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Rheumatology + Dermatology 8th May 2025, Dr Yi; Dr AeronRheumatology+ Derm; MLAContent map ● Skin cancer: Melanoma, basal cell carcinoma, squamous cell carcinoma ● Psoriasis: Diagnosis, management, and treatments ● Rheumatoid arthritis: Diagnosis, management, and DMARDs ● Systemic lupus erythematosus: Diagnosis, management ● Gout: Diagnosis, treatment, and lifestyle interventions ● Vasculitis: Types, clinical presentation, and managementQuestion 1 A 45M presents to AMU with a unilateral painful knee. On examination it is red hot and swollen, worse on movement. He denies fevers or general malaise. He has tried paracetamol and ibuprofen to no effect. Joint aspiration showed crystals on microscopy with no organisms or blood cells in the sample. What is the most appropriate treatment for this patient? a) Add on naproxen b) Start Allopurinol c) Start Colchicine d) Topical ibuprofen e) Start IV antibioticsQuestion 1 A 45M presents to AMU with a unilateral painful knee. On examination it is red hot and swollen, worse on movement. He denies fevers or general malaise. He has tried paracetamol and ibuprofen to no effect. Joint aspiration showed crystals on microscopy with no organisms or blood cells in the sample. What is the most appropriate treatment for this patient? a) Add on naproxen b) Start Allopurinol c) Start Colchicine d) Topical ibuprofen e) Start IV antibioticsGout A form of arthritis comprising of Diagnosis: monosodium urate crystals deposit in joints. This causes both acute inflammation (flares) Joint aspiration - classically needle shaped and chronic, progressive gouty arthritis with negatively birefringent crystals tophi (hard deposits of monosodium urate crystals in soft tissues). Note: colchicine for acute flares, allopurinol for prophylaxis *after* the flare has resolved +/- NSAIDs for inflammation and pain (topical and oral formulations)Gout A form of arthritis comprising of Diagnosis: monosodium urate crystals deposit in joints. This causes both acute inflammation (flares) Joint aspiration - classically needle shaped and chronic, progressive gouty arthritis with negatively birefringent crystals tophi (hard deposits of monosodium urate crystals in soft tissues). Note: colchicine for acute flares, allopurinol for prophylaxis *after* the flare has resolved +/- NSAIDs for inflammation and pain (topical and oral formulations)Question 2 A 5 M presents to SDEC from GP with a new rash and painful joints. This has been rapidly progressing over the past week. On further questioning she has recently recovered from a viral respiratory illness. The rash is purple-pink, palpable on touch and is predominantly across the lower limbs and buttock region. What is the most appropriate initial management of this condition? a) IV Antibiotics b) Supportive management of symptoms c) Topical emollients d) Renal biopsies e) Referral to respiratoryQuestion 2-HSP A 5 M presents to SDEC from GP with a new rash and painful joints. This has been rapidly progressing over the past week. On further questioning she has recently recovered from a viral respiratory illness. The rash is purple-pink, palpable on touch and is predominantly across the lower limbs and buttock region. What is the most appropriate initial management of this condition? a) IV Antibiotics b) Supportive management of symptoms c) Topical emollients d) Renal biopsy e) Referral to respiratoryVasculitis-HSP Common benign vasculitis in children 4-6yo peak incidence Treatment: Exact aetiology unknown, however classically follows a viral URTI. Conservative, rest + supportive IgA immune complexes deposited in small blood vessels in the skin, joints, kidneys, and gastrointestinal tract which 98% recover with no further sequelae, some causes inflammation. may have less-severe recurrence Tested triads: arthralgia/arthritis, abdominal pain, palpable purpura, +/- renal disease. Darker skin: check paler areas of the skin like the palms of the hands and soles of the feet to identify possible purpuraVasculitis-HSP Common benign vasculitis in children 4-6yo peak incidence Treatment: Exact aetiology unknown, however classically follows a viral URTI. Conservative, rest + supportive IgA immune complexes deposited in small blood vessels in the skin, joints, kidneys, and gastrointestinal tract which 98% recover with no further sequelae, some causes inflammation. may have less-severe recurrence Tested triads: arthralgia/arthritis, abdominal pain, palpable purpura, +/- renal disease. Darker skin: check paler areas of the skin like the palms of the hands and soles of the feet to identify possible purpuraQuestion 3 A 26M presents to your GP surgery with dry and itchy elbows. He reports self-managing with OTC emollients however this has recently stopped working, and that the itchy regions have spread to his scalp. On examination he has large, silvery scaly plaques over the back of his