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Dermatology and Miscellaneous: Eczema, Psoriasis, Skin Cancers, Medical Ethics and Law

This article covers various topics in dermatology, including eczema, psoriasis, skin cancers, and medical ethics and law. It provides information on the clinical features, complications, investigations, and treatment of these conditions.

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Dermatology and Miscellaneous: Eczema, Psoriasis, Skin Cancers, Medical Ethics and Law

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  1. Dermatology (and Miscellaneous) For Phase 2 Katie Knappett Phase 3B The Peer Teaching Society is not liable for false or misleading information…

  2. Topics • Dermatology • Eczema • Psoriasis • Skin Cancers • Medical Ethics and Law • Poisoning The Peer Teaching Society is not liable for false or misleading information…

  3. Eczema • Eczema / Dermatitis • Atopic • Discoid • Seborrhoeic • Venous • Contact Dermatitis The Peer Teaching Society is not liable for false or misleading information…

  4. Atopic Eczema • Young children • Often resolves with age • FH of atopy • Asthma / Allergic Rhinitis • Increased IgE The Peer Teaching Society is not liable for false or misleading information…

  5. Atopic Eczema Clinical Features • Itchy • Erythematous • Scaly • Flexural pattern • Weeping / Exudative • Nailbed involvement (pitting/ridging) The Peer Teaching Society is not liable for false or misleading information…

  6. Atopic Eczema Complications • Staph aureus infection • HSV infection (Eczema Herpeticum) Investigations • Clinical diagnosis • ↑ serum IgE • Eosinophilia in differential WCC • RAST (RadioAllergoSorbent Test) The Peer Teaching Society is not liable for false or misleading information…

  7. 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 The Peer Teaching Society is not liable for false or misleading information…

  8. Discoid Eczema • Well demarcated scaly patches • Esp on limbs • DDx: Psoriasis • Commoner in adults • Often infective component (s.aureus) • Rx: emollients, topical steroids, antihistamines The Peer Teaching Society is not liable for false or misleading information…

  9. Seborrhoeic Eczema • Fungal infection • Yeast overgrowth (Malassezia furfur) • Childhood – “Cradle cap” • Yellowish, greasy thick crusts on scalp • Revolves • Young adults (>males) • 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

  10. Seborrhoeic Eczema Treatment • Suppressive, not curative • Mild steroid (e.g. 1% Hydrocortisone) • Antifungal cream (e.g. miconazole) • Emollients/soap substitutes/ketoconazole shampoo The Peer Teaching Society is not liable for false or misleading information…

  11. Venous Eczema • Aka varicose / gravitational • Chronic venous hypertension • Endothelial hyperplasia • Extravasation of RBC/WBC • Inflammation, purpura, pigmentation The Peer Teaching Society is not liable for false or misleading information…

  12. Venous Eczema Clinical Features • Older people (>women) • Lower legs/ankles • PMH: VTE, Venous ulcers, varicose veins • Brown pigmentation (haemosiderin) The Peer Teaching Society is not liable for false or misleading information…

  13. Venous Eczema Treatment • Emollients • Moderate potency topical steroid • Support stockings / compression bandages / leg elevation The Peer Teaching Society is not liable for false or misleading information…

  14. 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) The Peer Teaching Society is not liable for false or misleading information…

  15. Contact Dermatitis Management • Trigger identification and avoidance • PPE • Barrier creams • Topical steroids The Peer Teaching Society is not liable for false or misleading information…

  16. Psoriasis The Peer Teaching Society is not liable for false or misleading information…

  17. 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) The Peer Teaching Society is not liable for false or misleading information…

  18. Psoriasis Aetiology • Polygenic • Environmental factors • Infection (Group A Strep) • Drugs (e.g. Lithium) • UV Light • Alcohol abuse • Stress • T-Lymphocyte driven disorder The Peer Teaching Society is not liable for false or misleading information…

  19. Psoriasis Pathogenesis Thickened epidermis ; Keratin build up at horny layer ; Rete ridges are elongated ; Polymorphs infiltrate into stratum corneum ; Dilated capillaries ; T-lymphocyte infiltration The Peer Teaching Society is not liable for false or misleading information…

  20. 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 The Peer Teaching Society is not liable for false or misleading information…

  21. Psoriasis Guttate Psoriasis • Guttate = “rain drop” • Acute, symmetrical erruption 2 weeks post-strep throat • Young adults • Usually trunk/limbs The Peer Teaching Society is not liable for false or misleading information…

  22. Psoriasis Flexural Psoriasis • Well-demarcated red glazed plaques in flexures e.g. groin, natal cleft, sub-mammary • Older patients The Peer Teaching Society is not liable for false or misleading information…

