Questions Flashcards
1
Q
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]
A
Actinic keratosis
Tx: Imiquimod
2
Q
Pyoderma gangrenosum is associated not only with IBD and RA but also with [2]
A
Pyoderma gangrenosum is associated not only with IBD and RA but also with myeloproliferative disorders (myelofibrosis) and AML
3
Q
What is an important underlying cause of erythema nodosum? [1]
A
Erythema nodosum may be caused by pregnancy
4
Q
One of the main clues in the question is the combination of a rash with pain. Other than [1], there are not many conditions which cause both.
A
One of the main clues in the question is the combination of a rash with pain. Other than shingles, there are not many conditions which cause both.
5
Q
While working in general practice you see a 21-year-old female with pityriasis rosea. How long does the associated rash last? [1]
A
The rash from pityriasis rosea to resolve in 6-12 weeks
6
Q
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?
A
keratoacanthoma
- 1st line tx is surgical excision
7
Q
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]
A
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.
8
Q
A
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.
9
Q
[] is usually first-line for oral thrush.
In which cases would you use an alternative [2] and when would you use them? [2]
A
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
10
Q
[] presents with photosensitive blistering rashes on sun-exposed areas, often triggered by alcohol consumption.
A
Porphyria Cutanea Tarda presents with photosensitive blistering rashes on sun-exposed areas, often triggered by alcohol consumption.
11
Q
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.
A
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.
12
Q
Erythema multiforme is commonly triggered by [] virus, presenting with target lesions on the skin.
A
Erythema multiforme is commonly triggered by herpes simplex virus, presenting with target lesions on the skin.
13
Q
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]
A
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.
14
Q
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
A
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
15
Q
What is the difference between actinic keratosis and keratoacanthoma? [2]
A
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.
16
Q
How do you differentiate between alopecia areata and tinea capitis? [1]
A
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.
17
Q
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
A
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
18
Q
What is the most likely diagnosis?
Actinic keratosis
Basal cell carcinoma
Keratoacanthoma
Malignant melanoma
Pyogenic granuloma
A
Actinic keratosis
19
Q
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]
A
patient has hereditary haemorrhagic telangiectasia (HHT):
- It commonly presents in teenagers, with nosebleeds being the primary symptom in over 90% of cases.
20
Q
A patient has pemphigus vulgaris.
This is caused by antibodies agaisnt…[1]
A
Desmosomes of skin
21
Q
Dx? [1]
Tx of systemic, extensive disease? [2]
A
BP
- Prednisolone is the first line therapy. Azathioprine, Ciclosporin, and Mycophenolate mofetil can be used second line.
22
Q
A
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.
23
Q
Dx? [1]
Investigation? [1]
Tx? [1]
A
Tinea corporis (ringworm)
- microscopy and culture of skin scrapings
- Topical antifungal
24
Q
A
25
Describe the clinical features of discoid eczema [3]
Weepy multiple lesions
Erythematous lesions
Well dermarcated
26
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?**
* 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
27
28
**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**]
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.
29
30
31
Describe the difference between Eron Class II & III [2]
**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.
32
33
The presentation of a rapidly growing, dome-shaped nodule with a central crust that is tender when palpated is consistent with the diagnosis of **[]**
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**
34
What is the treatment for headlice? [1]
Wet combing or application of dimethicone 4% gel twice, at least 7 days apart
35
Describe what syndesmophytes are [1]
**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.
36
What differentiates a nodule from a papule? [1]
Both raised lesions
**Nodule** is found in the deeper layers of the skin
37
Which sign would help indicate a patient has a dermatofibroma? [1]
**Positive dimple sign**
38
Describe what is meant by Chondrodermatitis nodularis chronica helicis [1]
a benign inflammatory condition that affects the skin and cartilage of the pinna
39
What is the treatment for hidradenitis suppurativa? [2]
**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
40
Female x spots on jawline
What should you suspect? [1]
**PCOS**
41
42
If you suspected a patient to have pityriasis versicolor, describe how you would quickly investigate? [1]
Can scrape off the fungal Malassezia (mica)
43
First line treatment for acitinic keratosis? [1]
**Cryotherapy or 5-fluorouracil cream**
44
Why should you be concerned if you see a presentation of pemphis vulgaris? [1]
Paraneoplastic disease
45
A young child is vomiting.
