Questions

Question 1

A 55-year-old male patient presents with several rough, scaly patches on his scalp, forehead, and ears, which are non-tender and non-itchy. He has a history of significant sun exposure over his lifetime.

What is the most likely diagnosis? [1]

What is the most appropriate management for the likely diagnosis? [1]

Answer 1

Actinic keratosis
Tx: Imiquimod

Question 2

A 26-year-old male presents with a rapidly growing, dome-shaped lesion on his forearm, first noticed six weeks ago. It has now reached 2 cm in diameter, with a raised, well-demarcated border and a central keratin plug. He denies pain or systemic symptoms but reports significant sun exposure. Examination reveals a firm, non-tender lesion without lymphadenopathy.

Given the lesion’s rapid growth and crateriform appearance, what is the most likely diagnosis, and what is the next best step in management?

Answer 2

keratoacanthoma
- 1st line tx is surgical excision

Question 3

Depigmented skin areas fluoresce bright blue-white on Wood’s lamp inspection

Dx? [1]
What other blood results might you see in this patient? [2]

Answer 3

Vitiligo is caused by the autoimmune destruction of melanocytes in the interfollicular dermis and is associated with a number of HLA subtypes, including DR4, B13 and B35. Phototherapy, corticosteroids and tacrolimus ointment have all been employed as successful therapies for vitiligo.
- raised thyroid-stimulating hormone (TSH) and weight gain suggest the possibility of hypothyroidism, an autoimmune disease associated with vitiligo.

Question 4

Answer 4

The patient has tinea corporis, a dermatophyte fungal infection. The picture shows annular, scaly plaques with raised edges and central clearing (ringworm). Trichophyton rubrum is the most common causative organism, particularly in people who play contact sports. Topical azoles (eg. econazole, ketoconazole, clotrimazole and miconazole) are also effective. Occasionally systemic treatment with terbinafine or itraconazole is required.

Question 5

[] is usually first-line for oral thrush.

In which cases would you use an alternative [2] and when would you use them? [2]

Answer 5

Miconazole is usually first-line for oral thrush

Nystatin suspension is used to treat oral candidiasis if a patient is using simvastatin as the combination with oral miconazole increases the risk of statin induced myopathy

Oral fluconazole is used for patients with HIV

Question 6

[] presents with photosensitive blistering rashes on sun-exposed areas, often triggered by alcohol consumption.

Answer 6

Porphyria Cutanea Tarda presents with photosensitive blistering rashes on sun-exposed areas, often triggered by alcohol consumption.

Question 7

The development of a maculopapular rash after antibiotic administration for glandular fever warrants suspicion of [] especially in presence of left shoulder pain, tachycardia, abdominal pain, and signs of haemodynamic instability.

Answer 7

The development of a maculopapular rash after antibiotic administration for glandular fever warrants suspicion of splenic rupture, especially in presence of left shoulder pain, tachycardia, abdominal pain, and signs of haemodynamic instability.

Question 8

Erythema multiforme is commonly triggered by [] virus, presenting with target lesions on the skin.

Answer 8

Erythema multiforme is commonly triggered by herpes simplex virus, presenting with target lesions on the skin.

Question 9

A patient likely has orbital cellulitis, as indicated by the presence of: erythema and swelling surrounding the left eye, fevers, diplopia (due to extra-ocular eye muscle involvement), and pain.

What is the imaging of choice? [1]
What is the treatment? [1]

Answer 9

CT imaging is essential for diagnosing orbital cellulitis, which presents with eye pain, swelling, fever, and diplopia, often following facial trauma.
- Patients with orbital cellulitis require admission for IV antibiotics and close monitoring with input from the ophthalmology, ear, nose and throat and medical teams.

Question 10

A diagnosis of pemphigus vulgaris is made.

IgG autoantibodies to which protein is the pathogenesis of this disease due?

Collagen type XVIII
Desmoglein
Bullous pemphigoid antigen
Keratin
Desmoplakin
#42140

Answer 10

A diagnosis of pemphigus vulgaris is made.

IgG autoantibodies to which protein is the pathogenesis of this disease due?

Collagen type XVIII
Desmoglein
Bullous pemphigoid antigen
Keratin
Desmoplakin
#42140

Question 11

What is the difference between actinic keratosis and keratoacanthoma? [2]

Answer 11

Actinic keratosis
- viewed as a premalignant lesion because there are atypical keratinocytes present in the epidermis. In a person with 7 actinic keratosis, the risks of subsequent SCC is of the order of 10% at 10 years. The primary lesion is a rough erythematous papule with a white to yellow scale. Lesions are typically clustered at sites of chronic sun exposure.

Keratoacanthoma
- Dome-shaped erythematous lesions that develop over a period of days and grow rapidly. They often contain a central pit of keratin. They then begin to necrose and slough off. They are generally benign lesions although some do view them as precursors of malignancy. They may be treated by curettage and cautery. If there is diagnostic doubt (they can mimic malignancy) then formal excision biopsy is warranted.

Question 12

How do you differentiate between alopecia areata and tinea capitis? [1]

Answer 12

Alopecia areata is characterised by discrete, smooth and circular areas of hair loss over the scalp:
- no associated scaling, inflammation or broken hair, and it may involve single or multiple areas.

Tinea capitis:
- may be scaly or much more inflamed, boggy, and exude pus (kerion). Broken-off hairs occur in tinea but do not taper at the base as in the ‘exclamation mark’ hairs of alopecia areata.

Question 13

A patient has been diagnosed with melanoma on his right hand, which measures 1.5 cm. He is booked in to have surgery to remove it.

During the excision biopsy, what margin size will be taken?

