Dermatology incorrects

Question 1

which subtype of melanoma is the most aggressive and metastises early?

Answer 1

Nodular melanoma

“nodular is not nice”

appears as a lump vs a growing mole for superficial spreading melanoma

seen in middle aged people vs superficial spreading in young

Question 2

patient has tried topical benzoyl peroxide for acne but has not worked.

what is next step in management?

when do ORAL antibiotics get involved in management?

Answer 2

topical benzoyl peroxide + topical clindamycin!!

antibiotics should not be prescribed alone due to antibiotic resisitance, thats why you keep the benzoyl peroxide

For people with mild to moderate acne: CKS
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

oral antibiotics only used for moderate to severe acne!!! or in pregnqncy eg oral erythromycin -> signs of scarring or hyperpigmentation

Question 3

first line treatment for plaque psoriasis?

how long is the break between courses?

Answer 3

topical steroid (eg betnovate, betamethasone) + topical calcipotriol (vitamin D)

4-week breaks

Question 4

what are the drugs used in patients with cellulitis that are penicillin allergic?

which is used in a penicillin allergic PREGNANT patient?

treatment for Severe cellulitis?

Answer 4

oral clarithromycin, erythromycin or doxycycline

erythromycin!!! -> in pregnancy

oral/IV co-amoxiclav!!!, oral/IV clindamycin, IV cefuroxime or IV ceftriaxone (all start w c )

Question 5

picture of a squamous cell carcinoma to identify -> it was not a bcc as the telangiectasia was on surrounding skin rather than the edges of the skin lesion

Question 6

immunosuppression following renal transplant increases the risk of what skin malignancy?

other risk factors for this malignancy?

Answer 6

squamous cell carcinoma

excessive exposure to sunlight / psoralen UVA therapy
actinic keratoses and Bowen’s disease
immunosuppression e.g. following renal transplant, HIV
smoking
long-standing leg ulcers (Marjolin’s ulcer)
genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism

Question 7

sore throat 2 weeks ago
now has a papular rash with FINE SCALE on anterior and posterior torso and parts of limbs

What is diagnosis?
next step in management?

Answer 7

guttate psoriasis!! (can occur following strep throat)

emollients and reassurance!!

Question 8

scabies second line treatment?

how long can pruritus persist following successful treatment?

Answer 8

malathion!! -> first is premethrin

up to 6 weeks -> delayed hypersensitivity reaction

Question 9

red hot swollen left shin points to cellulitis as DVT affects the CALF

next investigation for cellulitis?

Answer 9

no investigations - clinical dx

Question 10

patient on aspirin, candesartan, clopidogrel, metoprolol and simvastatin

has exacerbation of psoriasis, what drugs caused this?

list all drugs causing exacerbation

Answer 10

aspirin and metoprolol

beta blockers, lithium!, antimalarials! (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors!, infliximab

Question 11

what skin cancer does PUVA (UVA light therapy increase risk of?

Answer 11

squamous cell carcinoma

Question 12

impetigo treatment for localised vs extensive disease

Answer 12

localised = topical hydrogen peroxide!!! or 2nd line is topical fusidic acid

extensive disease = flucloxacillin!! (erythromycin if pen allergic)

Question 13

urticaria management?

management for severe episodes?

Answer 13

non sedating antihistamine = loratidine cetirizine

prednisolone in severe episodes -> short course 5 days + cetirizine for 6 weeks

Question 14

if patient presents with eczema herpeticum and impetigo, treat EH first

Question 15

A 55 year old gentleman presents with a new skin lesion to the forehead. On examination there is a 6mm diameter scaly patch which does not appear indurated or ulcerated. He works as a gardener. He has a past medical history of type 1 diabetes and renal transplant, and his medications include insulin, aspirin, simvastatin, and tacrolimus. What is the most appropriate course of action?

Answer 15

urgent referral to dermatology

although might just be actinic keratosis, squamous cell carcinoma may present atypically and due to the history of immunosuppression/renal transplant you MUST refer

scc = indurated (firm) . can be nodular or plaque like, frequently ulcerate
acitnic keratoses = soft

Question 16

side effect of topical betamethasone administration to darker skin?

