Dermatology past paper questions Flashcards
A 32-year-old man presents to his GP with a dry scaly rash in his hair. He says it has been there since he had the flu one month previously. He reports that his mother and sister sometimes have a similar rash but it does not involve their scalp.
Given the most likely diagnosis, which of the following are areas where this rash would also often appear?
Extensor surfaces of elbows and knees
Hands and feet
Groin
Flexor surfaces of knees
Chest
Extensor surfaces of elbows and knees
This is the correct answer. This gentleman has psoriasis. Psoriasis most commonly presents on the scalp and extensor surfaces of the knees and elbows. There is a known genetic predisposition to this disease
A 17 year old boy attends the GP with a rash. He is otherwise well, other than a mild cold over the last few days.
On examination there is a 3 cm discoid patch on his right arm that is red and scaly. There are a number of similar but smaller lesions across his chest and back. These smaller rashes developed a day after the initial patch. The lesions are not itchy or painful.
Which of the following is the most appropriate next step in the management of this patient?
Trial topical anti-fungal
Trial topical corticosteroids
Reassure and discharge the patient
Trial topical retinoid
Review vaccination history
Reassure and discharge the patient
This patient has pityriasis rosea- this is a self-limiting condition with no treatment
A 72 year old male presents to the GP. He is concerned about skin lesions on the backs of both his hands and wrists, which have been gradually worsening over several years. The lesions do not cause him any symptoms. He is a retired gardener and reports frequently sun burning. On examination, the image shown below is seen with similar skin changes on his other hand. Considering the most likely diagnosis, which of the following treatments is the most appropriate in managing this skin condition?
Topical Betnovate
Topical Benzoyl peroxide
Topic Fusidic Acid
Topical Dithranol
Topical 5-Fluorouracil
The skin condition described in this case is Actinic Keratosis. Actinic Keratosis (also known as Solar Keratosis) is a premalignant skin condition which can precede the development of a Squamous Cell Carcinoma (SCC). Actinic Keratoses are thought to be caused by sunlight causing DNA damage and hence are found on sun exposed areas of skin, such as the backs of hands. A history of sunburn and an outdoor occupation are both risk factors. Actinic Keratoses present as thickened papules or plaques with surrounding erythematous skin and a keratotic, rough, warty surface. This can be seen in the image above.
Actinic Keratoses are treated to prevent them developing into an SCC. For larger areas (such as in this case), topical therapies are used. These include 5-Fluorouracil (a cytotoxic agent), a non-steroidal anti-inflammatory (NSAID) or Imiquimod (which modifies immune response). For localised lesions, cryotherapy, curettage and surgical excision can be used
An 8 year old girl is brought into the GP by her father with a rash.
On examination there is a papular rash on the palmar aspect of the wrist and in the finger webs. Her father reports that the rash is intensely itchy and is more itchy at night.
How should she be treated?
Topical malathion 0.5% + treat household members
Oral ivermectin + treat household members
Topical permethrin 5%
Topical malathion 0.5%
Topical permethrin 5% + treat household members
Topical permethrin 5% + treat household members
A 70-year-old man sees his doctor about a skin growth on his cheek. It first appeared six weeks ago as a small smooth red spot. He says it then started to get bigger and look like an ulcer. It is painful to touch and has bled on three occasions. His only past medical history is asthma and osteoarthritis. The patient is an ex-smoker and a retired construction worker. On examination, a pink nodule with crusted raised edges and an irregular border is visible on his left cheek. What is the most likely diagnosis?
Basal cell carcinoma (BCC)
Squamous cell carcinoma (SCC)
Actinic keratosis
Lichen planus
Seborrhoeic keratosis
Squamous cell carcinoma (SCC)
This is a typical description of SCC, an aggressive and invasive type of skin cancer. It usually appears on sun-exposed areas of skin and should prompt an urgent referral to dermatology.
An 82-year-old man presents to the GP, worried about a lesion on his head. He says it has been there for quite some time but his wife is very worried about it. He tells you that it is not tender but can sometimes be itchy. On examination, the patient has a 5 mm, white, scaly plaque on the top of his head. Another similar lesion around the back of his head is also noted. The surrounding skin on his head has some hyperpigmentation and there are some very pale patches.
Given the history and examination, what is the most likely diagnosis?
