1
Q
Give 4 risk factors for malignant melanoma
A
- sun exposure
- severe sunburn in childhood
- fair hair and skin
- many naevi
- fhx
- solar keratosis
2
Q
What is the ABCDE of signs for a malignant melanoma?
A
Assymetry, irregular Boarder, Colour irregularity, Diameter >7mm, Evolving
3
Q
What are the referral criteria for a malignant melanoma? (major and minor criteria)
A
Major criteria (2pts): change in size, irregular shape, irregular colour Minor criteria (1pt): >7mm, inflammation, oozing, sensation change Need 3 or more points for 2WW
4
Q
What is the prognosis like for malignant melanoma?
A
5yr survival for men is 73% and 85% for women, so good
5
Q
What does a seborrhoeic keratosis look like? What are they?
A
- flat or crusty topped or wart looking lesions that seem stuck onto the skin, usually pigmented, well circumscribed, soft texture, may be itchy or inflamed after minor trauma but usually asymptomatic
- they are benign hyperketatotic skin lesions associated with ageing
6
Q
What do basal cell carcinomas look like? where do they appear and how fast to they grow?
A
- slow growing lesions usually on face/ sun exposed areas
- early lesions look translucent and pearly with rolled edges and telangiectasia
- late lesions have a ‘rodent ulcer’ appearance
7
Q
How should suspected BCCs be managed by a GP?
A
- routine referal if suspect BCC or excision in primary care
- 2ww if delay may have significant impact due to lesion size or shape or think may be SCC
- small BCCs can be treated with imiquimod cream
- prognosis very good as they rarely metastasise
8
Q
How do squamous cell carcinomas present?
A
- indurated nodular keratinising or crusted lesions which may ulcerate
- may present as non healing ulcer
- no pigment change
- found on sun exposed areas
9
Q
How should SCCs be managed by a GP?
A
- All should get 2WW
- most lesions can be excised in primary care
- large lesions of those in cosmetically sensitive or risky areas may have part of it biopsied before later surgery
- node biopsy and MRI may be indicated in advanced disease due to met risk, but will be initiated by secondary care
- Prognosis is good as few metastasise but if they have metastasised they are quite aggressive with 5yr survival 25-40%
10
Q
How does measles present?
A
- prodromal illness (cough, runny nose) for 3 days
- many have fever
- rash starts on face and spreads across body over 3-4 days
- rash is redish- brown, macules which coalesce to patches and can cover whole body, sometimes itchy
- rash will go within 3-4 days in order of appearance
11
Q
How should measles be managed by a GP?
A
- notifiable disease
- salivary swabs for measles specific immunoglobulin M for diagnosis
- paracetamol and ibuprofen
- advise good oral intake, stay at home to prevent spread of infection, monitor carefully
- Any infants, pregnant women or immunocompromised people who may have been exposed need post exposure prophylaxis with MMR vaccine or immunoglobulins
12
Q
Give 3 complications of measles
A
- pneumonia
- encephalitis
- diarrhoea
- increased risk of miscarriage and prematurity and pneumonitis in pregnancy (which is why pregnant ppl should stay away)
13
Q
How does rubella present?
A
- more mild prodromal illness followed by rash
- usually no fever
- rash is red- pink discrete macules that coalsece, starting behind ears and on face and then trunk and extremities
14
Q
How should rubella be managed in primary care?
A
- notifiable disease
- health protection unit will provide serological PCR testing kit for diagnosis
- no specific management- keep child away from school for 4 days after rash appears, encourage oral intake, paracetamol etc
- must keep away from pregnant women
- watch out for complications of encephalopathy, arthralgia and thrombocytopenia (bleeding)- all rare
15
Q
Why must pregnant women be kept away from children with measles?
A
causes serious birth defects if exposed in the first trimester
16
Q
How is a pregnancy managed if the women is IgM positive
for rubella in the first 16 weeks of pregnancy?
A
pregnancy is terminated
17
Q
How does erythema infectosum/ slapped cheek/ 5th disease present? What does the rash look like?
A
- prodromal illness (headache, rhinitis, sore throat, fever, malaise)
- 7-10 days after illness resolves a rash appears on the cheek (spares the nose)
- rash is red, macular/ morbiliform and not itchy
- rash on cheeks may disappear after a few days
- may get rash on extensor surfaces of extremities at same time as or after the cheek rash
18
Q
What virus causes slapped cheek/ erythema infectosum and how is it transmitted?
