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  • Question 1 - A 42-year-old female patient visits the GP clinic with two circular patches on...

    Correct

    • A 42-year-old female patient visits the GP clinic with two circular patches on her scalp that have resulted in hair loss and scarring. She reports that she first noticed these patches 4 weeks after returning from a trip to Italy. Upon further inquiry, she also acknowledges experiencing persistent joint pain and stiffness. Could scarring alopecia be caused by any of the following?

      Your Answer: Lichen planus

      Explanation:

      Scarring alopecia can be caused by various factors such as trauma/burns, radiotherapy, discoid lupus, tinea capitis, and lichen planus. However, out of these options, lichen planus is the only cause that leads to scarring alopecia. The remaining causes, including alopecia areata, carbimazole, trichotillomania, and telogen effluvium, result in non-scarring alopecia.

      Input:
      Alopecia may be divided into scarring (destruction of hair follicle) and non-scarring (preservation of hair follicle). Scarring alopecia can be caused by trauma, burns, radiotherapy, lichen planus, discoid lupus, and untreated tinea capitis. Non-scarring alopecia can be caused by male-pattern baldness, drugs such as cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, and colchicine, nutritional deficiencies such as iron and zinc deficiency, autoimmune conditions such as alopecia areata, telogen effluvium, hair loss following a stressful period such as surgery, and trichotillomania.

      Output:
      – Alopecia can be categorized into scarring and non-scarring types.
      – Scarring alopecia is caused by trauma, burns, radiotherapy, lichen planus, discoid lupus, and untreated tinea capitis.
      – Non-scarring alopecia is caused by male-pattern baldness, drugs such as cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, and colchicine, nutritional deficiencies such as iron and zinc deficiency, autoimmune conditions such as alopecia areata, telogen effluvium, hair loss following a stressful period such as surgery, and trichotillomania.

    • This question is part of the following fields:

      • Dermatology
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  • Question 2 - A 25-year-old woman who is 14 weeks pregnant complains of worsening acne that...

    Correct

    • A 25-year-old woman who is 14 weeks pregnant complains of worsening acne that is causing her distress. Despite using topical benzyl peroxide, she has noticed limited improvement. During examination, non-inflammatory lesions and pustules are observed on her face. What would be the most suitable next course of action?

      Your Answer: Oral erythromycin

      Explanation:

      If treatment for acne is required during pregnancy, oral erythromycin is a suitable option, as the other medications are not recommended.

      Acne vulgaris is a common skin condition that typically affects adolescents, with the face, neck, and upper trunk being the most commonly affected areas. It is characterized by the obstruction of hair follicles with keratin plugs, leading to the formation of comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the presence and extent of inflammatory lesions, papules, and pustules.

      The management of acne vulgaris typically involves a step-up approach, starting with single topical therapy such as topical retinoids or benzoyl peroxide. If this is not effective, topical combination therapy may be used, which includes a topical antibiotic, benzoyl peroxide, and topical retinoid. Oral antibiotics such as tetracyclines may also be prescribed, but they should be avoided in pregnant or breastfeeding women and children under 12 years of age. Erythromycin may be used in pregnancy, while minocycline is now considered less appropriate due to the possibility of irreversible pigmentation. Oral antibiotics should be used for a maximum of three months and always co-prescribed with a topical retinoid or benzoyl peroxide to reduce the risk of antibiotic resistance.

      Combined oral contraceptives (COCP) are an alternative to oral antibiotics in women, and Dianette (co-cyrindiol) may be used as it has anti-androgen properties. However, it has an increased risk of venous thromboembolism compared to other COCPs, so it should generally be used second-line and for only three months. Oral isotretinoin is a potent medication that should only be used under specialist supervision, and it is contraindicated in pregnancy. Finally, there is no evidence to support dietary modification in the management of acne vulgaris.

    • This question is part of the following fields:

      • Dermatology
      16.8
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  • Question 3 - A 25-year-old male visits a dermatology clinic after being referred by his physician...

    Correct

    • A 25-year-old male visits a dermatology clinic after being referred by his physician due to a mole that has changed color. When asked, he mentions that he always burns and never tans when exposed to sunlight. He has fair skin and red hair. What is the appropriate Fitzpatrick grade for this skin type?