Describe how you would differentiate if this was caused by pyloric stenosis, malrotation or intestinal atresia [3+]
**Pyloric stenosis**
- Projectile, non-bilious vomiting at 4-6 wks old
**Malrotation**
- Bilious vomiting, abdominal pain, acutely unwell
**Intestinal atresia**
- Bilious vomiting if distal to ampulla of Vater, usually hours-days old
46
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]
**doxycycline** OD x 3months
47
Rosacea: a combination of **[]** + **[]** is first-line for patients with **severe papules and/or pustules**
Rosacea: a combination of **topical ivermectin + oral doxycycline** is first-line for patients with severe papules and/or pustules
48
**[]** is the treatment of choice for facial hirsutism
**Topical eflornithine** is the treatment of choice for facial hirsutism
49
What is the only method for treating rhinophyma? [1]
**CO2 and Erbium YAG lasers**
50
Acitretin is really useful for treating psoriasis.
Which populations can you not give it to? [1]
**Females of childbearing age** - extremely teratogenic and stays in blood for 3 years
51
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]
**Measles**
- Koplik spots
- Onset of rash coincides with highest fever 40C
52
Which type of melonoma is most common in pigmented skins? [1]
**Acral lentiginous**
53
Which manifestations of psoriasis would indicate a dermatologist referral? [2]
Ocular involvement
Rhinophyma
54
A diagnosis of actinic keratoses is made. What is the most appropriate first line management?
**Topical fluorouracil cream**
55
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
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.
56
Seborrhoeic dermatitis - first-line treatment is **[]**
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.
57
Difference between lichen planus and lichen sclerosus?
**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), **p**apular, **p**olygonal plaques; have white striae on them (**Wickham's stria**)
58
The most common dermatosis in pregnancy is []
The most common dermatosis in pregnancy is **atopic eruption of pregnancy**
59
Describe the ulcers seen in squamous cell carcinoma [4]
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**
60
Pneumonic for drugs that can cause TEN/SJS?
Never Press Skin As It Can Peel
**N**SAIDs, **P**henytoin, **S**ulphonamides, **A**llopurinol, IV Ig, **C**arbamazepine, **P**enicillins
## Footnote
NB: IV Ig is a treatment not cause
61
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
**Topical betamethasone valerate**
Scalp psoriasis - first-line treatment is topical potent corticosteroids
62
Which score is used to assess level of hirsutism? [1]
What scores would indicate a moderate to severe level? [1]
**Ferriman-Gallwey scoring system**:
- 9 body areas assigned a score from 0-4
- Score > 15 is indicates a moderate to severe level
63
[Infection] is associated with seborrhoeic dermatitis
**HIV** is associated with seborrhoeic dermatitis
64
[Neurological condition] is associated with seborrhoeic dermatitis
**Parkinsons Disease**
65
A non-healing painless ulcer associated with a **chronic** **scar** is indicative of []
A **non-healing painless ulcer** associated with a **chronic scar** is indicative of **squamous cell carcinoma (SCC)**
| Scar x SSC
66
Which sides (lateral/medial) are venous and arterial ulcers more likely to present on? [2]
vEnous - mEdial
Arterial - lAteral
67
What is this? [1]
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.