1 cm
3 mm
4 mm
1 mm
2 cm

Answer 13

A patient has been diagnosed with melanoma on his right hand, which measures 1.5 cm. He is booked in to have surgery to remove it.

During the excision biopsy, what margin size will be taken?

1 cm
3 mm
4 mm
1 mm
2 cm

Question 14

What is the most likely diagnosis?

Actinic keratosis
Basal cell carcinoma
Keratoacanthoma
Malignant melanoma
Pyogenic granuloma

Answer 14

Actinic keratosis

Question 15

This 40-year-old male first noticed the lesions on his lips when he was about 16 years old. Since then he has developed similar facial, nares, tongue, ears, hands, chest and feet lesions. The lesions blanch with pressure. His father was similarly affected.

Dx? [1]

Most common initial presentation? [1]

Answer 15

patient has hereditary haemorrhagic telangiectasia (HHT):
- It commonly presents in teenagers, with nosebleeds being the primary symptom in over 90% of cases.

Question 16

A patient has pemphigus vulgaris.

This is caused by antibodies agaisnt…[1]

Answer 16

Desmosomes of skin

Question 17

Dx? [1]
Tx of systemic, extensive disease? [2]

Answer 17

BP
- Prednisolone is the first line therapy. Azathioprine, Ciclosporin, and Mycophenolate mofetil can be used second line.

Question 18

Answer 18

Fungal infection: ringworm, tinea capitis of the scalp usually presents with dry scaling, broken hair, smooth areas of hair loss or yellow crusts on matted hair
- In alopecia areata there is usually complete hair loss in an affected area and no scaling.

Question 19

Dx? [1]
Investigation? [1]
Tx? [1]

Answer 19

Tinea corporis (ringworm)
- microscopy and culture of skin scrapings
- Topical antifungal

Question 20

Answer 20

Question 21

Describe the clinical features of discoid eczema [3]

Answer 21

Weepy multiple lesions

Erythematous lesions

Well dermarcated

Question 22

You have assessed a 6-year-old boy with dry itchy skin. You have diagnosed atopic dermatitis. You decide to prescribe 500g of Diprobase® cream as an emollient.

How would you explain to his mother how she should use this product?

Answer 22

• Apply in the direction of hair growth
• Apply as frequently as necessary
• Apply quickly
• Apply thinly
• Do not rub in
• It can be decanted into smaller containers for use at school
• There is a fire risk due to the high concentration of white soft paraffin. Take care with smokers/naked flames
• Apply within 5 minutes of bathing
• If topical steroid is used, apply Diprobase® first and allow to soak in

Question 23

Answer 23

Question 24

Asteatotic eczema is common in older adults and is thought to be caused by over-washing and a dry winter climate. There is also an association with [drug] use and [condition]

Answer 24

Asteatotic eczema is common in older adults and is thought to be caused by over-washing and a dry winter climate. There is also an association with diuretic use and hypothyroidism
- It commonly affects the limbs, causing dry, itchy skin with a characteristic ‘crazy paving’ pattern. The treatment is emollients and then mild topical steroids.

Question 25

Answer 25

Question 27

Describe the difference between Eron Class II & III [2]

Answer 27

Class II — the person is either systemically unwell or systemically well but with a comorbidity (for example peripheral arterial disease, chronic venous insufficiency, or morbid obesity) which may complicate or delay resolution of infection.

Class III — the person has significant systemic upset, such as acute confusion, tachycardia, tachypnoea, hypotension, or unstable comorbidities that may interfere with a response to treatment, or a limb-threatening infection due to vascular compromize.

Question 28

Answer 28

Question 29

The presentation of a rapidly growing, dome-shaped nodule with a central crust that is tender when palpated is consistent with the diagnosis of []

Answer 29

The presentation of a rapidly growing, dome-shaped nodule with a central crust that is tender when palpated is consistent with the diagnosis of keratoacanthoma

Question 30

What is the treatment for headlice? [1]

Answer 30

Wet combing or application of dimethicone 4% gel twice, at least 7 days apart

Question 31

Describe what syndesmophytes are [1]

Answer 31

Syndesmophytes are bony growths originating inside a ligament, commonly seen in ankylosing spondylitis. These develop between vertebrae and contribute to the fusion of the spine (ankylosis), which can lead to the “bamboo spine” appearance on X-ray.

Question 32

What differentiates a nodule from a papule? [1]

Answer 32

Both raised lesions

Nodule is found in the deeper layers of the skin

Question 33

Which sign would help indicate a patient has a dermatofibroma? [1]

Answer 33

Positive dimple sign

Question 34

Describe what is meant by Chondrodermatitis nodularis chronica helicis [1]

Answer 34

a benign inflammatory condition that affects the skin and cartilage of the pinna

Question 35

What is the treatment for hidradenitis suppurativa? [2]

Answer 35

Tetracycline antibiotics such as lymecycline and doxycycline are often tried initially.

The combination of clindamycin and rifampicin is another option for a 10-week course

Question 36

Female x spots on jawline

What should you suspect? [1]

Answer 36

PCOS

Question 38

If you suspected a patient to have pityriasis versicolor, describe how you would quickly investigate? [1]

Answer 38

Can scrape off the fungal Malassezia (mica)

Question 39

First line treatment for acitinic keratosis? [1]

Answer 39

Cryotherapy or 5-fluorouracil cream

Question 40

Why should you be concerned if you see a presentation of pemphis vulgaris? [1]

Answer 40

Paraneoplastic disease

Question 41

BP typically presents in older, frail patients.

Potent topical steroids work well but consideration needs to be given because of the effect of the steroids.