      Your Answer: Fitzpatrick type 1

      Explanation:

      Skin type 1 according to the Fitzpatrick classification is characterized by pale skin with features like blue eyes, red hair, and freckles. Individuals with this skin type always experience burning and never tanning. The classification system ranges from type 1, which is most prone to burning, to type 6, which is Afro-Caribbean skin that never burns.

      Skin type is a crucial factor in determining the risk of developing skin cancer. The Fitzpatrick classification system is commonly used to categorize skin types based on their response to UV radiation. This system divides skin types into six categories, ranging from those who always burn and never tan to those who never burn and always tan.

      Type I skin is the most sensitive to UV radiation and is characterized by red hair, freckles, and blue eyes. These individuals never tan and always burn when exposed to the sun. Type II skin usually tans but always burns, while Type III skin always tans but may sometimes burn. Type IV skin always tans and rarely burns, and Type V skin burns and tans after extreme UV exposure. Finally, Type VI skin, which is common in individuals of African descent, never tans and never burns.

      Understanding your skin type is essential in protecting yourself from skin cancer. Those with fair skin, such as Type I and II, are at a higher risk of developing skin cancer and should take extra precautions when exposed to the sun. On the other hand, those with darker skin, such as Type V and VI, may have a lower risk of skin cancer but should still take measures to protect their skin from UV radiation. By knowing your skin type and taking appropriate precautions, you can reduce your risk of developing skin cancer.

    • This question is part of the following fields:

      • Dermatology
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  • Question 4 - A 6-year-old boy is presented for surgery after the appearance of multiple small,...

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    • A 6-year-old boy is presented for surgery after the appearance of multiple small, umbilicated lesions on his right leg. He has no prior history of such lesions and is generally healthy, except for a history of allergies. What is the best course of action for management?

      Your Answer: Reassure

      Explanation:

      Understanding Molluscum Contagiosum

      Molluscum contagiosum is a viral skin infection that is commonly seen in children, particularly those with atopic eczema. It is caused by the molluscum contagiosum virus and can be transmitted through direct contact or contaminated surfaces. The infection presents as pinkish or pearly white papules with a central umbilication, which can appear anywhere on the body except for the palms of the hands and soles of the feet. In children, lesions are commonly seen on the trunk and in flexures, while in adults, sexual contact may lead to lesions developing on the genitalia, pubis, thighs, and lower abdomen.

      While molluscum contagiosum is a self-limiting condition that usually resolves within 18 months, it is important to avoid sharing towels, clothing, and baths with uninfected individuals to prevent transmission. Scratching the lesions should also be avoided, and treatment may be considered if the itch is problematic. However, treatment is not usually recommended, and if necessary, simple trauma or cryotherapy may be used. In some cases, referral may be necessary, such as for individuals who are HIV-positive with extensive lesions or those with eyelid-margin or ocular lesions and associated red eye.

      Overall, understanding molluscum contagiosum and taking appropriate precautions can help prevent transmission and alleviate symptoms.

    • This question is part of the following fields:

      • Dermatology
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  • Question 5 - A 58-year-old woman develops a red and hot right shin. She is afebrile...

    Correct

    • A 58-year-old woman develops a red and hot right shin. She is afebrile and otherwise well. She has no known allergies. Her Wells' score is -2.
      Which of the following would be the best option?
      Select the SINGLE best option from the list below. Select ONE option only.

      Your Answer: Oral flucloxacillin

      Explanation:

      Treatment Options for Cellulitis and the Use of Doppler Ultrasound for DVT Diagnosis

      Cellulitis is a common bacterial skin infection that can be treated with oral flucloxacillin, according to UK antimicrobial guidelines. Hospital admission for cellulitis treatment is only necessary for febrile and ill patients or those with comorbidities. Oral co-amoxiclav is recommended for facial cellulitis, but not for cellulitis in other locations. Oral vancomycin is used for Clostridium difficile infection, not cellulitis.

      A Doppler ultrasound scan can be useful in diagnosing deep venous thrombosis (DVT), but it is unlikely to be necessary for a patient with cellulitis who is otherwise well and has a low Wells’ score. The Wells’ score is a tool used to assess the likelihood of DVT based on clinical features.

    • This question is part of the following fields:

      • Dermatology
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  • Question 6 - A 60-year-old man presents to his primary care physician with a chief complaint...

