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 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 2

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 3

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

Answer 3

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 4

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 4

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 5

What is the most likely diagnosis?

Actinic keratosis
Basal cell carcinoma
Keratoacanthoma
Malignant melanoma
Pyogenic granuloma

Answer 5

Actinic keratosis

Question 6

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 6

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

Question 7

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

Answer 7

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

Question 8

Answer 8

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 9

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

Answer 9

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

Question 10

Answer 10

Question 11

Describe the clinical features of discoid eczema [3]

Answer 11

Weepy multiple lesions

Erythematous lesions

Well dermarcated

Question 12

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 12

• 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 13

Answer 13

Question 14

Answer 14

Question 16

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

Answer 16

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 17

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 17

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 18

What is the treatment for headlice? [1]

Answer 18

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

Question 19

Describe what syndesmophytes are [1]

Answer 19

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 20

What differentiates a nodule from a papule? [1]

Answer 20

Both raised lesions

Nodule is found in the deeper layers of the skin

Question 21

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

Answer 21

Positive dimple sign

Question 22

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

Answer 22

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

Question 23

What is the treatment for hidradenitis suppurativa? [2]

Answer 23

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 24

Female x spots on jawline

What should you suspect? [1]

Answer 24

PCOS

Question 26

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

Answer 26

Can scrape off the fungal Malassezia (mica)

Question 27

First line treatment for acitinic keratosis? [1]

Answer 27

Cryotherapy or 5-fluorouracil cream

Question 28

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

Answer 28

Paraneoplastic disease

Question 29

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 29

doxycycline OD x 3months

Question 30

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

Answer 30

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

Question 31

[] is the treatment of choice for facial hirsutism

Answer 31

Topical eflornithine is the treatment of choice for facial hirsutism

Question 32

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

Answer 32

CO2 and Erbium YAG lasers

Question 33

Acitretin is really useful for treating psoriasis.

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

Answer 33

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

Question 34

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 34

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

Question 35

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

Answer 35

Acral lentiginous

Question 36

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

Answer 36

Ocular involvement
Rhinophyma

Question 37

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

Answer 37

Topical fluorouracil cream

Question 38

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 38

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 39

Seborrhoeic dermatitis - first-line treatment is []

Answer 39

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 40

Difference between lichen planus and lichen sclerosus?

Answer 40

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 41

The most common dermatosis in pregnancy is []

Answer 41

The most common dermatosis in pregnancy is atopic eruption of pregnancy

Question 42

Describe the ulcers seen in squamous cell carcinoma [4]

Answer 42

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 43

Pneumonic for drugs that can cause TEN/SJS?

Answer 43

Never Press Skin As It Can Peel

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

NB: IV Ig is a treatment not cause

Question 44

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 44

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

Question 45

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

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

Answer 45

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

Question 46

[Infection] is associated with seborrhoeic dermatitis

Answer 46

HIV is associated with seborrhoeic dermatitis

Question 47

[Neurological condition] is associated with seborrhoeic dermatitis

Answer 47

Parkinsons Disease

Question 48

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

Answer 48

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

Scar x SSC

Question 49

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

Answer 49

vEnous - mEdial
Arterial - lAteral

Question 50

What is this? [1]

Answer 50

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 51

Pityriasis rosea often follows a [] infection

Answer 51

Pityriasis rosea often follows a viral infection

Question 52

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

Answer 52

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

Question 53

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

Answer 53

Oral steroids are the first-line treatment for pyoderma gangrenosum

Question 54

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

Answer 54

Acne vulgaris in pregnancy - use oral erythromycin if treatment needed

tetracyclines have a risk of teratogenicity

Question 55

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 55

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 56

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

Answer 56

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

Question 57

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

Answer 57

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

Question 58

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

Answer 58

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

Question 59

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

Answer 59

Solitary firm papule/nodule that dimples on pinching → dermatofibroma

Question 60

Answer 60

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

Question 61

Dx? [1]

Usual pattern of disease? [1]

Answer 61

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 62

Dx? [1]
Tx ? [1]

Answer 62

Pemphigoid gestationis:
- oral corticosteroids are usually required

Question 63

Dx? [1]
Tx? [1]

Answer 63

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

Question 64

Erysipelas is localised skin infection caused by []

How do you differentiate this from cellulitis? [1]