68
Pityriasis rosea often follows a [] infection
Pityriasis rosea often follows a **viral** infection
69
**[]** is often the most effective treatment for prominent telangiectasia in rosacea
**Laser therapy** is often the most effective treatment for prominent telangiectasia in rosacea
70
Oral [] are the first-line treatment for pyoderma gangrenosum
**Oral steroids** are the first-line treatment for pyoderma gangrenosum
71
Acne vulgaris in pregnancy - use oral **[]** if treatment needed
Acne vulgaris in pregnancy - use oral **erythromycin** if treatment needed
## Footnote
tetracyclines have a risk of teratogenicity
72
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.
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.
73
In acute urticaria a sedating antihistamine (e.g. **[]**) may be considered for night-time use for troublesome sleep symptoms
In acute urticaria a sedating antihistamine (e.g. **chlorphenamine**) may be considered for night-time use for troublesome sleep symptoms
74
Severe urticaria - A short course of an oral **[]** may required in addition to a non-sedating antihistamine
Severe urticaria - A short course of an **oral** **corticosteroid** may required in addition to a non-sedating antihistamine
75
Which three risk factors increase the risk of a patient presenting (often in a q) with pityriasis rosea? [3]
**Present on trunk, flaky and recent sun exposure** all suggest Piyriasis Vesicolour
76
Solitary firm papule/nodule that dimples on pinching → **[]**
Solitary firm papule/nodule that dimples on pinching → **dermatofibroma**
77
This man has a **rhinophyma**, a complication of **acne rosacea**.
78
Dx? [1]
Usual pattern of disease? [1]
**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
79
Dx? [1]
Tx ? [1]
**Pemphigoid gestationis**:
- oral corticosteroids are usually required
80
Dx? [1]
Tx? [1]
**Atopic eruption of pregnancy**:
it typically presents as an eczematous, itchy red rash.
- **no specific treatment** is needed
81
**Erysipelas** is localised skin infection caused by []
How do you differentiate this from cellulitis? [1]
Erysipelas is localised skin infection caused by **Streptococcus pyogenes**
- It is differentiated from cellulitis due to its raised and **well defined border.**
82
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]
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**
## Footnote
Telangi-edge-tasia
83
What is the difference between port-wine stains and salmon patches? [1]
**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.
84
Malignant melanoma: the **[]** is the single most important prognostic factor
Melanoma: the **invasion depth of the tumour** is the single most important prognostic factor
85
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
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
86
87
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]
**anti-sedating**:
**Loratadine** or **cetirizine**
**sedating antihistamine**:
- **chlorphenamine**
88
What is a dermoid cyst? [1]
Where are they usually found? [1]
**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.**
89
Whats the treatment for a dermoid cyst? [1]
**Complete excision** is requires as they have a propensity to local recurrence if not excised.
90
What is desmoid tumour? [1]
Where do they develop? [1]
**Desmoid tumour**:
- **aggressive fibromatosis** and consist of fibroblast dense lesions (resembling scar tissue)
- most commonly develop in **ligaments and tendons**
91
Dermatitis in acral, peri-orificial and perianal distribution can be caused by a deficiency in which mineral? [1]
Dermatitis in acral, peri-orificial and perianal distribution → **zinc deficiency**
92
Aim for a **[]** **week** **break** in between courses of topical corticosteroids in patients with **psoriasis**
Aim for a **4 week break** in between courses of topical corticosteroids in patients with psoriasis
93
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
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
94
What is the name for widespread soft un-pigmented hair that covers an entire body? [1]
What can this be caused by? [1]
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.**
95
What is the first line treatment for lichen planus? [1]
**Topical betamethasone valerate 0.1%**
96
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]
**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**
97
The most common malignancy in the **lower** **lip** is a **[]**
The most common malignancy in the lower lip is a **squamous cell carcinoma**
98
Erythema multiforme is which type of HS reaction? [1]
**type 4**
99
Eczema herpeticum is a primary infection of the skin caused by herpes simplex virus (HSV) and uncommonly **[]**
Eczema herpeticum is a primary infection of the skin caused by herpes simplex virus (HSV) and uncommonly **coxsackievirus**
100
Which type of skin cancer is the most aggressive? [1[
**Nodular melanoma:** Invade aggressively and metastasise early
101
[] is the most common side-effect of isotretinoin
**Dry skin** is the most common side-effect of isotretinoin
102
What information should be given about the infectiveness of shingles to patients ? [1]
People with shingles should be advised that they are **infectious** **until** the vesicles have **crusted over**, usually **5-7 days following onset**
103
When do you use topical amorolfine vs oral terbinafine to treat nail dermatophyte infection? [1]