What is an alternative treatment? [1]

Answer 41

doxycycline OD x 3months

Question 42

Rosacea: a combination of [] + [] is first-line for patients with severe papules and/or pustules

Answer 42

Rosacea: a combination of topical ivermectin + oral doxycycline is first-line for patients with severe papules and/or pustules

Question 43

[] is the treatment of choice for facial hirsutism

Answer 43

Topical eflornithine is the treatment of choice for facial hirsutism

Question 44

What is the only method for treating rhinophyma? [1]

Answer 44

CO2 and Erbium YAG lasers

Question 45

Acitretin is really useful for treating psoriasis.

Which populations can you not give it to? [1]

Answer 45

Females of childbearing age - extremely teratogenic and stays in blood for 3 years

Question 46

Macular rash that starts on face, that spreads to trunk and limbs. Spares the palms of hands and feet.

Dx? [1]
What other features would indicate this dx? [2]

Answer 46

Measles
- Koplik spots
- Onset of rash coincides with highest fever 40C

Question 47

Which type of melonoma is most common in pigmented skins? [1]

Answer 47

Acral lentiginous

Question 48

Which manifestations of psoriasis would indicate a dermatologist referral? [2]

Answer 48

Ocular involvement
Rhinophyma

Question 49

A diagnosis of actinic keratoses is made. What is the most appropriate first line management?

Answer 49

Topical fluorouracil cream

Question 50

A man is dx with Basal Cell Carcinoma (BCC).

Which of the following is the most appropriate management?

Radiotherapy
Laser therapy
Mohs micrographic surgery
Sun Cream
Immunosuppressants

Answer 50

A man is dx with Basal Cell Carcinoma (BCC).

Which of the following is the most appropriate management?

Mohs micrographic surgery
- Mohs micrographic surgery involves examining excised tissue under the microscope as it is removed. This ensures all the tumour is removed whilst preserving the maximum amount of healthy tissue possible. It is used in cosmetically sensitive areas, for example near the eye as in this case, and for ill-defined BCCs.

Question 51

Seborrhoeic dermatitis - first-line treatment is []

Answer 51

Seborrhoeic dermatitis - first-line treatment is topical ketoconazole
- It is thought to be related to an overgrowth of yeast-like fungi from the genus Malassezia, which are part of the normal skin flora.

Question 52

Difference between lichen planus and lichen sclerosus?

Answer 52

Lichen sclerosus
- usually affects the genitalia and is more common in elderly females. Lichen sclerosus leads to atrophy of the epidermis with white plaques forming

Lichen planus:
- Planus = all the Ps
purple (violaceous), papular, polygonal plaques; have white striae on them (Wickham’s stria)

Question 53

The most common dermatosis in pregnancy is []

Answer 53

The most common dermatosis in pregnancy is atopic eruption of pregnancy

Question 54

Describe the ulcers seen in squamous cell carcinoma [4]

Answer 54

typically on sun-exposed sites such as the head and neck or dorsum of the hands and arms
rapidly expanding painless, ulcerate nodules
may have a cauliflower-like appearance
there may be areas of bleeding

Question 55

Pneumonic for drugs that can cause TEN/SJS?

Answer 55

Never Press Skin As It Can Peel

NSAIDs, Phenytoin, Sulphonamides, Allopurinol, IV Ig, Carbamazepine, Penicillins

NB: IV Ig is a treatment not cause

Question 56

The dermatologist diagnoses scalp psoriasis.

What is the most appropriate management for her new diagnosis?

Oral methotrexate
Phototherapy
Topical betamethasone valerate
Topical vitamin D
GP review in 2 weeks

Answer 56

Topical betamethasone valerate
Scalp psoriasis - first-line treatment is topical potent corticosteroids

Question 57

Which score is used to assess level of hirsutism? [1]

What scores would indicate a moderate to severe level? [1]

Answer 57

Ferriman-Gallwey scoring system:
- 9 body areas assigned a score from 0-4
- Score > 15 is indicates a moderate to severe level

Question 58

[Infection] is associated with seborrhoeic dermatitis

Answer 58

HIV is associated with seborrhoeic dermatitis

Question 59

[Neurological condition] is associated with seborrhoeic dermatitis

Answer 59

Parkinsons Disease

Question 60

A non-healing painless ulcer associated with a chronic scar is indicative of []

Answer 60

A non-healing painless ulcer associated with a chronic scar is indicative of squamous cell carcinoma (SCC)

Scar x SSC

Question 61

Which sides (lateral/medial) are venous and arterial ulcers more likely to present on? [2]

Answer 61

vEnous - mEdial
Arterial - lAteral

Question 62

What is this? [1]

Answer 62

This is a common presentation of a dermatofibroma - they are usually asymptomatic and are often precipitated by an injury to the site, such as an insect bite.

Question 63

Pityriasis rosea often follows a [] infection

Answer 63

Pityriasis rosea often follows a viral infection

Question 64

[] is often the most effective treatment for prominent telangiectasia in rosacea

Answer 64

Laser therapy is often the most effective treatment for prominent telangiectasia in rosacea

Question 65

Oral [] are the first-line treatment for pyoderma gangrenosum

Answer 65

Oral steroids are the first-line treatment for pyoderma gangrenosum

Question 66

Acne vulgaris in pregnancy - use oral [] if treatment needed

Answer 66

Acne vulgaris in pregnancy - use oral erythromycin if treatment needed

tetracyclines have a risk of teratogenicity

Question 67

A man has presented with a rash consistent with seborrhoeic dermatitis, which is a particular risk given a past medical history of []. The first-line treatment for this condition is topical ketoconazole.

Answer 67

A man has presented with a rash consistent with seborrhoeic dermatitis, which is a particular risk given a past medical history of [HIV]. The first-line treatment for this condition is topical ketoconazole.

