MISCELLANEOUS FACTS FROM PASSMED Flashcards
What is the aetiology of vitiligo?
Vitiligo is an autoimmune condition which results in the loss of melanocytes and consequent depigmentation of the skin. It is thought to affect around 1% of the population and symptoms typically develop by the age of 20-30 years.
What are the features of vitiligo?
Well demarcated patches of depigmented skin
Peripheries tend to be most affected
Trauma may precipitate new lesions (Koebner phenomenon)
What conditions are associated with vitiligo?
Type 1 diabetes mellitus
Addison’s disease
Autoimmune thyroid disorders
Pernicious anaemia
Alopecia areata
How do we treat vitiligo?
Sun block for affected areas of skin
Camouflage make-up
Topical corticosteroids may reverse the changes if applied early
There may also be a role for topical tacrolimus and phototherapy, although caution needs to be exercised with light-skinned patients
A 41-year-old man develops itchy, polygonal, violaceous papules on the flexor aspect of his forearms. Some of these papules have coalesced to form plaques. What is the most likely diagnosis?
Lichen planus
Scabies
Lichen sclerosus
Morphea
Psoriasis
Lichen planus
Lichen planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham’s striae over surface. Oral involvement common
Lichen sclerosus: itchy white spots typically seen on the vulva of elderly women
A 19-year-old man comes for review after burning himself with an iron. On examination he has a 4 by 3 cm area of pale pink skin the left forearm. In the middle of the area there are two small, fluid filled blisters. What is the most accurate description for this type of injury?
Partial thickness (deep dermal) burn
Partial thickness (superficial dermal) burn
Superficial epidermal burn
Major scald
Minor scald
Partial thickness (superficial dermal) burn
A 34-year-old man with a long history of back pain asks you to have a look at his back. He has had a bad back over the last few days which has been helped by analgesia and warmth. His wife has noticed a rash. What is the most likely type of rash?
Pityriasis rosea
Erythema multiforme
Erythema ab igne
Pityriasis versicolor
Cold urticaria
Erythema ab igne
A 40-year-old man complains of widespread pruritus for the past two weeks. The itching is particularly bad at night. He has no history of note and works in the local car factory. On examination he has noted to have a number of linear erythematous lesions in between his fingers. What is the most likely diagnosis?
Polyurethane dermatitis
Fiberglass exposure
Cimex lectularius infestation (Bed-bugs)
Scabies
Langerhans cell histiocytosis
Scabies
A 34-year-old man with a history of polyarthralgia, back pain and diarrhoea is found to have a 3 cm red lesion on his shin which is starting to ulcerate. What is the most likely diagnosis?
Systemic Shigella infection
Syphilis
Metastatic colon cancer
Erythema nodosum
Pyoderma gangrenosum
Pyoderma gangrenosum
This patient is likely to have ulcerative colitis, which has a known association with large-joint arthritis, sacroilitis and pyoderma gangrenosum
Erythema nodosum is also associated with ulcerative colitis but does not tend to ulcerate.
A 22-year-old woman presents due to hypopigmented skin lesions on her chest and back. She has recently returned from holiday in Spain and has tanned skin. On examination the lesions are slightly scaly. What is the most likely diagnosis?
Tinea corporis
Pityriasis versicolor
Porphyria cutanea tarda
Lyme disease
Psoriasis
Pityriasis versicolor
A 67-year-old man with a history of Parkinson’s disease presents due to the development of an itchy, red rash on his neck, behind his ears and around the nasolabial folds. He had a similar flare up last winter but did not seek medical attention. What is the most likely diagnosis?
Levodopa associated dermatitis
Seborrhoeic dermatitis
Flexural psoriasis
Acne rosacea
Fixed drug reaction to ropinirole
Seborrhoeic dermatitis
A 52-year-old man asks you to look at the side of his tongue. The white patches have been present for the past few months and are asymptomatic. He is a smoker who is known to have type 2 diabetes mellitus. What is the most likely diagnosis?
Candidiasis
Squamous cell carcinoma
Lichen sclerosus
Oral leukoplakia
Geographic tongue
Oral leukoplakia
What is a cherry haemangioma?