Answer 64

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

Question 65

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 65

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 66

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

Answer 66

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 67

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

Answer 67

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

Question 68

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 68

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 70

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 70

anti-sedating:
Loratadine or cetirizine

sedating antihistamine:
- chlorphenamine

Question 71

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

Answer 71

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 72

Whats the treatment for a dermoid cyst? [1]

Answer 72

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

Question 73

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

Answer 73

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

Question 74

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

Answer 74

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

Question 75

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

Answer 75

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

Question 76

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 76

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 77

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

What can this be caused by? [1]

Answer 77

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 78

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

Answer 78

Topical betamethasone valerate 0.1%

Question 79

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 79

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 80

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

Answer 80

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

Question 81

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

Answer 81

type 4

Question 82

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

Answer 82

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

Question 83

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

Answer 83

Nodular melanoma: Invade aggressively and metastasise early

Question 84

[] is the most common side-effect of isotretinoin

Answer 84

Dry skin is the most common side-effect of isotretinoin

Question 85

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

Answer 85

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

Question 86

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

Answer 86

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 87

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

Answer 87

First line: topical potent steroids

Question 88

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 88

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 89

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 89

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

Squamous cell cancer

Question 90

Key side effect of ketoconazole? [1]

Answer 90

Gynecomastia

Question 91

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

Answer 91

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 92

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 92

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 93

Scarlet fever is caused by []

Answer 93

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

Question 94

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

Answer 94

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

Question 95

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

Answer 95

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

Question 96

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 96

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 97

Describe the rash typically seen in rubella [1]

Answer 97

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

Question 98

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

Answer 98

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 99

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 99

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 100

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 100

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 101

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 101

Pemphigus vulgaris

Question 102

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 102

Topical miconazole and topical hydrocortisone

Question 103

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

Answer 103

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

Question 104

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

Answer 104

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

Question 105

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

Answer 105

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

Question 106

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 106

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 107

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

Answer 107

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

Question 108

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

Answer 108

Lichen planus:
- potent topical steroids

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

Question 109

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

Answer 109

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 110

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 110

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 111

Which is the name for scalp ringworm? [1]

What is the treatment? [2]

Answer 111

Scalp ringworm - Tinea capitis

Treatment: Oral itraconazole and topical ketoconazole

Question 112

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

Answer 112

ITP

Question 113

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

Answer 113

Tinea rubris:
- topical clotrimazole

Question 114

A patient presents with suspected lichen sclerosis.

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

Name an example [1]

Answer 114

Potent topical corticosteroid
- E.g. dermovate

Question 115

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

What monitoring would you perform and why? [1]

Answer 115

terbinafine - perform LFTs every 6 months

Question 116

Answer 116

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

Question 117

How would you treat this patient (Figure 1)?

Answer 117

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 118

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

Answer 118

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

Question 119

Ciclosporin can cause what metabolic effect? [1]

Answer 119

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

Question 120

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 120

E. Methotrexate

Question 121

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 121

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

Question 122

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 122

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 123

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 123

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

Question 124

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

Answer 124

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

Question 125

Dx? [1]

Answer 125

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 126

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

Answer 126

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

Tx:
- Oral abx
- Incision and drainage under local

Question 127

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 127

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 128

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

Answer 128

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

Question 129

Dx? [1]

Answer 129

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

Question 130

Dx? [1]

Answer 130

This has the typical appearances of a BCC including:

Translucent edges
Central depression/ulceration with rolled edges

Question 131

Dx? [1]

Answer 131

Acitinic / solar keratosis

Question 132

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

Answer 132

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

Question 133

Capsule

What is the treatment for eczema herpticum? [3]

Answer 133

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

Question 134

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

Answer 134

Exudative pressure sore:
- alginate dressing

Question 135

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

Answer 135

Non-exudative pressure sore:
- hydrocolloid dressing

Question 136

What scores are used to assess pressure sores for:

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

Answer 136

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

Question 136

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

• 2
• 4
• 6
• 8
• 10

Answer 136

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

• 2
• 4
  - 6
• 8
• 10

Question 137

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

Answer 137

Patients scoring 10 and over are at risk

Question 138

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

Answer 138

Question 139

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 139

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 140

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

Answer 140

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 141

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 141

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 142

Answer 142

Epidermis

Question 143

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 143

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 144

Answer 144

Question 145

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

Answer 145

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 146

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

Answer 146

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

Question 147

*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 147

*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 148

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

Answer 148

• 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 149

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 149

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).