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228 Cards in this Set
- Front
- Back
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Side effects of topical retinoids |
Erythema and irritation Photosensitivity Teratogenicity |
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5 Pillars of acne |
Increase sebum excretion rate Basal keratinocyte proliferation in pilosebaceous follicles P.Acnes proliferation Comedone formation Inflammation |
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Topical first line to treat moderate acne |
Topical retinoids Antibacterials Antibiotics |
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Antibacterials - used in papulopustular acne |
Benzyl peroxide Azelaic acid |
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Anitbiotics - papulopustular acne |
Erythromycin (zineryt, steimycin) Clindamycin Benzamycin (erythro + BPO) Duac (Clinda + BPO)
Less resistance with combination with BPO
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1st line systemic antibiotics in acne |
Cyclines: Lymecycline Doxycycline Tetracycline
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2nd line systemic antibiotics in acne |
Macrolides: erythromycin
S/E G.I. |
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3rd Line antibiotic treatment in acne |
Trimethoprim - unlicensed |
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Alternative in women to treat acne |
Hormonal control: Cyproterone antiandrogen - found in dianette contraceptive pill |
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In resistant acne cases, cases where rapid relapses occur following the cessation of treatment or cases with bad scaring |
Isotretinoin
Remember the side effects!! |
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Name 4 commensal bacteria |
Staphylococci Micrococci Corynebacteria Proprionibacteria |
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Commonest bacteria to cause impetigo |
Staphylococcus |
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What indicates that the impetigo may be cause by Strep? |
Regional lymphadenopathy |
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Treatment of impetigo |
Topical antibiotics if localised. Systemic flucloxacillin or erythromycin if otherwise |
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Bacteria causing folliculitis? |
Staph aureus |
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Treatment of folliculitis |
Short course of flucloxacillin OR Longer course of tetracycline |
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Ecthyma causative organism |
Strep pyogenes B-Haemolytic streptococci |
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Cellulitis is: |
Oedematous, erythematous lesion with poorly defined margin, regional lymphadenopathy, heat, fever and malaise Bilateral cellulitis is rare...think varicose eczema |
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Cellulitis causative organism |
Strep or staph - usually Beta haemolytic |
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Treatment of cellulitis |
Systemic antibiotics - I.V. or PO Benzylpenicillin or Flucloxacillin If penicillin allergy try erythromycin |
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Erysipelas |
More superficial than cellulitis with a well defined margin - may have blistering at active edge |
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Causative organism in erysipelas |
Streptococcus pyogenes |
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Cellulitis |
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Erysipelas |
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Impetigo |
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Folliculitis |
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Ecthyma |
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Bullous Impetigo |
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Scalded skin syndrome cause: |
Staphylococcus aureus |
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SSS presentation |
Unwell, fever, erythema, peeling |
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Treatment of SSS |
I.V. antibiotics, fluids and analgesia |
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Localised form of scalded skin syndrome |
Bullous impetigo |
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Scalded skin syndrome |
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Erythema Nodosum causative factors: |
Streptococcal infection Drugs e.g. sulphonamides and OCP Systemic conditions e.g. sarcoidosis and IBD |
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Treatment of erythema nodosum |
Treat underlying cause and give NSAIDs |
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Erythema nodosum |
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Erythema multiform: Cause |
Hypersensitivity reaction - can be caused by streptococcal antigens Other triggers: HSV, TB, Mycoplasma Hep, Drugs |
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Erythema multiforme |
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Necorotising fasciitis causative organism |
Step and staph have synergistic action |
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Eczema herpeticum Treat with systemic acyclovir ASAP then treat underlying eczema |
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Vesicles from shingles (VZV) on EAM may lead to which syndrome |
Ramsay Hunt syndrome
Shingles treatment if severe = acyclovir or famcyclovir Treat post herpetic neuralgia with analgesia or amitryptilline |
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Filliform warts |
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Mosaic warts |
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Plantar warts |