elbows, as well as smaller plaques seen over his anterior scalp. He is itching his elbows and you also notice mild bleeding over his scalp. What is the most appropriate management for the patient? a) Prescribe greasy emollients b) Prescribe topical antibiotics c) Prescribe topical steroids and coal tar shampoo d) Prescribe topical steroids only e) Encourage increased sun exposureQuestion 3-Psoriasis-Scalp treatments A 26M presents to your GP surgery with dry and itchy elbows. He reports self-managing with OTC emollients however this has recently stopped working, and that the itchy regions have spread to his scalp. On examination he has large, silvery scaly plaques over the back of his elbows, as well as smaller plaques seen over his anterior scalp. He is itching his elbows and you also notice mild bleeding over his scalp. What is the most appropriate management for the patient? a) Prescribe greasy emollients b) Prescribe topical antibiotics to plaques c) Prescribe topical steroids and coal tar shampoo d) Prescribe topical steroids only e) Encourage increased sun exposurePsoriasis A chronic inflammatory disorder of the skin - seen as scaly, erythematous, pruritic plaques. Often follows a relapsing and remitting course. 10-15% cases it is associated with psoriatic arthritis Treatment: Emollients +++ Corticosteroids Need to apply to where the plaques are - skin, scalpQuestion 4 A 45F presents to your clinic with itching. She reports her children starting school 4 weeks ago, and that they are also complaining of new itching. The itch is more predominant at night and she reports more itching over her hands, wrist and abdomen. On examination you can see excoriation marks, with red papular marks over her wrists. What is the most appropriate treatment for her? a) Treat with topical emollients b) Start systemic steroids c) Treat patient with topical permethrin d) Treat patient + family with topical permethrin e) Contact public health to inform of caseQuestion 4-Scabies/parasites-treatment + advice(home contacts) A 45F presents to your clinic with itching. She reports her children starting school 4 weeks ago, and that they are also complaining of new itching. The itch is more predominant at night and she reports more itching over her hands, wrist and abdomen. On examination you can see excoriation marks, with red papular marks over her wrists. What is the most appropriate treatment for her? a) Treat with topical emollients b) Start systemic steroids c) Treat patient with topical permethrin d) Treat patient + family with topical permethrin e) Contact public health to inform of caseScabies Highly contagious skin infestation caused by Close contacts the mite Sarcoptes scabiei. All contacts, included members from Found in the inter-web spaces, flexures the same household, are treated on the of the wrist, axillae, abdomen and groin. same day + recent sexual contacts The itch is classically worse at night. Close contacts - sharing the same kitchen is my go-to rule Treatment: Transmission: direct contact, is easily Permethrin should be applied to cool dry skin (i.e. not after a hot bath) transmissible via bedding, towels, Applied to the whole body (including the face clothes, and upholstery - wash at 60C, drying in a hot dryer, or and scalp). Leave for 12 hours before washing dry-cleaning (patient counselling points) off. 7 day course.Question 5 A 21M presents to his GP with worsening of his acne. Over the past 3 months he has reported his skin blemishing to be increasing in area and severity. After examination you diagnose mild-moderate acne and start topical treatment. What is one important side effect to warn the patient of? a) Increased sun sensitivity when using topical treatment b) Increased risk of allergic reaction with topical treatment c) Risk of weight gain with the treatment d) Increased risk of bleeding with the treatment e) Increased risk of dry skin while using topical treatmentQuestion 5-Acne treatment side effects A 21M presents to his GP with worsening of his acne. Over the past 3 months he has reported his skin blemishing to be increasing in area and severity. After examination you diagnose mild-moderate acne and start a 12-week course of topical treatments. What is one important side effect to warn the patient of? a) Increased sun sensitivity when using topical treatment b) Increased risk of allergic reaction with topical treatment c) Risk of weight gain with the treatment d) Increased risk of bleeding with the treatment e) Increased risk of dry skin while using topical treatmentAcne Treatment options: A acute/chronic condition comprised of In this case (mild-moderate) NICE recommends a 12-week course of a open/closed comedones, inflammatory combination-treatment: papules and pustules, and/or nodules and ● topical adapalene with topical benzoyl peroxide (0.1% or cysts if severe. 