A
parovirus b19
transmitted by resp secretions
19
Q
Describe the incubation and infectious period of slapped cheek/ erythema infectosum?
A
- incubation period 4-20 days
- infective from 10 days pre rash
- not infective when rash present
20
Q
How should slapped cheek/ erythema infectosum be managed?
A
- no investigations needed unless pregnancy, immunocompromised or suspect aplastic crisis (rare)
- no specific treatment
- avoid pregnant people- 5% risk of miscarriage or fetal complications
- should all resolve within a couple of weeks
21
Q
How does roseola infantum present?
A
- high fever for 3-4 days with promdromal illness, diarrhoea and often swollen eyelids
- in younger infants (age 6 months- 1 yr)
- rash appears after fever
- rash is small pink spots on body then arms and legs, not usually on face
22
Q
What virus causes roseola infantum?
A
- human herpes virus 6 or 7
23
Q
How should roseola infantum be managed in primary care?
A
- just reassure
- mild infection with no long term problems, just reassure
24
Q
How does hand foot and mouth disease present?
A
- prodromal illness (fever, malaise, loss of appetite, sore mouth, throat and abdo pain)
- mouth lesions (yellow ulcers with red haloes) appear after prodrome
- skin lesions on hands and feet- start as 2-5mm macules but become vesicles, itchy and painful
- usually in infants and children younger than 10
25
What virus causes hand foot and mouth disease?
coxasckievirus or enterovirus
26
How should hand foot and mouth be managed by the GP?
- supportive treatment only
- lidocaine oral gel can ease pain from ulcers
- good hygiene to prevent spread
- refer to hopsital if signs of significant dehydration or neurological signs
- dont need to be kept away from school or pregnant women (no risk)
27
Give 3 complications of hand foot and mouth disease?
- secondary infection to scratched skin
- painful stomatitis leads to dehydration
- meningism
- cardioresp failure
(all rare)
28
How does scarlet fever present?
- sudden onset sore throat + fever and exudate on tonsils, headache, abdo pain common with it
- rash appears 12-48 hrs later
- rash appears on neck, chest, scapula and then legs and trunk later
- rash is red, macular and has a coarse sandpaper like texture
- tongue may start white and furry with red sports and then become red and inflamed with prominent papillae (strawberry tongue)
- usually in children <10
29
What causes scarlet fever?
exotoxin from strep pyogenes
30
How is scarlet fever diagnosed?
clinical diagnosis based on signs and symptoms
| - can do throat swab if unsure with 90% sensitivity
31
How is scarlet fever managed by the GP?
- penicillin or azithromycin for 10 days
- refer to hospital if difficulty swallowing or severe complication arises
- can do back to school after 24 hrs of abx
32
Give 3 complications of scarlet fever
| When are these complications more likely?
- mastoiditis
- peritonsilar abscess
- pneumonia
- meningitis
- post strep glomerular nephritis
- osteomyelitis
- septic arthritis
- rheumatic fever
These are more common in children who have had chicken pox recently
33
How does staphylococcal scalded skin syndrome present?
- fever, skin tenderness and sometimes a prodrome of sore throat and conjunctivitis
- then blisters and areas of red peeling skin appear, usually on back and trunk, which look like burns
- tends to affect children <5
34
What causes staphylococcal scalded skin syndrome?
- certain staph a releasing an epidermolytic toxin
35
How should staphylococcal scalded skin syndrome be managed?
- clinical diagnosis: can take swabs to confirm
- hospitalisation usually required to replace fluids and give IV flucoxacillin
- prognosis is however good, skin heals without scarring and mortality is low
36
Give 2 complications of staphylococcal scalded skin syndrome
- dehydration
- cellulitis
- pneumonia
37
How does impetigo present?
- red sores around the face and nose, sometimes the hand and feet
- they develop pop and develop honey coloured crusts
- there are bullous and non bullous forms (non bullous much more common)
- usually affects children but can affect any age
38
How is impetigo diagnosed and managed in primary care?