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Common warts - warts on feet are otherwise known as verrucas |
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What causes molluscum contageosum |
Poxvirus |
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Junctional naevus Flat and dark |
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Compound naevus Dome shaped brown papule |
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Intradermal naevus Dome shaped skin coloured lesion |
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Atypical naevus Assymetrical, irregularly pigmented and large |
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Halo Naevus |
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Blue naevus |
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Describe the features of a typical melanoma |
Asymmetrical Irregular Border Irregular colour >6mm in diameter Evolving over time |
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Differential diagnoses of benign and malignant moles |
Suborrhoeic wart Pigmented BCC Dermatofibroma Pyogenic granuloma Atypical mole (ugly duckling sign)
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Different subtypes of melanoma |
In situ melanoma - Lentigo maligna Melanoma in situ Invasive melanoma - Superficial spreading melanoma (most common) Nodular melanoma (rare) Acral melanoma |
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Pigmented BCC |
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Dermatofibroma |
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Solar Lentigo - arises from solar lentigo in sun exposed areas |
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Superficial spreading melanoma - thin and expands rapidly |
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Nodular melanoma - thick and invades vertically --> poorer prognosis |
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Acral melanoma -rapidly invasive |
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Appropriate sun protection advice |
SLIP - tshirt |
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Features of an eczematous rash |
Erythema Scaling Dryness Fissures Vesicles/Blisters Lichenification - chronic lesions especially Pruritic Pain Bleeding Weeping |
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Eczema that is symmetrical in the flexures is: |
Atopic |
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Eczema that is in area in contact with jewellery and well demarcated etc is: |
Allergic |
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Eczema that is in the gaiter area is: |
Venous |
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Eczema that is in the scalp, eyebrows and nasolabial folds is: |
Sebherroeic |
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Eczema that is on the hands is: |
Irritant |
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Atopic eczema |
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Adult Seborrhoeic dermatitis cause: |
Malassezia reaction (a yeast commensal) |
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Adult Seborrhoeic dermatitis treatment: |
Emollients, topical antifungals, mildly potent topical steroids and immunomodulators if long term steroids are difficult to withdraw without relapse |
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Seborrhoeic dermatitis |
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Discoid eczema |
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Asteatotic eczema |
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Varicose eczema - look for signs of chronic venous disease |
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Irritant contact dermatitis Patient will have no previous exposure to the substance |
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Allergic contact dermatitis = Type 4 hypersensitivity reaction Patient will have previous sensitisation Skin reaction presents 46-96 hours after exposure Allergy is persistent Activation of previously sensitised sites by substance can cause reaction at distant site (auto-sensitisation) |
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Pompholytic eczema - blisters on palms and soles of feet followed by inflamed, dry skin
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Causes of pompholytic eczema |
Fungal skin infection Contact allergy Emotional stress Sweating |
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Treatment of pompholytic eczema |
Usually self limiting but can give emollients and topical steroids |
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Topical steroid treatments available |
Mild: Hydocortisone 1% Moderate: Eumovate Potent: Elocon, Betnovate Very Potent: Dermovate |
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Treatment of eczema |
1st line: Emollients and topical steroids
2nd line: Topical immunomodulators, Bandaging/wet wraps and systemic treatments including: Prednisolone PO, Cyclosporin, Azathioprine and UV light |
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Describing a solitary lesion? |
Assymetry Border Colour Diameter Evolution |
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Describing a rash? |
Distribution Configuration Morphology: Macule, papule, nodule, plaque, vesicles and bullae |
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Dermatophyte clinical infection? |
Tinea |
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Tinea corporis |
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Tinea crura |
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Tinea manuum - Spreads from wrist proximally with advancing edge |
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Tinea pedis |
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Tinea unguium (onchomycosis) Spread is distal to proximal. Differentiate from psoriasis where spread is proximal to distal with other psoriatic nail changes |
