21- Skin & Hand MSQs Only

Question 1

1 of 30

A 70 year old lady presents with a number of skin lesions that she describes as unsightly. On examination she has a number of raised lesions with a greasy surface located over her trunk. Apart from having a greasy surface the lesions also seem to have scattered keratin plugs located within them. What is the most likely diagnosis?

Answer 1

Seborrhoeic keratosis

Seborrhoeic keratosis may have a number of appearances. However, the scaly, thick, greasy surface with scattered keratin plugs makes this the most likely diagnosis.

Question 2

3 of 30

A 72 year old man presents with a large nodule on his face. It is friable. There is no regional lymphadenopathy. He is lost to follow up and re-attends several months later. On this occasion the lesion has been noted to resolve with scarring. What is the most likely lesion?

Answer 2

Keratoacanthoma

Keratoacanthomas may reach a considerable size prior to sloughing off and scarring.

Question 3

4 of 30

A 22 year old woman presents with a newly pigmented lesion on her right shin, it has regular borders and normal appearing dermal appendages. However, she reports a recent increase in size. What is the best course of action?

Answer 3

Excision biopsy

Lesions bearing normal dermal appendages and regular borders are likely to be a benign pigmented naevi. Therefore diagnostic and not radical excision is indicated. Incision biopsy should not be done.

Question 4

6 of 30

Which of the skin lesions listed below are most likely to resemble a malignant melanoma?

Answer 4

Spitz naevus

Spitz naevi can often resemble melanoma and are best excised.

Question 5

8 of 30

A 72 year old man is investigated for weight loss. On examination, he is deeply jaundiced and cachectic. He also has a dark velvety lesion coating his tongue. What is the most likely diagnosis?

Answer 5

Acanthosis nigricans

Question 6

9 of 30

An 83 year old lady presents with multiple patches of pigmented irregular, superficial lesions over the torso. They do not bleed but have become increasingly itchy. What is the best course of action?

Answer 6

Shave biopsy

This is most likely to be seborrhoeic warts. These are usually superficially sited and are best managed with shave biopsy and cautery.

Question 7

10 of 30

A patient with Crohns disease has a purple coloured skin lesion near an ileostomy site. What is the most likely diagnosis?

Answer 7

Pyoderma gangrenosum

Pyoderma gangrenosum may occur in Crohns disease. Cutaneous involvement of granulomas a.k.a metastatic crohns is recognized but very rare and much less likely and therefore not the correct answer.

Question 8

11 of 30

A 58 year old lady presents with changes that are suspicious of lichen sclerosus of the perineum. What is the best course of action?

Answer 8

Punch biopsy

Punch biopsies are a useful option for obtaining a full thickness tissues sample with minimal tissue disruption. In this situation, the other differential would be AIN or VIN and punch biopsies would be useful in distinguishing these.

Question 8

12 of 30

A 22 year old man presents with an infected sebaceous cyst. The cyst itself is swollen, discharging pus and has some surrounding erythema. What is the most appropriate treatment?

Answer 8

Incision and drainage with excision of the cyst wall and packing of the defect
…………………………………………………………….
The correct treatment for an infected sebaceous cyst is incision and drainage with removal of the cyst wall. Conservation of the cyst wall will invariably lead to recurrence. Under no circumstances should an infected wound like this be primarily closed. The administration of antibiotics without drainage of sepsis is futile.

Question 9

14 of 30

A 89 year old women presents with long standing seborrhoeic warts of her abdominal wall, they have caused troublesome itching. What is the best treatment?

Answer 9

Shave excision and cautery

These lesions are often extensive and superficial. Shave excision will suffice, material must be sent for histology.

Question 10

15 of 30

A 17 year old boy is brought to the clinic by his mother who is concerned about a lesion that has developed on the dorsal surface of his left hand. On examination, he has a soft fluctuant swelling on the dorsal aspect of the hand, it is most obvious on making a fist. What is the nature of the lesion?

Answer 10

Ganglion

Ganglions commonly occur in the hand and are usually associated with tendons. They are typically soft and fluctuant. They do not require removal unless they are atypical or causing symptoms.

Question 11

16 of 30

A 21 year old lady presents with a nodule on the posterior aspect of her right calf. It has been present at the site for the past 6 months and occurred at the site of a previous insect bite. Although the nodule appears small, on palpation it appears to be nearly twice the size it appears on examination. The overlying skin is faintly pigmented. What is the most likely cause?