Cherry haemangiomas (Campbell de Morgan spots) are benign skin lesions which contain an abnormal proliferation of capillaries.
In which group of patients are cherry haemangiomas most commonly found in?
They are more common with advancing age but affect men and women equally.
What are the features of cherry haemangiomas?
Erythematous, papular lesions
Typically 1-3 mm in size
Non-blanching
Not found on the mucous membranes
How do we treat cherry haemangiomas?
As they are benign no treatment is usually required.
A 72 year old man attends to discuss laboratory results for nail clippings taken 6 weeks ago. He initially presented with extensive thickening and discolouration of all the nails on his left foot. His past medical history includes type 2 diabetes and hypertension. He is currently well and his repeat medications include metformin, simvastatin and ramipril. The laboratory report confirms onychomycosis. What treatment should you offer him?
Oral terbinafine
Topical itraconazole
Oral fluconazole
Topical amorolofine
Footcare advice
Oral terbinafine
What is onychomycosis?
Fungal infection of the nail
What are the three main types of fungus that cause onychomycosis?
Dermatophytes - mainly Trichophyton rubrum, accounts for 90% of cases
Yeasts - such as Candida
Non-dermatophyte moulds
What are the features of onychomycosis?
‘Unsightly’ nails are a common reason for presentation
Thickened, rough, opaque nails are the most common finding
What investigations would you do for someone in whom you suspected onychomycosis?
Nail clippings sent off to lab
Scrapings of the affected nail sent off to lab
How do we manage someone with onychomycosis caused by dermatophyte infection?
Diagnosis should be confirmed by microbiology before starting treatment:
Oral terbinafine is currently recommended first-line with oral itraconazole as an alternative.
6 weeks - 3 months therapy is needed for fingernail infections whilst toenails should be treated for 3 - 6 months
How do we manage someone with onychomycosis caused by candida infection?
Diagnosis should be confirmed by microbiology before starting treatment:
Mild disease should be treated with topical antifungals (e.g. Amorolfine)
More severe infections should be treated with oral itraconazole for a period of 12 weeks
A 25-year-old man presents with a pruritic skin rash. This has been present for the past few weeks and has responded poorly to an emollient cream. The pruritus is described as ‘intense’ and has resulted in him having trouble sleeping. On inspecting the skin you notice a combination of papules and vesicles on his buttocks and the extensor aspect of the knees and elbows. What is the most likely diagnosis?
Lichen planus
Chronic plaque psoriasis
Henoch-Schonlein purpura
Dermatitis herpetiformis
Scabies
Dermatitis herpetiformis
A 62-year-old male is referred to dermatology by his GP due to a lesion over his shin. On examination shiny, painless areas of yellow skin over the shin are found with abundant telangiectasia. What is the most likely diagnosis?
Pretibial myxoedema
Necrobiosis lipoidica diabeticorum
Erythema nodosum
Pyoderma gangrenosum
Syphilis
Necrobiosis lipoidica diabeticorum
What is the differential diagnosis for skin lesions over the skin?
Erythema nodosum
Pretibial myxoedema
Pyoderma gangrenosum
Necrobiosis lipoidica diabeticorum
What are the characteristic features of erythema nodosum and what are the conditions with which it is associated?
Symmetrical, erythematous, tender, nodules which heal without scarring
Causes:
Infection: streptococci, TB, brucellosis
Systemic disease: sarcoidosis, inflammatory bowel disease, Behcet’s
Malignancy/lymphoma
Drugs: penicillins, sulphonamides, combined oral contraceptive pill
Pregnancy
What are the characteristic features of pretibial myxoedema and what are the conditions with which it is associated?
symmetrical, erythematous lesions
Shiny, orange peel skin
Seen in Graves’ disease
What are the characteristic features of pyoderma gangrenosum and what are the conditions with which it is associated?
Initially small red papule
Later deep, red, necrotic ulcers with a violaceous border
Idiopathic in 50%, may also be seen in inflammatory bowel disease, connective tissue disorders and myeloproliferative disorders
What are the characteristic features of necrobiosis lipoidica diabeticorum and what are the conditions with which it is associated?