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Tinea capitis with kerion Differentials: Seborrhoeic dermatitis, discoid lupus erythematosus |
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How do you treat local fungal skin infections? |
Terbinifine Polyenes (nystatin) Azoles (ketokonazole) |
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When do you use systemic fungal treatment? |
For treatment of nails, scalp, hair and widespread infections. Also in immunocompromised patients Terbinafine Azoles (itraconazole) Griseofulvin |
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How long do you give terbinafine 250mg o.d. for: 1. Toenails 2. Fingernails 3. Skin |
1. 12 weeks 2. 6 weeks 3. 2 weeks |
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Why is ketoconazole used topically and not systemically? What do you use instead? |
S/E: Hepatitis and inhibition of androgen synthesis --> gynacomastia
Fluconazole ad itraconazole |
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What would you use to treat tinea in children? How long is the treatment for: Skin/hair? Toenails |
Griseofulvin 6 weeks 6-12months |
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How do you differentiate discoid eczema from tinea? |
No central clearing of discoid eczema plaques as seen in tinea |
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How would you differentiate erythrasma from tinea? |
Wood light examination - erythrasma fluoresces pink. Erythrasma requires antibiotic treatment! |
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How would you tell the difference between candidiasis and tinea? |
In candidiasis erythema extends out of the folds with small satellite lesions and pustules at the edge of the eruption |
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How would you treat candidiasis? |
Polyenes: Nystatin and amphotericin B (systemic) Azoles: Clotimazole (topical), fluconazole (oral) |
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2 skin condition attributed to malassezia furfur? |
Pityriasis versicolor Seborrhoeic dermatitis |
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Pityriasis versicolor |
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How would you treat pityriasis versicolor? |
Topical antifungals e.g. ketoconazole Selenium suphide shampoo Imidazole creams Itraconazole for extensive infection or in immunocompromised |
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How would you treat seborrhoeic dermatitis |
Emollients, topical antifungals and mildly potent topical steroids. Can use immunomodulators in relapsing cases |
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Crusted scabies found in elderly with decreased sensory functions and in immunocompromised. |
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Scabies burrows and pustules. Papules are commonly found on the penis |
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How do you treat scabies? |
Permethrin (% dermal cream) - apply all over body for 24 hours reapplying if any washes off Treat close contacts |
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How do you treat head lice? |
Malathoin (also 2nd line in scabies treatment), carbaryl, phenothrin but usually treat with what is recommended as can often become resistant |
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Atrophie blanche : Fibrosis of subcutaneous tissue --> dilated capillary loops and local loss of pigment. * Star-shaped or polyangular, ivory-white depressed atrophic plaques* Prominent red dots within the scar due to enlarged capillary blood vessels * Surrounding pigmentation |
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Lipodermatosclerosis: ill defined band causing tapering. Caused by hypertrophy of overlying dermis in lymphadenopathy * Pain* Hardening of the skin * Localised thickening * Moderate redness * Increased pigmentation * Small white scarred areas (atrophie blanche) * Increased fluid in the leg (oedema) * Varicose veins * Leg ulcers |
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Give 4 typical presentations of a venous ulcer: |
1. Gaiter area 2. Superficial 3. Signs of chronic venous disease e.g. atrophy blanche, varicose veins and lipdermatosclerosis 4. May or may not be painful |
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Describe an arterial ulcer |
Painful, small, punched out, deep, dry base without granulation tissue |
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Where do arterial ulcers typically occur? |
Over bony prominences, pretibial area, dorsum of foot and toes |
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Name 5 types of ulcers: |
Arterial Venous Neuropathic Infectious Malignant causes - suspect if rolled proliferative edge Pyoderma gangrenosum |
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Describe a lesion typical of pyoderma gangrenosum |
Rapidly developing Purulent lesions Violet or gunmetal edge VERY painful |
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What disorders are associated with pyoderma gangrenosum |
Ulcerative collitis Rheumatoid vasculitis Malignancy especially myeloproliferative disorders |
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How might you treat pyoderma gangrenosum? |
Oral steroids or immunosuppressant agents |
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Venous ulcer |
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Arterial ulcer |
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Neuropathic ulcer |
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Ulcer associated with malignancy |
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Pyoderma gangrenosum |
