DERMATOLOGY

Question 1

Centor Criteria

Answer 1

Used to identify the likelihood of a bacterial infection in adult patients complaining of sore throat, Group A streptococcus.

C- Cough Absent
E- Exudate
N- Nodes (tender anterior cervical lymphadenopathy)
T- Temperature (fever)
OR

Score of 3 or more is indication for antibiotics

Question 2

Drug causes of gingival hyperplasia

Answer 2

-Phenytoin
-Ciclosporin
-Calcium channel blockers (especially nifedipine)

Question 3

Meniere’s disease

Answer 3

Excessive pressure and progressive dilation of the endolymphatic system. More common in middle-aged adults but may be seen at any age.

• VERTIGO
• Hearing loss (sensorineural)
• Tinnitus
• Aural fullness
• Nystagmus
• Positive Romberg test

Typically symptoms are unilateral but bilateral symptoms may develop after a number of years

Question 4

Ramsay Hunt syndrome

Answer 4

Reactivation of the varicella zoster virus in the geniculate ganglion of the facial nerve.
- Facial nerve paralysis
- Ear pain
- Vesicles on the ear/ in the ear
- Dry eyes and mouth

Question 5

Dermatitis herpetiformis

Answer 5

Chronic autoimmune blistering skin condition, characterised by blisters filled with a watery fluid that is intensely itchy! DH is a cutaneous manifestation of Coeliac disease.

Itchy, vesicular skin lesions on the extensor surfaces (e.g. elbows, knees, buttocks)

Mx:
- Gluten-free diet
- Dapsone

Question 6

Pyoderma gangrenosum

Answer 6

Inflammatory skin disease where painful pustules or nodules become ulcers that progressively grow. Idiopathic in 50%. Commonly associated with other immune conditions such as: IBD, RA, SLE

• Typically on lower limbs
• Initially small red papule
• Later deep, red, necrotic ulcers with a violaceous border
• may be accompanied systemic symptoms e.g. fever, myalgia

Mx: Oral steroids

Question 7

Erythema nodosum

Answer 7

Inflammation of subcutaneous fat. Tender, erythematous nodules or lumps that are usually seen on both shins. Self limiting (resolves within 6 weeks).

Causes:
- Streptococcal infection
- TB
- Sarcoidosis
- IBD
- Behcet’s
- Non Hodgkins lymphoma
- Drugs: peniciliins, sulphonamides (sulfasalazine), COCP

Question 8

Erythema multiforme

Answer 8

Hypersensitivity reaction most commonly triggered by infections.

• Target lesions
• Initially seen on the back of hands/feet before spreading to torso
• Upper limbs Affected > lower limbs
• Pruritus (mild) occasionally

Causes:
- HSV
- Idiopathic
- Bacteria: Mycoplasma, Streptococcus
- Drugs: penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill, nevirapine
connective tissue disease e.g SLE
- Sarcoidosis
- Malignancy

Erythema multiforme major: Mucosa involvement, more severe

Question 9

Basal cell carcinoma

Answer 9

Most common skin cancer type.
- Rodent ulcers
- Slow growing, local invasion and rarely metastasize
- Initially a pearly, flesh-coloured papule with telangiectasia may later ulcerate leaving a central ‘crater’
- Routine referral if suspected

Mx: Surgery, curettage, cryotherapy, topical cream (imiquimod, fluorouracil), radiotherapy

Question 10

Eczema most commonly occurs on which surface of the body?

Answer 10

Flexor

Question 11

Subtypes of Psoriasis?

Answer 11

-Plaque psoriasis: the most common sub-type resulting in the typical well demarcated red, scaly patches affecting the extensor surfaces, sacrum and scalp

-Flexural psoriasis: in contrast to plaque psoriasis the skin is smooth

-Guttate psoriasis: transient psoriatic rash frequently triggered by a streptococcal infection. Multiple red, teardrop lesions appear on the body

-Pustular psoriasis: commonly occurs on the palms and soles

Question 12

First line management for Rosacea?

Answer 12

-Topical metronidazole: used for mild symptoms (limited number of papules and pustules, no plaques).

• Topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia.
• More severe disease is treated with systemic antibiotics e.g. Oxytetracycline (doxycycline)

Question 13

Management for pityriasis versicolor?

Answer 13

Pityriasis versicolor, also called tinea versicolor, is a superficial cutaneous fungal infection caused by Malassezia furfur.

• Topical antifungal. NICE advise Ketoconazole shampoo as this is more cost effective for large areas.
• If failure to respond to topical treatment then consider alternative diagnoses (e.g. send scrapings to confirm the diagnosis) + oral itraconazole.

Question 14

Differentiating spider naevi and telangiectasia?

Answer 14

Spider naevi can be differentiated from telangiectasia by pressing on them and watching them fill. Spider naevi fill from the centre, telangiectasia from the edge.

Question 15

Symmetrical erythematous lesions with an orange peel texture over both shins?

Answer 15

Pretibial myxoedema
- symmetrical, erythematous lesions seen in Graves’ disease
- shiny, orange peel skin

Question 16

Treatment for scalp psoriasis?

Answer 16

Potent corticosteroids are usually recommended as first-line used once daily for 4 weeks.

Example of potent corticosteroid: Topical betamethasone valerate 0.1%

Question 17

First line Acne vulgaris management?

Answer 17

Mild-moderate acne:

A 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 18

Management for scalp seborrhoeic dermatitis?

