1
Q
def eczema
A
pattern of inflammation on the skin
inflamed, dry, occasionally scaly and vesicular skin rash
2
Q
clinical features of eczema
A
acute eruption: erythema, vesicular/bullous lesions, exudates
secondary bacterial infection: above + golden crusting
chronicity of inflammation: increased scaling, xerosis (dryness), lichenification
3
Q
pathophysiology of atopic eczema
A
mutation of filaggrin gene breakdown of skin barrier function inflammatory cascade (Th2 cell)
4
Q
endogenous type of eczema
A
seborrhoea dermatitis varicose eczema discoid eczma atopic eczema pompholyx
5
Q
exogenous types of eczema
A
irritant eczema
allergic eczema
photodermatitis
6
Q
secondary changes in eczema
A
lichen simplex
asteatotic
pompholyx
infection
7
Q
def pompholyx
A
relapsing-remitting vesicular eruption affecting palms and soles
associated with increased sweating
8
Q
def eczema herpeticum
A
rare but severe disseminated infection with herpes simplex
9
Q
presentation of eczema herpeticum
A
fever grouped vesicles eroded, punched out lesions rapidly worsening, painful eczema usually on neck/face
10
Q
diagnostic critetria for atopic eczema in children
A
- child has itchy skin condition AND 3 of the following
- visible flexural dermatitis (asian and black children may have it on extensor surfaces)
- personal history of flexural dermititis
- personal history of dry skin in th last 12/12
- personal history of asthma or allergic rhinitis (or history of first degreee relative)
- onset of signs and symptoms under the age of 2 y
11
Q
treatment of atopic eczema
A
- education (recognising flare ups)
- emollient therapy (oitments and creams, soap substitutes)
- topical steroids (for flare ups)
- antibiotics for infection
step up from topical treatment:
- phototherapy
- azathioprine
- ciclosporin
- biologics
12
Q
epidemiology of psoriasis
A
- men and women are equally affected
- presents in mid 20s typically
- genetic component
13
Q
triggers of psoriasis
A
- medications (antimalarials, NSAIDs, beta blockers, lithium, terbinafine)
- alcohol
- psychological stress
- infection
14
Q
pathogenesis of psoriasis
A
- epidermal hyperplasia (thickening and scaling): keratonocyte function dysregulated: increase in prod of keratonocytes and cell transit time in epidermis
- angiogenesis: auspitz sign
- T cell infiltration in skin
15
Q
what is Auspitz sign
A
keratonocytes that are poorly adherent and easily scraped off revealing underlying dilated blood vessels
16
Q
presentation of psoriasis
A
- plaques on elbows, knees, scalp and trunk (may improved with sun, only midly itchy)
- scaling
- erythema
- pustules (palmo-plantar pustulosis and deep seated yellowish sterile pustules)
- Koebner’s phenomenon
- nails: pitting, onycholysis, subungal hyperkeratosis, oil spots, beau’s lines, splinter haemorrhage
17
Q
what is Koebner’s phenomenon
A
psoriasis in scares and areas of minor skin trauma
18
Q
types of psoriasis
A
- chronic stable plaque psoriasis
- guttate psoriasis
- flexural psoriasis
- unstable psoriasis
- pustular psoriaisis
- psoriasis arthropathy
19
Q
chronic stable plaque psoriasis features
A
persistent symmetrical plaques
20
Q
gutatte psoriasis features
A
- most seen in children
- can be triggered by sore throat
- small, numerous patches < 1 cm across
- must refer to dermatology if covers > 50% of body surface area
21
Q
flexural psoriasis features
A
- affects genitalia and axillae
- erythematous, slightly shiny appearance
22
Q
unstable psoriasis features
A
- plaques lose clear cut edges, enlarged and join up
- erythrodermic psoriasis: erythema over 90% of body (+ if unwell, admit for treatment)
23
Q
pustular psoriasis deatures
A
present either as
- palmo-plantar pustulosis (red areas contain mix of new yellow pustules and older brown dried up pustules)
- widespread pstular psoriasis (needs urgent hospital admission)
24
Q
psoriatic arthropathy features
A
- affects distal interphalangeals
- symmetrical polyarthritiss
- assymetrical oligoarthitis
- arthritis mutilans
- spondyloarthropathy
25
investigations for psoriasis
- determine severity of disease and response to treatment
- history
- examination
26
treatment of sporiasis
- education
- emolients
- topical steroids
- vit D analogues
- phototherapy (UVB or PUVA, 2-3 times a week for 10/52)
- systemic (if failed phototherapy): ciclosporin, methotrexate, acitritin, fumaric acids, apremilast
- biologics (for PASI and DLQI > 10): TNFi, IL12/IL13i, IL17i
27
what do you use to determine severity of disease in psoriasis
- PASI (psoriasis area severity index): obj measure of disease severity
- DLQI (dermatology of life index): impact of disease on patient's life
- PEST (psoriasis epidemiology screening tool: screen for psoriasis arthritis
28
complications of psoriasis
MI
T2DM
hyperlipidaemia
metabolic syndrome
29