Question 68

In acute urticaria a sedating antihistamine (e.g. []) may be considered for night-time use for troublesome sleep symptoms

Answer 68

In acute urticaria a sedating antihistamine (e.g. chlorphenamine) may be considered for night-time use for troublesome sleep symptoms

Question 69

Severe urticaria - A short course of an oral [] may required in addition to a non-sedating antihistamine

Answer 69

Severe urticaria - A short course of an oral corticosteroid may required in addition to a non-sedating antihistamine

Question 70

Which three risk factors increase the risk of a patient presenting (often in a q) with pityriasis rosea? [3]

Answer 70

Present on trunk, flaky and recent sun exposure all suggest Piyriasis Vesicolour

Question 71

Solitary firm papule/nodule that dimples on pinching → []

Answer 71

Solitary firm papule/nodule that dimples on pinching → dermatofibroma

Question 72

Answer 72

This man has a rhinophyma, a complication of acne rosacea.

Question 73

Dx? [1]

Usual pattern of disease? [1]

Answer 73

Pemphigoid gestationis
- pruritic blistering lesions
- peri-umbilical region, later spreading to the trunk, back, buttocks and arms
- usually presents 2nd or 3rd trimester and is rarely seen in the first pregnancy

Question 74

Dx? [1]
Tx ? [1]

Answer 74

Pemphigoid gestationis:
- oral corticosteroids are usually required

Question 75

Dx? [1]
Tx? [1]

Answer 75

Atopic eruption of pregnancy:
it typically presents as an eczematous, itchy red rash.
- no specific treatment is needed

Question 76

Erysipelas is localised skin infection caused by []

How do you differentiate this from cellulitis? [1]

Answer 76

Erysipelas is localised skin infection caused by Streptococcus pyogenes
- It is differentiated from cellulitis due to its raised and well defined border.

Question 77

How do you differentiate between liver failure and hereditary hemorrhagic telangiectasia when a patient presents with small lesions with a number of tiny blood vessels radiating from the middle? [1]

Answer 77

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

Telangi-edge-tasia

Question 78

What is the difference between port-wine stains and salmon patches? [1]

Answer 78

Salmon patches or ‘stork bites:
- are small pink or red patches that typically form on the eyelids, between the eyes or on the back of the neck which typically FADE and disappear by the age of two

A port-wine stain
- is a flat, pink, red, or purple coloured birthmark and does not disappear over time and so would not be the right answer in this scenario.

Question 79

Malignant melanoma: the [] is the single most important prognostic factor

Answer 79

Melanoma: the invasion depth of the tumour is the single most important prognostic factor

Question 80

A depressed intra-articular fracture of the lunate fossa of the distal radius is also known as a…
Barton fracture
chauffeur fracture
Colles fracture
die-punch fracture
Smith fracture

Answer 80

A depressed intra-articular fracture of the lunate fossa of the distal radius is also known as a…
Barton fracture
chauffeur fracture
Colles fracture
die-punch fracture
Smith fracture

Question 82

Name a first line non-sedating antihistamine that might be used for acute urticaria [1]

Name a sedating antihistamine that might be used for acute urticaria for nightime use [1]

Answer 82

anti-sedating:
Loratadine or cetirizine

sedating antihistamine:
- chlorphenamine

Question 83

What is a dermoid cyst? [1]
Where are they usually found? [1]

Answer 83

Dermoid cysts are embryological remnants and may be lined by hair and squamous epithelium (like teratomas).
- located in the midline and may be linked to deeper structures resulting in a dumbbell shape to the lesion.

Question 84

Whats the treatment for a dermoid cyst? [1]

Answer 84

Complete excision is requires as they have a propensity to local recurrence if not excised.

Question 85

What is desmoid tumour? [1]
Where do they develop? [1]

Answer 85

Desmoid tumour:
- aggressive fibromatosis and consist of fibroblast dense lesions (resembling scar tissue)
- most commonly develop in ligaments and tendons

Question 86

Dermatitis in acral, peri-orificial and perianal distribution can be caused by a deficiency in which mineral? [1]

Answer 86

Dermatitis in acral, peri-orificial and perianal distribution → zinc deficiency

Question 87

Aim for a [] week break in between courses of topical corticosteroids in patients with psoriasis

Answer 87

Aim for a 4 week break in between courses of topical corticosteroids in patients with psoriasis

Question 88

A 34-year-old man presents for the removal of a mole. Where on the body are keloid scars most likely to form?

Sternum
Lower back
Abdomen
Flexor surfaces of limbs
Scalp

Answer 88

A 34-year-old man presents for the removal of a mole. Where on the body are keloid scars most likely to form?

Sternum
Lower back
Abdomen
Flexor surfaces of limbs
Scalp

Question 89

What is the name for widespread soft un-pigmented hair that covers an entire body? [1]

What can this be caused by? [1]

Answer 89

This question provides an example of a patient with ‘lanugo hair’. This is generally found in newborn babies and those with chronic malnutrition. It is an important sign to remember as it can be found in patients with anorexia nervosa.

