetic reasons and the possibility of nerve damage.
Why does the eyelids require extra care in managing skin cancers?
Scarring can cause entropion.
Why does the lips and helix of the ear require extra care in managing skin cancers?
Because of malignant potential.
Why does the neck require extra care in managing skin cancers?
Where the accessory nerve is superficial.
Why does the fingers require extra care in managing skin cancers?
Function is a major consideration.
Why does the lower limb require extra care in managing skin cancers?
Healing can be very slow.
What are the recommendations for prevention of skin cancer?
- Clothing: closely woven fabrics that aren't transparent when held against the light.
- Wear hats and sunglasses.
- Seek shade. Avoid the sun in the middle of the day.
- Use SPF15+ sunscreen. Reapply every 2 hours.
- Advise against the use of sunbeds, tanning booths and tanning lamps.
What are the clinical features of seborrheic keratoses?
- Usually found on the face and trunk.
- Slightly elevated.
- Ovoid.
- Yellow-brown.
- Well-defined papules.
- Greasy appearance.

- Later thickens to become brownish black.
- Surface is irregular and shows minute pits.
How is seborrheic keratoses managed?
When flat and pigmented, seborrhoeic keratoses may require biopsy to differentiate them from lentigo maligna melanoma.

Removed with a number of destructive techniques such as:
- Cryotherapy.
- Curettage.
- Electrosurgery.
- Shave excision.
What would you need to rule out with multiple seborrheic keratoses?
Known as Leser-Trelat sign - it is a potential sign for internal malignancy.
What are the clinical features of dermatofibromas?
- Benign tumours of fibroblasts.
- Firm, solitary, dermal nodules.
- Usually found on the limbs of young people.
- 'Iceberg' effect - it feels larger than it looks.
- Overlying epidermis often lightly pigmented.
- Dimples when nodule is squeezed.
How is dermatofibromas managed?
No treatment necessary, although biopsy may be required if diagnosis is uncertain.
What are the clinical features of a porokeratosis?
- Uncommon, distinctive, benign lesions.
- Shows varying degrees of dysplasia.
- Annullar dry plaques surrounded by a raised fine keratotic wall.
- May be isolated or multiple.
- Most often appears on limbs.
What is the management of porokeratosis?
None usually needed. If lesions are hyperkeratotic or multiple, cryotherapy may be performed.
What are solar keratoses?
Solar keratoses are common lesions associated with dysplasia, particularly with basal keratinocytes. The present a potential precursor of SCC, although only a small percentage evolve into invasive SCC.
What are the clinical features of solar keratoses?
- Found chronically on sun exposed sites such as the head and neck, dorsa of the hands, and the forearms.
- Erythematous macule with superimposed hyperkeratosis.
- Generally multiple and can be confluent.
What is the differential diagnosis of solar keratosis?
- Bowen Disease.
- SCC.
- Solar lentigo.
- Lentigo maligna if pigmented.
What management options are there for solar keratosis?
- No treatment.
- Cryotherapy.
- 5-flurouracil.
- Imiquimod.
- Curettage.
- Laser resurfacing.
With a solar keratosis, what indicators might indicate transformation into an invasive SCC?
Thickening and tenderness on lateral palpation.
What is Bowen's disease?
Bowen disease (intraepidermal SCC) is associated with full thickness epidermal dysplasia with follicular involvement and is classified as an intraepidermal SCC. Despite this, they tend to have a prolonged in-situ phase that may last many years.
What are the clinical features of Bowen's disease?
- Longstanding, slowly enlarging lesions.
- Predilection for lower legs (especially in females) but may occur at any site.
- Sharply-defined.
- Round to oval.
- Erythematous hyperkeratotic plaque.
- May transform to an SCC (but low rate of transformation).
What is the differential diagnosis of Bowen's disease?
- Superficial BCC.
- Psoriasis.
- SCC.
- If pigmented, may mimic superficial spreading melanoma.
What are the management options for Bowen's disease?
- Surgical excision.
- Cryotherapy.
- Imiquimod.
- 5-flurouracil.
- Curettage and diathermy.
- Photodynamic therapy.
- Superficial radiotherapy.
- Laser ablation.
What problem may occur with with superficial treatment modalities of Bowen's disease.
Due to extension of keratinocyte atypia, down hair follicles recurrence after treatment with superficial modalities (eg. cryotherapy) can occur, particularly on the face.
What are keratoacanthomas?
Keratoacanthoma are lesions that can be thought of as a well differentiated forms of SCC characterised by spontaneous resolution.
What are the clinical features of keratoacanthomas?
- Most common on chronically exposed sites of the head, neck, hands and forearms.
- Rapidly enlarge over a period of 4-8 weeks.
- Forms a tender, erythematous nodule with a central keratotic plug.
- Resolution takes 6-12 weeks, sometimes leaving a scar.
- A minority will persist to SCC.
What is the differential diagnosis of keratoacanthomas?
- SCC.
- Atypical fibroxanthoma.
- Merkel cell carcinoma.
- Amelanotic melanomal.
What are the management options for keratoacanthomas?
- Partial biopsy will almost always be reported as a well differentiated SCC as pathology requires the entire architecture to suggest the possibility of keratoacanthoma. If in doubt, treat as a SCC.

