Dermatology

Question 1

1st line treatment acne

Answer 1

Benzoyl peroxide 5%
Adapalene 0.1%
Epiduo- adapalene+ benzoyl peroxide 5%
Duac- clindamycin + benzoyl peroxide

Question 2

Moderate acne treatment

Answer 2

1st- Duac or clindamycin+benzoyl peroxide
2nd- tretinoin 0.025% + clindamycin 1%
Or Dalacin T (clindamycin monotherapy) and Zineryt (erythromycin and zinc complex
Stop at 6 months
+ COCP?

Question 3

3rd line moderate acne

Answer 3

Continue with topical benzoyl peroxide, azelaic acid, or retinoid preparation.
Doxycycline 100 mg OD or lymecycline 408 mg OD
Reserve erythromycin for patients aged 12 years or younger, pregnant women, and patients unresponsive or unable to tolerate tetracyclines.
Take abx 2 to 3 months then assess

Question 4

Criteria for referral to dermatology for acne

Answer 4

Severe cystic acne with scarring
Extreme psychological response to acne
Prolonged acne beyond the age of 25 years
No response or relapse on treatment with oral antibiotics
For consideration of isotretinoin

Question 5

Red flag in eczema

Answer 5

Eczema herpeticum

Sudden and rapid deterioration in eczema.
Painful punched-out erosions and blisters usually prominent on the head and neck.
The patient may be unwell with flu-like symptoms, fever, and lymphadenopathy.

Risk of encephalitis/keratitis of cornea

Question 6

Venous eczema features

Answer 6

Itchy red, blistered and crusted plaques on lower legs
Orange-brown macular pigmentation due to haemosiderin
Atrophie blanche (white irregular scars surrounded by red spots)
‘Champagne bottle’ lipodermatosclerosis

Question 7

Treatment seborrhoeic dermatitis

Answer 7

Non soap cleaner for face BD
Keratolytics for scale (salicylic acid/urea)
Ketoconazole shampoo
Mild topic steroids for flares
Coal tar for scalp
Phototherapy/tacrolimus/oral itraconazole if severe

Question 8

Steroid cream potency

Answer 8

Mild- hydrocortisone
Mod- eumovate
Potent- betnovate
Very potent- dermovate

Question 9

Risk factors for poor outcome in fungal nail infections

Answer 9

Diabetes mellitus
Immunosuppression
Previous history of fungal nail infection
More than 50% nail plate involvement
Chronic paronychia

Question 10

When would you treat fungal nail infections?

Answer 10

fungal nail is severe, painful, or debilitating, or
patient has peripheral vascular disease, diabetes, or is immunocompromised.

Question 11

Treatments of fungal nail infections and likelihood of cure

Answer 11

25% fail cure with any treatment.
OTC amorolfine 5% nail lacquer.-
Treat up to 2 affected nails, cure rate 50%.
Requires good mobility and time to file, cleanse, and apply.
Oral terbinafine:
Fingernail– 250 mg OD 6 -12 weeks.
Toenail – 250 mg OD for 3- 6 months.
cure rate of 70%, monitor LFT before treatment then periodically after 6 weeks

Question 12

Features suggestive of melanoma

Answer 12

7‑point weighted checklist for pigmented skin lesions. Suspect melanoma if 3 or more (66% of melanoma cases).

Major features (worth 2 points each):
Change in size
Irregular shape
Irregular colour
Minor features (worth 1 point each):
Largest diameter is 7 mm or more
Inflammation
Oozing
Change in sensation or itching
elevated, firm, and growing over a period of 4 to 6 weeks are suspicious for melanoma, even if non‑pigmented.

Question 13

What is acral lentiginous melanoma?