**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.
104
Do you use oral or topical steroids for lichen planus? [1]
**First line: topical potent steroids**
105
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
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
106
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
Which one of the following complications is most associated with psoralen + ultraviolet A light (PUVA) therapy?
**Squamous cell cancer**
107
Key side effect of ketoconazole? [1]
**Gynecomastia**
108
How can you distinguish polymorphic eruption in pregnancy to pemphigoid gestationis based on area of body affected? [1]
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.
109
Which of the following complications is a patient with PsA at higher risk of?
Cardiovascular disease
Lung cancer
Neutropenia and splenomegaly
Pericarditis
Mononeuritis multiplex
Which of the following complications is a patient with PsA at higher risk of?
**Cardiovascular disease**
Lung cancer
Neutropenia and splenomegaly
Pericarditis
Mononeuritis multiplex
110
Scarlet fever is caused by **[]**
Scarlet fever is caused by group A haemolytic streptococci (usually **Streptococcus pyogenes**)
111
Describe the characteristic rash in scarlet fever [1]
what other change occurs in children? [1]
The characteristic rash is described as ‘**sandpaper**’ texture and children can develop ‘**strawberry** **tongue**’
112
*rash worsens after eating spicy food* indicates which pathology? [1]
1st line Tx? [1]
**Rosacea**:
- **Topical ivermectin** is an appropriate first-line treatment for papulopustular rosacea
113
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
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**
114
Describe the rash typically seen in rubella [1]
The rash typically **begins** on the **face** and **spreads to the trunk, arms, and legs**
115
When do you perform sentinel node biopsies in MM? [1]
**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
116
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?**
**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.
117
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
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.
118
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]
**Pemphigus vulgaris**
119
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]
**Topical miconazole and topical hydrocortisone**
120
a bright red rash across the cheeks, reticular rash across the body and viral prodrome most likely has **[]** nfection
a bright red rash across the cheeks, reticular rash across the body and viral prodrome most likely has **Parvovirus B19 infection**
121
Parvovirus B19 infection during the first 20 weeks of pregnancy can cause [1]
**Parvovirus B19** infection during the first 20 weeks of pregnancy can cause **hydrops fetalis**
122
PUVA and UV-B are both forms of light therapy. Which is generally used as first line and why? [1]
**UV-B**
- PUVA is far more phototoxic with more side effects.
123
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%
**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).
124
Describe the changes seen in nails in 10& of those suffering from lichen planus [1]
**Lichen planus** causes **longitudinal ridges** in nails in **10% of patients**
125
How do you treat lichen planus? [1]
How do you treat lichen planus with oral involvement? [1]
**Lichen planus:**
- potent topical steroids
**Lichen planus with oral involvement**
- potent topical steroids, with benzydamine being used for oral involvement.
126
How long does chickenpox usually lost? [1]
When is it safe to let children return to school? [1]
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.*
127
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
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
128
Which is the name for **scalp ringworm?** [1]
What is the **treatment**? [2]
Scalp ringworm - **Tinea capitis**
Treatment: **Oral itraconazole and topical ketoconazole**
129
Previous viral infection x non-blanching rash x purpura = ? [1]
**ITP**
130
Name [1] and treatment [1] for athletes foot?
**Tinea rubris:**
- **topical clotrimazole**
131
A patient presents with suspected lichen sclerosis.