Keratoacanthoma
Basal cell carcinoma
Actinic keratosis
Pyoderma gangrenosum
Seborrheic keratosis
Actinic keratosis
This is the correct answer. Actinic keratosis is a pre-cancerous, crusty, thick area of skin found most commonly on sun exposed areas of fair skinned individuals. They are usually asymptomatic
A 25-year-old woman visits her GP due to a three day history of itching and discomfort around her genital area. She has also felt several ‘bumps’ there. The patient mentions her partner has similar symptoms and wonders if this is due to a sexually transmitted infection. On examination, there are numerous dark pink papules around the vulva. Given the likely diagnosis, what is the most appropriate treatment option?
Topical salicylic acid
Topical adapalene
Topical 5-fluorouracil
Topical podophyllotoxin
Topical podophyllin
Topical podophyllotoxin
Genital warts are benign superficial skin growths, most commonly caused by human papillomavirus types 6 and 11. They are contagious and sexually transmitted. A proportion of cases resolve spontaneously without treatment. If they are to be treated, topical podophyllotoxin is commonly used for genital warts. It treats them by preventing cell division and viral replication of infected cells.
A 70-year-old man books a GP appointment due to a spot on his cheek which he first noticed a few months ago and which has grown in size. It is slightly tender but not itchy and it has never bled. On examination, he has a single erythematous nodule with a central depression and rolled edges on his right cheek. It has a shiny appearance and there is associated telangiectasia. Given the likely diagnosis, what is the most appropriate management option?
Routine referral to dermatology
Topical imiquimod
Suspected cancer pathway referral to dermatology
Watchful waiting
Immediate referral to dermatology
Routine referral to dermatology
This patient likely has basal cell carcinoma. According to NICE guidelines, most suspected cases can be referred routinely to dermatology due to the slow growing nature of the lesion. An urgent two week wait referral is only indicated if there are specific concerns, such as lesions in problematic sites like the eyelids, large lesions > 1cm, or if there is diagnostic uncertainty.
An 80-year-old retired gardener presents to his General Practitioner with a skin lesion. He mentions that he has had this for a while and is confident it has grown since he last checked. On examination, the following lesion is seen:
What is the most likely diagnosis?
Keratotic Basal Cell Carcinoma
Nodular Basal Cell Carcinoma
Pigmented Basal Cell Carcinoma
Acral lentiginous melanoma
Superficial spreading melanoma
Nodular Basal Cell Carcinoma
This patient has a Basal Cell Carcinoma. The most common type of which is nodular Basal Cell Carcinoma. Other types include keratotic, pigmented, cystic and morphoeic.
A 60-year-old woman sees her doctor due to difficulty going up stairs for the past six months. Physical examination reveals significantly reduced strength in the deltoid and quadriceps muscles bilaterally. She is also noted to have scaly papules over the interphalangeal joints of her hands. Which of the following skin features is most associated with the suspected diagnosis?
Oil drop sign
Wickham striae
Heliotrope rash
Koplik spots
Port-wine stain
Heliotrope rash
This patient has bilateral proximal muscle weakness and Gottron’s papules which strongly suggest dermatomyositis. Another characteristic sign of this condition is a heliotrope rash which is a periorbital rash.
A mother brings her 9-year-old son to the GP as he has been complaining of a sore throat for two days. She states that he has also had a fever of 40 degrees and a rash that started one day ago. On examination, of his mouth, his tonsils are large, erythematous and his tongue has a white coating on it. The rash is found mainly on his torso and appears diffuse, red, and bumpy, giving the appearance of sandpaper.
Given the history and examination findings, what is the most likely diagnosis?
Rubella
Erythema infectiosum
Scarlet fever
Measles
Roseola infantum
This is the correct answer. Scarlet fever is a bacterial infection that results in a sore throat, fever, headache, lymphadenopathy, and a rash. The rash has a characteristic sandpaper look and the tounge looks red an bumpy, commonly known as strawberry tongue. Scarlet fever most commonly affects children aged 5-15
A 45-year-old man presents to his GP with a rash on his face, upper chest and hands. He states that it has been getting worse for the last few weeks. He doesn’t remember changing his diet or starting any new medication in this time. On further questioning, he also reveals that he has been feeling weaker and finding it more difficult at work to move heavy boxes. On examination, he has a lilac rash on his eyelids. He has red papules on the proximal joints of his fingers. Excoriations and evidence that some of the lesions have bled is also noted.
Given the history and examination findings, what is the most likely diagnosis?
Polymyositis
Psoriasis
Systemic lupus erythematosus (SLE)
Scleroderma
Dermatomyositis
Dermatomyositis is an inflammatory disorder that is most common in individuals aged 40-50. It presents typically as a purple rash, commonly on the eyes, but can be in a number of other place, and muscle weakness
An 8 month old baby is brought into A&E by his mother. Over the last 24 hours he has been febrile and irritable and now he has developed a rash.
