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Dermatology (and Miscellaneous)

• For Phase 2
• Katie Knappett
• Phase 3B

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or misleading information
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Topics

• Dermatology
• Eczema
• Psoriasis
• Skin Cancers
• Medical Ethics and Law
• Poisoning

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Eczema

• Eczema / Dermatitis
• Atopic
• Discoid
• Seborrhoeic
• Venous
• Contact Dermatitis

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Atopic Eczema

• Young children
• Often resolves with age
• FH of atopy
• Asthma / Allergic Rhinitis
• Increased IgE

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Atopic Eczema

• Clinical Features
• Itchy
• Erythematous
• Scaly
• Flexural pattern
• Weeping / Exudative
• Nailbed involvement (pitting/ridging)

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Atopic Eczema

• Complications
• Staph aureus infection
• HSV infection (Eczema Herpeticum)
• Investigations
• Clinical diagnosis
• ? serum IgE
• Eosinophilia in differential WCC
• RAST (RadioAllergoSorbent Test)

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Atopic Eczema

• Treatment
• Education irritant avoidance
• Emollients, bath oils, soap substitutes,
  bandaging
• Topical therapies steroids, immunomodulators
• Adjunct therapies oral abx, sedating
  antihistamines
• Severe eczema immunosuppression
• Everyday Rx vs. acute flare Rx

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Discoid Eczema

• Well demarcated scaly patches
• Esp on limbs
• DDx Psoriasis
• Commoner in adults
• Often infective component (s.aureus)
• Rx emollients, topical steroids, antihistamines

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Seborrhoeic Eczema

• Fungal infection
• Yeast overgrowth (Malassezia furfur)
• Childhood Cradle cap
• Yellowish, greasy thick crusts on scalp
• Revolves
• Young adults (gtmales)
• Erythematous nasolabial folds. Dandruff. May also
  affect eyebrows, eyes, axillae, groin glans
  penis
• Elderly
• Can be more severe and involve large areas of
  body
• Erythroderma

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Seborrhoeic Eczema

• Treatment
• Suppressive, not curative
• Mild steroid (e.g. 1 Hydrocortisone)
• Antifungal cream (e.g. miconazole)
• Emollients/soap substitutes/ketoconazole shampoo

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Venous Eczema

• Aka varicose / gravitational
• Chronic venous hypertension
• Endothelial hyperplasia
• Extravasation of RBC/WBC
• Inflammation, purpura, pigmentation

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Venous Eczema

• Clinical Features
• Older people (gtwomen)
• Lower legs/ankles
• PMH VTE, Venous ulcers, varicose veins
• Brown pigmentation (haemosiderin)

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Venous Eczema

• Treatment
• Emollients
• Moderate potency topical steroid
• Support stockings / compression bandages / leg
  elevation

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Contact Dermatitis

• Dermatitis precipitated by an exogenous agent
• Irritants not allergens
• Fluids, abrasives, chemicals, solvents, soaps
• Clinical Presentation
• Hands and Face
• Occupation / hobbies
• Nickel sensitivity most common (10 F 1 M)

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Contact Dermatitis

• Management
• Trigger identification and avoidance
• PPE
• Barrier creams
• Topical steroids

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Psoriasis
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Psoriasis

• Well-demarcated red scaly plaques
• Inflammation and hyperproliferation of skin
• 10x normal proliferation rate
• 2 peaks of onset
• Early (age 16-22) associated with ve FH
• Late (age 55-60)

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Psoriasis

• Aetiology
• Polygenic
• Environmental factors
• Infection (Group A Strep)
• Drugs (e.g. Lithium)
• UV Light
• Alcohol abuse
• Stress
• T-Lymphocyte driven disorder

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Psoriasis
Pathogenesis
Thickened epidermis Keratin build up at horny
layer Rete ridges are elongated Polymorphs
infiltrate into stratum corneum Dilated
capillaries T-lymphocyte infiltration
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Psoriasis

• Chronic Plaque Psoriasis
• Most common
• Well-defined red plaques with a silver scale
• Extensor surfaces
• Sites of trauma e.g. Surgical scars Koebner
  Phenomenon
• Itchy / Sore

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Psoriasis

• Guttate Psoriasis
• Guttate rain drop
• Acute, symmetrical erruption 2 weeks post-strep
  throat
• Young adults
• Usually trunk/limbs

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Psoriasis

• Flexural Psoriasis
• Well-demarcated red glazed plaques in flexures
  e.g. groin, natal cleft, sub-mammary
• Older patients