acne vulgaris def
expansion and blockage of hair follicles and sebaceous gland and inflammation
30
aetiology of acne vulgaris
- familial tendency
- endogenous/exogenous androgenic hormones
- acne bacteria
- innate immune activation w/ inflam mediators
- distention and occlusion of hair follicles
31
causes of flares in acne vulgaris
- PCOS
- drugs (steroids, hormones, anticonvulsants, epidermal growth factor receptor inhibitors)
- application of occlusive cosmetics
- high environmental humidity
- diet high in dairy and glycaemic foods
32
acne vulgaris clinical features
- open and closed uninflamed comedomes (blackheads and whiteheads)
- inflammed papules and pustules
- nodules and pseudocysts
- post inflammatory erythematous or pigmented macules and scars
33
acne vulgaris pathophysiology
- early comedome: accumulation of epithelial cells and keratin, plugginf
- late comedone; accumulation of shed keratin and sebum
- inflammatory papule/pustule: propionbacterium acnes proliferation and mild inflammation
- nodule/cyst: marked inflammation, sscarring
- androgens: hyperkeratinisation, increase sebocyte differentiation and production
34
severity grading in acne vulgaris
- mild acne: total lesion count < 30
- moderare acne: lesions: 30-125
- severe: > 125
35
differentials of acne vulgaris
acne rosacea
acne congloblata
pyoderma faciale
acne exorciee
36
treatment of acne vulgaris
```
LIFESTYLE
- avoid humidity
low glycaemic, dairy and protein diets
- stop smoking
- avoid cosmetics and abraasive skin treatment
- exposure to sunlight
```
MILD ACNE
- topical antiacne agents
- low dose COC
- antiseptic or keratolytic washes (contains salicylic acid) ie benzyol peroxide
- light/laser therapy
MODERATE ACNE:
- as for mild +
- tetracycline daily for 6m
- antiandrogen therapy
- isotretinoin (if failed response to topical retinoid and oral antibiotics for 3m)
SEVERE ACNE
- referral to dermatologist
- oral antibiotics
- oral isotretinoin
37
ACNE types of drugs that inhibit sebaceous gland function
anti androgens
oestrogens
isotretinion
38
ACNE drugs that normalise pattern of follicular keratinisation
topical retinoids
39
ACNE drugs with anti-inflammatory effects
anibiotics
| corticosteroids
40
ACNE drugs with antibacterial effects
antibiotics
benzyol peroxide
retinoids
41
acne conglobata/fulminans
- severe form of acne
- more common in boys and in tropical climates
- extensive, nodulocystic acne and abscess formation affecting trunk, face and limbs
42
presentation of rosacea
- facial flushing and persistent eryhtema (exacerbated by heat, excercise, hot or food/drinks, emotion, alcohol and sunlight)
- telangiectasia (causing permanent facial eryjthema)
- inflammatory papules
- pustules
- absence of comedomes
- oedema
- can be on cheek or nose
- chronic (coarse in texture, rhinophyma)
- associated symptoms: conjunctivitis, blepharitis, eyelid oedema
43
treatment of rosacea
avoid exacerbators
topical treatment:
- water based emolients
- metronidazole gel/cream
- ivermectin 1% cream
- azelaic acid
- tacrolimus cream
Systemic treatments:
- tetracycline antibiotics
- low dose isotretinoin
44
differentials of rosacea
- acne (wider distribution, improvement with sunlight)
- seborrhoeic eczema (no pustules, eczematous changes present, scalp flaking)
- SLE (light sensitivity, erythema, scarring, no pustules)
- perioral dermatitis (pustules and erythema around chin, precipitated by potent topical steroids and premenstrual exacerbation)
45
def actinic keratoses
pre cancerous area of thick, scaly or crusty skin
46
presentation of actinic keratoses
- on face, dorsal hands, distal limbs, bald scalp (exposed skin)
- Hx of working outdoors or high intensity UV
- rough areas of skin to raised keratotic lesion
- irregular edge < 1cm
47
management of actinic keratoses
- removal
- liquid nitrogen
- topical treatment: (5FU cream, diclofenac, ingenol mebutate gel)
- photodynamic therapy
- observation
48
risks of actinic keratoses
- further actinic keratoses
| - increase risk of SCC, BCC and melanoma
49
what is the most common skin cancer
basal cell carcinoma
50
risk facrtors for BCC
- age
- fair skin
- high intensity UV exposure
- radiation
- immunosuppression
- previous Hx of BCC or other skin cancers
- Gorlin's syndrome
51
presentation of BCC
- usually on sun exposed area
- lesion starts as small papule and slowly grows
- colour: clear to deeply pigmented
- spontaneous bleeding or ulceration
- rolled edges
52
complications of BCC
- reccurent BCC
| - metastasis (rare)
53
types of BCC
- nodular lesions
- superficial lesions
- pigmented lesions
- pigmented lesions
- morphoeic or sclerosis lesions
54
management of BCC
- excision (Mohs surgery)
- grapting
- curettage and cautery
- radiotherapy
- cryotherapy
- imiquimif 5%
55
bad prognosis of BCC