Shiny, painless areas of yellow/red skin
Often associated with telangiectasia
Typically on the shin of diabetics
Which one of the following conditions is most associated with vitiligo?
Addison’s disease
Asthma
Iron-deficiency anaemia
Toxic multinodular goitre
Type 2 diabetes mellitus
Addison’s disease - autoimmune conditions
A 32 year old lady presents with hair-loss which she thinks started after the birth of her second child 7 months ago. She is normally fit and well and is not on any regular or over the counter medication. On examination you notice patches of hair loss around her occiput. The skin looks normal and a few short broken hairs are obvious at the edges of two of the patches. What condition is most likely?
Trichotillomania
Alopecia areata
Tinea capitis
Early scarring alopecia
Telogen effluvium
Alopecia areata
How do we subdivide alopecia?
Scarring and non-scarring
What are the causes of scarring alopecia?
Trauma, burns
Radiotherapy
Lichen planus
Discoid lupus
Tinea capitis - scarring may develop in untreated tinea capitis if a kerion develops
What are the causes of non-scarring alopecia?
Male-pattern baldness
Drugs: cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, colchicine
Nutritional: iron and zinc deficiency
Autoimmune: alopecia areata
Telogen effluvium (hair loss following stressful period e.g. surgery)
Trichotillomania
What is alopecia areata?
Alopecia areata is a presumed autoimmune condition causing localised, well demarcated patches of hair loss. At the edge of the hair loss, there may be small, broken ‘exclamation mark’ hairs
How do we manage someone with alopecia areata?
Hair will regrow in 50% of patients by 1 year, and in 80-90% eventually. Careful explanation is therefore sufficient in many patients.
Other treatment options include:
Topical or intralesional corticosteroids
Topical minoxidil
Phototherapy
Dithranol
Contact immunotherapy
Wigs
What are the skin disorders associated with SLE?
Photosensitive ‘butterfly’ rash
Discoid lupus
Alopecia
Livedo reticularis: net-like rash
Which one of the following best describes the typical distribution of atopic eczema in a 10-month-old child?
Nappy area and flexor surfaces of arms and legs
Face and trunk
Nappy area and trunk
Flexor surfaces of arms and legs
Scalp and arms
Face and trunk
A 54-year-old man is referred by his GP to the dermatology outpatient department due to a facial rash which has persisted for the past 12 months. On examination there is a symmetrical rash consisting of extensive pustules and papules which affects his nose, cheeks and forehead. What is the most appropriate treatment?
Ciprofloxacin
Isotretinoin
Oxytetracycline
Hydroxychloroquine
Prednisolone
Oxytetracycline
Acne rosacea treatment:
Mild/moderate: topical metronidazole
Severe/resistant: oral tetracycline
You review a 24-year-old man who has recently presented with large psoriatic plaques on his elbows and knees. You recommend that he uses an emollient to help control the scaling. What is the most appropriate further prescription to use as a first-line treatment on his plaques?
Topical steroid
Topical steroid + topical calcipotriol
Topical coal tar
Topical calcipotriol
Topical dithranol
Topical steroid + topical calcipotriol
A 54-year-old man presents with a two month history of a rapidly growing lesion on his right forearm. The lesion initially appeared as a red papule but in the last two weeks has become a crater filled centrally with yellow/brown material. On examination the man has skin type II, the lesion is 4 mm in diameter and is morphologically as described above. What is the most likely diagnosis?
Seborrhoeic keratosis
Keratoacanthoma
Pyoderma gangrenosum
Basal cell carcinoma
Malignant melanoma
Keratoacanthoma
What are the features of a keratocanthoma?
Features - said to look like a volcano or crater
Initially a smooth dome-shaped papule
Rapidly grows to become a crater centrally-filled with keratin
How do we treat a keratocanthoma?
Spontaneous regression of keratoacanthoma within 3 months is common, often resulting in a scar. Such lesions should however be urgently excised as it is difficult clinically to exclude squamous cell carcinoma. Removal also may prevent scarring.