- Curettage +/- cryotherapy.
- Shave excision.
- Surgical excision.
- Intralesional methotrexate.
- Superficial radiotherapy.
What may happen with keratoacanthomas in immunosuppressed patients?
They may progressively grow instead of involute. Extra caution is required.
What is the pathological features of a squamous cell carcinoma?
Squamous cell carcinomas are
characterised by lobular proliferation of keratinocytes
with intradermal invasion and
prominent keratin production. The majority of SCCs are thought to arise from solar keratoses.
What are the clinical features of an SCC?
- Tender erythematous papules or nodules.
- Variable amount of hyperkeratosis.
- Enlarges over a period of months.
- Usually with associated tenderness.
- May bleed or ulcerate.
With an SCC, what features increase the risk of metastasis?
- Tumour thickness.
- Clinical immunosuppression.
- Poorly differentiated tumour.
- Tumours located on lips, ears or scalp.
What is the differential diagnosis of an SCC?
- Hyperkeratotic solar keratosis or Bowen disease – clinical diagnosis can be difficult in the early stages.
- Nodular basal cell carcinoma.
- Amelanotic melanoma.
- Atypical fibroxanthoma – particularly if on the scalp.
What are the management options for an SCC?
- Surgical excision.
- Superficial radiotherapy.
What is the pathological basis of BCCs?
Basal cell carcinomas (BCCs) are tumours derived from basal keratinocytes. Their onset is insidious. In months or years they extend
peripherally as well as in depth and are capable of destroying cartilage and bone.
Metastases rarely develop from BCCs, the main risk being recurrence after incomplete removal.
What are the 3 common growth patterns of BCCs?
- Superficial multifocal.
- Nodular.
- Morphoeic.
What are the clinical features of a superficial multifocal BCC?
- Generally occurs on trunk and limbs.
- Bright pink and shiny.
- Usually well-defined erythematous macular lesions.
- Pearly edge.
- Progressive enlargement over months to years.
- Ulceration and bleeding are uncommon.
- Recurrence common.
- With time, areas of nodular or even sclerosing growth patterns may supervene.
What is the differential diagnosis of a superficial multifocal BCC?
- Bowen disease.
- Solar keratosis.
- Psoriasis.
- Eczema.
What are the management options for a superficial multifocal BCC?
- Cryotherapy.
- Imiquimod.
- 5-flurouracil.
- Photodynamic therapy.
- Surgical excision.
- Curettage and diathermy.
- Superficial radiotherapy.
What are the clinical features of a nodular BCC?
- Most commonly found on head and neck.
- Shiny, translucent (pearly).
- Telangiectatic papule or nodule.
- Recurrent ulceration is frequent.
- Pigmentation may suggest melanoma.
What is the differential diagnosis of a nodular BCC?
- Nonpigmented intradermal naevi.
- Neuromas.
- SCC.
- Amelanotic nodular melanoma.
What are the management options for a nodular BCC?
- Surgical excision.
- Superficial radiotherapy.
- Intralesional interferon alfa.
- Imiquimod.
- Photodynamic therapy.
Describe the histology of a morphoeic BCC.
Morphoeic lesions have a sclerosing growth pattern with fibrosis surrounding areas of BCC.
What are the clinical features of a morphoeic BCC?
- Mostly on the head and neck.
- Can be clinically difficult to detect.
- Often indurated to palpation.
- Frequently asymptomatic.
- Tend to look like a pale scar.
- Usually long-standing.
- Tend to be deeply invasive.
What are the management options for a morphoeic BCC?
- Consider referral for specialist care.
- Moh’s micrographic surgery.
- Superficial radiotherapy.
What are the clinical features of solar lentigo?
- Macular area of pigmentation.
- Appears after either acute or chronic sun exposure.
- Histologically, there is a linear increase of melanocytes at the dermoepidermal junction without cytologic atypia.
- Back of hands, face and shoulders most common.
- May evolve into seborrheic keratoses?
What can solar lentigo eventually evolve into over time?
Seborrheic keratoses.
What are the management options for solar lentigo?
- Cryotherapy can lighten solar lentigo, but care should be taken in olive skinned patients as they may hyperpigment.
- Laser.
What do you need to differentiate solar lentigo from and how might you have to do this?
Shave biopsy may be necessary to distinguish solar lentigo from lentigo maligna or superficial spreading melanoma.
What is an ink spot lentigo?
Ink spot lentigo are small (less than 5 mm) densely black macules, usually on sun exposed skin. They can be cause for concern because of their dark colour and
