Revision Lecture - Dermatology

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  • XP – AR defective repair of UV-damaged DNA
  • Th1 predominance
  • F:M 3:1. ? Microangiopathy results in collagen degeneration, subsequent dermal inflammation.
  • Localised myxoedema can also present as diffuse non pitting oedema of shins or feet that evolves into elephantiasis. Hypertrichosis and hyperhidrosis can occur in pretibial myxoedematous skin. Often itchy and painful
  • Wegener’s – systemic vasculitis, necrotizing granulomatous inflammation of the upper and lower respiratory tract and glomerulonephritis
  • Revision Lecture - Dermatology

    1. 1. Revision Lecture Dermatology C Wong Manchester Royal Infirmary
    2. 2. Common conditions • Skin tumours • Inflammatory dermatoses – psoriasis, eczema • Acne vulgaris • Rosacea • Disorders of pigmentation • Blistering disorders • Associations with systemic disease
    3. 3. Basal Cell Carcinoma • Commonest form of skin cancer • Usually face ( exposed sites) • Pearly papule with telangiectasia • Ulcerate with rolled edges ( rodent ulcer) • Locally invasive • Rarely metastasizes • UV exposure, type I and II skin, genetic predisposition ( Gorlin’s syndrome), immunosuppression, arsenic, Xrays and ionizing radiation
    4. 4. Basal Cell Carcinoma • Pearly papule or nodule • Telangiectasia • May ulcerate • Exposed sites
    5. 5. Treatment • Surgery – Mohs’ micrographic surgery for high risk sites and ill defined • Curettage and cautery • Radiotherapy • Cryotherapy - superficial • Photodynamic therapy - superficial
    6. 6. Bowens disease • Intraepidermal carcinoma (premalignant) • Lower legs elderly women • May transform into SCC • May resemble discoid eczema, psoriasis, superficial BCC • Treatment : cryotherapy, curettage, excision, topical 5-fluorouracil, photodynamic therapy
    7. 7. Bowen’s disease • Pink or erythematous plaque • Well demarcated • Scaly • Lower legs • trunk
    8. 8. Squamous cell carcinoma • Malignant tumour derived of keratinocytes • Often arises in sun damaged skin • Can metastasize • Risks – Cumulative UV exposure, xrays and ionizing radiation, chronic ulceration and scarring, genetic ( xeroderma pigmentosa), immunosuppression
    9. 9. Treatment • Surgical excision • radiotherapy
    10. 10. Squamous Cell Carcinoma • Indurated papule, plaque or nodule • Fleshy • Hyperkeratotic with firm margin • Eroded or ulcerated
    11. 11. Malignant melanoma • Malignant tumour of melanocytes • May arise in preexisting mole or in normal looking skin • Change – size, colour, bleeding, itching • A – asymmetry • B – border • C – colour • D – Diameter • metastasize
    12. 12. Malignant melanoma • Repeated short intensive exposure to UV • Family history • Previous MM • Dysplastic naevi • Type I skin
    13. 13. Malignant Melanoma • Wide excision • Prognosis dependent tumour depth – Breslow thickness • Good prognosis < 1mm • Poor prognosis > 4 mm
    14. 14. Seborrhoeic keratoses • Basal cell papilloma • Trunk and face elderly and middle aged • Stuck on appearance with keratin plugs • Treatment – Curettage – cryotherapy
    15. 15. Psoriasis • Chronic often life long inflammatory condition with spontaneous exacerbations and remissions • Characterised by well demarcated erythematous plaques topped by silvery scale • Disfiguring, causes significant psychological morbidity • 2-3 % western europe
    16. 16. Psoriasis • Bimodal age of onset – 20 – 25 50 - 55 • Type 1 < 40 • Type 2 > 40 • Hyperproliferation of epidermis • T cell mediated disease
    17. 17. Psoriasis • Complex interaction between genetic predisposition and environmental factors • Genetic : positive FH ~ 30% • Polygenic – multiple susceptible loci • HLA Cw6 – most strongly associated with type I
    18. 18. Psoriasis • Environment • Infection – acute streptococcal infections • Stress • Alcohol • Drugs eg lithium, antimalarials • Sunlight • Trauma – koebner phenomenon
    19. 19. Psoriasis • Arthropathy • 8-10% patients • Seronegative • Symmetrical peripheral polyarthropathy • Monoarthritis • Distal interphalangeal arthritis • Sacroiliitis • ‘arthritis mutilans’
    20. 20. Topical Treatment • Emollients • Tar • Dithranol • Vitamin D analogues • Retinoids • Topical steroids – mild for flexures and face
    21. 21. Treatment • Phototherapy – UVB, PUVA • Systemic – Methotrexate – Cyclosporin – Acitretin – Hydroxyurea – New biologicals
    22. 22. Eczema • Chronic itchy inflammatory condition of the skin • Endogenous – constitutional : atopic • Exogenous – Irritant contact dermatitis – Allergic contact dermatitis – Drug induced – Photosensitive
    23. 23. Atopic eczema • Atopy – eczema, asthma, hayfever • High Ig E • Infants – within 1st 6 months • Childhood – antecubital fossae, popliteal fossae, neck, wrists, ankles, face • Adults – hands, generalised and lichenified
    24. 24. Atopic eczema • Increased risk of bacterial infections – Staphylococcal infection • Increased risk of viral infections – Molluscum contagiosum – Herpes simplex ( eczema herpeticum )
    25. 25. Treatment • Emollients • Topical steroids • Topical tacrolimus/pimecrolimus • Topical antibiotics ( if infected ) • Phototherapy • Immunosuppressants – azathioprine, cyclosporin
