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Name & describe all the layers of skin
- Epidermis → Stratum corneum/ granulosum/ spinosum/ basale
- Basement Membrane
- Dermis
- Subcutaenous Tissue → BV & hair follicles
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What are the functions of skin?
- Protection
- Barrier
- Trauma
- pressure
- T variation
- Micro-organisms
- radiation/chemicals
- Regulation
- Body T → sweat & hair
- Changes in peripheral circulation
- fluid balance
- Vit D synth
- Sensation
- Encapsulated nerve endings → Meissner [light touch] Ruffini [vibration & stretching] & Pacini [mechanoceptors]
- Free nerve endings → Merkel cells [localised pressure]
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Presentation of Psoriasis?
(incl guttate & erythrodermic Psoriasis)
- Psoriasis
- Chronic relapsing remitting scaling skin disease
- any age and place [common 20-30 && 50-60]
- Appearance
- salmon coloured plaques
- well demarcated
- Hyperkeratosis on top of plaque
- ^ @ sites of trauma
- Nails → pitting, upturned, white
- Guttate Psoriasis
- Smaller version of standard plaques
- younger PMH sore throat
- progress to full blown psoriasis
- Erythrodermic
- severe & sudden onset
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What is the immune mechanism of Psoriasis?
- T cell mediated
- Abnormal infiltration of T cells
- Release of inflammatory cytokines → INF, IL & TNF
- ^keratinocyte proliferation
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Mx of Psoriasis
Dependant on → severity, Pt wants & cope with, ?arthopathy
- Tx
- Topical cream & ointments → moisutrisers & steroids
- Slow keratinocyte proliferation → Vit D analogues, coal tar, topical retinoids [tarzotene]
- Phototherapy → non-specific immunosuppressant, short respite
- Systemic therapy → acitretin, methotrexate, ciclosporin, biologic [infliximab/ rituximab]
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What Conditions are associated with Psoriasis?
- Psoriatic Arthirtis
- Metabolic syndrome
- Liver disease/ alcohol misuse
- Depression
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How does eczema present?
- interchangeable w dermatitis
- atopic itchy inflammatory skin condition
- Appearance
- background erythema
- broken skin [spontaneous/scratching]
- Face in infants
- Flexural sites in adults
- Secondary infections common [S. aureus, HSV]
- Lychenification → exaggerated skin markings
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Describe the subtypes of Eczema?
Endogenous
- Atopic
- Poor fillagrin expression [filament prot, buind to keratin]
- Standard eczema
- Seborrhoeic
- chronic scaly inflamm 'dandruff'
- face, scalp, eyebrows & upper chest
- Severe in HIV
- Mx → medicated shampoo
Discoid
- Venous Dermatitis
- underlying venous disease
- affects lower legs → incompitatnt lower veins → stretched skin → dermatitic response
- Mx → correct vascular, moisturiser, mild steroid, compression
Pompholyx
Exogenous
- Contact Dermatitis
- precipitated by noxious agent → T4 hypersensitivity
- Photoreaction
- Allergy/Drugs
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Mx of Eczema?
- Emollients
- Topical Steroids
- [emollient first, then steroid]
- Also → bandages, antihistamines
- Tx any complications
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What is the CF, Prognosis & Mx of BCC?
Basal Cell Carcinoma
- CF
- most common skin cancer
- 80% head & neck
- Subtypes (BCC is Not Suitable Pour Moi!)
- Nodular → raised [>5mm], pearly + telangectasia, well demarcated, central ulceration
- Superficial → raised pearly edge, telangectasia, ulcerated & depressed centrally
- Pigmented → not common, pearly raised edge, pigment [melanocytes]
- Morphoeic/Scarred/Sclerotic → dificult to Dx/Mx, shiny pale skin, BV @ edge, central depression
- Prognosis
- usually good
- Recurring/young age? PTCH Mt
- rarely mets
- Mx
- Single incision → 3-4mm margin, local anaesthetic
- Curatage & cautery → scrape it off
- Cryotherapy → freeeze thaw = cell death, older Pts
- Mohs Micrographic surgery
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What is the CF, Prognosis & Mx of SCC
- Squamous Cell Carcinoma
- induced by UV & chronic injury [burns]
- originates from keratinocytes
- CF
- Premalignant → actinic keratoses, bowens disease
- Appearance → crusty keratin plaque, background inflammation
- Site → any exposed to UV, ears & lips = ^^risk
- Prognosis
- Good, but potentially disfiguring surgery
- Mx
- Gold standard → surgical excision, 4mm margin [cure 95%]
- Curettage & cautery → older Pt [cure ~70%]
- Pre-malignant → topical imiquimod/5-flouracil
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What is the CF, Prognosis & Mx of MM
- Malignant Melanoma
- Malignant tumour of melanocytes
- CF
- 75% of SCa deaths
- Site → Skin [UV], also eye & bowel
- Growth → radial then vertical, depth determines prognosis
Subtypes → various, lentigo maligna [pre-malignant]
- Prognosis
- related to Breslow Depth [stratum Granulosum → deepest malignant cell]
- 97% for <1mm
- 71% for >4mm
- Mx
- Surgical → cm for each mm of Breslow
- ?Mets → Chemo [limb isolation]
- Lt follow-up
- Assess lymph nodes
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Outline the features of a malignant melanoma?