irregular lateral margin. Melanocyte numbers and melanin production are increased in these lesions but there is no cellular atypia.
What are the clinical features of atypical naevi?
- Usually larger than ordinary naevus.
- Predominant on the trunk.
- Mixture of tan, dark brown and pink areas.
- Surface texture is often 'pebbly'.
- Border is often 'smudgy'.
- Increased melanoma risk.
What does atypical naevus syndrome refer to?
Occurrence of multiple (>80) dysplastic naevus in an individual.
Is there an increased risk of melanoma in atypical naevi?
Yes.
What is the management of atypical naevi?
Surveillance (baseline photography and regular 6–12 month follow up) enables early
diagnosis of melanoma. This is much more cost effective in preventing life threatening melanoma than prophylactic excision of atypical naevi.
For a in situ melanoma (level 1), what is the recommended margin of re-excision?
0.5cm.
For a melanoma of thickness less than 2mm, what is the recommended margin of re-excision?
1.0cm.
For a melanoma of thickness more than 2mm, what is the recommended margin of re-excision?
2.0cm.
What proportion of melanomas are comprised of lentigo malignant melanoma?
15%.
What populations does lentigo malignant melanoma mainly occurs in?
Exposed skin of elderly.
What does a lentigo malignant melanoma look like?
An irregularly pigmented and shaped macule (lentigo
maligna/Hutchinson melanotic freckle) may have been enlarging slowly for many years as an in-situ melanoma before an invasive nodule
(lentigo maligna melanoma) appears.
What is the differential diagnosis of lentigo maligna melanoma?
- Solar lentigo.
- Flat pigmented seborrheic keratosis.
What are the management options for a lentigo maligna melanoma?
- Shave biopsy of the lesion’s centre is recommended
if there is diagnostic
uncertainty.
• Surgical excision.
• Superficial radiotherapy.
Superficial spreading melanoma account for what percentage of melanomas?
50-75%. It may develop on any part of the body at any age.
What are the physical characteristics of a superficial spreading melanoma?
- Variegated colour.
- Irregular expanding margin.
What is the differential diagnosis of a superficial spreading melanoma?
- Atypical (dysplastic) naevus.
- Pigmented BCC.
- Pigmented seborrhoeic keratosis.
- Haemangioma.
What is the management of a superficial spreading melanoma?
Surgical excision.
Nodular melanoma represents what percentage of all melanomas?
15-35%.
What proportion of melanomas are comprised of lentigo malignant melanoma?
15%.
What populations does lentigo malignant melanoma mainly occurs in?
Exposed skin of elderly.
What does a lentigo malignant melanoma look like?
An irregularly pigmented and shaped macule (lentigo
maligna/Hutchinson melanotic freckle) may have been enlarging slowly for many years as an in-situ melanoma before an invasive nodule
(lentigo maligna melanoma) appears.
What is the differential diagnosis of lentigo maligna melanoma?
- Solar lentigo.
- Flat pigmented seborrheic keratosis.
What do nodular melanomas look like?
- Pigmented (occasionally flesh coloured).
- Amelanotic nodule.
- No antecedent in situ stage.
- Most rapidly growing and aggressive of all melanomas.
What are the management options for a lentigo maligna melanoma?
- Shave biopsy of the lesion’s centre is recommended
if there is diagnostic
uncertainty.
• Surgical excision.
• Superficial radiotherapy.
What proportion of melanomas comprise nodular melanomas?
15-35%.
What are the physical characteristics of nodular melanoma?
- Pigmented (occasionally flesh coloured).
- Amelanotic nodule.
- No antecedent in-situ phase.
What is the most rapidly growing and aggressive type of melanoma?
Nodular melanoma.
What is the differential diagnosis of a nodular melanoma?
- Pigmented BCC.
- SCC or pyogenic granuloma if amelanotic.
What is the management of a nodular melanoma?
- Surgical excision.
Acral lentiginous melanoma represents what percentage of melanomas?
5-10%.
Where is acral lentiginous melanomas normally located?
Palmar, plantar, ungual surfaces.
What is the differential diagnosis of acral lentiginous melanoma?
- Melanocytic naevus.
- Subungal heamatoma.
- Talon noir – a pigmented petechial area on the heel following minor trauma.
What is the management of acral lentiginous melanoma?
Surgical excision.
Why should partial biopsy of suspected melanoma be avoided?
Interferes with accurate histological staging.
1. Flexural eczema predominates in what populations?