- lesions involving eyelid margins, ear and lips
- perineural invasion on histology
- recurrent lesion
- lesions in immunosupressed patients
56
def SCC
dysplastic proliferaton of abnormal keratinocytes
57
risk factors for SCC
- increasing age
- fair skin
- smoking
- high intensity UV exposure
- radiation
- immunosuppression (HPV or renal transplant)
- previous hx of SCC
- xeroderma pigmentosum
- will dvlp in any chronic wound or scar
58
pathophysiology of SCC
- de novo
- pre existing skin lesion (actinic keratoses or bowens disease)
- gene mutation (BCL2, RAS, p53)
- alterations in intracellular signal transduction pathways
59
investigations for BCC
biopsy
60
presentation of SCC
- high risk sites: lip, ear, hands/feet, genitalia
- rapidly growing nodular lesions
- painful
- markerdly keratotic
- surface changes (crusting, ulceration, formation of a cutaneous horn, may be verucuous)
61
managament of SCC
prophylaxis:
- education
- UV protection
with lesion:
- surgival excision + grafting
- radiotherapy
62
SCC worse prognosis if
- immunosupression
- lesions on lips or ear
- tumours > 2cm in size
- invasion > 4mm
- perineural invasion
- poorly differentiated
63
NICE weighted 7 point checklist of pigmented lesion
Major features (scoring 2 points each):
- change in size
- irregular shape
- irregular colour
Minor features (scoring 1 point each):
- >7 mm diameter
- inflammation
- oozinf
- change in sensation
2WW referral if > 3
64
worrying features of pigmented lesion: ABCDE approach
```
Assymetry (Can be first sign of melanoma)
Border (irregular, blurred)
Colour (More than 3 colours)
Diameter (>6mm)
Evolution (Sudden onset/change)
```
65
def melanocytic naevus
mole
66
types of naevi, location and appearance
- junctional: mel present in dermo-epidermal junction. Brown colour and flat
- intradermal: mel found in dermis. skin coloured and raised
- compound: mel found in dermo-epidermal junction and within dermis. Brown and raised
67
risk factors for melanoma
- age
- fair, freckled skin, burns easily
- large nb of moles
- atypical moles
- personal/FH of melanoma
- UV radiation
- immunocompromised
- inflam conditions (IBD)
- obesity
68
pathophysiology of melanoma
50% arise from pre-existing moles
| 50% de novo
69
what is development of melanocyte into melanoma
```
melanocyte
benign mole
atypical mole
melanoma in situ
radical growth phase melanoma
vertical growth phase melanoma
```
70
types of melanoma
- superfical spreading melanoma
- nodular melanomas
- lentigo maligna melanomas
- acral lentigious melanoma
71
presentation of melanoma
- existing/new mole changing rapidly over periods of weeks to months
- colour: brown, blacks, grays and red
- diametre: > 7mm or 'ugly duckling'
- if mole inflammed or reddish edge, bleeding, oozing or crusting, starts feeling itch/pain
- regression: pale around mole
72
management of melanoma
- excision of lesion with narrow margin of normal skin (do not need bipsy, must be done same day/Week)
- BRAF inhibitors (if BRAF V600 mutation and stage 3-4)
73
likely places of metastasis of melanoma
```
nodal
lung/pleura
brain
liver
bone
```
74
prognosis of melanoma
- related to depth of invasion (Breslow thickness: distance in mm from granular layer in epidermis to deepest level of invasion in dermis)
- nodular melanoma worse prognosis
75
indications for 2WW for moles
- a new mole growing quickly in a patient
- a long standing mole which is changing in shape and colour
- a mole which has >3 colours and lost its symmetry
- any new nodule which is growing, and is pigmented or vascular in appearance
- new pigmented line in a nail
- something growing under a nail, especially if there is vascular tissue or pigment
76
causes of widespread itch
neuro:
- peripheral neuropathy
- post herpatic neuropathy
- MS
psychogenic:
- parasitophobia
- OCD
- depression/anxiety
metabolic:
- hyperthyroidism
- CKD (secondary hyperparathyroidism, uraemic pruritis)
- diabtes
GI:
- cholestasis
Malignancy:
- Hodgkin's pruritis
- myeloid and lymphatic leukaemia
- solic malignant tumours (paraneoplastic manifestations)
haematological:
- Polycythaemia rubra vera
- myeloid dysplasia
infection:
- HIV
Hep C
drugs
77
skin markers of internal malignancy
- acanthosis nigricans: gastric adenoma
- figurate erythema: bronchilal/oesophageal/breast carcinoma
- pruritis: lymphoma
- dermatomyositis: lung/breast/ovarian/testicular carcinomas
- acquired ichthyosis: Hodgkin's disease, sarcoma, lymphoma
78
def seborrhoeic keratoses
benign epidermal skin lesion in older people
79
features of seborrhoeic keratoses
- large variation in colour from flesh to light brown/black
- have a stuck on appearance
- keratotic plugs on surface
80
managemen,t of seborrhoeic keratoses
- reassurance about benign nature
| - option for removal
Year 4
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