Answer 11

Dermatofibroma

Dermatofibromas may be pigmented and are often larger than they appear. They frequently occur at sites of previous trauma.

Question 12

17 of 30

A 65 year old man presents with a 5cm ulcerated area over his medial malleolus. It has been present for many years and the nurses have complained that it is not healing with simple bandages. What is the best course of action?

Answer 12

Perform a punch biopsy

This is likely to be a venous ulcer and should usually be managed with compression bandaging if there is no arterial compromise. Long standing lesions may be complicated by the development of malignancy and for this reason a punch biopsy of long standing or non healing lesions is advisable.

Question 13

18 of 30

A 68 year old farmer presents with a skin lesion on his forehead. It has been present for the past 6 months and has grown slightly in size during that time. On examination, he has an ulcerated lesion with pearly white raised edges that measures 2cm in diameter. What is the most likely diagnosis?

Answer 13

Basal cell carcinoma

The raised pearly edges in an ulcerated lesion at a sun exposed site makes BCC most likely.

Question 14

19 of 30

A 28 year old man undergoes an ileocaecal resection and end ileostomy for Crohn’s disease. One year later he presents with a deep painful ulcer at his stoma site. What is the most likely diagnosis?

Answer 14

Pyoderma gangrenosum

Pyoderma gangrenosum is associated with inflammatory bowel disease (this patient had a stoma for crohns!). It is commonly found on lower limbs and described as being painful, the size of an insect bite and growing. It looks like a margherita pizza (with a red base and yellow topping!) Treatment involves steroids. It would be rare for a poorly fitting appliance to cause a deep painful ulcer.

Question 15

21 of 30

Which of the following statements relating to sebaceous cysts is false?

Answer 15

When infected are also known as Cocks peculiar tumour

Typically contain pus(Right)

Are usually associated with a central punctum

Most commonly occur on the scalp

They will typically have a cyst wall
………………………………………………………..
Sebaceous cysts usually contain sebum, pus is only present in infected sebaceous cysts which should then be treated by surgical incision and drainage.

Question 16

20 of 30

A 30 year old man cuts the corner of his lip whilst shaving. Over the next few days a large purplish lesion appears at the site which bleeds on contact. What is the most likely diagnosis?

Answer 16

Pyogenic granuloma

Pyogenic granulomas often appear at sites of trauma.

Question 17

22 of 30

Which of the following statements relating to Keloid scars is untrue?

Answer 17

They have a predilection for sternal , mandibular and deltoid area wounds

They are confined to the margins of the original injury(Right)

They often recur following excision

May occur even after superficial injury

They may be treated by injection of triamcinolone
………………………………………………………..
Hypertrophic scars remain confined to the wound edges.

Keloids (by definition) will tend to extend beyond the margins of the wound and in wounds of any
depth.

Question 18

23 of 30

A 73 year old man presents with a 1.5cm ulcerated basal cell carcinoma on his back. What is the best course of action?

Answer 18

Excision with 0.5cm margin

A small lesion such as this is adequately treated by local excision. The British Association of Dermatology guidelines suggest that excision of conventional BCC (<2cm) with margins of 3-5mm have locoregional control rates of 85%. Morphoeic lesions have higher local recurrence rates.

Question 19

25 of 30

A 72 year old man presents with a lesion on his back. Its appearances are as shown below:
What is the most likely diagnosis?

Answer 19

Basal cell carcinoma

The lesion has all the characteristic features of a basal cell carcinoma. Including raised surface and overlying telangectasia. Amelanotic melanomas are rare lesions and usually have a more ulcerated appearance. Since the question is directed towards the most likely diagnosis the correct answer is basal cell carcinoma.

Question 20

24 of 30

A 53 year old man presents with a nodule on his chin. He is concerned because it has grown extremely rapidly over the course of the preceding week. On examination, he has a swollen, red, dome shaped lesion with a central defect that contains a keratinous type material. What is the most likely cause?

Answer 20

Keratoacanthoma

Keratoacanthomas are characterised by a rapid growth phase. This may mimic amelanotic melanoma (although such rapid growth is rare even in these lesions). The keratin core is the clue as to the true nature of the lesion.

Question 21

26 of 30

A 29 year old man presents with a lump in his scalp. It is located approximately 4cm superior to the external occipital protuberance. It feels smooth and slightly fluctuant and has a centrally located small epithelial defect. What is the most likely underlying diagnosis?