2. Facial and truncal eczema predominates in what populations?
1. Children and adults.

2. Infants.
Inflammation in the skin in eczema is mediated by...
T cells.
Eczema often initially appears during what age?
Often in the first 12 months of life. Eczema is the first of the atopic conditions to appear in childhood.
What factors contribute to the onset of atopic eczema?
- Climate.
- Allergies.
- Infection.
- Emotions.
- Hygiene hypothesis.
- Other environmental influences.
What percentage of eczema settles in the first 5 years of life?
75%.
What are the 3 main symptoms that you're trying to control in eczema primary management?
- Heat.
- Dryness.
- Prickle.

By controlling these factors, itch, exacerbations and complications can be controlled.
What can be done to reduce dryness in eczema?
- Avoid soaps (they're drying).
- Replace soap with substitutes and bath oils.
- Bland, greasy emollients and bath preparations (no plant extracts that can induce sensitisation).
- Perfumed, coloured, and bubble baths are to be avoided.
- Moisturiser twice a day, especially straight after a bath.
- Liquid and white soft paraffin.
- Glycerol, sorbolene.
What is a possible complication of overmoisturing with greasy emollients in eczema?
Sterile folliculitis due to blocked pores.
What can be done to reduce heat factors in eczema?
- Avoid overdressing.
- Don't overburden with sheets, blankets and stuff in bed.
- Daily bath (lukewarm <29 degrees and not before sleep).
What can be done to reduce prickle in eczema?
It is wise to avoid wearing prickly fabrics such as wool, and other irritants such as sandpits. Hair, when long around the neck, also adds to prickle.
Wet dressings are particularly helpful in what situations?
- Stubborn eczema not responding to standard therapy.
- Lichenification present.
- Poor sleep.
What does wet dressings entail in treating eczema?
Moistened soft cloths (eg. chux) are placed around the limbs and held in place with dry, crepe bandages. These may be placed over the top of moisturisers alone, or topical steroids and moisturisers. They should be kept moist or changed after about 4–6 hours if used during the day to prevent their becoming too hot.

A wet t-shirt and bandannas used for the trunk, scalp and neck.