What level of topical corticosteroid would you prescribe? [1]
Name an example [1]
**Potent** topical corticosteroid
- E.g. **dermovate**
132
A patient is treated for fungal nail infection with which drug? [1]
What monitoring would you perform and why? [1]
**terbinafine** - perform LFTs every 6 months
133
The well-defined erythematous plaque with fine scaling is indicative of **psoriasis**.
134
How would you treat this patient (Figure 1)?
**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.
135
Why would chronic alcohol use CI MTX as a treatment? [1]
The patient's liver health would require careful monitoring as pre-existing fatty liver disease increases the risk of methotrexate-induced liver injury.
136
Ciclosporin can cause what metabolic effect? [1]
**Ciclosporin can also increase the lipids**, though as with acitretin, this issue would not be a complete contraindication.
137
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
E. Methotrexate
138
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
**Acitretin** appears to reduce the risk of keratinocyte cancer. Immunosuppression increases the risk of further skin cancer.
139
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
B. Correct. **Ciclosporin** appears to be safe in pregnancy. It is also suited to treating a young, otherwise fit patient with an acute exacerbation.
140
**What is this? [1]**
* Seborrhoeic wart
* Solar lentigo
* Benign naevus
* Malignant melanoma
* Dermatofibroma
* Pigmented basal cell carcinoma
**What is the next investigational step? [1]**
**Malignant melanoma:**
**Investigate with excision with narrow margins** (followed later by wider local excision)
141
What determines how wide the excision is for a malignant melonama? [1]
The margin used at the wide local excision depends on the **Breslow thickness of the lesion**
142
Dx? [1]
**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.
143
Name for this condition? [1]
What is the treatment? [2]
**Paronychia** is an infection around the nail usually caused by **Staphylococcus or Streptococcus**:
**Tx**:
- Oral abx
- Incision and drainage under local
144
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
**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.
145
Amoxicillin can cause rashes in when patients have which conditions? [2]
Causes **erythematous rashes** in patients with:
- **infectious mononucleosis**
- **CLL**
146
Dx? [1]
Signs of **SCC** include – a firm, red nodule; a flat sore with a scanty crust; fast-growing.
147
Dx? [1]
This has the typical appearances of a **BCC** including:
Translucent edges
Central depression/ulceration with rolled edges
148
Dx? [1]
**Acitinic / solar keratosis**
149
What are signs that would indicate that acitinic is at risk of developing to SCC? [3]
Alerting signs to development of SCC include **lesions that persist in spite of treatment, are hyperkeratotic or become nodular.**
150
# Capsule
What is the treatment for eczema herpticum? [3]
**Acyclovir** will treat the HSV.
**Flucloxacillin** is useful for secondary bacterial infection.
**Stopping topical steroids** prevents the HSV infection from spreading further.
151
What type of dressing would you put on this pressure sore? [1]
**Exudative pressure sore**:
- **alginate dressing**
152
What type of dressing would you put on this pressure sore? [1]
**Non-exudative pressure sore**:
- **hydrocolloid dressing**
153
In cases of tonsillitis with a Centor score of 2, **[]** is the primary management approach.
In cases of tonsillitis with a Centor score of **2**, **supportive care with analgesia and hydration** is the primary management approach.
154
A 6-month-old boy is found to have a continuous murmur, heard best at the left sternal edge, which is consistent with a persistent patent ductus arteriosus (PDA).
Which of the following abnormalities is most likely to be found in this patient?
Cyanosis
Nail clubbing
Bisferiens pulse
Radio-femoral delay
Collapsing pulse
**Collapsing pulse**
- A collapsing pulse arises from the increased pressure gradients and a continuous murmur from turbulent flow across the ductus arteriosus.