Answer 16

skin depigmentation

Question 17

which bacteria found on the skin contributes to acne?

Answer 17

Propionibacterium acnes

Question 18

the most common malignancy of the lower lip is squamous cell carcinoma.

what is the least invasive treatment that can be used?

Answer 18

mohs micrographic surgery

Question 19

most useful next investigation for a patient with erythema nodosum?

Answer 19

CXR -> helps exclude sarcoidosis and TB

Question 20

A 32-year-old lady attends with a facial rash for several weeks. She has an erythematous rash which looks greasy and has a fine scale over her face affecting her cheeks, nasolabial folds, eye brows, nasal bridge and scalp. What is the most likely diagnosis?

Answer 20

Seborrhoeic dermatitis

Question 21

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. most likely diagnosis?

Answer 21

acanthosis nigricans -> can be associated with GI malignancies

Question 22

40-year-old Afro-Caribbean woman with a history of eczema has been applying a topical corticosteroid cream to her legs for several months to control flare-ups. While her eczema symptoms have lessened, she has observed the appearance of multiple light-coloured, irregularly shaped patches on her legs. These patches are lighter than the surrounding skin and are not associated with itching or burning sensations. Physical examination reveals well-defined, hypopigmented patches demarcated from the normal skin.

What is the most likely diagnosis?

Answer 22

steroid use

Question 23

On examination, there is pitting of the nail beds and there is dactylitis of the left ring finger.

Considering her past medical history, what other findings are most likely to be seen on examination?

Answer 23

Painless detachment of the nail from the nail bed - oncycholysis

Question 24

sebohhreic keratosis look on white skin

Question 25

A mother brings her 4-year-old boy to you with a burn. She said it happened yesterday and is not sure how it happened; her best guess is he poured a hot beverage on his arm. She was going to bring him in sooner but he said it was not painful anymore and therefore she delayed the presentation. You notice a white lesion on his forearm that covers about 2% of his total body surface area.

what type of burn is this?

Answer 25

full thickness burn

Superficial epidermal First degree Red and painful, dry, no blisters
Partial thickness (superficial dermal) Second degree Pale pink, painful, blistered. Slow capillary refill
Partial thickness (deep dermal) Second degree Typically white but may have patches of non-blanching erythema. Reduced sensation, painful to deep pressure
Full thickness Third degree White (‘waxy’)/brown (‘leathery’)/black in colour, no blisters, no pain

Question 26

A 32-year-old woman has noticed painful lesions on both of her shins in the past 2 weeks.

She is currently 18 weeks pregnant and reports that she was treated with a course of cefalexin for a urinary tract infection 3 weeks ago. She also has a history of hypothyroidism and increased her levothyroxine dose in her first trimester after her blood tests indicated she was undertreated. In addition, she has irritable bowel syndrome which is well-managed at present. She smokes 2 cigarettes a day.

On examination, there are multiple erythematous nodular lesions distributed symmetrically on her lower legs, measuring between 1 and 5 cm in size.

Which part of her medical history is most likely to have caused her dermatological condition?

Answer 26

pregnancy - cause of erythema nodosum

Question 27

molluscum contagiosum is caused by what virus?

Answer 27

pox virus

Question 28

A 2-year-old girl presents to the GP with her mother with concerns regarding her activity levels. Over the past 3 days, she has been lethargic and has stopped her usual activities entirely.

Today can walk but is not interested in jumping or playing when asked to. She can draw a circle and says sentences with 2-3 words. At home, she can drink and feed herself with a spoon. There are purple petechiae and purpura on her knees, elbows, and calf which have appeared over the last 48 hours. Her only medical history is viral sinusitis 3 months ago.

What is the most appropriate next step for the GP to take?