Cool compresses on the face every hour for a period of 5 minutes if severe.
Corticosteroid ointments vs Corticosteroid cream. Which is better for eczema?
Ointments as they are better absorbed and have moisturising qualities. They also tend to sting less on broken skin.
What are the disadvantages of corticosteroid ointments for eczema?
- Less well tolerated.
- Sticky and difficult to rub in.
- Blocked pores and folliculitis can develop in skin folds and trunks.
What strength steroid should be used on areas such as the face and nappy areas?
Weak steroids (1% hydrocortisone) is required for delicate areas.
Why does the face require only weak steroids?
Thinner skin, allowing for greater absorption.
What strength steroid is used for the trunk and limbs in eczema?
Potent steroids (e.g. mometasone 0.1% once/day or methylprednisolone aceponate twice per day).
How long should potent steroids be used for an exacerbation of asthma on the trunks or limbs?
Until cleared, and then intermittently for a few days before ceasing use.
What are potential complications with overuse of topical corticosteroids?
- Perioral dermatitis (most common).
- Atrophy (only if used continuously for months).
- Striae.
- Cataracts with steroids used around the eye.
What is pimecrolimus?
Calcineurin inhibitor used to treat eczema. It is a topical immunomodulator.
What is the advantage of using pimecrolimus on the face?
It does not cause skin atrophy, so can be used on the face when hydrocortisone is not strong enough and the risk of steroid side effects is greatest.
What are some side effects of pimecrolimus?
- Local stinging and redness (diminishes with continued use).
- Theoretical risk of increased skin cancers with higher potency forms.
How many PBL authority applications are allowed per patient for pimecrolimus?
10mg/g (1%) cream
1 x 15g with 1 repeat.
Once every 6 months
What are the main complications of eczema?
- Infection.
- Growth delay.
What should bacterial skin infection that complicates eczema be treated with?
Flucloxacillin or cephalexin for 7-10 days.
What is the most common viral skin infection that complications eczema?
Herpes virus - producing clear, distinct vesicles.
Why should topical antibiotics such as fusidic acid be avoided in eczema-complicated skin infection?
High rates of resistance.
What is herpes infection in eczema known as?
Eczema herpeticum.
Molluscum contagiosum is more common in children with what skin condition?
Eczema. The molluscum is more likely to become widespread.
Should topical steroids should be continued in the cases of eczema herpeticum and molluscum contagiosum?
No.
When should a child get acyclovir (7-10 days) for herpes infection complicating eczema?
If the child has:
- Fever.
- Unwell.
- Extensive lesions (especially if face is affected).
When should eczema be referred?
- Failure to thrive.
- Refractory to treatment for a period of months.
Why shouldn't oral steroids be used for eczema?
- Side effects.
- Rebound flares.
What non-drug treatments are available for eczema?
- CBT.
- Massage.
- Hypnotherapy.
- Education.
- UV therapy (older children or adults with extensive eczema).
When could cyclosporin and other immunosupppressive agents be used for eczema?
Severe cases in hospital settings.
What is pimecrolimus restricted to on the PBS for eczema?
1. Treatment of facial or eyelid atopic dermatitis in patients aged between 3 months and 18 years in whom topical corticosteroids are contraindicated because of:
- Perioral or periorbital dermatitis.
- Rosacea.
- Epidermal or dermal atrophy.
- Allergy to topical corticosteroids.
- Cataracts.
- Glaucoma.
- Raised intraocular pressure.

2. Short term (up to 3 weeks) intermittent treatment of atopic dermatitis of the face or eyelids in patients aged between 3 months and 18 years who fail to achieve satisfactory disease control with intermittent topical corticosteroid therapy, and where more than 3 months have passed since the initial diagnosis of atopic dermatitis.
If histology indicates that further surgery is required for a skin cancer, what do you do with the sutures?
Leave them in. They are a marker of the location and direction of the initial surgery. One does not need to worry that sutures left a long time might cause a reaction – the skin is set to go in subsequent surgery.
What are the 3 broad groups of basal cell carcinomas?
- superficial BCCs (SBCCs)
- simple nodular BCCs, and
- tough BCCs.
What is the benchmark treatment for a touch BCC?
Moh's surgery.
SCCs at greater risk of spreading include:
- Recurrent SCCs.
- Tumours on lip, ear and scalp.
- Large tumours, and
- Aggressive poorly differentiated or spindle malignancies.
What needs to be done if perineural invasion is noted on a pathology report for a skin lesion?
Tumour can ‘skip’ down the nerve. This means that a tumour may have continued well beyond histologically clear margins. Options include further surgery and radiotherapy. Offer a radiotherapy consult.
A patient who has had one nonmelanoma skin cancer has a ____ chance of developing another.
A patient who has had one nonmelanoma skin cancer has a 66% chance of developing another.
How long should you dress an sutured wound after skin excision?
Sutured wounds have better cosmetic outcomes if covered with an occlusive dressing for at least 4 days.
What do you need to look out for when taking a history about the duration and time course of a skin lesion?
‘Months’ is the key. Changes or growth over days or weeks are often due to inflammation. It may soon change back or disappear. If it has not changed for years then it probably won’t change any time soon. If the patient says the lesion is changing or growing and staying changed for months, be quick to biopsy.