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3 complications of chronic venous ulceration |
Infection - staph, strep or pseudomonas Malignant change - Marjolin's ulcer - squamous cell carcinoma transformation Compression bandaging may --> arterial blood flow impairment resulting in ischaemia and necrosis |
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ABPI values and their significance >0.8 0.6-0.8 0.4-0.6 <0.4 |
>0.8 - not important 0.6-0.8 - unlikely to be limb threatening, may cause impaired healing. Consider intervention and reduce compression bandaging 0.4-0.6 - Severe ischaemia - intervene or healing may be unlikely. Do not use compression <0.4 - Limb threatening ischaemia |
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Solar keratosis |
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How would you treat solar keratosis? |
Cryotherapy 5-flourouracil if problem is diffuse Curettage and cautery Photodynamic therapy Diclofenac gel Imiquimod (immune response modulator) |
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Intraepidermal carcinoma (Bowen's Disease) |
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What is Bowen's disease? |
An SCC in situ. Full thickness epidermal dysplasia. |
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How does Bowen's disease classically present? |
Scaley erythematous plaque on lower legs of elderly women. Can mimic eczema or psoriasis |
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How do you treat Bowen's disease? |
5-flourouracil cream Cryotherapy - but can --> ulceration Curettage and cautery Excision Photodynamic therapy Imiquimod |
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What represents 80% of skin cancers? |
Basal cell carcinoma |
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What are the subtypes of BCC? |
Nodula BCC Superficial BCC Morpheic/sclerosing BCC Pigmented BCC |
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Nodula BCC |
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Superficial BCC |
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Morpheic BCC |
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Pigmented BCC |
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Why would you use Moh's micrographic surgery and on which BCC in particular? |
If there are ill-defined excision margins or if there has been a previous incomplete excision. Morpheic BCCs classically have ill-defined margins. |
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How do the excision margins for BCCs compare to melanomas? |
BCC- 4mm margin Melanoma - 1-2cm margin |
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What is the 5 year recurrence rate of BCCs |
<2% |
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What are the non-surgical options for BCC treatment? |
Radiotherapy - can be as adjuvant or sole treatment. Risk of radionecrosis or SCC formation Imiquimod - cosmetic results better but recurrence higher Photodynamic therapy |
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Factors increasing the risk of BCC recurrence? |
Larger tumour Lesions of the central face Histological subtype - morpheic Histological features of aggression - perineural or perivascular invasion Previous treatment failure |
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SCC |
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What skin lesion is commonly seen in patients with neurofibromatosis type 1? |
Neurofibroma |
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What are the 3 types of neurofibroma? |
Discrete cutaneous neurofibroma Discrete subcutaneous neurofibroma Deep nodular neurofibroma |
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Discrete cutaneous neurofibroma |
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Discrete subcutaneous neurofibroma OR Deep nodular neurofibroma - involves tissues underneath the dermis |
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Epidermoid cyst - usually present on parts of body with little hair |
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Pilar cyst aka sebaceous cyst Smooth, mobile and filled with keratin |
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Keratocanthoma |
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How might a keratocanthoma present? |
Indistinguishable from SCC Rapid growth over few weeks which stops then shrinks. Often excised to rule out SCC |
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Cherry angioma |
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Haemangioma / Strawberry naevus - grow up to age of 3-4 years then regress which can take up to 10 years |
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Pyogenic granuloma / lobular capillary haemangioma |
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How do you treat pyogenic granuloma? |
Rarely resolve spontaneously so curettage and cautery otherwise can bleed following minor trauma |
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What are the risk factors for developing skin cancer? |
Long term UV exposure Fair skin Age Immunosuppression --> more aggressive tumours Genetic - Gorlin's syndrome in BCCs Sites of chronic inflammation HPV |
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Name 5 different types of skin biopsy |
Punch biopsy Shave biopsy Saucerisation biopsy Wedge biopsy Incisional biopsy Excisional biopsy |
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What is the underlying cause of psoriasis |
Increased turnover of skin due to increased keratinocyte proliferation |
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What are the common sites of psoriasis |
Scalp and extensor surfaces |
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What is the normal rate of skin turnover? |
Every 23 days |
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Describe chronic plaque psoriasis |
