Phase 2A Revision 24 th April 2015 Ashy Rengit The Peer Teaching Society is not liable for false or...

Phase 2A Revision 24 th April 2015 Ashy Rengit The Peer Teaching Society is not liable for false or misleading information

Acne Eczema Psoriasis Skin ulceration Venous, arterial, neuropathic, infective, traumatic, vasculitic Skin cancer Squamous cell carcinoma, basal cell carcinoma, melanoma Infections Cellulitis, necrotising fasciitis The Peer Teaching Society is not liable for false or misleading information Topics

The Peer Teaching Society is not liable for false or misleading information Acne: Basic Science http://www.gloaesthetics.sg/images/hair_anatomy.gif Definition Inflammation of pilosebaceous skin unit Epidemiology Often pubertal Commonly (not always) with age Pathophysiology Bacterium Staphylococcus epidermidis Pityrosporum yeast Propionibacterium acnes Follicular hyperkeratinisation + pilosebaceous duct obstruction Increased production + impaired flow of sebum

The Peer Teaching Society is not liable for false or misleading information Acne: Subtypes http://www.gloaesthetics.sg/images/hair_anatomy.gif Acne vulgaris Most common type (ref: clinical presentation) Acne Rosacea Affects mostly women aged 30+ Red rashes on nose, cheeks, forehead & chin Blackheads are unlikely

The Peer Teaching Society is not liable for false or misleading information Acne: Subtypes http://www.gloaesthetics.sg/images/hair_anatomy.gif Acne Conglobata Most severe subtype Commonly found in males Multiple interconnected large lesions ( face, back, chest, upper arms & thighs) Acne Fulminans Usually found in young men Scarring (disfigurement) Ulcers and cysts

The Peer Teaching Society is not liable for false or misleading information Acne: Subtypes http://www.gloaesthetics.sg/images/hair_anatomy.gif Gram-negative Folliculitis Bacterial infection associated with longterm Acne vulgaris (antibiotic) treatment Associated with pustules and cysts Rosacea Fulminans Aka Pyoderma Faciale 20 to 40 year old females Large, painful nodules/ pustules (scarring) May occur without previous history of acne

The Peer Teaching Society is not liable for false or misleading information Acne: Clinical Presentation http://www.gloaesthetics.sg/images/hair_anatomy.gif History Demographic: puberty PMH: PCOS (polycystic ovarian syndrome), Cushings syndrome, prolactinoma Acute onset, skin greasy/ painful Examination Blackheads Closed comedones oxidation of melanin pigment Whiteheads Open comedones Papules Solid, raised lesion with no fluid Pustules Solid, raised lesion containing fluid or pus Nodules Solid, raised lesion with no fluid (larger than papules) Cysts Fluid filled sac beneath the skin

The Peer Teaching Society is not liable for false or misleading information Acne: Management http://www.gloaesthetics.sg/images/hair_anatomy.gif Investigations BLOOD Luteinising hormone levels ( LH:FSH in PCOS) Prolactin ( in prolactinoma) Sex-hormone binding globulin Testosterone 17-OH-progesterone (Congenital adrenal hyperplasia) URINE 24 hour urinary cortisol ( in Cushings syndrome) IMAGING Pelvic ultrasound (ovarian cysts, PCOS) Treatment Mild/ moderate acne Non-greasy cosmetics/ creams OTC benzoyl peroxide/ azelaic acid Moderate/ severe acne Topical antibiotic e.g. Clindamycin (blocks bacterial ribosomes) Vit. A derivatives (retinoin) Severe inflammatory acne OR failed topical treatment Systemic antibiotics e.g. erythromycin or oxytetracycline Severe acne Oral vitamin A (isoretinoin) SE: Teratogenic, hyperlipidaemia Female: should take contraceptive pill or cyproterone acetate (antigonadotropin)

Definition Pruritic (itchy) papulovesicular ( papule solid raised lesion, vesicle filled with fluid) skin reaction to endogenous or exogenous agents Pathophysiology of the subtypes Irritant eczema: prolonged skin contact with cell-damaging irritant (e.g. ammonia) Contact eczema: Type 4 delayed hypersensitivity reaction (e.g. perfumes or latex) Atopic eczema Impaired epidermal barrier function due to structural abnormality (increased sensitivity) Immune function disorder (inflammatory response to environ by Langerhans and T cells) Seborrhoeic eczema (Pityrosporum yeast mediated) Varicose eczema: Increased venous pressure in lower limbs The Peer Teaching Society is not liable for false or misleading information Eczema: Basic Science

