Venous leg ulcer MC location, Ix + Mx
- Above the medial malleolus as this region is particularly susceptible to venous hypertension
- ABPI - to assess for poor arterial flow which could impair healing
- ankle pressure/arm pressure
- <0.9 indicates reduced perfusion + possible PAD
- Mx:
- compression bandaging, usually four layer (only treatment shown to be of real benefit)
- oral pentoxifylline, a peripheral vasodilator, improves healing rate
guttate psoriasis Vs pityriasis rosea
PR Mx: They may require symptomatic treatment if bothered by itching. This may include emollients, topical steroids or sedating antihistamines at night to help with sleep (e.g. chlorphenamine).
adverse effect of topical steroid in dak skin
steroid-induced depigmentation
lichen planus features, causes and Mx
features:
- itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms
- rash often polygonal in shape, with a ‘white-lines’ pattern on the surface (Wickham’s striae)
- Koebner phenomenon may be seen
- oral involvement in around 50% of patients: typically a white-lace pattern on the buccal mucosa
- nails: thinning of nail plate, longitudinal ridging
Causes
- drug eruptions - gold, quinines, thiazides
Mx:
- potent topical steroids
- benzydamine mouthwash or spray is recommended for oral lichen planus
- extensive lichen planus may require oral steroids or immunosuppression
scabies: Mx, severe form [when it occurs and how its managed]
Mx:
- permethrin 5% is first-line [topical]
- malathion 0.5% is second-line [topical]
- apply the cream all over the body including scalp and allow to sit for 8-12 or 24 hours respectively.
- repeat treatment 7 days later
severe form = Crusted (Norwegian) scabies
- seen in patients with suppressed immunity, especially HIV
- skin is crusted and teeming with mites [yikes]
- Mx = oral ivermectin.
what does this describe:
generalised monomorphic blistering rash, some of which have ruptured to release a clear yellow fluid. Some of the blisters have central dimples. A 5cm by 6cm patch over the chest contains pustules and honey-coloured crusted erosions
eczema herpeticum
what does this describe + what is the Mx:
- monomorphic punched-out erosions (circular, depressed, ulcerated lesions) usually 1-3 mm in diameter
eczema herpeticum
Iv aciclovir - generally admit pts for treatment due to the risk of rapid dissemination, systemic involvement, and potential complications such as secondary bacterial infection or encephalitis
- what is erythema multiforme
- causes
- features
- a hypersensitivity reaction that is most commonly triggered by infections. also triggered by drugs and can be idiopathic
- minor form affects skin only
- major form affects mucosa as well as skin
Causes:
- viruses:
- bacteria
- drugs: allopurinol, NSAIDs, oral contraceptive pill, penicillin, carbamazepine
- idiopathic
Features:
- target lesions
- initially seen on the back of the hands / feet before spreading to the torso
- upper limbs are more commonly affected than the lower limbs
- pruritus is occasionally seen and is usually mild
acne brief pathophysiology and classification
- characterised by the obstruction of the pilosebaceous follicles with keratin plugs which results in comedones, inflammation and pustules
classification
- mild: open and closed comedones with or without sparse inflammatory lesions
- moderate acne: widespread non-inflammatory lesions and numerous papules and pustules
- severe acne: extensive inflammatory lesions, which may include nodules, pitting, and scarring
actinic keratosis Vs bowens Vs SCC
- mx
AK and bowen’s are both precursors to SCC but develop via different pathways.
AK:
- multiple scaly, erythematous plaques with yellowish crust and ill-defined borders on a bald, sun-exposedareas [scalp MC]. May be pink, red, brown or the same colour as the skin
Bowen’s
- presents as a solitary, well-demarcated, erythematous, scaly patch with a “velvety” surface rather than multiple thin crusted plaques. Histologically, it represents squamous cell carcinoma in situ
Mx of both = 5-fluorouracil [1st], imiquimod [2nd] cryotherapy [3rd or if pt declines creams] also sun avoidance and sun creams are supportive measures.
