Dermatology

Question 1

Management for mild- moderate acne?

Answer 1

12-week course of topical combination therapy should be tried first-line:

-a fixed combination of topical adapalene with topical benzoyl peroxide

-a fixed combination of topical tretinoin with topical clindamycin

-a fixed combination of topical benzoyl peroxide with topical clindamycin

topical benzoyl peroxide may be used as monotherapy if these options are contraindicated or the person wishes to avoid using a topical retinoid or an antibiotic

Question 2

Management for moderate-severe acne?

Answer 2

12-week course of one of the following options:

-a fixed combination of topical adapalene with topical benzoyl peroxide

-a fixed combination of topical tretinoin with topical clindamycin

-a fixed combination of topical adapalene with topical benzoyl peroxide + either oral lymecycline or oral doxycycline

-a topical azelaic acid + either oral lymecycline or oral doxycycline

Question 3

Important points for prescribing acne management?

Answer 3

1. avoid tetracyclines in pregnant/ breastfeeding and children <12 years
2. erythromycin can be used in pregnancy
3. topical retinoid/ benzoyl peroxide should be co-prescribed with oral abx to reduce risk of abx-resistance
4. Topical and oral antibiotics should not be used in combination
5. Gram-negative folliculitis may occur as a complication of long-term antibiotic use - high-dose oral trimethoprim is effective if this occurs
6. combined oral contraceptives (COCP) are an alternative to oral antibiotics in women
7. oral isotretinoin: only under specialist supervision

Question 4

What treatment methods should not be used for acne due to risk of antibiotic resistance?

Answer 4

To reduce the risk of antibiotic resistance developing the following should not be used to treat acne:

-monotherapy with a topical antibiotic
-monotherapy with an oral antibiotic
-combination of a topical antibiotic and an oral antibiotic

Question 5

NICE referral guidelines to dermatology for acne?

Answer 5

-conglobate acne
-nodulo-cystic acne
-mild-moderate acne that has not responded to 2 completed courses of treatment
-moderate to severe acne has not responded to previous treatment that includes an oral antibiotic
-scarring
-persistent pigment changes
-psychological/ MH distress

Question 6

What causes arterial ulcers?

Answer 6

Insufficient blood supply to the skin due to PAD

Question 7

What causes venous ulcers?

Answer 7

Pooling of blood and waste products in the skin secondary to venous insufficiency

Question 8

Arterial vs venous ulcers characteristics?

Answer 8

Arterial:
-affect toes or dorsum of foot
-associated with PAD
-less likely to bleed
-pain worse at night/on elevation but better on lowering leg
-worse pain
-deeper
-punched out appearance/well-defined boarders
-smaller than venous

Venous:
-larger
-occur after minor injury to leg
-affect top of foot/ bottom of calf muscles- medial malleolus
-superficial
-irregular/ sloping boarders
-more likely to bleed
-pain relieved by elevation/ worse on lowering
-less painful
-assocated with venous ezcema
-

Question 9

Investigations for leg ulcers?

Answer 9

-Physical exam + peripheral pulses
ABPI- assess for PAD (ratio of BP in ankle-arm)
-Doppler USS- assess blood flow in arteries to detect stenosis/ occlusion
-MRA/ CTA- more detailed images of vessels and extent of blockages
-Bloods- FBC, CRP, HbA1c, lipids, clotting, G&S
-Charcoal swabs- infection
-Skin biopsy- if SCC suspected and 2WW

Question 10

What is eczema herpeticum?
Management?

Answer 10

Primary infection caused by HSV 1 or2
Common in children with atopic eczema (rapidly progressing painful rash)

Life-threatening and needs to admitted for IV Aciclovir

Question 11

Name the topical steroids from weakest to strongest?

Answer 11

Hydrocortisone 0.5%
Betamethasone valerate (Betnovate) 0.025%
Clobetasone (Eumovate) 0.05%
Fluticasone propionate (cutivate) 0.05%
Betamethasone valerate 0.1%
Dermovate 0.05%

Question 12

Management for BCC?