Question 90

What is the first line treatment for lichen planus? [1]

Answer 90

Topical betamethasone valerate 0.1%

Question 91

What is the treatment for:
- For patients with rosacea with predominant flushing but limited telangiectasia [1]
- Rosacea and mild-to-moderate papules and/or pustules [1]
- moderate-to-severe papules and/or pustules [1]

Answer 91

Rosacea with predominant flushing but limited telangiectasia
- consider prescribing brimonidine gel: provides temporary relief of flushing and erythema symptoms is the most appropriate option. It reduces erythema within 30 minutes

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 92

The most common malignancy in the lower lip is a []

Answer 92

The most common malignancy in the lower lip is a squamous cell carcinoma

Question 93

Erythema multiforme is which type of HS reaction? [1]

Answer 93

type 4

Question 94

Eczema herpeticum is a primary infection of the skin caused by herpes simplex virus (HSV) and uncommonly []

Answer 94

Eczema herpeticum is a primary infection of the skin caused by herpes simplex virus (HSV) and uncommonly coxsackievirus

Question 95

Which type of skin cancer is the most aggressive? [1[

Answer 95

Nodular melanoma: Invade aggressively and metastasise early

Question 96

[] is the most common side-effect of isotretinoin

Answer 96

Dry skin is the most common side-effect of isotretinoin

Question 97

What information should be given about the infectiveness of shingles to patients ? [1]

Answer 97

People with shingles should be advised that they are infectious until the vesicles have crusted over, usually 5-7 days following onset

Question 98

When do you use topical amorolfine vs oral terbinafine to treat nail dermatophyte infection? [1]

Answer 98

Symptomatic dermatophyte nail infections should be treated with oral terbinafine, if there are no contraindications.

Topical amorolfine can be used in patients who are asymptomatic or if they are not experiencing pain or significant psychological distress due to cosmetic appearance of the nail.

Question 99

Do you use oral or topical steroids for lichen planus? [1]

Answer 99

First line: topical potent steroids

Question 100

A 65-year-old lady presents to her GP with a 3 month history of weight loss and feeling generally unwell. She has also noticed the skin under her armpits has become darker and slightly thicker. What is the most common malignancy associated with acanthosis nigricans?

Gastrointestinal adenocarcinoma
Phaeochromocytoma
Bile duct cancer
Endometrial carcinoma
Non-Hodgkin’s lymphoma

Answer 100

A 65-year-old lady presents to her GP with a 3 month history of weight loss and feeling generally unwell. She has also noticed the skin under her armpits has become darker and slightly thicker. What is the most common malignancy associated with acanthosis nigricans?

Gastrointestinal adenocarcinoma
Phaeochromocytoma
Bile duct cancer
Endometrial carcinoma
Non-Hodgkin’s lymphoma

Question 101

Which one of the following complications is most associated with psoralen + ultraviolet A light (PUVA) therapy?

Squamous cell cancer
Osteoporosis
Basal cell cancer
Dermoid cysts
Malignant melanoma

Answer 101

Which one of the following complications is most associated with psoralen + ultraviolet A light (PUVA) therapy?

Squamous cell cancer

Question 102

Key side effect of ketoconazole? [1]

Answer 102

Gynecomastia

Question 103

How can you distinguish polymorphic eruption in pregnancy to pemphigoid gestationis based on area of body affected? [1]

Answer 103

One of the main clinical features of polymorphic eruption in pregnancy is periumbilical sparing

The skin rash in pemphigoid gestationis usually starts in the periumbilical area and can cause blisters.

Question 104

Which of the following complications is a patient with PsA at higher risk of?

Cardiovascular disease
Lung cancer
Neutropenia and splenomegaly
Pericarditis
Mononeuritis multiplex

Answer 104

Which of the following complications is a patient with PsA at higher risk of?

Cardiovascular disease
Lung cancer
Neutropenia and splenomegaly
Pericarditis
Mononeuritis multiplex

Question 105

Scarlet fever is caused by []

Answer 105

Scarlet fever is caused by group A haemolytic streptococci (usually Streptococcus pyogenes)

Question 106

Describe the characteristic rash in scarlet fever [1]
what other change occurs in children? [1]

Answer 106

The characteristic rash is described as ‘sandpaper’ texture and children can develop ‘strawberry tongue’

Question 107

rash worsens after eating spicy food indicates which pathology? [1]
1st line Tx? [1]

Answer 107

Rosacea:
- Topical ivermectin is an appropriate first-line treatment for papulopustular rosacea

Question 108

A 5-year-old girl presents with a rash that started on her face and spread to her trunk. She also has a low-grade fever and swollen lymph nodes behind her ears.
Which of the following viruses is most likely causing her symptoms?

Epstein-Barr virus (EBV)

Influenza virus

Varicella-zoster virus (VZV)

Human papillomavirus (HPV)

Rubella virus

Answer 108

A 5-year-old girl presents with a rash that started on her face and spread to her trunk. She also has a low-grade fever and swollen lymph nodes behind her ears.
Which of the following viruses is most likely causing her symptoms?

Epstein-Barr virus (EBV)

Influenza virus

Varicella-zoster virus (VZV)

Human papillomavirus (HPV)

Rubella virus

Question 109

Describe the rash typically seen in rubella [1]

Answer 109

The rash typically begins on the face and spreads to the trunk, arms, and legs

Question 110

When do you perform sentinel node biopsies in MM? [1]

Answer 110

Where the Breslow thickness is greater than 1mm, a sentinel node biopsy should be performed to look for evidence of metastases and stage the cancer

Question 111

A 9-year-old boy is brought to the GP by his mother who is worried as he has developed a fever and a rash since yesterday. On examination, the rash is erythematous, widespread across the body and feels rough. His tongue is bright red and appears bumpy and he has enlarged cervical lymph nodes. He has also has a temperature of 38.5.

Based on the most likely diagnosis, what is the most appropriate management?

Answer 111

Phenoxymethylpenicillin:
- The features in this case - a rash which is rough to touch, strawberry tongue, cervical lymphadenopathy and fever - point towards a diagnosis of scarlet fever. Scarlet fever is caused by group A streptococcus (specifically streptococcus pyogenes). It is treated first-line with a 10 day course of phenoxymethylpenicillin.

Question 112

A 70-year-old gentleman presents to his GP with a spot on his forehead. Examination reveals a 2cm round lesion with an ulcerated centre.
Given the history and examination findings, what is the most appropriate management?