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Psoriasis

• Nail Changes
• Onycholysis
• Pitting

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Psoriasis

• Complications
• Psoriatic arthropathy
• Erythroderma
• Koebner Phenomenon

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Psoriasis

• Treatment
• Long-term therapy required

• Topical Therapies
• Vit D Analogues
• Topical Corticosteroids
• Coal tar preparations
• Dithranol

• Systemic Therapies
• Methotrexate
• Retinoids
• Ciclosporin
• Biological agents

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Skin Cancers

• Basal Cell Carcinoma
• Rodent ulcer
• Sun exposure found on exposed areas
• Pearly nodule, slow-growing
• Non-healing ulcertion
• Do not metastasise
• LOCALLY INVASIVE
• Need surgical excision
• Radiotherapy/Cryotherapy
• Follow up

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Skin Cancers

• Squamous Cell Carcinoma
• More aggressive than BCC
• Will metastasize if untreated
• Sun exposure
• Immunosuppression
• Keratotic ill-defined nodules
• Ulcerated with hard, raised edges
• Examine LN
• Surgical excision

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Skin Cancers

• Malignant Melanoma
• Metastasizes early
• Most serious form
• Risk Factors
• Sun exposure
• Pale skin
• Immunosuppression
• FH

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Skin Cancers

• Malignant Melanoma
• ABCDE Criteria
• A Asymmetry
• B Border irregularity
• C Colour variegation
• D Diameter gt6mm
• E - Elevation

• Glasgow 7-point Checklist
• Major Criteria
• Change in size
• Change in shape
• Change in colour
• Minor Criteria
• Diameter gt6mm
• Inflammation
• Oozing/Bleeding
• Itch/altered sensation

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Skin Cancers

• Malignant Melanoma
• gt1mm thick, refer to MDT
• Surgery Wide excision with good margins
• Sentineal node biopsy
• Metastatic disease LN excision, Radiotherapy,
  Chemotherapy.

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Medical Ethics and Law

• 4 principles
• Moral foundations
• Negligence
• Confidentiality
• Consent
• Capacity
• The Doctor-Patient Relationship

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Obligations and Duties

• Foundation of medical ethics is the Four Ethical
  Principles
• Autonomy
• Beneficence
• Non-Maleficence
• Justice

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Moral Foundations
DUTY We owe a duty to one another May end up
telling the truth without considering the
consequences
CONSEQUENCES Consider ends, not means ? Can
you always tell what the consequence will
be Some actions are evidently wrong even if the
consequences are great
MORAL CHARACTER With the right character, the
best actions and outcomes will necessarily
flow Characteristics which promote human
flourishing (patience, kindness, compassion,
courage)
Deontology
Consequentialist
virtue
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Negligence

• Harm caused by carelessness not intentional
  harm
• How is it decided if one has been negligent in
  their actions?

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Negligence

• 1. Is there a duty of care?
• 2. Was there a breach in that duty?
• 3. Did the patient come to any harm?
• 4. Did the breach cause the harm?

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Negligence

• Bolam 1957
• If a doctor reaches the standard of a responsible
  body of medical opinion, he is not negligent
• Bolitho 1997
• A judge can choose between differing bodies of
  professional opinion and can reject any opinion
  if it is logically indefensible

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Negligence

• Was there a breach?
• Are your actions supported by others?
• Would a group of reasonable doctors do the same?
  (Bolam Test)
• Would it be reasonable of them to do so? (Bolitho
  Test)

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Confidentiality

• GMC Guidelines 2009
• Confidentiality is an important duty but it is
  not absolute
• When can confidentiality be broken by a doctor?

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Confidentiality

• If it is required by law
• Notifiable diseases
• If ordered by a judge
• Ix of fitness to practice of a health
  professional
• If it is justified in the public interest
• Serious crime / terrorism
• If the benefits to an individual/society outweigh
  the interest of maintaining confideniality
• If the patient has consented

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Confidentiality

• If releasing any information, always attempt to
  obtain consent from the patient if practicable
• You CAN go against a patients withheld consent
  if necessary.

