Skin Signs in Systemic Conditions - Essential GP Revision

Skin signs revision for general practice exams.

Video version: https://youtu.be/31Rw1P1IkJM

Notes, questions and flashcards: https://zerotogp.com/

Books and flashcards: https://zerotofinalsshop.com/

Full AKT Revision Course: https://zerotofinals.com/courses/zerotoakt/

Transcript

SPEAKER_00 0:00

Hi, this is Tom and welcome to the Zero to GP Podcast. In this episode, we're going to be talking about skin signs of systemic disease. Ideally, this episode is best watched as a YouTube video. You can find the Zero to GP YouTube channel, in which case you'll see images of these conditions that I'm talking about. Although to make it accessible for this podcast version, I'll try and describe as best I can the images as well as the presentation. So you should still be able to get to the correct diagnosis. The format, as always, is I'm going to ask you questions, I want you to come up with your answer, and then we'll go through an explanation. So let's jump straight into this episode. The first case is a 67-year-old man who presents with general fatigue, nothing particularly specific. And he uh he shows you that he's got this skin change on the back of his neck, where he has thick, velvety, hyperpigmented skin on the back of his neck. He also notices the same thing in his armpit or axilla and a bit in his groin as well. So the first question is what is the name for this skin change? This is called acinthosis nigricans. The next question I have is what's the associated condition with this uh skin change? This skin change is particularly associated with insulin resistance, which can be, you know, contribute to type 2 diabetes. It can occur without any insulin resistance and without any complications, but if you see this skin change, particularly in your exams, think about insulin resistance and potentially type 2 diabetes. Okay, on to the next one. We got a 33-year-old woman, and she presents with some abdominal abdominal bloating and mouth ulcers. And she shows you this really, really itchy, blistering rash affecting her elbows. It also protect uh it also affects her buttocks. My next question for you is what's this skin change called? The name for this itchy blistering rash is dermatitis herpetiformis. And what is this associated with? What as what general condition is this associated with? Dermatitis herpetiformis is associated with celiac disease, which is why she's getting the abdominal bloating and the mouth ulcers. So she needs testing for celiac disease, which would be anti-TTG antibody testing, and then referral to gastroenterology for an endoscopy and biopsy. On to the next patient. We've got a 34-year-old woman and pres and she presents with these tender red nodules on both shins. My next question is what is this skin change? These tender red nodules on the shins?

SPEAKER_01 3:34

What are they called?

SPEAKER_00 3:43

This condition is called erythema nodosum. So what's the associated systemic conditions that are associated with erythema nodosum? If you see erythema nidosum in your exams, think about inflammatory bowel disease and sarcoidosis. There are a long list of things that can be associated with erythema nidosum, including certain medications and infections like tuberculosis. But systemic condition-wise, think about inflammatory bowel disease and sarcoidosis. Okay, on to the next patient. We've got a 64-year-old woman, and she presents because she says she's struggling with stairs when she's climbing upstairs and getting up out of a chair. So she's noticed some proximal muscle weakness. She's also got these changes. So she's got a purplish rash around her eyes on her eyelids, and she's got a kind of red-purple, scaly rash across her knuckles and across the joints of her hands. My question for you is what are these skin changes? The skin changes around her eyelids, this purplish skin change around the eyelids is called a heliotrope rash, and the scaly, purplish skin changes on the knuckles are called gotron papilles. My next question for you is what associated condition is associated with the heliotrope rash around the eyes and the gotrum papules on the knuckles? These changes are associated with dermatomyocytis, which is a type of myocytis causing muscle inflammation, which is why she's got this progressive muscle weakness. My next question is if you're suspecting dermatomyocytis as a GP, what blood test specifically are you going to request? You should request a creatine kinase blood test. Creatine kinase will be raised with muscle inflammation. The two key times you would um organize a creatine kinase is if you're suspecting myositis, which is either dermatomyocytis or polymyocytis. Okay, on to the next patient. We've got a 50-year-old man, and he presents with fatigue, joint aches, and reduced libido. And when you look at him, despite the fact he's not been on holiday for a few years and he has, say, an indoor job, he has really tanned bronze-colored skin. My question for you is what's your suspected diagnosis in this patient with bronze-colored skin? Here you're suspecting hemochromatosis. What's the initial blood test for hemochromatosis if suspected? The initial blood test is a serum ferritin level, which will be raised in the condition. Remember, hemochromatosis is an iron storage condition, it's a genetic condition, and it causes iron to be retained in the body and deposited in the tissues. It will cause all sorts of problems, including fatigue, jointaches as it's deposited in the joints, reduced libido as it's deposited in the testes, and affects the hormone production of testosterone, and it'll be affect it'll be um it'll be deposited in a bunch of other tissues, causing a bunch of problems. So raised ferritin is the initial blood test. You'd also want to check transferrin saturation and then the HFE gene mutations and refer to hematology. Okay, on to the final case, which is a 34-year-old man, and he presents with a progressive dry cough and dysphia or shortness of breath. He generally feels unwell. And when you examine him, he's got these purplish papules across his skin. So these large purple kind of papules. My question for you is what is this skin condition?

SPEAKER_01 9:07

What condition are you suspecting here?

SPEAKER_00 9:19

So in this case, you should suspect uh caposy sarcoma, which is a type of uh skin malignancy. What's the underlying diagnosis here in this patient with dry cough and shortness of breath and capose sarcoma? You should be suspecting late stage HIV or AIDS, acquired immunodeficiency syndrome. My final question for you is what would be the cause of the dry cough and the shortness of breath in this patient with Capose sarcoma and late stage HIV. You should be suspecting pneumocystis geovecci pneumonia or PCP. Both pneumocystis geovecneumonia and carposisarcoma are AIDS-defining illnesses in late-stage HIV. So thanks for listening to this episode on uh skin conditions or skin changes in systemic conditions. Hopefully it was helpful. Uh these are key things that you'll that will come up in your AKT exam where they'll give you an image and ask you the diagnosis or underlying condition or next test. Um so this this should hopefully get you a few extra points in the AKT exam. If you're preparing for your AKT exam, remember there's the revision book. But particularly, I'd suggest checking out the AKT revision course coming up on the 13th of September this year. Um, if you head over to the link in the description, you'll see some of the reviews and the feedback and testimonials from the course where people have gone on to do really well in the AKT exam. In some instances where they failed the exams multiple times before, come to the course, and then scored really well on their exam. So I recommend checking that out. But either way, I'll see you in the next episode, which will be in about a week's time.