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DERMATOLOGY FINALS2FOUNDATION DR MALLAIKA VISWANATHQUESTION 1  A 22 year old student attends GP with recurrent mild acne. She is currently on adapalene (retinoid) monotherapy topically but still struggling with breakouts. What is the most appropriate next step in management?: a) Topical retinoid + Topical Benzoyl peroxide b) Topical steroid c) Topical retinoid + clindamycin d) Topical retinoid + doxycycline QUESTION 1  A 22 year old student attends GP with recurrent mild acne. She is currently on adapalene (retinoid) monotherapy topically but still struggling with breakouts. What is the most appropriate next step in management?: a) Topical retinoid + Topical Benzoyl peroxide b) Topical steroid Acne vulgaris Management : c) Topical retinoid + oral clindamycin st 1 line = Topical therapies – this can be monotherapy d) Topical retinoid + oral doxycycline with a retinoid or combination of Benzoyl peroxide/ clindamycin + retinoid 2 line = Topical therapies + ORAL antibiotics (lymecycline/ doxy/ clindamycin) 3 line = Oral antibiotic + Azelaic acid BD Other options: COCP, spironolactone, isotretinoinQUESTION 2  Considering the student before, which of the following investigations are most important to order? a) Acne swabs b) Lipid profile c) Sex hormone panel: Serum free testosterone/ DHEA/ FSH andLH d) Pelvic ultrasound QUESTION 2  Considering the student before, which of the following investigations are most important to order? a) Acne swabs b) Lipid profile c) Sex hormone panel: Serum free testosterone/ DHEA/ FSH and LH PCOS d) Pelvic ultrasound - A common cause of acne in young women - Can get dyslipidaemia but raised free testosterone = most sensitive test - Can consider pelvic ultrasound if strong clinical suspicion/ hormone panel elevated - LH/FSH ratio >3 suggests PCOSQUESTION 3 B A  Can you name the dermatological condition shown in each of these pictures? C D  Feel free to write it in the chat or speak up with your mics!QUESTION 3 B A  Can you name the dermatological condition shown in each of these pictures? A. Basal Cell carcinoma B. Squamous cell carcinoma C D C. Melanoma D. Actinic keratosis – cancer precursorMELANOMA DEADLIEST SKIN CANCER DUE TO UV EXPOSURE MORELIKELY TO METASTASISE STARTS IN THEMELANOCYTES — CELLS IN EPIDERMIS THAT MAKE PIGMENT. KEY WORDS IN EXAM TO LOOK OUT FOR: - MOLE THAT’S CHANGING SHAPE/SIZE/ APPEARANCE - ASYMMETRICAL / UGLY DUCKLING - ITCHING/ BURNING/ BLEEDING MOLE – REDFLAG(SIGNS OF CELL TURNOVER)RAPID ANSWERS:  What’s the top differential that pops into your mind as soon as you see this on a patient->QUESTION 4  A 58 year old gentleman presents to ED with redness and swelling of his right 2 , 3 and 4 toes. The swelling started 4 days ago and has progressively become more painful. O/E: the area is swollen, erythematous, hot to touch and there is a weeping superficial ulcer between the toes. The wound is crusted and malodorous. He had a temperature of 37.8 this morning. Currently, NEWS 3 for tachycardia and high BP. His PMH includes T2 diabetes, hypertension, hyperlipidaemia and he had an MI 2 years ago. Shx: Works as a farmer with heavy machinery, smokes 20 / day for last 25 years but has quit last year. Alcohol: 26 units/ week.  What is the first line antibiotic choice for this gentleman?: A. Oral amoxicillin B. IV flucloxacillin + metronidazole C. Oral flucloxacillin D. IV Amox + met + gentQUESTION 4  A 58 year old gentleman presents to ED with redness and swelling of his right 2 , 3 and 4 toes. The swelling started 4 days ago and has progressively become more painful. O/E: the area is swollen, erythematous, hot to touch and there is a weeping superficial ulcer between the toes. The wound is crusted and malodorous. He had a temperature of 37.8 this morning. Currently, NEWS 3 for tachycardia and high BP. His PMH includes T2 diabetes, hypertension, hyperlipidaemia and he had an MI 2 years ago. Shx: Works as a farmer with heavy machinery, smokes 20 / day for last 25 years but has quit last year. Alcohol: 26 units/ week. NKDA.  What is the first line antibiotic choice for this gentleman? A. Oral amoxicillin Diabetic foot infection: A diabetic presenting with cellulitis, fever and an ulcer B. IV flucloxacillin + metronidazole requires urgent initiation of IV antibiotics – oral is not C. Oral flucloxacillin enough! D. IV Amox + met + gent First choice = flucloxacillin for cellulitis. Metronidazole provides anaerobic cover. AMG provides empirical cover but we have a source so fluclox is a better choice for S Aureus. Pen allergic: co-trimoxQUESTION 5 nd rd th  A 58 year old gentleman presents to ED with redness and swelling of his right 2 , 3 and 4 toes. The swelling started 4 days ago and has progressively become more painful. O/E: the area is swollen, erythematous andthere is a weeping superficial ulcer between the toes. The wound is crustedand malodorous. He had a temperature of 37.8 this morning. Currently, NEWS 3 for tachycardia and high BP. His PMH includes T2 diabetes, hypertension, hyperlipidaemia and he hadan MI 2 years ago. Shx: Works as a farmer with heavy machinery, smokes 20 / day for last 25 years but has quit last year. Alcohol: 26 units/ week.  