155
Describe an xray feature of Rickets [1]
**Widened epiphyseal plates**
156
**[]** is the most common non-haematological primary malignant neoplasm of bone in children and adolescents
- Describe typical x-ray results [2]
**Osteosarcoma** is the most common non-haematological primary malignant neoplasm of bone in children and adolescents
- The **x-ray findings of new bony growth and a periosteal reaction** causing a **sunburst appearance** are typical of **osteosarcoma**
157
Antibiotics are only indicated in children if...[4]
* **Eardrum is perforated**
* **< 2 years old and bilateral infection**
* **Present for ≥4 days**
* **< 3 months old**
158
The best initial management of necrotising enterocolitis is [2]
The best initial management of necrotising enterocolitis is **broad spectrum antibiotics and parenteral nutrition to prevent infection and rest the bowel**
159
A neonate is born and has a greenish-tinged skin. Why? [1]
What other symptoms might they have? [1]
**Meconium can stain the skin of a baby** and aspiration can result in **respiratory distress**
160
161
What scores are used to assess pressure sores for:
Paediatric and Neonate [1]
Adults [1]
Maternity [1]
Paediatric and Neonate: **Adapted Braden Score**
Adults **Waterlow score**
Maternity **Adapted Waterlow score**
162
All patients should have a pressure ulcer ris asssessment within [] hrs of admission:
- 2
- 4
- 6
- 8
- 10
All patients should have a pressure ulcer ris asssessment within [] hrs of admission:
- 2
- 4
**- 6**
- 8
- 10
163
164
**Waterlow score:**
Patients scoring **[]** and over are at risk
Patients scoring 10 and over are at risk
165
What is the difference between a pressure ulcer and moisture lesion with regards to :
- Location
- Shape
- Depth
- Necrosis
- Edges
- Colour
166
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?**
.
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.**
167
Describe if Marjolins ulcer is short / rapid growing and if its painful / less? [2]
It grows **slowly**, as the scar is relatively **avascular**, and it is **painless** because the **tissue contains no nerves.**
## Footnote
A Marjolin’s ulcer is a squamous cell carcinoma which develops in a scar
168
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
**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.
169
**Epidermis**
170
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]
**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.**
171
172
What is the difference between moisture associated skin damage and a pressure ulcer? [1]
**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**.
173
*Encourage patients who have been assessed as at risk **(Waterlow 10-14)** to change their position frequently and at least every **[] hours**
*Encourage patients who have been assessed as at risk **(Waterlow 10-14**) to change their position frequently and at least **every 6 hours**
174
*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**
*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**
175
What pressure ulcers do you report on datix? [3]
* 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**
176
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
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).
177
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]**
178
Describe what a grade 2 pressure ulcer looks like [2]
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**
179
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[
**Group A Streptococcus** (**Streptococcus pyogenes**)
180
A patient has skin trauma. This then descends it being an indurated lesion with raised borders that has blood and pus. Dx? [1]
**Marjolin's ulcer**
- malignant transformation of a chronic wound, burn scar, or area of previous trauma into squamous cell carcinoma (SCC)
181
A patient has alopecia.
Which strength / name steroid would you use to treat? [1]
What is the step up treatment if over 12? [1]
**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
182
The long-term (usually over several months or years) side effects of ciclosporin include **[2]**
The long-term (usually over several months or years) side effects of ciclosporin include **reduced function of the kidneys and raised blood pressure**
183
What advise would you give to patients trying ciclosporin for the first time? [1]
Try a patch test on arm/leg. If doesn't burn can use on face
184
Why are cleaning teeth and having dental check-ups encouraged for ciclosporin use? [1]
**reduces the chances of developing gum overgrowth.**
185
Describe the order you should apply steroids vs emollients after a shower for eczema [1]
- Why? [2]
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
186
**[]**, a selective-serotonin-reuptake inhibitor, is the only antidepressant medication licensed for children and has the best evidence base for use in children.
**Fluoxetine**, a selective-serotonin-reuptake inhibitor, is the only antidepressant medication licensed for children and has the best evidence base for use in children.