The Peer Teaching Society is not liable for false or misleading information Eczema: Subtypes Contact & Irritant Often a well-localised rash Acute inflammation Autosensitisation possible (spread to other sites) Atopic Acute inflammatory rash with dry and scaly patches Common on face and flexures (elbows and knees)

Seborrhoeic Yellow, greasy scales on erythematous plaques Nasolabial folds, eyebrows, scalp and presternal area Pompholyx Acute and recurrent Painful vesiculobulbous eruption Palms and soles The Peer Teaching Society is not liable for false or misleading information Eczema: Subtypes

Varicose Eczema in lower limbs Associated with marked varicose veins May spread to forearms Nummular Coin shaped rashes On legs and trunk The Peer Teaching Society is not liable for false or misleading information Eczema: Subtypes

Asteatotic Dry patterned patches Often occurs in the elderly History on presentation Severe itching Heat, tenderness, redness Occupational exposure e.g. bleach Family history of atopy e.g. asthma Examination Acute Poorly demarcated dry scaly patches (red and inflamed) Papules/ vesicles with exudation and crusting (scratch marks) Chronic Thickened epidermis (lichenification/ fissures) Change in pigmentation The Peer Teaching Society is not liable for false or misleading information Eczema: Subtypes

Investigations SKIN PATCH TESTING Contact dermatitis Diluted allergen applied to part of skin After 48 hours red raised lesion TESTING IgE LEVELS Not used routinely or currently recommended SKIN SWAB Infected lesions Commonly Staph. aureus, Herpes simplex (life-threatening) and Molluscum contagiosum *Eczema + Thrombocytopenia (haematological malignancy) = WISKOTT-ALDRICH SYNDROME Treatment Irritant or contact dermatitis Avoid precipitant/ protection (gloves) Atopic dermatitis Avoid precipitant Emollient creams and soaps Low potency steroids/ antihistamines Tacrolimus (calineurin inhibitor) if severe Systemic immunosuppression/ phototherapy as a last resort Seborrhoeic dermatitis 1% hydrocortisone cream + antifungal (ketoconazole shampoo for scalp) Pompholyx Topical steroid (systemic if severe) Potassium permangante salts The Peer Teaching Society is not liable for false or misleading information Eczema: Management

Definition Chronic inflammatory skin disease that is often relapsing/ remitting May be complicated by arthritis Can be disfiguring (psychosocial complications) Epidemiology Peak age of onset 20 years Aetiology & Pathophysiology Unknown causes: genetic ? Environmental strep. infections? Drugs antimalarial agents, lithium, beta-blockers ? Rapid cell turnover mediated by lymphocytic cytokines Excessive proliferation of epidermal cells Upward migration of immature keratinocytes (silver plaque appearance) The Peer Teaching Society is not liable for false or misleading information Psoriasis: Basic Science

The Peer Teaching Society is not liable for false or misleading information Psoriasis: Subtypes Discoid/ nummular Symetrical well- demarcated erythematous plaques Silver scales on extensor surface (knee, elbows, scalp, sacrum) Flexural Less scaly plaques Flexures (axilla, groin, perianal, genital)

The Peer Teaching Society is not liable for false or misleading information Psoriasis: Subtypes Guttate Small teardrop lesions Trunk & limbs Associated with Strep. (sore throat) Palmoplantar Erythematous plaques with pustules Smoking, middle-aged, female, autoimmune thyroid S- ynovitis A- cne P- ustulosis H- yperostosis O- steitis

The Peer Teaching Society is not liable for false or misleading information Psoriasis: Subtypes Generalised Pustular Pustules (limbs/ torso) Hyperparathyroidism History Itching/ tenderness AUSPITZ PHENOMENON Pinpoint bleeding with removal of scales KOEBNER PHENOMENON Skin lesions develop at sites of trauma/ scarring

The Peer Teaching Society is not liable for false or misleading information Psoriasis: Clinical Presentation Nails Joints (seronegative arthritis) Monoarthritis Distal asymmetrical oligoarthritis (interphalangeal) Dactylitis (flexor tenosynovitis) Rheumatoid arthritis-like Arthritis mutilans Ankylosing spondylitis Pitting Onycholysis Nail lifted off nailbed Subungual hyperkeratosis (salmon patch)