On examination there is widespread erythema and there are large fluid filled blisters across his body, many of which have ruptured. There are patches of desquamation and Nikolsky sign is positive. There is marked crusting and fissuring around his mouth, although his oral mucosa is unaffected.
The boy has no relevant past medical history and is up to date with his vaccinations.
Which of the following is the most likely diagnosis?
Kawasaki disease
Toxic epidermal necrolysis
Pemphigus vulgaris
Bullous pemphigoid
Staphylococcal scalded skin syndrome
Staphylococcal scalded skin syndrome
The age of this patient, the de-squamation, the positive Nikolsky sign and the sparing of the oral mucosa points towards staphylococcal scalded skin syndrome (SSSS)
A 3-year-old boy with a background of atopic dermatitis is brought by his mother to the GP due to a new skin rash. She says ‘itchy red spots’ appeared on his face, armpits, groin and the back of his knees a couple of days ago. They look different to his usual eczema rash. On examination, there are clusters of small pink papules with a central dimple over the areas she mentioned. What is the most likely diagnosis?
Erythema multiforme
Milia
Lichen planus
Molluscum contagiosum
Verruca vulgaris
Molluscum contagiosum
White, pink or brown papules with an umbilicated (depressed) central punctum are characteristic of molluscum contagiosum. This is a very contagious skin condition caused by a poxvirus which occurs most often in children and people who are immunocompromised, for example due to HIV infection. Atopic dermatitis / eczema can also predispose to this condition. The lesions tend to appear in warm locations like the armpit, groin and the back of the knees.
A 26-year-old woman presents to A&E with a very tender, swollen finger. She reports that it has been getting worse over the last few days and she is concerned that she may have broken it. However, she denies any recent injury to that finger. On examination, her right index finger is swollen at the distal interphalangeal joint but the metacarpophalangeal joint is normal. The patient appears otherwise well, apart from some dry scaly skin around her hairline.
Given the history and examination findings, what is the diagnosis?
Psoriatic arthritis
Rheumatoid arthritis
Osteoarthritis
Right index finger fracture
Ankylosing spondylitis
Psoriatic arthritis
Psoriatic arthritis typically affects the interphalangeal joints and spares the metacarpophalangeal joints. In addition, it appears the patient has psoriatic plaques on her scalp which is one of the most common places for them to appear
A 53 year old female presents to the GP. She has developed a red rash over her face which is worse following sun exposure. Aside from this, the patient reports no other symptoms and feels well. On examination, red papules are visible on her forehead, cheeks and nose on a background of erythematous skin with telangiectasia. The GP diagnoses her with Rosacea. Which of the following would be the most appropriate treatment for this patient’s Rosacea?
Topical Benzoyl peroxide
Topical emollient
Topical vitamin D analogue
Topical corticosteroid
Topical antibiotic
A topical antibiotic, such as Metronidazole, can be used to treat Rosacea. Antibiotics can also be taken orally if symptoms are more severe. Other topical treatments can be used including Azelaic acid, Brimonidine and Ivermectin. Other general measures to manage the symptoms of Rosacea include using camouflage creams, sun protection and avoiding alcohol intake, spicy foods and warm baths. Laser therapy can be used to manage persistent telangiectasia and surgery can be used to manage an associated rhinophyma (a large, disfigured nose resulting as a complication of untreated Rosacea)
A 26-year-old male patient attends the Emergency Department after falling asleep for 2 hours on a tanning bed.
He has burns covering his anterior chest and anterior abdomen, the anterior of both upper limbs as well as the anterior of both lower limbs. His face and neck were spared.
Approximately what % surface area of his body has been burned?
50
41
45
27
36
45%
Wallace’s Rule of Nine: Each of the following is 9% of the body when calculating surface area % if a burn:
Head + neck, each arm, each anterior part of leg, each posterior part of leg, anterior chest, posterior chest, anterior abdomen, posterior abdomen
Important for meLess important
Anterior left upper limb is half the left upper limb (0.5 x 9) = 4.5%
Anterior right upper limb is half the right upper limb (0.5 x 9) = 4.5%
Anterior abdomen = 9%
Anterior chest = 9%
Anterior right lower limb = 9%
Anterior left lower limb = 9%
Total = 4.5 + 4.5 + 9 + 9 + 9 + 9 = 45%
You are the GP reviewing an 81-year-old man with varicose veins. When he removes his right sock, you notice an ill-defined area of ulceration in the region of the medial malleolus. There is also pedal oedema to the mid-shins and some cutaneous changes of chronic venous insufficiency. Pulses are present. You decide to refer to vascular surgery.