Salmon pink patches and plaques Well demarcated Silvery scales Extensor surfaces Symmetrical Nail changes |
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What nail changes would you expect to see in chronic plaque psoriasis |
Pitting Onycholysis - lifting of nail from nail bed Subungal Hyperkeratosis - due to XS proliferation of nail bed = accumulation of white material under nail Splinter haemorrhages |
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Chronic plaque psoriasis |
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Palmoplantar psoriasis |
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Flexural psoriasis - don't often get scaling, just erythema |
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How would you differentiate subherroeic dermatitis and flexural psoriasis? |
In sebhorroeic dermatitis in skin folds there tends to be salmon pink patches that are not as well defined as in flexural psoriasis |
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Guttate psoriasis |
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What causes guttate psoriasis? |
Acute streptococcal infection |
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Erythrodermic psoriasis |
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What is erythroderma? |
Where more than 90% of the body surface area is covered in a rash. |
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Pustular psoriasis - palmoplantar is the commonest form |
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In which demographic is palmoplantar pustular psoriasis more common? |
Female adult smokers. |
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What can cause the onset of generalised pustular psoriasis? |
Steroid withdrawal in chronic plaque psoriasis |
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What are the systemic complications of severe psoriasis? |
Heart, fluid and protein loss from severe inflammation Arthritis |
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Name 5 aggravating factors for psoriasis |
Strep throat infection Medications: Beta blockers, lithium, antimalarials Stress Alcohol and smoking Trauma or friction |
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What is kobner phenomenon? |
The tendency of skin conditions to occur within scars or sites of trauma |
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Name some topical treatments of psoriasis |
Coal tar Dithranol Vitamin D analogues Topical steroids Topical retinoids e.g. tazerotene |
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What are the cons of coal tar? |
Messy treatment that requires hospital admission, can cause irritation and folliculitis |
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When might you use dithranol? What are the risks of it's use? |
On thick psoriasis plaques. Can cause burning (avoid flexures) and staining (avoid face) |
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What are the second line treatments of psoriasis? |
Phototherapy PUVA Acitretin (oral retinoid) Methotrexate Ciclosporin Biological agents |
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What must you monitor with methotrexate treatment and why? |
LFTs - Liver fibrosis FBC - Bone marrow suppression |
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What are the side effects of ciclosporin therapy? |
Raised BP Renal dysfunction Hypertrichosis (extensive hair growth) Gum hypertophy Tingling peripheries Carcinogenesis |
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Granuloma annulare |
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Name the cutaneous manifestations of diabetes |
Granuloma annulare Necrobiosis lipiodica Fungal/yeast/bacterial infections Ulcers Diabetic dermopathy Acanthosis nigricans Rubeosis - flushed face Vitilligo Lipodystrophy Balanitis |
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Necrobiosis lipiodica - one or more tender yellowish brown patches develop slowly on the lower legs. They may persist for years. They may be round, oval or an irregular shape. The centre of the patch becomes shiny, pale, thinned, with prominent blood vessels (telangiectasia). A minor injury to an established patch can cause it to ulcerate. |
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Ulcer - multifactoral in diabetes |
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Diabetic dermopathy - atrophic hyperpigmented lesions on lower legs M>F |
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Acanthosis nigricans - hyperpigmentation and hyperkeratosis of skin |
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What are the causes of acanthosis nigricans |
Diabetes Adenocarcinoma of the stomach - especially if abrupt and severe onset |
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Pretibial myxoedema - discoloured pink or purple skin with prominent hair follicles like peau d'orange. Can be painful and pruritic |
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What percentage of Graves' disease patients get pretibial myxoedema? |
5% - and sometimes associated with under active thyroid |
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What causes pretibial myxoedema? |
Mucin deposition |
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Chilblain |
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What causes chilblains? |
They occur in SLE as a reaction to the cold. They are a localised form of vasculitis |
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Butterfly malar rash typical of acute lupus. Acute lupus is mainly associated with systemic disease. |
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How might chronic cutaneous (discoid) manifestations present in SLE? |
Inflamed plaques with scarring and atrophy |