Answer 12

-Surgical removal with 4mm margin and 6mm for high-risk lesions- almost always
-Mohs micrographic surgery- areas where skin preservation is required (nose, ears or ill-defined areas)
-Curettage, cryotherapy, topical cream: imiquimod, fluorouracil (for small, flat superficial lesions)
-Radiotherapy
-Immunotherapies for advanced or metastatic BCC
-Lifestyle- sun cream

Question 13

Causes of erythema nodosum?
NODOSUM + P

Answer 13

NO- NO cause (Idiopathic)
D- Drugs, particularly sulphonamides and dapsone
O- Oral contraceptive pill (OCP)
S- Sarcoidosis
U- UC, Crohn’s disease, Bachet’s
M- Microorganisms: Tuberculosis, Streptococcus, Toxoplasmosis, malignancy
Pregnancy

Question 14

Causes of erythema multiforme?

Answer 14

HSV- most common
Drugs- NSAIDs, allopurinol, OCP, sulphonamides, carbamazepine, penicillin
Sarcoidosis
Malignancy
Bacteria- mycoplasma, strep A

Question 15

What is Gutte psoriasis?

Answer 15

-Guttate psoriasis is more common in children and adolescents.
-It may be precipitated by a streptococcal infection 2-4 weeks prior to the lesions appearing
-Tear drop papules on the trunk and limbs

Question 16

Eron class I management for cellulitis?

Answer 16

Oral flucloxacillin- first line

Oral clarithromycin, erythromycin in pregnancy or doxycycline if allergy

Question 17

Eron class II management for cellulitis?

Answer 17

NICE recommend: ‘Admission may not be necessary if the facilities and expertise are available in the community to give intravenous antibiotics and monitor the person - check local guidelines.’

Question 18

Eron class III-IV management for cellulitis?

Answer 18

Admit

NICE recommend:
-oral/IV co-amoxiclav, oral/IV clindamycin
-IV cefuroxime or IV ceftriaxone

Question 19

Causes of folliculitis?

Answer 19

Inflammation of hair follicles caused by infection, chemicals or physical injury

Bacterial Infections:
Most commonly due to Staphylococcus aureus.
Pseudomonas aeruginosa- spas/ pools

Fungal infections:
Candida species or dermatophytes -immunocompromised individuals.

Viral: HSV can cause herpetic folliculitis.

Non-infectious:
Chemical Folliculitis: Caused by topical steroids, oils, or tar.

Physical Folliculitis: Due to shaving, tight clothing, or occlusive dressings.

Question 20

Causes of impetigo?

Answer 20

Staphylcoccus aureus or Streptococcus pyogenes.

Question 21

Management for impetigo?

Answer 21

limited localised disease:
hydrogen peroxide 1% cream

topical abx:
-fusidic acid
-Mupirocin if fusidic acid resistance suspected
-if MRSA use mupirocin

Extensive disease:
-oral flucloxacillin
-oral erythromycin if penicillin-allergic

School exclusion
children should be excluded from school until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment

Question 22

How are head lice diagnosed and managed?

Answer 22

Diagnosis:
-fine-toothed combing of wet or dry hair

Management:
-treatment is only indicated if living lice are found
-a choice of treatments should be offered - malathion, wet combing, dimeticone, isopropyl myristate and cyclomethicone

household contacts of patients with head lice do not need to be treated unless they are also affected

Question 23

Nail changes seen in psoriasis?

Answer 23

Nail bed pitting
Onycholysis
Arthritis
Sublingual hyperkeratosis

Question 24

Exacerbating factors in psoriasis?

Answer 24

Alcohol
Trauma
Drugs- B-Blockers, lithium, anti-malarial, NSAISDs, ACEi, infliximab
Withdrawal from steroids

Question 25

Management for chronic-plaque psoriasis?

Answer 25

regular emollients may help to reduce scale loss and reduce pruritus First-line: -potent corticosteroid applied once daily + vitamin D analogue applied once daily -should be applied separately, one in the morning and the other in the evening) -up to 4 weeks as initial treatment Second-line: if no improvement after 8 weeks then offer: -vitamin D analogue twice daily Third-line: if no improvement after 8-12 weeks then offer either: -potent corticosteroid applied twice daily for up to 4 weeks, or a coal tar preparation applied once or twice daily -short-acting dithranol can also be used

Question 26

Secondary care management for psoriasis?

Answer 26

Secondary care management Phototherapy -narrowband ultraviolet B light is now the treatment of choice. If possible this should be given 3 times a week -photochemotherapy is also used - psoralen + ultraviolet A light (PUVA) adverse effects: skin ageing, squamous cell cancer (not melanoma)

Question 27

Systemic therapy for psoriasis?