0.3% adapalene with 2.5% benzoyl peroxide). ● topical tretinoin with topical clindamycin (0.025% tretinoin with 1% clindamycin). Typically affects the face, neck, chest, and ● topical benzoyl peroxide with topical clindamycin (3% or 5% benzoyl peroxide with 1% clindamycin). back. Can affect over 80% of adolescents. Adapalene: Increasing the turnover of skin cells, helping unblock pores Common side effects are a mild burning sensation, redness and dryness of the treated Areas. Increased sensitivity to sunlight - SPF 50 everydayA 45 year old male presents to your GP clinic with numbness down both his hands and wrists. He mentions the numbness occurs from his thumb to middle finger on both sides. He also notes dry eyes that are mildly uncomfortable despite using eye drops. On hand examination you note a swan neck deformity on his index finger, Z-thumb and Atrophy of the Thenar muscles. This is the same on both sides. There are no nail bed changes or rashes to note. Tinel’s and Phalen’s tests are positive Considering the most likely diagnosis what specific antibody markers should the GP request? A) Anti Ro and Anti LA B) pANCA and cANCA C) HLA B27 D) Anti Citrullinated Peptide and Rheumatoid Factor E) Anti-CentromereA 45 year old male presents to your GP clinic with numbness down both his hands and wrists. He mentions the numbness occurs from his thumb to middle finger on both sides. He also notes dry eyes that are mildly uncomfortable despite using eye drops. On hand examination you note a swan neck deformity on his index finger, Z-thumb and Atrophy of the Thenar muscles. This is the same on both sides. There are no nail bed changes or rashes to note. Tinel’s and Phalen’s tests are positive Considering the most likely diagnosis what specific antibody markers should the GP request? A) Anti Ro and Anti LA: Sjogren’s B) pANCA and cANCA: (Eosinophillic) Granulomatosis with Polyangiitis C) HLA B27: Seronegative Arthritis (e.g Psoriatic, Ankylosing Spondylitis)) D) Anti Citrullinated Peptide and Rheumatoid Factor: RA! E) Anti-Centromere: Limited Systemic SclerosisMonoarthritis (1 joint) Oligoarthritis (<5 joints) Polyarthritis (>5 joints) 1) Septic Arthritis 1) Juvenile Idiopathic Asymmetrical 2) Gout Arthritis (JIA) ● Late Osteoarthritis 3) Pseudogout 2) Vasculitis 4) Reactive Arthritis 3) Enteropathic Arthritis 5) Trauma/Necrosis 4) Early OA Symmetrical 6) Haemarthrosis ● Rheumatoid Arthritis ● Psoriatic Arthritis 7) Early OA ● Enteropathic Arthritis ● Ankylosing SpondylitisSymptoms worse at start of day!: gets better when using jointsDMARDSWhich of the below options regarding Systemic Lupus Erythematosus is false? A) When testing for Complement Protein levels, the levels of C3 and C4 will be higher than the upper limit each B) If an FBC is done, it will show Anaemia, Thrombocytopenia, and Leukopenia C) Psychosis is an uncommon feature of SLE D) Malar and Discoid Rashes can be exacerbated upon exposure to UV light E) Isoniazid is a cause of SLE-like syndrome (Drug induced Lupus)Which of the below options regarding Systemic Lupus Erythematosus is false? A) When testing for Complement Protein levels, the levels of C3 and C4 will be higher than the upper limit each B) If an FBC is done, it will show Anaemia, Thrombocytopenia, and Leukopenia C) Psychosis is an uncommon feature of SLE D) Malar and Discoid Rashes can be exacerbated upon exposure to UV light E) Isoniazid is a cause of SLE-like syndrome (Drug induced Lupus)SLE Type III Hypersensitivity autoimmune disease; inadequate T cell suppressor activitywith increased B cell activity. * Increased deposition of self antibodies around various areas of the body causes widespread immune response causing complex and variable presentations! Has a FHx - Female more common (9:1) esp early adulthood - Oestrogens are thought to be permissive for autoimmunity. Oestradiol may prolong the life of autoreactive B and TlymphocytesSuspecting Drug Induced Lupus = Anti Histone +veA 55 year old woman barges into the Accident and Emergency Department in a panic. Upon calming her down she yells that there is a growing dark patch at the top of her right eye that has been going on for the past few hours at her right eye, with a headache on the same side which she describes as “agonizing”. Her PMHx includes Polymyalgia Rheumatica, Previous TIA, HTN and Migraines. She has NKDA. She takes Prednisolone, Clopidogrel, Amlodipine, Candesartan and Propranolol. Examination reveals reduced peripheral fields but intact central fields on the Right eye. The left eye’s visual fields are intact. She doesn’t report floaters, flashing lights, or photophobia. During this exam as you try to steady her head your hand runs on her scalp on the right, making her jolt in pain. Neurological examination of her upper and lower limbs are normal. NIHSS = 3 What is the next best management step at this point of time? A) Urgent referral to Ophthalmology B) Start high dose Prednisolone C) Organise an urgent Temporal Artery Ultrasound D) Start Sumatriptan