Alongside surgery for his varicose veins, which treatment would be most appropriate?
Oral flucloxacillin
Graduated compression hosiery
Femoral endarterectomy
Compression bandaging
Intermittent pneumatic compression
Management of venous ulceration - compression bandaging
A 49-year-old woman presented to her general practitioner with a 10-day history of a painful lesion on her ankle. She reports that she initially thought she caught her leg on a branch whilst gardening but since says the lesion has been growing in size. Other than occasional myalgia, there are no other symptoms to report.
On examination, her observations are within normal limits. Her leg is examined, as shown below:
What is the most likely diagnosis?
Arterial ulcer
Cellulitis
Necrotising fasciitis
Pyoderma gangrenosum
Venous ulcer
Pyoderm genrenosum
The image above shows an ulcerated, purple-coloured lesion with undefined borders. There is evidence of central bleeding through broken-down skin. This is in keeping with a diagnosis of pyoderma gangrenosum. Pyoderma gangrenosum is a rapidly enlarging, painful ulcer that often starts as a small red pustule following a minor injury. The condition is associated with autoimmune inflammatory conditions such as inflammatory bowel disease and rheumatoid arthritis, however, they do not need to be present to make the diagnosis.
A 17-year-old male presents with a new skin condition which his mum noticed when they were on holiday in Spain. On examination, he has skin type V, with multiple small patches of depigmentation to the upper back. The patches appear mildly flaky but they are asymptomatic. He is usually well and has never had this condition before. Which of the following is the most likely diagnosis?
Pityriasis rosea
Atopic eczema
Vitiligo
Guttate psoriasis
Pityriasis versicolor
This is a typical history of pityriasis versicolor, a skin condition caused by an overgrowth of Malassezia yeast. It is most common in young people, especially males. It causes multiple patches of skin discolouration, mainly to the trunk. The patches may appear pale brown, pink, or may appear depigmented especially in patients with dark skin. They may also be mildly flaky and itchy. The condition can often present after spending time in sunny, humid environments. It is treated with topical antifungals eg. ketoconazole shampoo.
A 78-year-old man asks you to look at a lesion on the right side of nose which has been getting slowly bigger over the past 2-3 months. On examination you observe a round, raised, flesh coloured lesion which is 3mm in diameter and has a central depression. The edges of the lesion appear rolled and contain some telangiectasia.
What is the single most likely diagnosis?
Molluscum contagiosum
Actinic keratosis
Squamous cell carcinoma
Malignant melanoma
Basal cell carcinoma
Basal cell carcinoma
A mother brings her 3-year-old son to your GP surgery. She has noticed that he has been itching his face, particularly around his mouth and that he has developed some ‘spots and scabs’ in the area. The patient does not appear systemically unwell or distressed. The child has a history of atopic eczema and viral-induced wheeze.
On examination of the child’s face you note the presence of pustules and vesicles surrounding the mouth and nose area along with some honey-coloured plaques. You diagnose impetigo and prescribe topical fusidic acid as well as advising good hygiene measures.
The mother is concerned about sending the child to daycare. What do you advise?
Now that the patient is on treatment he may return to daycare
The patient must have been on treatment for 24h before returning to daycare
The patient must have been on treatment for 48h before returning to daycare
The patient must wait until 4 days following the appearance of the lesions before returning to daycare
The patient can return to daycare immediately because he feels well
The patient must have been on treatment for 48h before returning to daycare
The most common malignancy associated with acanthosis nigricans is
is gastrointestinal adenocarcinoma
Beta-blockers are known to exacerbate
plaque psoriasis
A 5-year-old girl is brought to the general practice due to body lesions noticed by their father during bathing. There are 3 discrete lesions on the back - the lesions are raised pink papules with central umbilication. The child is unaware of them and is otherwise well.
What is the next best management step?
Cryotherapy
Oral fluconazole
Reassurance
Skin biopsy
Topical fusidic acid
Molluscum contagiosum in children - treatment is not usually recommended.
A 28-year-old Caucasian male presents with itchy red spots on is abdomen, back and arms, which he reports appeared quite suddenly. He has no significant past medical history, but states he had a sore throat a few weeks ago. On examination, you notice he has a white pus-like discharge over his palatine tonsils. He states that he a similar rash last winter, when he had a sore throat.