Answer 18

Scalp disease:
1. First-line treatment is ketoconazole 2% shampoo

2. Over the counter preparations containing zinc pyrithione (Head & Shoulders) and tar (Neutrogena T/Gel) may be used if ketoconazole is not appropriate or acceptable to the person

• Selenium sulphide and topical corticosteroid may also be useful.

Question 19

Eczema Herpeticum is caused by?

Answer 19

Eczema herpeticum describes a severe primary infection of the skin by herpes simplex virus 1 or 2.

It is more commonly seen in children with atopic eczema and often presents as a rapidly progressing painful rash.

Mx: IV Aciclovir

Question 20

Features of Lichen Planus?

Answer 20

Lichen Planus:
- Purple, Pruritic, Papular, Polygonal rash on flexor surfaces.

• Itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms
• Wickham’s striae over surface (reticulated white lines)
• Oral involvement common, typically a white-lace pattern on the buccal mucosa

Question 21

Morphea?

Answer 21

Morphea or localized scleroderma usually presents as single or multiple hardened plaques on the skin that are initially erythematous or violaceous and then turn yellowish or ivory coloured.

Question 22

Bullous pemphigoid VS pemphigus vulgaris?

Answer 22

Bullous Pemphigoid:
- No mucosal involvement
- Tense, pruritis blisters

Pemphigus vulgaris:
- Mucosal involvement
- Flaccid blisters

Question 23

Management for scabies?

Answer 23

1. Permethrin 5% is first-line
2. Malathion 0.5% is second-line

Pruritus persists for up to 4-6 weeks post eradication

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.

Question 24

Features of Pityriasis Rosea?

Answer 24

Pityriasis rosea describes an acute, self-limiting rash which tends to affect young adults. The aetiology is not fully understood but is thought that herpes hominis virus 7 (HHV-7) may play a role.

• in the majority of patients there is no prodrome, but a minority may give a history of a recent viral infection
  herald patch (usually on trunk).
• Followed by erythematous, oval, scaly patches which follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer. This may produce a ‘fir-tree’ appearance.

Question 25

Features of polymorphic eruption of pregnancy?

Answer 25

• Pruritic condition associated with last trimester.
• Lesions often first appear in abdominal striae
• Management depends on severity: emollients, mild potency topical steroids and oral steroids may be used

Question 26

Who commonly develops necrobiosis lipodica?

Answer 26

This condition is a rare skin disorder that typically presents in middle-aged women with diabetes, although it can also occur in non-diabetic individuals. It is characterised by bilateral, well-demarcated erythematous plaques on the shins which are often surrounded by telangiectasia and may have a yellowish hue due to lipid deposition. The lesions are usually asymptomatic but may be associated with tenderness or itchiness.

Question 27

Mx for Impetigo?

Answer 27

1. Hydrogen peroxide 1% cream for ‘people who are not systemically unwell or at a high risk of complications’.
2. Topical antibiotic creams:
   - Topical fusidic acid
   - Topical mupirocin should be used if fusidic acid resistance is suspected

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

Question 28

Where is venous ulcer typically seen?

Answer 28

Venous ulceration is typically seen above the medial malleolus.

Ankle-brachial pressure index (ABPI) is important in non-healing ulcers to assess for poor arterial flow which could impair healing.

Question 29

Mx for rosacea?

Answer 29

Typically affects nose, cheeks and forehead
flushing is often first symptom - worsen by alcohol
telangiectasia are common
later develops into persistent erythema with papules and pustules
- Sunlight may exacerbate symptoms

• Topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia

Mild-to-moderate papules and/or pustules:
Topical ivermectin is first-line

Moderate-to-severe papules and/or pustules:
Combination of topical ivermectin + oral doxycycline

Question 30

Who does lichen sclerosus commonly occur in?

Answer 30

Lichen sclerosus: itchy white spots typically seen on the vulva of elderly women.

• White patches that may scar
• Itch is prominent
• May result in pain during intercourse or urination
• Increased risk of vulval cancer.

Question 31

Features of BCC?

Answer 31

BCC lesions are also known as rodent ulcers and are characterised by slow-growth and local invasion. Metastases are extremely rare.

• Sun-exposed sites, especially the head and neck account for the majority of lesions
• Initially a pearly, flesh-coloured papule with telangiectasia
• May later ulcerate leaving a central ‘crater’

Routine referral to Derm except if at high risk areas - eyelid, nasal ala

Question 32

Guttate psoriasis is preceeded by which condition?

Answer 32

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
• Tends to be acute onset over days

Question 33

Stuck on appearance of lesion?

Answer 33

Seborrhoeic keratoses are benign epidermal skin lesions seen in older people.

• large variation in colour from flesh to light-brown to black
• have a ‘stuck-on’ appearance
• keratotic plugs may be seen on the surface

Question 34

Mx for flexural psoriasis?

Answer 34

Topical Steroid.

• Flexural psoriasis which responds well to topical steroids.
• Topical calcipotriol is usually irritant in flexures.

Question 35

What is telogen effluvium?

Answer 35

Telogen effluvium is the name for a common cause of temporary hair loss due to the excessive shedding of resting or telogen hair after some shock to the system. New hair continues to grow. Telogen hair is also known as a club hair due to the shape of the root. Triggered by stress, pregnancy.

• Non scarring alopecia.

Question 36

Which conditions do not cause scarring alopecia? (non scarring alopecia)

Answer 36

alopecia areata
carbimazole
trichotillomania (hair pulling disorder)
telogen effluvium

Question 37

Side effect of Minocycline used in acne treatment?

Answer 37

Irreversible pigmentation.