- surgical excision may be preferred for bowens for certainty and complete removal
causative organisms of eczema herpeticum
- herpes simplex virus 1 or 2.
- Coxsackievirus A16
- vaccinia virus
rosacea:
- features
- mx
- referral criteria
Features
- typically affects nose, cheeks and forehead - naso-labial fold involvement.
- flushing is often first symptom
- telangiectasia are common
- later develops into persistent erythema with papules and pustules
- rhinophyma
- ocular involvement: blepharitis
- sunlight may exacerbate symptoms
Mx:
- topical ivermectin
- topical metronidazole
- topical azelaic acid
- topical ivermectin + oral doxycycline for severe cases
- topical brimonidine if flushing and erythema are main sx [alpha adrenergic agonist]
Referral:
- rhinophyma - requires isotretinoin
- no improvement with optimal Mx in primary care
what is lichen sclerosis
- Sx
- Mx
- Complications
- An inflammatory condition causing atrophy of the epidermis => white plaque formation. MC affects the genitalia in elderly women
- Sx: itching, pain during sex or urination.
- Mx = potent topical steroid - [clobetasol] + emmolients
- Complication: increases risk of vulval cancer t4 need monitoring
what is Dermatitis herpetiformis and what causes it
Dermatitis herpetiformis is a blistering skin condition linked to coeliac disease. The condition is caused IgA deposition in the dermis
what is erythema nodosum
- features
- causes
- Ix
Erythema nodosum = inflammation of the subcutaneous fat => tender, erythematous, nodular lesions MC found on the shins
CFs:
- lesions are tender
- usually occurs over shins, may also occur elsewhere (e.g. forearms, thighs)
- usually resolves within 6 weeks
- lesions heal without scarring
Causes:
- infection: TB, streptococci
- systemic disease: sarcoidosis, IBD, Behcet’s
- drugs: penicillin, COCP
- malignancy / lymphoma
- pregnancy
Ix: look for underlying cause:
- chest x-ray (to assess for sarcoidosis, tuberculosis, other pulmonary infections, and lymphoma)
cellulitis 1st line Tx and alternatives for pen-allergy
- flucloxacillin
- allergy:
- clidamycin
- cephalexin if the allergy is not severe
Scabies:
- how long after contracting scabies do symptoms appear
- RFs for contracting scabiies
- ~ 6 weeks
- living in crowded areas e.g. care homes and also extremes of age.
what is bullous pemphigoid and what causes it
- Bullous pemphigoid is an autoimmune condition causing sub-epidermal blistering of the skin.
- This is secondary to the development of antibodies against hemidesmosomal proteins BP180 and BP230.
bullous pemphigoid Ix and Mx
Ix:
- immunofluorescence shows IgG and C3 at the dermoepidermal junction.
Mx:
- oral corticosteroid
- topical corticosteroids, immunosuppressants and antibiotics are also used
how is body percentage calculated in burns pts
Wallace’s Rule of Nine: Each of the following is 9% of the body when calculating surface area % if a burn:
- Head + neck,
- each arm,
- each anterior part of leg,
- each posterior part of leg,
- anterior chest,
- posterior chest,
- anterior abdomen,
- posterior abdomen
why is total body surface area required in burns pt management
Accurate TBSA calculation is crucial for determining fluid resuscitation requirements in burn patients - using the parkland formula
initial Mx for burns pts
Fluid resuscitation
- Accurate TBSA calculation is crucial for determining fluid resuscitation requirements in burn patients.
- calculated using the Parkland formula
- (4 mL × weight in kg × %TBSA)
- half given in the first 8 hours and the remainder over the next 16 hours
scleroderma vs dermatomyostitis - key difference
internal organ involvement, distinguishes scleroderma from dermatomyositis
emergency complications of psoriasis
- Suspected generalised pustular psoriasis (emergency)
- Suspected erythrodermic psoriasis (emergency)
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