Topical 5-flourouracil

Excision biopsy (4mm margin)

Cryotherapy

Excision biopsy (6mm margin)

Curettage and cautery

Answer 112

A 70-year-old gentleman presents to his GP with a spot on his forehead. Examination reveals a 2cm round lesion with an ulcerated centre.
Given the history and examination findings, what is the most appropriate management?

Excision biopsy (6mm margin)
- As this lesion is 2cm in diameter it is considered high risk and requires a 6mm excision margin.

Question 113

A 32 year old woman attends the GP with a blistering skin condition. A biopsy was taken and immunofluorescence shows IgG deposition between cells in the epidermis.

Dx? [1]

Answer 113

Pemphigus vulgaris

Question 114

A 22-year-old woman presents with a pruritic, scaly rash between the toes of her right foot which has been present for several weeks.

What is the most appropriate management for the likely diagnosis? [2]

Answer 114

Topical miconazole and topical hydrocortisone

Question 115

a bright red rash across the cheeks, reticular rash across the body and viral prodrome most likely has [] nfection

Answer 115

a bright red rash across the cheeks, reticular rash across the body and viral prodrome most likely has Parvovirus B19 infection

Question 116

Parvovirus B19 infection during the first 20 weeks of pregnancy can cause [1]

Answer 116

Parvovirus B19 infection during the first 20 weeks of pregnancy can cause hydrops fetalis

Question 117

PUVA and UV-B are both forms of light therapy. Which is generally used as first line and why? [1]

Answer 117

UV-B
- PUVA is far more phototoxic with more side effects.

Question 118

A 26-year-old female presents with a scaly, erythematous rash on the flexor surfaces of her elbows and knees. She reports the rash is frequently itchy and has been ongoing for several months. On examination, localised skin thickening is noted. Her only past medical history of note is asthma.
Which of the following is the most appropriate treatment for this condition?

Oral corticosteroid

Clobetasone butyrate 0.5%

Hydrocortisone 1%

Topical calcineurin inhibitors

Betamethasone valerate 0.1%

Answer 118

Hydrocortisone
- Although this patient has presented with moderate eczema, NICE recommends initially prescribing a mild potency topical corticosteroid (such as hydrocortisone 1%) for delicate areas of skin (such as the face and flexures).

Question 119

Describe the changes seen in nails in 10& of those suffering from lichen planus [1]

Answer 119

Lichen planus causes longitudinal ridges in nails in 10% of patients

Question 120

How do you treat lichen planus? [1]
How do you treat lichen planus with oral involvement? [1]

Answer 120

Lichen planus:
- potent topical steroids

Lichen planus with oral involvement
- potent topical steroids, with benzydamine being used for oral involvement.

Question 121

How long does chickenpox usually lost? [1]
When is it safe to let children return to school? [1]

Answer 121

The disease course of chickenpox usually lasts 5 days;
it is around this time that lesions crust over, and the patient is no longer contagious

It is important to note that it is the lesions crusting over, not the time since the presentation, that determines whether a patient is infectious or not.

Question 122

Which type of malignant melanoma is most commonly found on the legs of young and middle aged adults?

Subungual melanoma

Superficial spreading melanoma

Nodular melanoma

Acral lentiginous melanoma

Lentigo maligna melanoma

Answer 122

Which type of malignant melanoma is most commonly found on the legs of young and middle aged adults?

Subungual melanoma

Superficial spreading melanoma

Nodular melanoma

Acral lentiginous melanoma

Lentigo maligna melanoma

Question 123

Which is the name for scalp ringworm? [1]

What is the treatment? [2]

Answer 123

Scalp ringworm - Tinea capitis

Treatment: Oral itraconazole and topical ketoconazole

Question 124

Previous viral infection x non-blanching rash x purpura = ? [1]

Answer 124

ITP

Question 125

Name [1] and treatment [1] for athletes foot?

Answer 125

Tinea rubris:
- topical clotrimazole

Question 126

A patient presents with suspected lichen sclerosis.

What level of topical corticosteroid would you prescribe? [1]

Name an example [1]

Answer 126

Potent topical corticosteroid
- E.g. dermovate

Question 127

A patient is treated for fungal nail infection with which drug? [1]

What monitoring would you perform and why? [1]

Answer 127

terbinafine - perform LFTs every 6 months

Question 128

Answer 128

The well-defined erythematous plaque with fine scaling is indicative of psoriasis.

Question 129

How would you treat this patient (Figure 1)?

Answer 129

Ciclosporin is a clear first choice here. The patient is young and healthy, and therefore likely to tolerate the drug well. It has the fastest onset of action of all the options and usually works well for acute guttate psoriasis.

Question 130

Why would chronic alcohol use CI MTX as a treatment? [1]

Answer 130

The patient’s liver health would require careful monitoring as pre-existing fatty liver disease increases the risk of methotrexate-induced liver injury.

Question 131

Ciclosporin can cause what metabolic effect? [1]

Answer 131

Ciclosporin can also increase the lipids, though as with acitretin, this issue would not be a complete contraindication.

Question 132

An otherwise well 35-year-old woman requires systemic treatment for both moderate chronic plaque psoriasis and psoriatic arthritis. She has not taken systemic medication in the past. Select the most appropriate drug from the list.

Select 1 option from the answers below, then Submit.

Possible answers:
A. Ciclosporin
B. Apremilast
C. Hydroxycarbamide
D. Leflunomide
E. Methotrexate

Answer 132

E. Methotrexate

Question 133

A 70-year-old retired man seeks treatment for his widespread psoriasis. He has not found topical treatment sufficiently helpful and his PASI score is 8.4. He has a history of a moderately differentiated squamous cell carcinoma on the right ear. He is unable to attend regularly for phototherapy as he is the main carer for his wife. Select the most appropriate drug from the list.

Select 1 option from the answers below, then Submit.