Investigations GUTTATE Anti-streptolysin-O-titre Throat swab FLEXURAL Skin swab (Ddx: candidiasis ?) NAIL Onychomyosis (fungal infections) JOINT Rheumatoid factor (negative) Radiographs distal interphalangeal joints (pencil-in-cup whittling deformity) Sacroiliitis Osteoporosis/ bone erosions Treatment GENERAL Avoid triggers (smoking/ alcohol) SKIN Emollients + topical steroids (Eumovate) Coal tar (reduce DNA synthesis) Vit. D3 analogue (calcipotriol) Topical retinoids PUVA (Psoratein PO + UV-A light therapy) UV-B light therapy JOINTS NSAIDs/ intra-articular steroid injections Severe: methotrexate +/ ciclosporin SYSTEMIC Methotrexate (teratogenic) Retinoids (pustular psoriasis, CI: pregnancy) Anti-TNF (infliximab)/ ciclosporin trials The Peer Teaching Society is not liable for false or misleading information Psoriasis: Management

The Peer Teaching Society is not liable for false or misleading information Skin Ulceration: Subtypes Venous Increased BP in lower limb due to poor venous return Fluid out of veins causes swelling/damage/ breakdown Investigation: ABPI (Ankle Brachial Pressure Index), Bloods (heart/kidney disease) and radiographs Prevention: stop smoking, improve nutrition, compression stockings Compression bandaging, surgery Appearance Break in the skin Oedema + fibrous exudate Localised pigment loss May encircle the lower limb

The Peer Teaching Society is not liable for false or misleading information Skin Ulceration: Subtypes Arterial Caused by ischaemia (reduced perfusion) Surrounding skin becomes weak, damaged (slow repair) Investigation: Bloods (clotting), arterial doppler scan/ pulse volume recording, radiographs (osteomyelitis) Prevention: diabetic nutrition, stop smoking Treatment: antibiotics if needed, surgery (debridement/ vascular bypass) Appearance Punched out appearance (intensely painful) Gray or yellow fibrotic base Pulses not palpable Thin, shiny skin or absent hair growth (poor perfusion)

The Peer Teaching Society is not liable for false or misleading information Skin Ulceration: Subtypes Neuropathic e.g. DM Altered metabolism results in slow wound healing and repair Ulcer persists and may worsen Investigation: Blood glucose, Doppler pressure scan, swabs (infection), radiograph / X-ray (osteomyelitis) Prevention: glycaemic control, stop smoking, comfortable shoes (lessen pressure), debridement Appearance Blisters and sores (chronic) Thickening callus formation Painless, punched out ulcers Superadded infection (cellulitis, abscess, osteomyelitis)

The Peer Teaching Society is not liable for false or misleading information Skin Ulceration: Subtypes Infective/ Traumatic Often occurs in wound/ pre- existing ulcer Associated with pus, exudate formation Investigation: Swabs, Bloods (WBC), Imaging (radiograph) Treatment: Initially broad- spectrum antibiotic, but once lab results are back use relevant narrow-spectrum antibiotic (ANTIBIOTIC RESISTANCE) + debridement Vasculitic Inflammatory destruction of blood vessels leads to ischaemia and ulcer formation Investigation: skin/ ulcer biopsy, bloods (ESR/ CRP/ WBC) Treatment: immunosuppression (corticosteroids e.g. prednisolone/ cyclophosphamide)

Epidermal keratinocytes Invade dermis and metastasise Often found on sun exposed areas (hyperkeratotic crusty) Risk factors Sunlight exposure (light skin) Radiation Carcinogens e.g. smoking Chronic skin disease HPV Longterm immunosuppression (middle aged) Investigations Skin biopsy (gold standard) Fine-needle aspirate/ lymph node biopsy (metastasis ?) Staging (CT/MRI/PET scan) Treatment Surgical excision Mohs micrographic surgery Sentinel lymph node biopsy Local radiotherapy/ chemoherapy in metastasis Intra-lesional interferons (topical 5 fluoracil) The Peer Teaching Society is not liable for false or misleading information Skin Cancer: Squamous Cell Carcinoma

The Peer Teaching Society is not liable for false or misleading information Skin Cancer: Squamous Cell Carcinoma