Answer 13

Characterised by site of origin – palm, sole, fingers, toes, or beneath the nail (subungual).
Not related to sun exposure – cause is unknown.
May present as an enlarging patch of discoloured skin, often thought initially to be a stain.
Over 30% of cases are hypomelanotic, and may mimic plantar warts or tinea infection

Question 14

Causes of itch without rash

Answer 14

Iron deficiency
Liver disease
Primary biliary cirrhosis
Malignancy, e.g. Hodgkin’s disease, leukaemia
Polycythaemia
Renal failure
Thyroid dysfunction
Dry skin, particularly in older people
Urticaria
Drugs
Pregnancy
Regional neuropathy
Delusion of parasitosis/amphetamine use

Question 15

Drug causes of itch

Answer 15

ACE inhibitors
Aspirin
Antibiotics
Antimalarials
Diuretics
Lamotrigine
Opiates
Statins

Question 16

Investigations of itch without primary rash

Answer 16

FBC, U+E, LFTs, blood glucose, ESR/CRP, immunoglobulins.
Iron studies, TSH, LDH
consider chest X-ray.
pregnancy test

Question 17

Treatment of itch

Answer 17

Moisturiser
Menthol ointment
Steroid cream
Antihistamines
Avoid hot showers, keep nails short

Question 18

What is guttate psoriasis? Any tests?

Answer 18

Young adults 2 to 3 weeks after tonsillitis or viral infection, rapid onset
Widespread, small, thin, teardrop lesions on the trunk.
Lasts 2 to 3 months.
UVB therapy, emollients
Ix for streptococcal throat infection to guide abx:
Throat swab microscopy, culture, and sensitivity
Anti-DNase B
Anti Streptococcal O Titre (ASOT)

Question 19

Risk factors for psoriasis

Answer 19

metabolic syndrome.
cardiovascular disease.
inflammatory bowel disease (especially Crohn’s disease).
coeliac disease.
depression.
alcoholism.

Question 20

Management psoriasis

Answer 20

Sun exposure
Tar shampoo, Polytar, Alphosyl 2 in 1.
Smoking cessation
Limiting alcohol
weight loss and exercise can improve psoriasis + metabolic syndrome.
Emollients
Steroid cream + calcipotriol
Exorex coal tar 5%

Question 21

Management scalp psoriasis and face psoriasis

Answer 21

Cocois ointment or Sebco ointment for 1 hour (or overnight if tolerated) and wash out with Polytar, Alphosyl 2 in 1. Use daily until skin is clear, then twice a week for maintenance.
If inadequate response after 2 weeks, change to betamethasone scalp application.
Face psoriasis in conjunction with seborrhoeic dermatitis Daktacort cream OD 7 to 10 days.

Question 22

Basal cell carcinoma (BCC) Characteristics

Answer 22

non‑healing sore with visible blood vessels.
slowly growing plaque or nodule.
skin‑coloured, pink, or pigmented.
varies in size from a few millimetres to several centimetres in diameter.
spontaneous bleeding or ulceration.
hyperkeratosis, which may indicate an SCC.
If you stretch the skin, pearly edge

Question 23

Features SCC

Answer 23

Classic – tenderness, thickening, and induration of lesion, often with hyperkeratosis
Keratoacanthoma – rapidly growing lesions, often with a smooth outer dome and central keratin core

Question 24

Treatment warts

Answer 24

No treatment.
Keep covered continuously with an occlusive dressing, e.g. duct tape or strapping tape.
Salicylic acid treatment has similar effectiveness to cryotherapy for verruca, but is less painful.
Cryotherapy, if offered in GP

Question 25

When to suspect underlying cause of hair loss

Answer 25

Absent or reduced eyebrows or eyelashes — may suggest a frontal fibrosing alopecia or alopecia areata.
Inflammation, papules or pustules, scaling, or scarring of the scalp — may suggest scarring alopecia.
Systemic disease, such as a recent severe infection, iron deficiency, or hypothyroidism.
Exposure to (or a change of) medication.
Change in dietary habits or rapid weight loss

Question 26

Causes of scarring alopecia

Answer 26

Tinea capitis —itchy, scaly scalp with patchy, irregular hair loss. Lymphadenopathy (post-auricular and cervical) if inflammatory tinea capitis, and in more severe cases, erythema, pustules, permanent alopecia, and scarring of hair follicles
Discoid lupus erythematosus — persistent scaly, disc-like plaques on the scalp, face, and ears that may cause violaceous or pink erythema, scarring, and hair loss.
Dermatomyositis —rare acquired inflammatory myopathy that is accompanied by an itchy reddish or bluish-purple patches, mostly on sun-exposed areas of the body.

Question 27

Treatment of male pattern hair loss

Answer 27

Minoxidil 5% scalp foam (Regaine for Men Extra Strength Scalp Foam 5%) can be prescribed or purchased OTC.

Finasteride 1 mg tablets (Propecia) private prescription.