What Investigations should we consider for this gentleman?QUESTION 5  A 58 year old gentleman presents to ED with redness andswelling of his right 2 , 3 and 4 toes. The swellingstarted 4 days ago andhas progressively become more painful. O/E: the area is swollen, erythematous and there is a weeping superficial ulcerbetween the toes. The wound is crusted andmalodorous. He had a temperature of 37.8 this morning. Currently, NEWS 3 for tachycardia and high BP. His PMH includes T2 diabetes, hypertension, hyperlipidaemia and he hadan MI 2 years ago. Shx: Works as a farmerwithheavy machinery, smokes 20 / day for last 25 years but has quit last year. Alcohol: 26 units/ week.  What Investigations should we considerfor this gentleman? ❖ Always consider sepsis 6 – he is not currently newsing highly but this canquickly change. ❖ Bloods incl CRP, FBC/Ues/ LFTS, Coag, G+S (if may need theatre for debridement/amputation), ❖ Blood cultures (ideally take these before starting abx) ❖ Wound swab ❖ X-ray – to check forOM ❖ Regular obs including fluidbalance and pain scoreQUESTION 6  A 6 year old child presents to ED afterhis mum became worried about a recent bite he sustained while on holiday in Ibiza. They think it happened about 3 days ago and mum is worried he’s havingan allergic reaction as it has become irritated and he has been scratching at it non-stop. O/E the childis playing with his iPad but happily allows you to examine the ankle while telling you all about his holiday. There is a 1.5cm round area of redness withvisible excoriations. There is a clear fluid weeping from it and there is some yellow crustingoverthe punctum of the rash. There is no surrounding erythema or swelling of the skin. The child looks well hydrated and mum denies any temperatures. PEWS 0. What is the most appropriate management? a) Oral flucloxacillin b) Topical steroid c) A/w swabs and Blood cultures before initiating antibiotic therapy d) Do nothing – manage conservatively at home QUESTION 6  A 6 year old child presents to ED after his mum became worried about a recent bite he sustained while on holiday in Ibiza. They think it happened about 3 days ago and mum is worried he’s having an allergic reaction as it has become irritated and he has been scratching at it non-stop. O/E the child is playing with his iPad but happily allows you to examine the ankle while telling you all about his holiday. There is a 1.5cm round area of redness with visible excoriations. There is a clear fluid weeping from it and there is some yellow crusting over the punctum of the rash. There is no surrounding erythema or swelling of the skin. The child looks well hydrated and mum denies any temperatures. PEWS 0. What is the most appropriate management? a) Oral flucloxacillin Insect bites! b) Topical steroid Spider bites: if infected then may need antibiotics/ c) A/w swabs and Blood cultures before initiating antibiotics surgical intervention Stings: always ensure stinger is removed to minimise d) Do nothing- manage conservatively at home venom injection Anaphylaxis: Urgent IM Epinephrine (in his age group 300mcg of 1 in 1000) Adult – 500 mcgQUESTION 7  The same kid comes back to mum a couple of months later with the itchiest scalp after borrowing his friend’s hat at school. Which of the following is the best treatment for the condition shown in this photo? a) Permethrin b) Malathion c) Dimeticone d) Wet combingQUESTION 7  The same kid comes back to mum a couple of months later Headlice! with the itchiest scalp after Wet combing with a special comb is the borrowing his friend’s hat at best method – pick through all the strands school. Which of the following and repeat on day 1, 5, 9 and 13 to catch is the best treatment for the newly hatched lice condition shown in this photo? Can also try medicated shampoos OTC a) Permethrin b) Malathion c) Dimeticone d) Wet combingCONDITIONS COVERED  Acne vulgaris  BCC/SCC  Malignant melanoma  Cutaneous warts  Bites and stings  Cellulitis  Headlice Useful resources: BMJ best practice, NICE CKS Guidelines, NHS informTHANKS FOR LISTENING! QUESTIONS?