187
*You are junior doctor at a GP practice. Your next patient is a 3-year-old girl who is notably irritable and teary. Her father explains that she has had a reduced appetite for the past couple of days*
*On examination you note multiple vesicles over both palms and around the mouth. She is also pyrexial.*
What is the dx and tx? [2]
**Hand, foot and mouth** **disease** requires **symptomatic treatment only**
188
Describe a sign with regards to hand preferances that would indicate cerebral palsy [1]
**Hand preference before 12 months is abnormal** - it could be an indicator of cerebral palsy
189
Describe what innocent murmurs in children are caused by [1]
How do they present [2]
**Venous hums**
- Due to the **turbulent blood flow in the great veins** returning to the heart.
- Heard as a **continuous blowing noise** heard **just below the clavicles**
**Still's murmur**
- Low-pitched sound heard at the lower left sternal edge
190
A 25-year-old male presents to the dermatology clinic with several small fleshy nodules around and under his finger and toenails. On further questioning it is noted that the patient has a history of difficult-to-control seizures.
What is the most likely underlying condition?
Neurofibromatosis I
von Hippel–Lindau disease
Neurofibromatosis II
Tuberous sclerosis
Sturge–Weber syndrome
**Tuberous sclerosis**
- **Periungual fibromas** (known as Koenen tumours) are seen in tuberous sclerosis.
- Tuberous sclerosis **predisposes to benign tumours** (hamartomas) forming in the **brain and on other organs such as the eyes, skin, kidney and heart.**
- Skin problems include **adenoma sebaceum, ‘ash leaf’ hypomelanic macules, café-au-lait patches, subcutaneous nodules and shagreen patches** (sacral plaques of shark-like skin)
191
Damage to which layer of the skin is responsible for skin scaling to occur?
Epidermis
Dermo–epidermal junction
Papillary dermis
Subcutis
Epidermal appendages
Within the **epidermis** is an **abnormal proliferation of keratinocytes** with a transit time of cells through the epidermis reduced to about four days, compared with the normal 28 days. **This leads to the formation of scales**. The stratum corneum is thickened, and there is a retention of cell nuclei in the keratinocytes in this layer (parakeratosis). There is no granular layer. The presence of scale is indicative that psoriasis is an epidermal disorder, in contrast to dermal conditions such as cellulitis or urticaria in which there is no scale.
192
A 30-year-old female with uncontrolled psoriasis is re-presenting with worsening symptoms. Potent topical treatments have failed to control her psoriasis.
What is the most appropriate progression in her management?
Changing the topical steroids
Add in narrow-band ultraviolet B (UVB) phototherapy
Commence biologics
Add in psoralen with local ultraviolet A (UVA) irradiation
Stop steroids and start narrow-band UVB phototherapy
**Add in narrow-band ultraviolet B (UVB) phototherapy**
- This is the most appropriate next stage for managing psoriasis when topical treatments alone have failed to work. It has quite a reasonable success rate, but its complications include an increased risk of skin cancer. This will often not be recommended if a patient has a significant history of skin cancer.
193
A 41-year-old West Indian diplomat, while on secondment in the United Kingdom, develops an uncomfortable raised rash on the anterior aspects of both her lower legs. She has prided herself on her remarkably good health over the years. She has recently visited Nigeria, Guyana and Vietnam for her work.
Which of the following would be the best initial investigation to perform?
Blood film
Chest X-ray
Ultrasound of the abdomen
Stool microbiology
Skin biopsy
A 41-year-old West Indian diplomat, while on secondment in the United Kingdom, develops an uncomfortable raised rash on the anterior aspects of both her lower legs. She has prided herself on her remarkably good health over the years. She has recently visited Nigeria, Guyana and Vietnam for her work.
Which of the following would be the best initial investigation to perform?
Blood film
**Chest X-ray**
Ultrasound of the abdomen
Stool microbiology
Skin biopsy