Answer 28

immediately refer to secondary care

Children with new-onset purpura should be referred immediately for investigations to exclude ALL and meningococcal disease

Question 29

An 84-year-old woman with a history of ischaemic heart disease is reviewed in a nursing home. She has developed tense blistering lesions on her legs. Each lesion is around 1 to 3 cm in diameter and she reports that they are slightly pruritic. Examination of her mouth and vulva is unremarkable. What is the most likely diagnosis?

Answer 29

bullous pemphigoid - no mucosal involvement

Question 30

A 23-year-old woman is seen in the dermatology clinic with a 3-month history of an intensely itchy rash over her hands and feet. She has been working as a veterinarian’s assistant for the last 9 months and there is no clear trigger for her symptoms. She finds the itching is exacerbated on hot days, particularly during her holiday to Spain 4 weeks ago. There is no past medical history of note and she has no known allergies. There is a family history of atopic eczema.

On examination, she has sweaty palms. There is a vesicular rash over her plantar and palmar surfaces. The surrounding skin is erythematous.

What is the most likely diagnosis?

Answer 30

Pompholyx eczema - a subtype of eczema characterised by an intensely pruritic rash on the palms and soles

Question 31

A 19-year-old man presents to the GP with a 6-month history of acne affecting his face and upper back. He reports using topical adapalene and benzoyl peroxide for 10 weeks, with most papules and pustules resolving. However, he is concerned about worsening darkened areas across his cheeks.

On examination, there are no active pustules or papules, but multiple areas of post-inflammatory hyperpigmentation are noted.

Which is the most appropriate next step in his management?

Answer 31

Severe acne (scarring, hyperpigmentation and widespread pustules) requires specialist dermatology referral

Question 32

A 27-year-old woman presents with itch and lethargy. She is having difficulty sleeping due to night sweats and is wondering if she may be ‘going through the change’. A chest x-ray is normal.

Answer 32

lymphoma

Question 33

A 67-year-old man presents in general practice with a new itchy rash that he has had for a ‘couple of weeks’. On examination, the rash is purple, raised, and has fine white lines on the surface. Inside the mouth, the patient has white striae on the oral mucosa which you identify as Wickham striae.

Given the likely diagnosis, what medication is the first-line management for this?

Answer 33

topical steroids eg topical clobetasone -> patient has lichen planus

benzydamine mouthwash or spray is recommended for oral lichen planus

Question 34

iron deficiency anaemia is a cause of pruritis

Question 35

what condition is most associated with sebhorrheic dermatitis?

Answer 35

HIV

Question 36

A 37-year-old man presents to the GP complaining of flushing over the past six months. He complains that this has been getting progressively worse and his face is now red all of the time.

On examination, there are multiple pustules and papules on a base of erythema covering the cheeks and nose. His nose is swollen with thickened skin. He has no significant past medical history or drug allergies.

Given the likely diagnosis, what is the most appropriate treatment for this patient?

Answer 36

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!!

patient has rosacea

Question 37

compression bandaging for venous ulceration NOT compression stockings

Question 38

molloscum contagiosum management?

Answer 38

Supportive care only and advise that the child can continue attending school

Question 39

A neonate is brought to your surgery because his mother has noticed some skin lesions on his face. On examination there are multiple tiny white papules on the nose. What is the most likely diagnosis?

Answer 39

millia

Erythema toxicum neonatorum is incorrect as this condition presents as erythematous macules and papules with surrounding erythema, often described as having a ‘flea-bitten’ appearance.

Question 40

A 23-year-old man presents with extensive 3rd-degree burns resulting from a spillage of fryer oil. You are asked to assess the patient to decide the volume of intravenous fluids required.

What tool should be used to most accurately take the necessary measurements?

Answer 40

Lund and Browder chart

Question 41

A 59-year-old man presents to the GP practice with his wife due to recent changes in his bowel habits. He reports that his stools have become very loose. He also mentions that he is losing some hair and on examination, the doctor notes numerous red rashes on the skin. The man is unable to recall when these rashes first appeared. He is currently taking rifampicin, isoniazid and pyrazinamide for a recent tuberculosis infection. Which of the following conditions is this man suffering from?