    26. 26. Lichen planus • Acute or chronic inflammatory pruritic dermatosis involving skin or mucous membranes • Characterised by flat topped, violaceous, polygonal papules with Wickham’s striae
    27. 27. Lichen planus • Cause unknown • Can be drug induced • Affects nails, can affect scalp • Can be self limiting • Topical steroids
    28. 28. Acne vulgaris • Chronic inflammation of pilosebaceous units • Increased sebum production • Pilosebaceous duct hyperkeratosis • Colonisation with Propionibacterium acnes • Release of inflammatory mediators • Formation of comedones, inflammatory papules, pustules and cysts
    29. 29. Acne vulgaris • Face, upper chest and back • Age ~ pre, at puberty – decade after • Can persist into 4th , 5th decades • Treatment • Topical - benzoyl peroxide, retinoids, antibiotics • Systemic – antibiotics, OCP, retinoids
    30. 30. Rosacea • Chronic inflammatory facial dermatoses characterised by erythema and pustules • Cause unknown • Middle aged • Flushing • Erythema, telangiectasia, papules, pustules, occasional lymphoedema : rhinophyma
    31. 31. Rosacea • Eye involvement – blepharitis, conjunctivitis • No comedones • Treatment • Topical – metronidazole • Systemic – antibiotics, retinoids, • Rhinophyma – laser, plastic surgery • Avoid topical steroids
    32. 32. Vitiligo • Acquired idiopathic disorder with white non scaly macules • Autoimmune – associated with pernicious anaemia, thyroid disease, addison’s disease, diabetes • FH ~ 30%
    33. 33. Vitiligo • Treatment – unsatisfactory • Camouflage cosmetics • Sunscreens • Potent topical steroids • Phototherapy – UVB, PUVA
    34. 34. Bullous Pemphigoid • Chronic autoimmune blistering eruption • Affects elderly • Very itchy • Tense blisters • Arising from erythematous, sometimes urticated or normal skin
    35. 35. Bullous pemphigoid • IgG autoantibodies to bullous pemphigoid antigens in the hemidesmosomes at the basement membrane zone bind complement which induces inflammation and protease release • Subepidermal bulla formation
    36. 36. Treatment • Superpotent topical steroids • Systemic steroids • Steroid sparing agents eg azathioprine • Minocycline, nicotinamide
    37. 37. Pemphigus vulgaris • Autoimmune blistering disorder affecting skin and mucuous membranes • IgG autoantibodies bind with desmoglein ( desmosomal cadherin involved in epidermal intercellular adhesion ) results in loss of adhesion and an intraepidermal split • Less common than pemphigoid • Middle aged or young adults
    38. 38. Pemphigus • Flaccid superficial blisters scalp, face, back, chest and flexures • Blistering not always obvious • Crusted erosions • Oral involvement common
    39. 39. Treatment • High dose systemic steroids • Azathioprine • cyclosphosphamide
    40. 40. • Pemphigoid • Subepidermal blisters • Tense blisters • Itchy • Elderly • Oral involvement less common • Pemphigus • Intraepidermal blisters • Flaccid blisters or erosions • Middle aged/ young adults • Oral involvement common
    41. 41. Necrobiosis Lipoidica • Yellow brown • Atrophic • Telangiectactic • Plaques surrounded by raised violaceous rims • Pretibial region
    42. 42. Necrobiosis Lipoidica • Cause unknown - ? Microangiopathy resulting in collagen degeneration, dermal inflammation • < 1% diabetics • > 2/3 of patients with NL are diabetic • No correlation between diabetic control and development or improvement of necrobiosis lipoidica
    43. 43. Pretibial myxoedema • Hyperthyroidism • Erythematous to skin coloured • Purple-brown, yellow • Waxy, indurated nodules or plaques • Peau d’orange appearance • Anterolateral lower legs
    44. 44. Discoid Lupus Erythematosus • Chronic cutaneous disorder characterised by scaly atrophic plaques in sun exposed sites • Treatment – photoprotection, topical steroids, antimalarials • SLE – facial butterfly rash, photosensitivity, alopecia, vasculitis
    45. 45. Systemic Lupus Erythematosus • Multisystem disease involving connective tissue and blood vessels • Fever • Skin lesions • Arthritis • Renal disease • Cardiac involvement • Pulmonary disease • Positive autoantibodies - ANA
    46. 46. Dermatitis Herpetiformis • Uncommon itchy blistering eruption affecting extensors • Associated with coeliac disease • Treatment – gluten free diet • dapsone
    47. 47. Vasculitis • Inflammation within or around blood vessels • Infections – streptococcal, hepatitis B and C • Drug induced • Connective tissue disease • Cryoglobulinaemia, macroglobulinaemia • Inflammatory bowel disease
    48. 48. • Small vessel – Henoch Schonlein purpura – Wegener’s granulomatosis – Churg Strauss syndrome – Essential cryoglobulinaemia • Medium vessels – Polyarteritis nodosa • Large vessel – Giant cell arteritis – Takayasu’s arteritis
    49. 49. Erythroderma • Erythema and scaling affecting > 90% body surface area • Eczema • Psoriasis • Lymphoma / Sezary syndrome • Acute drug eruptions • Pityriasis rubra pilaris
    50. 50. Complications of erythroderma • Cardiac failure • Hypothermia • Sepsis

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