How to describe a rash/skin lesion + secondary lesion
- End of the bed – where and what
distribution - Size, configuration (discrete, confluent, border, discoid, target)
- Colour (erythematous, purpuric,
hyperpigmented, hypopigmented,
depigmented) - Morphology (macule, patch, papule, nodule, plaque, vesicle, bulla, pustule, abscess, wheal, boil, carbuncle)
- Palpate – texture, elevation, crust,
temperature, fluctuance, mobility, tender
- Secondary lesions (excoriation, scales,
crusting, scarring, ulcer, fissure, striae)
Where to examine for skin
- Check nails and hands
- Hair and scalp
- End of bed + site
- Check lymph nodes if concern about
malignancy
What are the main questions to ask on hx for dermatology
Key sx:
o Rash
o Skin lesion
o Pain
o Itch
o Bleeding
o Discharge
o Blistering
o Systemic sx – fever, malaise, weight
loss, and arthralgia
- SOCRATES for pain/lesions
- Treatments tried already?
- Had before in the past (known condition do OPTICPR)
- Contact hx if infectious/spreadable
- Systemic inquiry
- Travel history
- Previous sun exposure/ tanning
beds/allergies
- Medications – any new?
- FHX of derm conditions
- Smoking and alcohol hx
- Diet
- Occupation – exposure to
allergens/chemicals
What are the different types of dermatitis (5)
- Atopic dermatitis – particularly prevalent in children, normally a family hx
- Irritant contact dermatitis – provoked by substance coming into contact with skin
- Allergic contact dermatitis – allergy to
substance such as nickel, rubber,
preservatives (often diagnosed with patch testing) - Seborrhoeic dermatitis – irritation from substance produced by Malassezia yeasts that live on the skin (in hair and face mostly)
- Gravitational dermatitis – lower legs of
elderly patients due to venous insufficiency
What are the specific questions to ask on hx for dermatitis
Triggers, Irritants
- Occupation? -exposure, health care workers, hairdressers
- Family history – hay fever, asthma, eczema
- Medications – previously tried, moisturiser,
What is the Ix and management for dermatitis
IX
- Rule out causes/irritants before diagnosing atopic/seborrhoeic dermatitis
- Patch testing may be done to identify the allergen
- Swabs to rule out infection in broken down skin
Management
- Soap substitute; Use lukewarm water
- Wear smooth clothing
- Avoid irritants on skin, wear gloves
- Use emollients – after bathing and
handwashing replenish with fatty
moisturisers
- Topical steroids until patch has cleared then continue and taper
- Medications:
o Antibiotics may be prescribed if
there is overlapping infection
o Antihistamines may be useful at
night
o Systemic steroids and phototherapy,
DMARDS may be requires in special
cases - discuss with a dermatologist
What to comment on in exam of acne/ rosacea
- Number and types of acne:
Open and closed uninflamed comedones (blackheads and
whiteheads)
Inflamed papules and pustules
In severe acne, nodules and pseudocysts
Post-inflammatory erythematous or pigmented macules and scars - Scarring, pitting
- Redness and inflammation, infection
- Face, neck, chest, back
history to cover for acne/ roseacea
STORY
- How long has the acne been there for?
- What kinds of inflammation do they get?
- Redness, flushing, inflammation
- History of treatments tried
- Birth control?
- Signs of hirsutism – PCOS
- Other medical conditions, psychiatric
history
- Current medications
- What are they using for skin care at the
moment?
- Expectations?
What is the management for mild, moderate and severe acne
Acne:
Mild acne: topical anti-acne
preparations,
- Light therapy: non-thermal intensity penetrate different levels of the skin exciting porphyrins from c.acnes which kills it
-Laser therapy: destroys sebaceous glands and c acnes
Moderate acne: add acne antibiotics such as tetracyclines and/or antiandrogens such as birth control pill
Severe acne: oral isotretinoin – now used more commonly.
what is the management for rosacea
- Water based skin products
- Not for topical steroids
- Protect from sun
- Avoid hot and spicy foods, alcohol, hot showers.
- Tetracycline antibiotics commonly used
- Oral isotretinoin has been shown to be
effective when antibiotics are poorly
tolerated or ineffective. - Vascular laser treatment can be used to treat persistent telangiectasia.
- Surgery to reshape rhinophyma (thickened nose sebaceous glands from untreated rosacea)
What are the risk factors + additional hx for melanoma
More common with increased age.White skin – Fitzpatrick type 1 or 2
HPC
Lesion how long there? Discharge or ulceration at the site ?
Systemic symptoms if longstandin : constituational
lung, liver, bones, brain
PMH
Previous invasive melanoma/melanoma in situ, or
Other skin cancer history
Many moles
Multiple atypical naevi
Parkinson’s
Family history
Occupation
Hx of sun exposure - little sunscreen
reporting exam findings for melanoma
- ABCDE
A- asymmetry,
B- border- irregular
C- colour (change)
D- diameter (larger than 5mm)
E- elevation/evolution)
With dermascope – looking for vascularity, irregular distribution of colour.
- Thickness – poorer prognosis, associated with spread.
What is the investigation and staging for melanoma
Excisional biopsy if small enough, may need removal by plastics if in tricky position or size requiring flap.
- CXR and liver USS
- CT/PET looking for mets if suspicious
Staging - based on breslow thickness to nearest 0.1 mm / ulceration and spread (clark level of invasion)
0- in situ, 1- <2mm thick, 2 - >2mm thick or >1 mm with ulceration
3. spread to local lymph nodes
4. distant metastases
Management of melanoma
Tx dependent on Breslow thickness/clark level –
deeper more likely to invade and may require more than local excision.
Wider local excision – melanoma in situ.
Deeper (>1mm) may require sentinel node biopsy to look for invasion. Or nodal clearance if thought to
be involved.
More invasive/metastatic melanoma can be treated with chemo and radiation therapy as well as newer
experimental treatments:
Immunotherapy: interleukin-2, interferon alfa 2b
BRAF inhibitors: dabrafenib and vemurafenib
MEK inhibitors: trametinib
etc
Requires follow up and lifelong regular skin checks
What is the difference in examination of a BCC vs SCC
- BCC
Slowly growing plaque or nodule
Skin coloured, pink or pigmented
Varies in size from a few millimetres to several centimetres in diameter
Spontaneous bleeding or ulceration - SCC
Enlarged scaly or crusted lumps
They grow over weeks to months
They may ulcerate
They are often tender or painful
Located on sun-exposed sites, particularly the face, lips, ears, hands,
forearms and lower legs
Size varies from a few millimetres to
several centimetres in diameter
Ix and management of BCC and SCC
INVESTIGATION
- Normally an excisional biopsy
- If low suspicion or large in size – core
biopsy sent away to confirm lesion then
wider excision.
MANAGEMENT
- BCC may be treated with imiquimod or 5-fluorouracil cream, if small.
- Cryotherapy
- Local excision with or without a flap is
usually sufficient to prevent further spread, Sent away to ensure complete margins
- If extensive – may require plastic surgery input to determine best way to excise and recover/reconfigure.
- If metastatic radiotherapy may be required