Possible answers:
A. Acitretin
B. Ciclosporin
C. Dimethyl fumarate
D. Methotrexate
E. Apremilast

Answer 133

Acitretin appears to reduce the risk of keratinocyte cancer. Immunosuppression increases the risk of further skin cancer.

Question 134

A 28-year-old woman, who is 23 weeks pregnant, presents with a severe exacerbation of chronic plaque psoriasis (her PASI score is 14.4 and the DLQI score is 24), which has not responded to topical treatment. She previously suffered significant burns from phototherapy and would not be prepared to risk this again. She also declines admission for more intensive topical treatment. Select the most appropriate drug from the list.

Select 1 option from the answers below, then Submit.

Possible answers:
A. Acitretin
B. Ciclosporin
C. Dimethyl fumarate
D. Methotrexate
E. Apremilast

Answer 134

B. Correct. Ciclosporin appears to be safe in pregnancy. It is also suited to treating a young, otherwise fit patient with an acute exacerbation.

Question 135

What is this? [1]
* Seborrhoeic wart
* Solar lentigo
* Benign naevus
* Malignant melanoma
* Dermatofibroma
* Pigmented basal cell carcinoma

What is the next investigational step? [1]

Answer 135

Malignant melanoma:
Investigate with excision with narrow margins (followed later by wider local excision)

Question 136

What determines how wide the excision is for a malignant melonama? [1]

Answer 136

The margin used at the wide local excision depends on the Breslow thickness of the lesion

Question 137

Dx? [1]

Answer 137

This mosaic wart
- It is a cluster of viral warts sometimes several cm in diameter. The distribution and character of these lesions is not suggestive of fungal infection or psoriasis. Eczema tends to present with dry peeling skin, sometimes with pustules.

Question 138

Name for this condition? [1]
What is the treatment? [2]

Answer 138

Paronychia is an infection around the nail usually caused by Staphylococcus or Streptococcus:

Tx:
- Oral abx
- Incision and drainage under local

Question 139

This lady had been to her GP two days before for a sore throat for which she was given antibiotic medication three times per day. She presented to hospital today, systemically well, but extremely concerned about this rash which had occurred this morning.

What is the likely cause? [1]s

Answer 139

Amoxycillin has caused a ‘penicillin’ reaction. This appearance can be typical for penicillin reaction. Always ask about medications which are a very frequent cause of rashes.

Question 140

Amoxicillin can cause rashes in when patients have which conditions? [2]

Answer 140

Causes erythematous rashes in patients with:
- infectious mononucleosis
- CLL

Question 141

Dx? [1]

Answer 141

Signs of SCC include – a firm, red nodule; a flat sore with a scanty crust; fast-growing.

Question 142

Dx? [1]

Answer 142

This has the typical appearances of a BCC including:

Translucent edges
Central depression/ulceration with rolled edges

Question 143

Dx? [1]

Answer 143

Acitinic / solar keratosis

Question 144

What are signs that would indicate that acitinic is at risk of developing to SCC? [3]

Answer 144

Alerting signs to development of SCC include lesions that persist in spite of treatment, are hyperkeratotic or become nodular.

Question 145

Capsule

What is the treatment for eczema herpticum? [3]

Answer 145

Acyclovir will treat the HSV.
Flucloxacillin is useful for secondary bacterial infection.
Stopping topical steroids prevents the HSV infection from spreading further.

Question 146

What type of dressing would you put on this pressure sore? [1]

Answer 146

Exudative pressure sore:
- alginate dressing

Question 147

What type of dressing would you put on this pressure sore? [1]

Answer 147

Non-exudative pressure sore:
- hydrocolloid dressing

Question 148

What scores are used to assess pressure sores for:

Paediatric and Neonate [1]
Adults [1]
Maternity [1]

Answer 148

Paediatric and Neonate: Adapted Braden Score
Adults Waterlow score
Maternity Adapted Waterlow score

Question 149

All patients should have a pressure ulcer ris asssessment within [] hrs of admission:

• 2
• 4
• 6
• 8
• 10

Answer 149

All patients should have a pressure ulcer ris asssessment within [] hrs of admission:

• 2
• 4
  - 6
• 8
• 10

Question 151

Waterlow score:
Patients scoring [] and over are at risk

Answer 151

Patients scoring 10 and over are at risk

Question 152

What is the difference between a pressure ulcer and moisture lesion with regards to :
- Location
- Shape
- Depth
- Necrosis
- Edges
- Colour

Answer 152

Question 153

This 13-year-old male, in addition to the lesions shown, has similar lesions on the buccal mucosa, on the palms and the soles and around the anus and genitalia. He has had several episodes of severe abdominal pain that have resolved without intervention. His father had similar mucocutaneous lesions as a boy, but these became less obvious as he grew older

Which condition are sufferers of disorder most at risk of developing?

.

Answer 153

The patient has Peutz–Jeghers syndrome, an autosomal dominant disorder with high penetrance, characterised by mucosal pigmentation of the lips and gums, with multiple intestinal hamartomatous polyps. It is an uncommon disorder with a prevalence of about 1 in 50 000.
- About 50% of patients develop and die from cancer by the age of 57 years (patients have a 15-fold increased risk of developing intestinal cancer compared with the general population).
- gastro-oesophageal, small bowel, colorectal and pancreatic, but breast, uterine and testicular cancers also occur.

Question 154

Describe if Marjolins ulcer is short / rapid growing and if its painful / less? [2]

Answer 154

It grows slowly, as the scar is relatively avascular, and it is painless because the tissue contains no nerves.

A Marjolin’s ulcer is a squamous cell carcinoma which develops in a scar

Question 155

A 45-year-old male with a long-standing history of extensive psoriasis affecting the trunk, arms, buttocks and nail beds is seen for review in Dermatology Outpatients. He has previously completed a course of phototherapy with minimal improvement and has shown no benefit on methotrexate for the past 12 months.