E) Organise an urgent CT HeadA 55 year old woman barges into the Accident and Emergency Department in a panic. Upon calming her down she yells that there is a growing dark patch at the top of her right eye that has been going on for the past few hours at her right eye, with a headache on the same side which she describes as “agonizing”. Her PMHx includes Polymyalgia Rheumatica, Previous TIA, HTN and Migraines. She has NKDA. She takes Prednisolone, Clopidogrel, Amlodipine, Candesartan and Propranolol. Examination reveals reduced peripheral fields but intact central fields on the Right eye. The left eye’s visual fields are intact. She doesn’t report floaters, flashing lights, or photophobia. During this exam as you try to steady her head your hand runs on her scalp on the right, making her jolt in pain. Neurological examination of her upper and lower limbs are normal. NIHSS = 3 What is the next best management step at this point of time? A) Urgent referral to Ophthalmology B) Start high dose Prednisolone C) Organise an urgent Temporal Artery Ultrasound D) Start Sumatriptan E) Organise an urgent CT HeadGiantCellArteritis (GCA)/TemporalArteritisSomeVasculitides to be aware of Small Vessel ● Granulomatosis with polyangiitis: cANCA ● Eosinophilic Granulomatosis with polyangiitis: pANCA ● Microscopic Polyangiitis (MPA): ANA, pANCA, anti-MPO Medium Vessel ● Polyarteritis Nodosa: ANCA -ve, ADA2 Mutation +ve Large Vessel ● Takayasu Arteritis: Clinical symptoms, Raised CRP + ESR, MRA on side of symptoms showing narrowing/occlusion of section of Aorta/branches Other Rheum conditions to read over Sjogren’s Syndrome: Anti Ro, Anti La Polymyositis and Dermatomyositis: ANA, Anti Jo1, +/- Myositis Specific Antibodies Polymyalgia Rheumatica: Clinical Diagnosis, Raised CRP and ESR, Trial with steroids Systemic Sclerosis: Anti-Centromere (limited), Anti Topoisomerase/Anti Scl 70 (diffuse) Hypermobility Syndrome: Clinical diagnosis + Beighton scoreA 60 year old woman was brought into the GP practice by her son who noticed this lesion at the back of her neck. It wasn’t noticed before as it was covered by hair prior to her recent appointment to the hairdressers. Based on this image, what is the most likely impression to consider? A) Squamous Cell Carcinoma B) Keratoacanthoma C) Basal Cell Carcinoma D) Molluscum Contagiosum E) Pyogenic GranulomaA 60 year old woman was brought into the GP practice by her son who noticed this lesion at the back of her neck. It wasn’t noticed before as it was covered by hair prior to her recent appointment to the hairdressers. Based on this image, what is the most likely impression to consider? A) Squamous Cell Carcinoma B) Keratoacanthoma C) Basal Cell Carcinoma D) Molluscum Contagiosum E) Pyogenic GranulomaPrecursors to SCC ● Keratoacanthomas ● Actinic Keratosis ● Bowen’s Disease NB Recent Organ Transplantation is linked to increased risk of SCCWhich of the below is a NOT a diagnostic Criteria for Melanoma? A) Altered sensation B) Inflammation C) Diameter <6mm D) Change in colour E) Change in shapeWhich of the below is a NOT a diagnostic Criteria for Melanoma? A) Altered sensation B) Inflammation MAJOR CRITERIA: Each 2 pts MINOR CRITERIA: each 1 pt C) Diameter <6mm 1) Change in shape 1) Diameter >6mm D) Change in colour 2) Change in size 2) Inflammation E) Change in shape 3) Change in colour 3) Altered sensation 4) Oozing or bleeding If >3 = URGENT 2ww DERM REFERRAL!!!A malignant tumour arising from melanocytes. It is among the most common forms of cancer in young adults, peaking most at 70s. Risk factors include sunlight exposure, fair skin (Fitzpatrick Type 1) and FHx Symptoms: A: Asymmetrical B: Irregular borders C: Not uniform (multiple dark colours) D: grows over time E: elevated Investigations Dermoscopy Biopsy for Dermatohistopathology + ImmunohistochemistryEXCISIONAL ● Other techniques would yield insufficient sample for histopathology ● Will need discussion with Dermatology for cosmesisPredicts outcomes and prognosis If depth >1mm = SENTINEL NODE BIOPSYTreatment 1) Surgical Excision 2) +/- Chemo 3) +/- Radio 4) +/- Immunotherapy Early stage has close to 99.9% survival prognosis in 5 years. So every minute counts!!Huh its a BCC??Other keydermatologyconditions to consider reading 1) Atopic Eczema, Eczema Herpeticum 2) Contact Dermatitis 3) Rosacea 4) SSSS 5) SJS and TEN 6) Bullous Pemphigoid, Pemphigus Vulgaris 7) Vitiligo vs Pityriasis Versicolor 8) Lichen Planus 9) Erythema Migrans 10) Pityriasis Rosea 11) Molluscum Contagiosum 12) Slapped Cheek Syndrome (Parvovirus B19) 13) Pyoderma Gangrenosum, Dermatitis Herpetiformis and Crohn’s 14) Kaposi’s Sarcoma and HIV SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! Sign up to our next session on MedAll Take part in our research survey See all our upcoming events www.medticteaching.com | Email: medticteaching@gmail.com | Youtube @medtic | Instagram @medtic.teaching | Tiktok @medticteaching