    Correct

    • A 60-year-old man presents to his primary care physician with a chief complaint of severe itching following his shower. The patient reports that this has been ongoing for approximately two months and has not improved. His medical history is significant for a previous deep vein thrombosis in his left leg three years ago and an episode of gout in his right hallux six years ago. What is the most probable diagnosis for this patient?

      Your Answer: Polycythaemia vera

      Explanation:

      Understanding Polycythaemia: Types and Causes

      Polycythaemia is a condition characterized by an increase in the number of red blood cells in the body. There are three types of polycythaemia: relative, primary, and secondary. Relative polycythaemia is caused by factors such as dehydration and stress, while primary polycythaemia rubra vera is a rare blood disorder that results in the overproduction of red blood cells. Secondary polycythaemia, on the other hand, is caused by underlying medical conditions such as COPD, altitude, and obstructive sleep apnoea.

      To differentiate between true polycythaemia and relative polycythaemia, red cell mass studies are sometimes used. In true polycythaemia, the total red cell mass in males is greater than 35 ml/kg and in women, it is greater than 32 ml/kg. It is important to identify the underlying cause of polycythaemia to determine the appropriate treatment plan. While polycythaemia is rarely a clinical problem, it is essential to monitor the condition to prevent complications.

    • This question is part of the following fields:

      • Dermatology
      14.9
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  • Question 7 - A 25-year-old woman presents to her General Practitioner concerned about a red, itchy...

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    • A 25-year-old woman presents to her General Practitioner concerned about a red, itchy rash that developed while she was on holiday in Spain. On examination, she has an inflamed eczematous rash on her face, neck, arms and legs, with a few blisters. She has sparing of skin in areas that have been covered by her swimwear. She is currently being treated for acne and takes no other regular medications. She has no other known medical conditions.
      Which of the following medications is most likely to have caused this patient’s rash?

      Your Answer: Oral lymecycline

      Explanation:

      Understanding Photosensitivity and Acne Treatments

      Photosensitivity is a common side-effect of certain medications used to treat acne. This abnormal reaction to ultraviolet (UV) radiation can cause a rash, particularly when exposed to UVA rays. Primary photosensitive conditions include polymorphic light eruption or solar urticaria, while secondary photosensitivity may be caused by medications such as tetracyclines or retinoids, or exposure to psoralens released by plants.

      Lymecycline, a tetracycline antibiotic commonly used to treat acne, is known to cause photosensitivity. Oral erythromycin, a macrolide antibiotic used to treat acne, does not typically cause photosensitive skin reactions. Topical azelaic acid and clindamycin are also used to treat acne but are not known to cause photosensitivity. Topical benzoyl peroxide may cause local skin reactions but is not associated with photosensitivity. It is important to be aware of the potential side-effects of acne treatments and to take precautions to protect the skin from UV radiation.

    • This question is part of the following fields:

      • Dermatology
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  • Question 8 - A 25-year-old female patient complains of hypopigmented skin lesions on her chest and...

    Correct

    • A 25-year-old female patient complains of hypopigmented skin lesions on her chest and back. She has just come back from a trip to Spain and has a tanned complexion. During examination, the lesions appear to be slightly scaly. What is the probable diagnosis?

      Your Answer: Pityriasis versicolor

      Explanation:

      Understanding Pityriasis Versicolor

      Pityriasis versicolor, also known as tinea versicolor, is a fungal infection that affects the skin’s surface. It is caused by Malassezia furfur, which was previously known as Pityrosporum ovale. This condition is characterized by patches that may be hypopigmented, pink, or brown, and it is most commonly found on the trunk. The patches may become more noticeable following a suntan, and scaling is a common symptom. Mild pruritus may also occur.

      Pityriasis versicolor can affect healthy individuals, but it is more likely to occur in those who are immunosuppressed, malnourished, or have Cushing’s syndrome. Treatment typically involves the use of topical antifungal medications, with ketoconazole shampoo being the recommended option due to its cost-effectiveness for larger areas. If topical treatment fails, alternative diagnoses should be considered, and oral itraconazole may be prescribed. Scrapings may also be sent for confirmation of the diagnosis. Understanding the features, predisposing factors, and management of pityriasis versicolor can help individuals recognize and effectively treat this common fungal infection.

    • This question is part of the following fields:

      • Dermatology
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  • Question 9 - A 21-year-old woman presents with a two day history of increasing dysuria. During...

    Correct

    • A 21-year-old woman presents with a two day history of increasing dysuria. During examination, inflamed blisters are observed on the outer labia.
      What is the most suitable treatment option?