ABCDE
- Asymmetry
- Border Irregularity
- Colour variability
- Diameter >6mm
- Evolving over time
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4 Tumour syndromes with cutaeneous Pc
- Gorlins
- multiple BCC, jaw cysts, FH BrCa
- Brook-Speigler
- multiple BCC, trichoepitheliomas
- Gardner syndrome
- soft tiss tumours, polyps, Bowel Ca
- Cowdens Syndrome
- multiple hamartomas, thyroid Ca, Bowel Ca
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Describe Cellulitis & the optimal Mx
- Cellulitis
- spreading infection of Dermis & subcut tissue
- lower limbs
- RF → broken skin, lymphoedema, fungal inf
- CF → erythema, bullae, heat, spreading, painless, ?SIRS
- Orgs → Staph aureus, B-haemolytic strep, ~gram neg [diabetic]
- Mx
- Flucloxacillin/ Pen V [clinda/vancomycin if Pen allergic]
- IV → flucloxacillan & Ben Pen
- Mark area, monitor progress
- ?MRSA → Vancomycin
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Describe the following Soft Tissue Infections
-Eysipelas
-Impetigo
-Necrotising Fascitis
-Abscess
- Erysipelas [Erys-EYE-pelas]
- similar to Cellulitis, but dermis
- CF → face/EYEs, well demarcated raised edge, Recurrance
- Orgs → Strep Pyogenes [group A strep] Staph Aureus
- Impetigo [Duffys manky face]
- CF → infected epidermis, perioral, golden crust, ^^transmissable
- Orgs → Staph Aureus
- Mx → remove crust, Flucloxacillan, beware HSV
- Necrotising Fascitis [Medical Emergency]
- rapid spreading infection of subcut fascia
- toxin mediated - superantigens & cytokines
- CF → initially ^^PAIN, becoming painless [necrosis], rapid spread, SIRS, dusky skin w necrosis, ?crepitations
- Orgs → mixed [aerobes & anaerobes]
- Mx → Rapid surgical assess & debridement of all necrotic tissue, tissue grams stain → rationalised Ab, initially broad cover
- Abscess [Trapped pus in membrane, Ab may not penetrate]
- CF → precipitation factor [trauma/IVDU], pain & swelling
- Orgs → mixed infection [if IVDU could be anything]
- Mx → drainage [Eli you boy!] C&S, consider U/S
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Give examples of the cutaenous features of Thyroid Disease. [3]
Hypothyroid → dry skin
- Graves [hyperthyroid]
- Thyroid Dermopathy → non-specific thickening, lower legs
- Thyroid Acropachy → digital clubbing & thickening
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Give examples of the cutaeneous features of Diabetes. [5]
- Necrobiosis lipoidica → shins [purple → waxy yellow] microvascular occlusion, can predate
- Diabetic Dermopathy → scarred itchy hyperpigmented shins [?ulcerated]
- Scleredema → puffy oedematous skin, erythema [intrascapular, neck]
- Leg Ulcers
- Granuloma Annulare → raised circular area on skin
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Give the cutaeneous features of Vit B deficiency.
- Vit B
- B6 → Pyridoxine → Dermatitis
- B12 → Cobalamin → Angular Stomatitis
- B3 → Niacin → Pellagra [Dementia, Dermatitis, Diarrhoea]
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Give the cutaeneous features of Zinc Deficiency.
- Zinc
- Acrodermatitis enteropathica [Inherited]
- head & neck → pustules, bullae & scaling
- Infants → inherited/poor maternal transfer [breast milk]
- Adults → Alcoholism/malabsorption/IBD
- Tx → Zinc rapid improvement
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Give the cutaeneous features of Vit C deficiency.
- Scurvy
- Punctate purpura/bruising → legs
- Corkscrew spiral curly hairs
- non-healing wounds
- Inflamed gums
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Describe Erythema Nedosum & some associated diseases.
- Erythema Nedosum
- Tender red nodules under skin
- Causes → strep throat, Pregnancy/OCP, Sarcoid, Drug RXN
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Describe Pyoderma Gangrenosum & some associated diseases.
- Pyoderma Gangrenosum
- Uncommon ulcerative condition. [?necrosis]
- Distinctive purple edge
- Causes → IBD, RA, Myeloma
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