Answer 41

pellagra - 4ds

induced by isoniazid

Question 42

A 29-year-old man presents with a rash on his trunk. Around two weeks ago he describes developing a patch of ‘eczema’ on his torso the size of 50 pence piece. Around a week later a number of smaller, red patches started to appear as well

most likely diagnosis?

Answer 42

pytyriasis rosea

Question 43

A 50-year-old man presents to general practice complaining of facial flushing. This has previously been transiently triggered by stress or spicy food, but his symptoms have become constant over the past week.

On examination, there is erythema over the nose and cheeks with minimal telangiectasia. The skin is not tense and the patient is systemically well. He has a past medical history of hypertension but nil else.

Given the likely diagnosis, what is the most appropriate first-line treatm

Answer 43

bromidine gel

predominant facial flushing and limited telangiectasia

Question 44

herpes simplex infection can cause what type of rash?

Answer 44

erythema multiforme

Question 45

A 42-year-old man with chronic plaque psoriasis is reviewed by his GP. He has been applying regular emollients, which help with itching, but his plaques have not visibly improved. After eight weeks of using a potent corticosteroid and a vitamin D analogue once daily, there is no improvement, and he reports frustration as symptoms interfere with work.

What is the most appropriate next step in management?

Answer 45

Prescribe a vitamin D analogue to be applied twice daily

Question 46

A man in his 50s presents with a lump under both his nipples. He is very embarrassed and states he no longer takes his shirt off in public anymore. Currently, he is taking 5 medications which include metformin, ramipril, ketoconazole, gliclazide, and co-codamol.

Which of the following is the most likely cause of his presenting complaint?

Answer 46

ketoconazole

Question 47

co amoxiclav can cause erethyma multiforme of hands, allopurinol can cause erythema multiforme

Question 48

A 28-year-old woman with a history of idiopathic urticaria presents with a moderate flare of itchy weals. There are no signs of angio-oedema or anaphylaxis. She has been taking fexofenadine daily which has helped, but is struggling with troublesome night-time itching which is interrupting her sleep.

Which of the following could be considered?

Answer 48

Oral chlorphenamine

can be used at night

Question 49

Ultrasound is not neccesary in a lipoma diagnosis unless > 5cm

Question 50

drugs causing TEN?

Answer 50

phenytoin
sulphonamides
allopurinol
penicillins
carbamazepine
NSAIDs

Question 51

keloid scars are most common in what location?

Answer 51

sternum

Question 52

if a patient with burns have been resuscitated, the next step is to transfer to regional burn centre once stabilised

if a patient with burns has rising ventilation pressures -> escharotomy is required

Question 53

causes of spider naevi?

Answer 53

liver disease
pregnancy
cocp!!

Question 54

Superficial dermal burns covering >3% TBSA in adults must be referred to secondary care

Question 55

vitiligo associations?

Answer 55

type 1 diabetes mellitus
Addison’s disease
autoimmune thyroid disorders
pernicious anaemia
alopecia areata!!

Question 57

sebhorreic

Answer 57

topical ketoconazole

Question 57

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) is incorrect. This is an autoimmune systemic vasculitis which is characterised by eosinophilia, granuloma formation and vasculitis. Although this can present with sinusitis and a vasculitic rash, one of the key features of eosinophilic granulomatosis with polyangiitis (EGPA) is the presence of asthma and eosinophilia, which are not mentioned here.

Question 57

rosacea = erythema + pustules
NOT acne which is just pustules

Question 58

Perioral dermatitis can be made worse by topical steroids

Question 59

A 45-year-old woman presents with bilateral, asymmetrical nodules over both shins. Over the past few months, she has experienced loose stools, weight loss and profuse sweating.

On examination, the nodules are non-pitting, firm, and have a shiny pink to purple-brown colour with a peau d’orange texture. Digital clubbing is present, and her heart rate is 106 beats per minute.

What is the most likely diagnosis of this skin lesion?

Answer 59

Grave’s disease, orange peel shin lesions - pretibial myxoedema