      Your Answer: Aciclovir

      Explanation:

      Understanding Genital Herpes and Treatment Options

      Genital herpes is a sexually transmitted infection caused by the herpes simplex viruses (HSV-1 or HSV-2). It presents as clusters of papules and vesicles on the outer genitals in both men and women, usually appearing 4-7 days after sexual exposure to HSV for the first time. Unfortunately, there is no cure for genital herpes, but treatment with aciclovir can reduce the duration of symptoms. Other treatment options include antibiotics like azithromycin and clindamycin for bacterial infections, antifungal agents like fluconazole for fungal infections, and metronidazole for anaerobic bacteria and protozoa. It is important to seek medical attention and start treatment as soon as possible to manage symptoms and prevent transmission to others.

    • This question is part of the following fields:

      • Dermatology
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  • Question 10 - A 79-year-old woman visits her GP complaining of a painless leg ulcer that...

    Incorrect

    • A 79-year-old woman visits her GP complaining of a painless leg ulcer that has been present for a few weeks. Upon examination, the GP observes a superficial erythematous oval-shaped ulcer above her medial malleolus, with hyperpigmentation of the surrounding skin. The patient's ankle-brachial pressure index (ABPI) is 0.95. What is the initial management strategy that should be employed?

      Your Answer: Hydrocolloid dressings

      Correct Answer: Compression bandaging

      Explanation:

      The recommended treatment for venous ulceration is compression bandaging, which is appropriate for this patient who exhibits typical signs of the condition such as hyperpigmentation and an ulcer located above the medial malleolus. Before initiating compression treatment, an ABPI was performed to rule out arterial disease, which was normal. Hydrocolloid dressings have limited benefit for venous ulceration, while flucloxacillin is used to treat cellulitis. Diabetic foot ulcers are painless and tend to occur on pressure areas, while arterial ulcers have distinct characteristics and are associated with an abnormal ABPI.

      Venous Ulceration and its Management

      Venous ulceration is a type of ulcer that is commonly seen above the medial malleolus. To assess for poor arterial flow that could impair healing, an ankle-brachial pressure index (ABPI) is important in non-healing ulcers. A normal ABPI is usually between 0.9 – 1.2, while values below 0.9 indicate arterial disease. Interestingly, values above 1.3 may also indicate arterial disease, particularly in diabetics, due to false-negative results caused by arterial calcification.

      The only treatment that has been shown to be of real benefit for venous ulceration is compression bandaging, usually four-layer. Oral pentoxifylline, a peripheral vasodilator, can also improve the healing rate. There is some small evidence supporting the use of flavonoids, but little evidence to suggest benefit from hydrocolloid dressings, topical growth factors, ultrasound therapy, and intermittent pneumatic compression. Proper management of venous ulceration is crucial to promote healing and prevent complications.

    • This question is part of the following fields:

      • Dermatology
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  • Question 11 - A 30-year-old man presents with multiple, ring-shaped, papular rashes on his legs. He...

    Correct

    • A 30-year-old man presents with multiple, ring-shaped, papular rashes on his legs. He has recently noticed a red, raised intra-oral lesion.
      What is the most likely diagnosis?

      Your Answer: Lichen planus

      Explanation:

      Skin Conditions: Lichen Planus, Erythema Multiforme, Psoriasis, Ringworm, and Tinea Versicolor

      Lichen Planus: A skin condition that affects cutaneous and mucosal surfaces, characterised by flat-topped plaques and papules with a purple hue and white striae. It can be treated with topical steroids and immunomodulators.

      Erythema Multiforme: A skin condition characterised by targetoid lesions with a central depression, usually starting on the acral extensor surfaces and progressing to involve the trunk and back. It can be caused by medications, infections, or underlying conditions.

      Psoriasis: An autoimmune chronic skin condition presenting with erythematous plaques and greyscale on the extensor surfaces of extremities. It is not associated with intra-oral mucosal lesions.

      Ringworm: A fungal skin infection characterised by erythematous, scaly patches on the skin surface of the trunk, back, and extremities. It can lead to the formation of pustules or vesicles.

      Tinea Versicolor: A fungal skin infection characterised by pale or dark, copper-coloured patches on the arms, neck, and trunk. It does not involve mucosal surfaces.