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How might subacute cutaneous lupus present? |
Widespread, non scarring round or psoriasis like plaques in photodistribution |
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Name some other, non-specific, cutaneous manifestations of SLE. |
Vasculitis (might present with purpura) Alopecia Oral ulcers Palmar erythema Periungual erythema Raynauds |
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Acquired ichthyosis |
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What general systemic diseases are associated with acquired ichthyosis? |
Underactive thyroid states Sarcoidosis Lymphoma Generalised cancer HIV infection |
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What diseases cause Pyoderma gangrenosum? |
UC or Crohn's Myelodysplasia Myeloproliferative disorders Rheumatoid disease Diabetes |
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Dermatomyositis may also have proximal muscle weakness. Reddish, purple patches. Purple eyelids Purple spots on boney prominences - Gottron papules Cheeks, nose, shoulders, upper chest and elbows Ragged cuticles and prominent blood vessels on nail folds |
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What is dermatomyositis? |
A rare acquired muscle disease that is accompanied by a skin rash |
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What causes dermatomyositis? |
Ovarian, Lung, Colorectal, Pancreatic cancers and hodgkin's lymphoma |
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Erythema nodosum - red tender nodules on calves or shins |
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What are the triggers of erythema nodosum? |
Infection - streptococcal, TB Drugs - sulphonamides, OCP Systemic disease - sarcoidosis, Bechets, IBD |
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List the causes of cutaneous vasculitis |
Connective tissue disorders: SLE, RA, Wegeners granulomatosis Infection: Meningococcal septicaemia, Post strep, Hep C Drugs |
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How might you investigate a case of cutaneous vasculitis? Justify the investigations |
FBC and ESR Anti-nuclear antibodies (ANA) and extractable nuclear antigens (ENA) Anti-strep antibodies - recent strep infection Hep B and C serology Protein and immunoglobulin electrophoresis - detect blood disorders e.g. multiple myeloma Cryoglobulins - antibodies in blood that precipitate in cold Antineutrophil cytoplasmic antibody (ANCA). c-ANCA = Wegener granulomatosis |
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Cutaneous vasculitis |
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Urticaria |
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How long after drug initiation does a reaction occur? |
8-21 days |
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Erythema multiforme - target lesions with >3 colours Often have elevated vesicle/bulla in centre |
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What is the commonest cause of erythema multiforme? |
Herpes simplex infection |
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Stephens Johnson Syndrome |
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What are the main causes of erythema multiforme and stephens johnson syndrome? |
Sulphonamides Phenylbutazone NSAIDs Immunisations Mycoplasma infection EM is more common from infections |
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Toxic epidermal necrolysis |
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How would you manage a patient with toxic epidermal necrolysis? |
STOP THE DRUGS!! Supportive care for burns, ITU with hydration and nutritional support |
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How might you manage skin failure such as urticaria and erythema multiforme? |
Take clear history and establish cause. Treat cause e.g. with antivirals in HSV or by stopping drug. Give regular emollients for dryness and itching Very itchy rashes may require short term topical steroids
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How would you treat urticaria with anaphylaxis? |
Prompt antihistamine with I.V. hydrocortisone and I.M. Adrenaline |
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How would you manage severe palmoplantar psoriasis? |
More severe palmoplantar psoriasis usually requires phototherapy or systemic agents, most often: * PUVA* Acitretin * Methotrexate |
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List the topical retinoids used in acne |
Isotretinoin (isotrex) Tretinoin (retin-A) Adapalene (Differin) |
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Which skin condition is most closely associated with: 1. Diabetes 2. Sarcoidosis 3. Hyperthyroidism 4. Herpes simplex |
1. Necrobiosis lipoidica 2. Erythema nodosum 3. Pretibial myxoedema 4. Erythema multiforme |
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Name a common cutaneous manifestation of rheumatoid disease |
Granulomatous nodules on the elbow |
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What is acne rosacea? |
A chronic, relapsing and remitting disorder of blood vessels and pilosebaceous units in convex central face areas of fair skinned people |
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What may occur in men as a result of acne rosacea? |
Rhinophyma - swelling and soft tissue overgrowth of the nose. |
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What topical treatments can be given in acne rosacea? |
Axelaic acid +/- metronydazole for mild to moderate disease |
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What systemic treatments can be given to treat acne rosacea? |
Doxycycline and azithromucin |
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Rhinophyma |
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Acne rosacea |