Which of the following is the most likely diagnosis?
Drug eruption
Urticaria
Guttate psoriasis
Lichen planus
Discoid eczema
Guttate psoriasis
A 28-year-old Caucasian male presents with itchy red spots on is abdomen, back and arms, which he reports appeared quite suddenly. He has no significant past medical history, but states he had a sore throat a few weeks ago. On examination, you notice he has a white pus-like discharge over his palatine tonsils. He states that he a similar rash last winter, when he had a sore throat.
Which of the following is the most likely diagnosis?
Drug eruption
Urticaria
Guttate psoriasis
Lichen planus
Discoid eczema
Guttate psoriasis
guttate psoriasis
Streptococcal throat infection may precipitate psoriasis (particularly guttate psoriasis). Patients with frequent exacerbations of guttate psoriasis due to streptococcal throat infections may benefit from tonsillectomy
A 42-year-old female presents to her general practitioner with a new-onset rash on her neck. She denies pruritus, but she has been recently troubled by a cold sore on her upper lip. She has a past medical history of sarcoidosis, well managed. Her rash is shown below:
Which one of the following is the most likely diagnosis?
Atopic dermatitis
Bullous pemphigoid
Erythema multiforme
Erythema nodosum
Stevens-Johnson syndrome
Erythema multiforme
This patient is presenting with some non-itchy target lesions on her neck. The name of target lesions comes from the fact they have three concentric colour zones, a darker centre with a blister, a ring around this that is paler pink and raised due to oedema and a bright red outermost ring. This shape of lesion is characteristic of erythema multiforme, a hypersensitivity reaction that is most commonly triggered by infections. In this case, the patient complains of a cold sore on her upper lip (herpes labials) that most likely triggered the reaction.
management of fungal toe nail infections
Trichophyton rubrum is one of the most common dermatophyte nail infection organisms. For dermatophyte nail infections, oral terbinafine is the first line.
No treatment is not correct here as he is symptomatic (pain on walking) and is keen on treatment.
Oral itraconazole would be more suitable for Candida infections, or second line for dermatophyte infections.
conservative management of BCC
if patient is elderly e.g. with dementia, could treat with dressings
management of BCC and SCC can be summarised as
Medical
Surgical
Radiotherapy
medical management of BCC and SCC
can be used if pretty superficial, or if patient going to have good attrition to treatment
- 5- fluorouracil (efudix) - can look worse before it gets better - AK and superficial BCC
- Imiquimod - used in AK and superficial BCC
surgical management of BCC and SCC
- Cryotherapy
- Cautery
- Phototherapy
- Wide local Excision (eye shape excision) - 4mm margin
- Mohs surgery (melanomas and facial BCC and SCC)- best
when can radiotherapy be used
large lesion on face that is histologically confirmed and surgically unfeasible
if patient allergic to penicillin could use
erythromycin
Doxycyline
relationship between AK, bowens and SCC
AK -> Bowens -> SC
- AK and Bowens are premalignant sun damage which have the potential to become squamous cell carcinomas
AK- most superifical
Bowens - superifcial but deeper than AK - SCC in situ
SC- invasive skin cancer
AK vs Bowens
Actinic keratoses (AKs) are precursors on the continuum of carcinogenesis toward squamous cell carcinomas (SCCs). However, each AK has a low risk of progression to malignancy and a high probability of spontaneous regression.1 Bowen disease (BD) is SCC in situ confined to the epidermis.
Pyoderma gangrenosum
Pyoderma gangrenosum is a rare, non-infectious, inflammatory disorder. It is an uncommon cause of very painful skin ulceration. It may affect any part of the skin, but the lower legs are the most common site.
Pathophysiology
pyoderma gangrenosum is classified as a neutrophilic dermatosis
Associations
- IBD
- SLE
- RA
- Blood cancers
- Granulomatosis with polyangiitis
Management
- oral immunosuppresives e.g. ciclosporin
- surgery postponed untill inflammatory phase over
Pyoderma gangrenosum
Pyoderma gangrenosum is a rare, non-infectious, inflammatory disorder. It is an uncommon cause of very painful skin ulceration. It may affect any part of the skin, but the lower legs are the most common site.
Pathophysiology
pyoderma gangrenosum is classified as a neutrophilic dermatosis
Associations
- IBD
- SLE
- RA
- Blood cancers
- Granulomatosis with polyangiitis
Management
- oral immunosuppresives e.g. ciclosporin
- surgery postponed untill inflammatory phase over