- diagnosis is clinical but swab may be useful if extensive or severe, MRSA suspected or fails to respond to treatment
- topical fusidic acid cream is 1st line
- oral flucoxacillin if extensive, resistant or causing systemic symptoms
- general measures in good hygeine and look out for complications such as scarlet fever, post strep GN, cellulitis, staph scalded skin syndrome
39
What causes impetigo?
- staph a or strep pyogenes infections of skin
40
How does kawaskai disease present?
- fever for >5 days
- irritable child age 6 months- 5 yrs
- bilateral conjucntivitis
- cervical lymphadenopathy
- confluent pink rash around genitals, on hands, cheek and feet 3-5 days after fever starts
41
What is kawasaki disease?
- rare idiopathic self limiting systemic vasculitis that usually affects children between 6 months to 5 years
- more common in asian children
42
How should kawasaki disease be managed?
- refer to paeds for investigtaions, diagnosis, IV immunoglobulins and aspirin
- TNFa inhibitors, steroids and stents may also be used
- they need ECG and echo as often get dilation and aneurysms of coronary arteries
43
How does tines corporis (ringworm) present?
- circular lesions
- well defined red rings, with pink- white skin inside, often raised
- lesions are often itchy and can get hair loss if affects scalp
- spreads between ppl, from soil and from animals
44
What causes tines corporis?
Dermatophytes- a group of fungi which invade and grow in dead keratin
45
How is tines corporis managed?
- imidazole cream (continue use for 1-2 weeks after lesion has gone)
- Good skin and nail hygiene
- avoid prolonged dampness of skin and feet. Loose fitting, clean underwear can help prevent
46
How does seborrhoeic dermatitis present?
- inflammed, itchy, red, raised, fine scaling/ flakey skin and/ or dandruff- (similar to eczema)
- found around skin folds (particularly around nose and nasolabial folds and/ or scalp)
47
What it thought to cause seborrhoeic dermatitis?
thought to be inflammatory reaction to a yeast which grows in oily areas of skin
48
How can seborrhoeic dermatitis be managed?
- Shampoos containing antifungals can be used if its affecting the scalp
- ketoconazole cream for 2-4 weeks +/- hydrocortisone cream for 1-2 weeks used for lesions on body
- oral antifungals can be used for severe or treatment resistant SD
49
How does pityriasis vesicolor present? (description, age group, time of year)
Areas of slightly hypo or hyperpigmented skin, which may be confluent or/ and made up of many smaller patches.
Tends to affect teens and young adults and worse in summer due to more sweat
50
How is pityriasis vesicolor treated?
- topical antifungals like ketoconazole (creams or shampoos)
- oral itraconazole may be used in wide spread or resistant areas
- may take several months to resolve
51
How does pityriasis rosea present?
- primary patch (herald patch) followed by distinctive generalised itchy rash 1-2 weeks later
- herald patch is usually a single erythematous, well defined lesion with some dry skin and can resemble ringworm
- the rash will last 5-8 weeks, lesions are small oval, dull pink and classically have a christmas tree distribution- usually affecting upper arms, legs and trunk
- may have prodromal illness before herald patch
52
How is pityriasis rosea managed?
- self limiting- will clear up without treatment within 5-8 weeks
- emollents, topical steroids and sedative anti histamines (at night) can help with the itching
- refer to derm if persists for >12 weeks, itch is severe or diagnosis is unclear
- small risk of miscarriage if contracted early in pregnancy
53
How does eczema present?
- itchy, red lesions on the flexor aspected on joints
- can be acutely inflamed or with dry skin
- often with history of asthma or hayfever
- usually first presents in childhood (rashes tend to be on extensor aspects, the neck and cheeks in babies)
- patient oriented eczema measure (POEM) can be used to asses severity
54
Give 5 potential triggers fo eczema
- irritants (soaps, detergents)
- infections (staph)
- allergens (dust mite, metals)
- humidity
- certain foods
55
How is mild eczema managed?
- lots of emmollients (E45, QDS, liberally, best when skin is a bit moist) and 1% hydrocortisone cream
56
How is moderate eczema managed?
- emollients + betamethasone valerate 0.025% or 1% hydrocortisone on face + cetirizine for itch
57
How is severe eczema managed?
- emollient + 0.1 % betamethasone valerate + cetiritizine
58
When should eczema be referred to secondary care?
not able to control with emollent and 0.1% betamethasone or recurrent secondary infections
59
how should infected eczema be managed?