Answer 21

Sebaceous cyst

Sebaceous cysts are most frequently located in the scalp and have an associated central punctum. They may become infected and develop superficial ulceration in which case they are known as “Cocks Peculiar Tumour”. The presence of a punctum is highly suggestive of a sebaceous cyst and are not typically found in the other lesions described.

Question 22

27 of 30

A 28 year old female presents with a small nodule located on the back of her neck. It is excised for cosmetic reasons and the histology report states that the lesion consists of a sebum filled lesion surrounded by the outer root sheath of a hair follicle. What is the most likely cause?

Answer 22

Pilar cyst

Pilar cysts may contain foul smelling cheesy material and are surrounded by the outer part of a hair follicle. Because of their histological appearances they are more correctly termed pilar cysts than sebaceous cysts.

Question 23

28 of 30

A 34 year old gardener presents with a lesion affecting the dorsum of his right hand. It has been present for the past 10 days and occurred after he had been pruning rose bushes. On examination, he has a raised ulcerated lesion which bleeds easily on contact. What is the diagnosis?

Answer 23

Pyogenic granuloma

Trauma is a common precipitant of pyogenic granuloma and contact bleeding and ulceration are common.

Question 24

29 of 30

A 23 year old lady presents with an itchy, bleeding pigmented lesion on her right thigh. What is the best course of action?

Answer 24

Excision biopsy
………………………………………..
Avoid incisional or punch biopsy of lesions suspected to be melanoma.

This may represent a malignant melanoma. Complete excision is required to allow accurate histological assessment. If the diagnosis is confirmed then re-excision of margins may be required. Clearly if the lesion is benign then no further action is required.

Question 25

1 of 6

A 52 year old male presents with discomfort in the fingers of his left hand. On examination, the ring and little fingers of his left hand are flexed and unable to extend completely. He is able to make a fist with the hand. Palpation reveals thickened nodules on the medial half of the palm. What is the most likely diagnosis?

Answer 25

Dupuytren’s contracture

Discomfort of the hand is not uncommon in Dupuytrens contracture, true pain is unusual. The disease most commonly affects the ring and little fingers.

Question 26

2 of 6

A 62 year old man presents after his wife commented on the unusual shape of his fingers. On examination, he has a hard swelling adjacent to the distal interphalangeal joint of his index finger of the right hand with lateral deviation of the finger tip. There is no sensory disturbance and the swelling is not tender. Which pathological process underpins the underlying diagnosis?

Answer 26

Osteoarthritis

The description fits with Heberdens nodes. These are bony outgrowths that occur in the distal interphalangeal joint in association with osteoarthritis. They may skew the finger tip sideways. Bouchards nodes are similar, but affect the proximal interphalangeal joint.

Question 27

3 of 6

A 63 year old lady presents with a three month history of pins and needles in the fingers of the right hand, particularly at night. On examination, there is some loss of the sensation over the palmar aspect of the lateral three fingers and wasting of the thenar eminence. What is the underlying diagnosis?

Answer 27

Carpal tunnel syndrome

Carpal tunnel syndrome commonly produces pain at night as the wrists are flexed during sleep. Compromise of the median nerve may produce wasting of the thenar eminence muscles.

Question 28

4 of 6

A 17 year old boy is brought to the clinic by his mother who is concerned about a lesion that has developed on the dorsal surface of his left hand. On examination, he has a soft fluctuant swelling on the dorsal aspect of the hand, it is most obvious on making a fist. What is the nature of the lesion?

Answer 28

Ganglion

Ganglions commonly occur in the hand and are usually associated with tendons. They are typically soft and fluctuant. They do not require removal unless they are atypical or causing symptoms.

Question 29

5 of 6

A 62 year old lady presents with a non tender lump overlying the distal interphalangeal joint of the index finger. On examination, she has a hard, non tender lump overlying the joint and deviation of the tip of the finger. What is the nature of the lesion?

Answer 29

Heberdens nodes

Heberdens nodes may produce swelling of the distal interphalangeal joint with deviation of the finger tip.

Question 30

6 of 6

A 42 year old lady who has systemic lupus erythematosus presents to the clinic with a 5 day history of a painful purple lesion on her index finger. On examination, she has a tender red lesion on the index finger. What is the diagnosis?

Answer 30

Oslers nodes

Osler nodes are normally described as tender, purple/red raised lesions with a pale centre. These lesions occur as a result of immune complex deposition. These occur most often in association with endocarditis. However, other causes include SLE, gonorrhoea, typhoid and haemolytic anaemia.