Commonest form (rodent ulcer) Basal cells invade dermis and metastasise (slow) Risk factors Prolonged sun exposure (light skin) UV radiation Elderly Examination Ill-defined nodulo-ulcerative Telangiectasia Superficial and pigmented Investigations Biopsy rarely needed Treatment Surgical excision Radiotherapy The Peer Teaching Society is not liable for false or misleading information Skin Cancer: Basal Cell Carcinoma

The Peer Teaching Society is not liable for false or misleading information Skin Cancer: Basal Cell Carcinoma

Neoplastic transformation of melanocytes (pigment forming cells) Life threatening A - symetry B order irregularity/ bleed C olour variation D iameter. 6mm E levation of lesion Investigations Excisional biopsy Lymphoscintigraphy (drainage) Sentinal lymph node biopsy Staging (CT/ MRI/ PET scan) Blood: LFT (metastasis) Treatment Prevention: avoid sunburn Wide local surgical excision Chemotherapy (cisplatin) Biological therapy (interferon) The Peer Teaching Society is not liable for false or misleading information Skin Cancer: Melanoma

The Peer Teaching Society is not liable for false or misleading information Skin Cancer: Melanoma

Acute non-prurulent spreading infection of subcutaneous tissue Overlying skin inflammation Periorbital: swollen eyelid Orbital: proptosis, impaired acuity and eye movement ! Often results from penetrating injury, lesions, fissuring Strep. pyogenes Staph. aureus (especially MRSA) H. influenza (especially in the orbit) Investigation Bloods (WBC, Blood cultures) Discharge (culture, sensitivity) Aspiration, if prurulent CT/MRI scan (orbital cellulitis) Treatment Benzylpenicillin/ tetracycline Orbital decompression Aspiration/ drainage of abscess Monitor optic nerve function The Peer Teaching Society is not liable for false or misleading information Infections: Cellulitis

The Peer Teaching Society is not liable for false or misleading information Infections: Cellulitis

Acute infection of deeper subcutaneous tissue layers Bacterium release toxins which destroy skin/ muscle tissue Can be caused by Strep. pyogenes Staph. Aureus (MRSA) Clostridium perfringens Investigations Bloods (CRP/ WBC/ Hb/ Na + / Creatinine/ Glucose) Suspect if Pain reported is greater than appearance of skin Inflammation, fever, tachycardia, D&V Quick discoloration to violet/ skin swelling (blister necrosis) EMERGENCY TREATMENT Presumptive Broad spectrum antibiotics Aggressive surgical debridement The Peer Teaching Society is not liable for false or misleading information Infections: Necrotising Fasciitis

The Peer Teaching Society is not liable for false or misleading information Infections: Necrotising Fasciitis

Skin manifestations of other disorders HIV/AIDs (Kaposi sarcoma red/violet/blue/black macules nodules) Tropical diseases (variable e.g. blisters) Amyloidosis (deposition of hyperpigmented macules) Breast disease Fibroadenoma (painless, firm, solitary and mobile lump) Cysts (smooth, easily mobile, but tender lump with variable size) Intraductal papilloma (small, painful lump + nipple discharge) Breast cancer (lump + puckering/ dimpling skin + inverted nipple) Lymphoedema Primary (filiariasis red, itchy swelling & migrating worm seen) Secondary (post-irradiation therapy skin reaction or bruising) The Peer Teaching Society is not liable for false or misleading information Brief: 2 skin disorders

May form a large part of the marks (SAQ Cellulitis) Part of questions involving systemic disorders Terminology and epidemiology is important (SBA identifying disease) One disease, many presentations Usually most common diseases/ presentations The Peer Teaching Society is not liable for false or misleading information Dermatology: Phase 2 Exams

The Peer Teaching Society is not liable for false or misleading information Additional Revision Resources http://www.dermnetnz.org/ http://library.med.utah.edu/kw/derm/DermQuiz/ https://itunes.apple.com/gb/app/dermatology-medical- student/id670207116?mt=8 https://itunes.apple.com/gb/app/dermatology-medical- student/id670207116?mt=8 https://play.google.com/store/apps/details?id=com.multipie. dermatology https://play.google.com/store/apps/details?id=com.multipie. dermatology Books Oxford Handbook of Clinical Specialties Rapid Medicine Lecture Notes Dermatology

Phase 2A Revision 24 th April 2015 Ashy Rengit The Peer Teaching Society is not liable for false or...

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