14 days flucoxacillin
| step up eczema management
60
What causes acne?
- thought to be due to blocked sebaceous glands due to increased sebum production (causing white (closed comedome) or black heads (open comedome))
- Which can become inflammed and/ or infected by propionibacteria leading to papules, pustules and nodules
61
What is 1st line management for acne?
- topical adapalene +/- benzyl peroxide 5%
- can step up to 10% benzyl peroxide (may cause peeling and burning sensation)
- can add 1% clinamycin cream with it
62
What is 2nd line management for acne? (or for back acne)
- lymecylcine or doxycyline for 3 months + adapalene +/- benzyl peroxide
- this can take 3 or 4 months to work
63
How can acne associate with periods be better controlled?
COCP often works
64
When should acne be referred to secondary care for isotetrion?
- severe
- scarring
- multiple treatments have failed
- significant psychosocial stress
65
Give 3 types of psoriasis and what they look like?
- plaque/ vulgar psoriasis: raised, red, scaley lesions, usually on extensor aspects and on scalp
- Guttate: multiple smaller lesions, which look like spots but with scaley tops
- inverse psoriasis: associated with skin folds
- pustular: pustules (white heads) on larger raised red lesions- doesnt always have scaling
- Psoriasis erythroderma: severe form of plaque psoriasis with more inflammation and peeling of skin leading to large areas of inflamed skin
- most present before age 35, its uncommon in children and 30% have fhx
66
What causes psoriasis?
T cell mediated autoimmune disorder causing keratinocyte hyperproliferation
67
What may trigger or relieve psoriasis?
- sunlight often improves it
| - infections, stress, smoking, alcohol, post partum hormone changes and trauma may make it worse
68
What is 1st line management for psoriasis?
- topical potent corticosteroids (1% betamethasone), Vit D analogues and emollients
69
What are 2nd line management options for psoriasis?
- uv and phototherapy
- ciclosporin
- methotrexate
- acitrein
70
What is 3rd line management for psoriasis?
- enteracept
| - infliximab
71
When should you refer someone with psoriasis?
- diagnostic uncertainty
- covers >10% body
- not responding to first line management
- significant psychosocial stress
72
Give 5 common triggers for urticarial rash?
- allergens (foods, bites, stings, meds)
- viral infections
- skin contact with irritants
- physical stimuli (rubbing, nettels, latex)
73
Name and describe 2 subtypes of chronic urticaria? (lasting >6 weeks)
- idiopathic
- autoimmune
- inducible dermatographism: hot/ cold water, rubbing, vibration, exercise, emotion or sun induce urticarial rash
74
How is urticaria managed?
- avoid triggers
- antihistamine creams
- cetirizine (non sedating) up to 4 times normal dose
- if severe give 40mg pred for 7 days
- avoid antihistamines in pregnancy
- anti leukotrienes (monteleukast) and biologicals can be used for chronic urticaria in secondary care
75
How does rosacea present?
- recurrent episodes of erythema, telangiectasia, papules and pustules on cheeks and nose
- rhinophyma (enlarged nose) is associated and only usually occurs in men
- most common in Caucasians, women and peak onset is age 30-60
76
How is rosacea managed? (5)
- avoid triggers
- topical metronidazole or azelaic acid is 1st line
- if mod to severe papulopustular you can give oral lymecyline or doxy
- refer to derm if psychosocial stress, not responding after 12 weeks treatment or uncertain diagnosis
- refer to plastics if prominent rhinophyma
77
How does folliulitis present?
- small red papules, often in grid like distribution
78
What causes folliculitis? What are the risk factors?
- causes can be staph infections, fungal infections, physical or chemical irritation or rarely autoimmune
- uncut beard, shaving against the grain, thick hair, tight clothing or excessive sweating can trigger
79
How should folliculitis be managed?
- avoid precipitating factors
- moisturise and anit bac shaving products
- reduce shave frequency and shave with grain
- topical anti septics like clorhexidine can help
- oral flucox for 4-6 weeks for deeper, severe or recurrent infections
80
How long should topical steroids be used for the face and body?
- on face, only use 1% hydrocortisone and try to use for <5 days
- on body can use 1% hydrocort, 0.025% betamethasone or 0.1% betamethasone (not in children without specialist advice) and try to use for <14 days
Y3 GP
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