A 34-year-old man presents with an itchy rash on his genitals and palms. He has also noticed the rash around the site of a recent scar on his forearm. Examination reveals papules with a white-lace pattern on the surface. What is the diagnosis?
Lichen planus
Scabies
Lichen sclerosus
Morphea
Pityriasis rosea
Lichen planus
Venous ulceration is most characteristically seen above the:
Lateral malleolus
Greater trochanter
Sacrum
Medial malleolus
Pre-tibial area
Medial malleolus
What investigations should be done for someone with a suspected venous ulcer?
Ankle-brachial pressure index (ABPI) is important in non-healing ulcers to assess for poor arterial flow which could impair healing
How do we manage venous ulceration?
Compression bandaging, usually four layer (only treatment shown to be of real benefit)
Oral pentoxifylline, a peripheral vasodilator, improves healing rate
Small evidence base supporting use of flavinoids
Little evidence to suggest benefit from hydrocolloid dressings, topical growth factors, ultrasound therapy and intermittent pneumatic compression
What are the cutaneous features of tuberous sclerosis?
Depigmented ‘ash-leaf’ spots which fluoresce under UV light
Roughened patches of skin over lumbar spine (Shagreen patches)
Adenoma sebaceum (angiofibromas): butterfly distribution over nose
Fibromata beneath nails (subungual fibromata)
café-au-lait spots* may be seen
A 57-year-old woman presents with pruritus. She states she has been gaining weight despite eating less and complains of constant nausea. On examination she is pale. What is the most likely diagnosis?
Liver disease
Hypothyroidism
Diabetes mellitus
Pregnancy
Chronic kidney disease
Chronic kidney disease
Pregnancy is unlikely given her age
What is lentigo maligna?
Lentigo maligna is a type of melanoma in-situ. It typically progresses slowly but may at some stage become invasive causing lentigo maligna melanoma.
What is the scientific name for athlete’s foot?
Tinea pedis. It is usually caused by fungi in the genus Trichophyton.
What are the features of tinea pedis (athlete’s foot)?
Typically scaling, flaking, and itching between the toes
What are the first line treatments for tinea pedis (athlete’s foot)?
Topical imidazole, undecenoate, or terbinafine
A 23-year-old female presents with red, thickened skin on the soles. On closer inspection a crop of raised lesions are seen. What is the most likely diagnosis?
Palmoplantar pustulosis
Callus
Idiopathic plantar hidradenitis
Exfoliative keratolysis
Contact dermatitis
Palmoplantar pustulosis
A 22-year-old man presents with a 3 cm area of hyperkeratotic skin on the heel of his right foot. A number of pinpoint petechiae are seen in the lesion. What is the most likely diagnosis?
Pitted keratolysis
Mosaic wart
Acquired keratoderma
Juvenile plantar dermatosis
Palmoplantar pustulosis
Mosaic wart
A 15-year-old complains of excessively smelly feet. On examination he has white skin over the sole of the forefoot bilaterally. Small holes can be seen on the surface of the affected skin. What is the most likely diagnosis?
Pitted keratolysis
Mosaic wart
Acquired keratoderma
Juvenile plantar dermatosis
Palmoplantar pustulosis
Pitted keratolysis
A 72 year-old woman presents to the GP with a large itchy, sore white plaque on her vulva. Upon examination, a diagnosis of lichen sclerosus is made. What is the first line management plan?
Topical tacrolimus
Topical clobetasol propionate
Symptom management with topical imiquimod cream
Surgical excision with access to reconstruction
Symptom management with analgesia
Topical clobetasol propionate
Lichen sclerosis is a dermatological condition that affects the vulva. The first line treatment is a strong topical steroid thus the answer is topical clobetasol propionate. In around 4-10% of women with lichen sclerosus, the disease will be resistant to steroids and in this case topical tacrolimus is the next line of treatment however this is only initiated in specialist clinics. Surgical excision with access to reconstruction is the first line treatment in vulval intraepithelial neoplasia but is not appropriate in treatment of lichen sclerosus. Topical imiquimod cream, a treatment for genital warts, has been described as inducing florid lichen sclerosus and as such is not a correct answer. Analgesia would not be sufficient treatment in this patient.