What is the next most appropriate step in the management of this patient?

Further course of phototherapy
Hydroxychloroquine
Infliximab
Rituximab
Topical tacrolimus
#48334

Answer 155

Infliximab
- Psoriasis is managed in a stepwise manner, as per the National Institute of Health Care and Excellence (NICE) guidelines, with anti-TNF alpha being considered after failure of topical therapy, phototherapy and systemic agents, such as methotrexate, acitretin and ciclosporin, or where these are not tolerated and/or contraindicated. Patients will require pneumococcal and seasonal influenza vaccination while receiving treatment due to an increased risk of these illnesses while on an anti-TNF alpha. Live vaccines should also be avoided.

Question 156

Answer 156

Epidermis

Question 157

A 75-year-old male has this lesion on his right arm that has been present for three weeks and is now 2 cm in diameter. It is not painful or tender and has not bled. It does not itch. There is no regional lymphadenopathy.

Dx? [1]
Tx? [1]

Answer 157

Keratoacanthoma is a relatively common low-grade malignancy that originates in the pilosebaceous glands.
- t clinically and pathologically resembles squamous cell carcinoma and rarely progresses into an invasive squamous cell carcinoma. Left untreated, most resolve in 4–6 months but leave residual scarring. - complete excision is the treatment of choice.

Question 158

Answer 158

Question 159

What is the difference between moisture associated skin damage and a pressure ulcer? [1]

Answer 159

Moisture Associate Skin Damage:
- is skin damage often
from urine and or faecal incontinence, or
sweat or exudate
- Incontinence associated dermatitis
(IAD) is damage caused by urine and or
faecal incontinence

It is important to note that skin damage
from moisture is not a pressure ulcer.

Question 160

*Encourage patients who have been assessed as at risk (Waterlow 10-14) to change their position frequently and at least every [] hours

Answer 160

*Encourage patients who have been assessed as at risk (Waterlow 10-14) to change their position frequently and at least every 6 hours

Question 161

*Encourage patients who have been assessed as being at high risk (>15) of developing a pressure ulcer to change their position frequently and at least every [] hours

Answer 161

*Encourage patients who have been assessed as being at high risk (>15) of developing
a pressure ulcer to change their position frequently and at least every 4 hours

Question 162

What pressure ulcers do you report on datix? [3]

Answer 162

• Pressure ulcers Grade 1 to 4 present on admission to Barts Health
• Pressure ulcers Grade 1 to 4 that develop during BH care
• ALL pressure ulcers that deteriorate (increase in grade) during BH care

Question 163

Which of the following statements is true regarding rodent ulcers?

They are squamous cell carcinomas
They are basal cell carcinomas
They only occur on the face
They show epithelial pearls
They metastasise via the bloodstream

Answer 163

A ‘rodent ulcer’ is a basal cell carcinoma. Treatment is dependent on the depth of the ulcer. There are multiple treatment options, including surgical excision (with an excision margin of 3–5 mm), Mohs micrographic surgery (used where wide excision is inappropriate such as on the face), radiotherapy (very effective) and curettage, cautery and cryotherapy (for superficial lesions).

Question 164

A 67-year-old female presents with a two-week history of spots, mainly on the fingers, toes, and lower legs. She has no significant past medical history. However, she mentions that she has been feeling more tired recently and experiencing pain in her hand joints. She has not been taking over-the-counter drugs. The lesions do not blanch on pressure. Some are just palpable on touch. Her blood pressure is 135/85 mmHg. The Dipstick urine test result is normal.

What is the most likely diagnosis? [1]

Answer 164

Question 165

Describe what a grade 2 pressure ulcer looks like [2]

Answer 165

In a grade 2 pressure ulcer, some of the skin’s outer surface (epidermis) or the deeper layer of skin (dermis) is damaged, leading to skin loss. The ulcer looks like an open wound or a blister.
- Partial-thickness skin loss and ulceration

Question 166

A patient presents with a tense, swollen, erythematous, and exquisitely tender leg, alongside systemic features of sepsis.

You suspect they have necrotising fasciitis.

What is this most likely pathogen causing this? [1[

Answer 166

Group A Streptococcus (Streptococcus pyogenes)

Question 167

A patient has skin trauma. This then descends it being an indurated lesion with raised borders that has blood and pus. Dx? [1]

Answer 167

Marjolin’s ulcer
- malignant transformation of a chronic wound, burn scar, or area of previous trauma into squamous cell carcinoma (SCC)

Question 168

A patient has alopecia.

Which strength / name steroid would you use to treat? [1]

What is the step up treatment if over 12? [1]

Answer 168

Dermovate
- These are applied to the bald patches on the scalp for around 6 weeks. The course of treatment can be repeated.

Can add on a JAK inhibitor if meets the requirements

Question 169

The long-term (usually over several months or years) side effects of ciclosporin include [2]

Answer 169

The long-term (usually over several months or years) side effects of ciclosporin include reduced function of the kidneys and raised blood pressure

Question 170

What advise would you give to patients trying ciclosporin for the first time? [1]

Answer 170

Try a patch test on arm/leg. If doesn’t burn can use on face

Question 171

Why are cleaning teeth and having dental check-ups encouraged for ciclosporin use? [1]

Answer 171

reduces the chances of developing gum overgrowth.

Question 172

Describe the order you should apply steroids vs emollients after a shower for eczema [1]
- Why? [2]

Answer 172

When treating eczema, it’s generally recommended to apply a topical steroid first after showering, then follow up with an emollient, allowing a few minutes to pass between applications to ensure the steroid is properly absorbed