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Consent

• Patients must consent to ANY BODILY CONTACT else
  you could be vulnerable to legal action (Assault
  Battery)
• Doctrine of necessity
• Emergency situations where it is not possible to
  gain consent
• Physician has a higher duty to save life

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Consent

• Valid Consent
• Patient must
• - Have capacity
• - Be acting voluntarily (free from coercion,
  constraint or deceit)
• - Be aware of what they are consenting to
• The action must also be consistent with public
  policy

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Consent

• Forms of Consent
• Express consent Verbal/Non-Verbal but clearly
  stated
• Implied Consent not expressly granted but
  inferred from the persons actions
• Informed consent A legal process
• Advance decisions made by a capable adult about
  the future if they were to lose capacity

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Consent

• Advance Decisions
• May be withdrawn / altered at any time
• Must be valid
• - In writing
• - Signed
• - Witnessed
• - Include express statement that it should
  stand even if life is at risk

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Capacity

• The ability to make decisions about ones life
• From simple decisions to major ones
• Assessment of capacity is DECISION SPECIFIC and
  is for that particular moment in time.

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Capacity

• Mental Capacity Act 2005
• 5 principles
• Presumption of capacity
• Maximise decision-making capacity
• Unwise decisions
• Best interests
• Least restrictive alternative

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Capacity

• 2 Stage Test
• Is there an impairment or disturbance in
  functioning of a persons mind or brain? If so..
• Has it made the person unable to make a
  particular decision?

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Capacity

• Mental Capacity Assessment
• Should be done by the healthcare professional
  proposing treatment
• 1st do the 2 Stage Test
• Then - MCA

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Mental Capacity Assessment

• Can the patient
• Understand the information
• Retain it
• Use / weigh up the information to make a decision
• Communicate their decision
• If the patient cannot perform any one part, they
  do not have relevant capacity

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Capacity

• So, a patient is deemed NOT to have capacity.
  What now?

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Best Interests

• Decision of physicians (Bolam Standard)
• Consider if/when the patient may regain capacity
• Take into account what the patient would have
  wanted, though this is not a legal obligation
• Discuss with family but remember CONFIDENTIALITY
• Consider Lasting Power of Attorney
• Exceptions to best interests?

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Best Interests

• Exceptions
• Advance directive refusing treatment
• Enrolment if incapacitated adults in certain
  forms of research (pharmaceutical trials,
  clinical trials)

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Consent / Capacity of lt18s

• Who can give consent for minors?

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Consent / Capacity of lt18s

• A child who is 16/17 and has capacity as
  determined by MCA
• A child under 16 who has significant
  understanding and intelligence (GILLICK
  COMPETENCE)
• Proxy those with parental responsibility though
  this must be in line with best interests

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Consent / Capacity of lt18s

• However
• COMPETENT MINORS CANNOT REFUSE TREATMENT
• If someone who has parental responsibility has
  consented, a minor can not override this by their
  refusal of consent.

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The Doctor-Patient Relationship

• Based on trust
• Confidentiality
• Best Interests
• Honesty
• Shared decision making

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The Doctor-Patient Relationship

• Transactional Analysis
• Paternalistic lack of autonomy
• Adult Co-operative
• Child-like
• Aim for cooperative adult discussion!

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Poisoning (by doctors!)

• Adverse Drug Reactions
• Important
• Very common
• 10-95 of people starting a new drug will notice
  new symptoms

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Poisoning

• Type B Bizarre
• Idiosyncratic
• Not dose-related
• Unpredictable
• Rare
• Usually serious
• High mortality
• Discovered after marketing

• Type A Anticipated
• Pharmacological
• Dose-related
• Preditable
• Common
• Usually not serious
• Low mortality
• Discovered before marketing

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Adverse Drug Reactions

• Mild
• No Rx required
• Moderate
• Marked Sx requiring treatment / hospitalization
• Severe
• Fatal / life threatening severe organ
  impairment lasting gt1 month

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Adverse Drug Reactions

• Common ADRs
• Warfarin
• Digoxin
• Prednisolone
• Antibiotics
• Diuretics
• Insulin
• Aspirin

Anticipated
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Adverse Drug Reactions

• Common ADRs
• Warfarin
• Digoxin
• Prednisolone
• Antibiotics
• Diuretics
• Insulin
• Aspirin

• Bleeding
• Toxicity
• Multiple S/E
• Skin / Gut reactions
• renal, gout
• Hypoglycaemia
• GI Bleeding

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Drug Safety

• Clinical Trials
• Yellow Card in BNF
• New drugs report all suspected reactions,
  however minor
• All drugs report all serious suspected reactions

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Adverse Drug Reactions

• Warn patients about potential side effects and
  then they are more likely to accept them!

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THE END

• ?

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