  23. Psoriasis Nail Changes • Onycholysis • Pitting The Peer Teaching Society is not liable for false or misleading information…

  24. Psoriasis Complications • Psoriatic arthropathy • Erythroderma • Koebner Phenomenon The Peer Teaching Society is not liable for false or misleading information…

  25. Psoriasis Treatment • Long-term therapy required • Topical Therapies: • Vit D Analogues • Topical Corticosteroids • Coal tar preparations • Dithranol • Systemic Therapies: • Methotrexate • Retinoids • Ciclosporin • Biological agents The Peer Teaching Society is not liable for false or misleading information…

  26. 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 The Peer Teaching Society is not liable for false or misleading information…

  27. 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 The Peer Teaching Society is not liable for false or misleading information…

  28. Skin Cancers Malignant Melanoma • Metastasizes early • Most serious form • Risk Factors • Sun exposure • Pale skin • Immunosuppression • FH The Peer Teaching Society is not liable for false or misleading information…

  29. Skin Cancers Malignant Melanoma ABCDE Criteria A – Asymmetry B – Border irregularity C – Colour variegation D – Diameter >6mm E - Elevation Glasgow 7-point Checklist Major Criteria: • Change in size • Change in shape • Change in colour • Minor Criteria: • Diameter >6mm • Inflammation • Oozing/Bleeding • Itch/altered sensation The Peer Teaching Society is not liable for false or misleading information…

  30. Skin Cancers Malignant Melanoma >1mm thick, refer to MDT Surgery – Wide excision with good margins Sentineal node biopsy Metastatic disease – LN excision, Radiotherapy, Chemotherapy. The Peer Teaching Society is not liable for false or misleading information…

  31. Medical Ethics and Law • 4 principles • Moral foundations • Negligence • Confidentiality • Consent • Capacity • The Doctor-Patient Relationship The Peer Teaching Society is not liable for false or misleading information…

  32. Obligations and Duties • Foundation of medical ethics is the Four Ethical Principles • Autonomy • Beneficence • Non-Maleficence • Justice The Peer Teaching Society is not liable for false or misleading information…

  33. 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 The Peer Teaching Society is not liable for false or misleading information…

  34. Negligence “Harm caused by carelessness; not intentional harm” • How is it decided if one has been negligent in their actions? The Peer Teaching Society is not liable for false or misleading information…

  35. 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? The Peer Teaching Society is not liable for false or misleading information…

  36. 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’ The Peer Teaching Society is not liable for false or misleading information…

  37. 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) The Peer Teaching Society is not liable for false or misleading information…

  38. Confidentiality • GMC Guidelines [2009] • Confidentiality is an important duty but it is not absolute • When can confidentiality be broken by a doctor? The Peer Teaching Society is not liable for false or misleading information…

  39. 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 The Peer Teaching Society is not liable for false or misleading information…

  40. Confidentiality • If releasing any information, always attempt to obtain consent from the patient if practicable • You CAN go against a patient’s withheld consent if necessary. The Peer Teaching Society is not liable for false or misleading information…

  41. 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 The Peer Teaching Society is not liable for false or misleading information…

  42. 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” The Peer Teaching Society is not liable for false or misleading information…

  43. Consent Forms of Consent • Express consent: Verbal/Non-Verbal but clearly stated • Implied Consent: not expressly granted but inferred from the person’s actions • Informed consent: A legal process • Advance decisions: made by a capable adult about the future if they were to lose capacity The Peer Teaching Society is not liable for false or misleading information…

  44. 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 The Peer Teaching Society is not liable for false or misleading information…

  45. Capacity “The ability to make decisions about one’s life” • From simple decisions to major ones • Assessment of capacity is DECISION SPECIFIC and is for that particular moment in time. The Peer Teaching Society is not liable for false or misleading information…

  46. Capacity Mental Capacity Act [2005] 5 principles: • Presumption of capacity • Maximise decision-making capacity • Unwise decisions • Best interests • Least restrictive alternative The Peer Teaching Society is not liable for false or misleading information…

  47. Capacity 2 Stage Test • Is there an impairment or disturbance in functioning of a person’s mind or brain? If so.. • Has it made the person unable to make a particular decision? The Peer Teaching Society is not liable for false or misleading information…

  48. Capacity Mental Capacity Assessment Should be done by the healthcare professional proposing treatment 1st – do the 2 Stage Test Then - MCA The Peer Teaching Society is not liable for false or misleading information…

  49. 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 The Peer Teaching Society is not liable for false or misleading information…

  50. Capacity So, a patient is deemed NOT to have capacity. What now? The Peer Teaching Society is not liable for false or misleading information…

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