Question 28

Ix for hyperhydrosis secondary causes

Answer 28

FBC, CRP, U+E, LFT, HbA1c, TFT
?HIV/tuberculosis
?Blood film for malaria
24-hour urine catecholamines, metanephrines (phaeochromocytoma) and 5-hydroxyindoleacetic acid (carcinoid tumours).
Chest X-ray

Question 29

2ndary causes hyperhidrosis

Answer 29

Anxiety
Pregnancy or menopause.
Infections — TB, brucellosis, HIV, and malaria.
Malignancy — Hodgkin’s disease, myeloproliferative disorders.
Endocrine — hyperthyroidism, diabetic hypoglycaemia, diabetes insipidus, phaeochromocytoma, acromegaly, carcinoid syndrome, hyperpituitarism, obesity, and gout.
Neurological — PD, epilepsy, hypothalamic lesions.
Drugs -SNRIs, SSRIs, TCAs,, pilocarpine; propranolol, ciprofloxacin, aciclovir, esomeprazole, and opioids.
Drug or alcohol misuse or withdrawal

Question 30

Management hyperhidrosis

Answer 30

20% aluminium chloride hexahydrate OTC
Apply at night to dry skin, wash off in morning.
Apply every 1–2 days as tolerated then PRN which may be up to every 6 weeks
Specialist treatments of glycopyrrolate, oxybutinin, glycopyrronium, propanthaline bromide, iontophoresis, botox

Question 31

Treatment alopecia

Answer 31

If non scarring + no hair regrowth trial potent topical corticosteroid betamethasone valerate 0.1% for 3 months
Specialist treatment: steroids, topical immunotherapy, topical minoxidil, PUVA, immunosupressants

Question 32

Hypopigmentation/depigmentation causes

Answer 32

-Vitiligo
-Hypopigmentation following eczema, psoriasis, lichen planus, scleroderma or systemic sclerosis, SLE, and syphilis.
-Lichen sclerosis -itchy, white atrophic plaques in the perineum
-Progressive macular hypomelanosis- ill-defined macules on trunk, often confluent in and around the midline
-Pityriasis versicolor- superficial yeast infection, small (less than 1 cm in diameter), round, pale hypopigmented, fine, dry scale.
-Tuberculoid leprosy

Question 33

Progressive macular hypomelanosis treatment

Answer 33

Narrowband UVB phototherapy
Oral tetracyclines
Topical anti-acne preparations eg, clindamycin and benzoyl peroxide

Question 34

Treatment pityriasis versicolour

Answer 34

Ketoconazole 2% shampoo OD for up to 5 days

Question 35

Perioral dermatitis

Answer 35

An acneiform eruption, surrounding skin scaly and flaky
Burning sensation, itch
Stop steroid cream + washes
4-8 weeks Metronidazole 0.75–1%
Erythromycin 1% gel

Question 36

Treatment rosacea

Answer 36

Sunscreen
Tinted cosmetics
Brimonidine 0.5% gel for flushing OD PRN
Topical ivermectin for moderate papules/pustules OD 8–12 weeks, or metronidazole 0.75% gel BD or azelaic acid 15% BD
If severe, topical ivermectin, + PO doxycycline MR 40 mg 8–12 weeks

Question 37

Bullous pemphigoid

Answer 37

Autoimmune subepidermal blistering disease, usually age>80
severe itch and (usually) large, tense bullae (fluid-filled blisters), which rupture forming crusted erosions
Ultrapotent steroid cream if < 10% of body surface
Moderate potency topical steroids and emollients
Prednisone 0.5 mg/kg/day
Doxycycline 200 mg/day if mild

Question 38

Pemphigus vulgaris

Answer 38

Rare autoimmune painful blisters and erosions on the skin and mucous membranes, most commonly inside the mouth, thin-walled flaccid blisters
PO prednisolone/IV methylpred

Question 39

Hidradenitis suppuritiva

Answer 39

Persistent or recurrent boil-like nodules and abscesses, axillae groin under breasts
benzoyl peroxide wash/hibiscrub
Topical clindamycin phosphate 1% with benzoyl peroxide
Topical antibiotics: fusidic acid, metronidazole.
PO doxycyline/erythromycin

Question 40

What to do if aktinic keratosis

Answer 40

Teledermatology for opinion
Efudix (flurouracil) ON 3-4 weeks