Answer 27

first-line: oral methotrexate ciclosporin systemic retinoids biologics- infliximab

Question 28

Scalp psoriasis management?

Answer 28

Potent topical corticosteroids used once daily for 4 weeks If no improvement after 4 weeks then either use a different formulation of the potent corticosteroid (for example, a shampoo or mousse) and/or a topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid

Question 29

Face, flexural and genital psoriasis management?

Answer 29

Mild or moderate potency corticosteroid applied once or twice daily for a maximum of 2 weeks Risk of skin atrophy, striae and rebound symptoms so do not use for more than 1-2 weeks/ month

Question 30

Important points for using steroids?

Answer 30

-Risk of skin atrophy, striae and rebound symptoms so do not use for more than 1-2 weeks/ month -systemic side-effects may be seen when potent corticosteroids are used on large areas e.g. > 10% of the body surface area -aim for a 4-week break before starting another course of topical corticosteroids -recommended using potent corticosteroids for no longer than 8 weeks at a time and very potent corticosteroids for no longer than 4 weeks at a time

Question 31

Management for scabies? Medication and general guidance

Answer 31

Management: -permethrin 5% is first-line -malathion 0.5% is second-line -pruritus persists for up to 4-6 weeks post-eradication Patient guidance on treatment: -avoid close physical contact with others until treatment is complete -all household and close physical contacts should be treated at the same time, even if asymptomatic -launder, iron or tumble dry clothing, bedding, towels, etc., on the first day of treatment to kill off mites.

Question 32

Management for scalp psoriasis?

Answer 32

oral antifungals: -terbinafine for Trichophyton tonsurans infections -griseofulvin for Microsporum infections. -Topical ketoconazole shampoo should be given for the first two weeks to reduce transmission

Question 33

Management for urticaria?

Answer 33

-Non-sedating antihistamines (loratadine or cetirizine) are first-line -this should be continued for up to 6 weeks following an episode of acute urticaria -Sedating antihistamine (chlorphenamine) may be considered for night-time use (in addition to day-time non-sedating antihistamine) for troublesome sleep symptoms -prednisolone is used for severe or resistant episodes

Question 34

Early features of Lyme disease? Late features of Lyme disease? Systemic features?

Answer 34

EARLY: Erythema migrans- bulls-eye rash that appears 1-4 weeks after inital bite (80%) SYSTEMIC: headache lethargy fever arthralgia LATE: Cardiovascular: heart block, peri/myocarditis Neurological: facial nerve palsy, radicular pain, meningitis

Question 35

Investigations for Lyme disease?

Answer 35

Clinical diagnosis ELISA abs to Borrelia burgdorferi and if positive/ equivocal then immunoblot test for Lyme disease should be done

Question 36

Management for asymptomatic and symptomatic tick bites?

Answer 36

Asymptomatic: Removal with tweezers Symptomatic: -oral doxycycline if early disease- Amoxicillin if pregnancy -people with erythema migrans should be commenced on antibiotic without the need for further tests -ceftriaxone if disseminated disease -Jarisch-Herxheimer reaction is sometimes seen after initiating therapy: fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)

Question 37

What malignancy is associated with acanothosis nigricans?

Answer 37

Gastrointestinal adenocarcinoma

Question 38

Management for rosacea?

Answer 38

Conservative: -daily sunscreen -camouflage creams may help conceal redness Flushing/ erythema concerns: -topical brimonidine gel (for flushing but limited telangiectasia) used PRN and reduces redness in 30mins mild-to-moderate papules/ pustules -topical ivermectin is first-line -alternatives include: topical metronidazole or topical azelaic acid moderate-to-severe papules/ pustules combination of topical ivermectin + oral doxycycline laser therapy for prominent telangiectasia via referral

Question 39

When does Guttate psoriasis present?

Answer 39

-more common in children and adolescents -precipitated by a streptococcal infection 2-4 weeks prior to the lesions appearing -tear-drop or lace-like rash -Most cases resolve spontaneously within 2-3 months -Topical agents as per psoriasis -UVB phototherapy

Question 40

What is pyoderma gangrenosum associated with?

Answer 40

IBD

Question 41

What is a Marjolin's ulcer?

Answer 41

Squamous cell carcinoma occurring at sites of chronic inflammation or previous injury.

Question 42

What are plantar ulcers associated with?

Answer 42

Plantar ulcers in association with peripheral neuropathy are often neuropathic. They classically occur at pressure points.