      Understanding Different Skin Conditions

    • This question is part of the following fields:

      • Dermatology
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  • Question 12 - A 50-year-old woman presents to dermatology after being referred by her physician for...

    Correct

    • A 50-year-old woman presents to dermatology after being referred by her physician for lesions on both shins. Upon examination, symmetrical erythematous lesions with an orange peel texture are observed. What is the probable diagnosis?

      Your Answer: Pretibial myxoedema

      Explanation:

      Pretibial myxoedema is a condition characterized by orange peel-like lesions on the skin of the shins, often associated with Grave’s disease.

      Understanding Shin Lesions: Differential Diagnosis and Characteristic Features

      Shin lesions can be caused by a variety of conditions, and it is important to differentiate between them in order to provide appropriate treatment. The four most common conditions that can cause shin lesions are erythema nodosum, pretibial myxoedema, pyoderma gangrenosum, and necrobiosis lipoidica diabeticorum.

      Erythema nodosum is characterized by symmetrical, tender, erythematous nodules that heal without scarring. It is often caused by streptococcal infections, sarcoidosis, inflammatory bowel disease, or certain medications such as penicillins, sulphonamides, or oral contraceptive pills.

      Pretibial myxoedema, on the other hand, is seen in Graves’ disease and is characterized by symmetrical, erythematous lesions that give the skin a shiny, orange peel appearance.

      Pyoderma gangrenosum initially presents as a small red papule, which later develops into deep, red, necrotic ulcers with a violaceous border. It is idiopathic in 50% of cases, but may also be seen in inflammatory bowel disease, connective tissue disorders, and myeloproliferative disorders.

      Finally, necrobiosis lipoidica diabeticorum is characterized by shiny, painless areas of yellow/red skin typically found on the shin of diabetics. It is often associated with telangiectasia.

      In summary, understanding the differential diagnosis and characteristic features of shin lesions can help healthcare professionals provide appropriate treatment and improve patient outcomes.

    • This question is part of the following fields:

      • Dermatology
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  • Question 13 - A 38-year-old man presents with pruritic, violaceous papules in a polygonal pattern on...

    Correct

    • A 38-year-old man presents with pruritic, violaceous papules in a polygonal pattern on the flexor surface of his forearms. Several of these papules have merged to form plaques. What is the probable diagnosis?

      Your Answer: Lichen planus

      Explanation:

      Lichen planus is a rash that appears as purple, itchy, polygonal papules on the flexor surfaces of the body. It is often accompanied by Wickham’s striae on the surface and can also affect the mouth. In contrast, lichen sclerosus is characterized by white, itchy spots that commonly appear on the vulva of older women.

      Understanding Lichen Planus

      Lichen planus is a skin condition that is believed to be caused by an immune response, although the exact cause is unknown. It is characterized by an itchy, papular rash that typically appears on the palms, soles, genitalia, and flexor surfaces of the arms. The rash often has a polygonal shape and a distinctive white-lines pattern on the surface, known as Wickham’s striae. In some cases, new skin lesions may appear at the site of trauma, a phenomenon known as the Koebner phenomenon.

      Oral involvement is common in around 50% of patients, with a white-lace pattern often appearing on the buccal mucosa. Nail changes may also occur, including thinning of the nail plate and longitudinal ridging. Lichenoid drug eruptions can be caused by certain medications, such as gold, quinine, and thiazides.

      The main treatment for lichen planus is potent topical steroids. For oral lichen planus, benzydamine mouthwash or spray is recommended. In more extensive cases, oral steroids or immunosuppression may be necessary.

    • This question is part of the following fields:

      • Dermatology
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  • Question 14 - A 45-year-old woman presents to the Dermatology Clinic for regular follow-up of her...

    Correct

    • A 45-year-old woman presents to the Dermatology Clinic for regular follow-up of her psoriasis. This had previously been well controlled after phototherapy six months ago; however, she has recently deteriorated.
      Her current treatment regime includes topical calcipotriol (Dovonex), topical coal tar ointment and topical hydromol ointment, in addition to amoxicillin for a recent respiratory infection. She is otherwise fit and well.
      On examination, she has an erythematous rash covering much of her back, with widespread patches on her arms and legs. The rash is tender and warm, though she appears to be shivering. There are no oral lesions. Her pulse is 98 beats per minute, while her blood pressure (BP) is 95/50 mmHg and her temperature is 38.2 °C.
      What is the most important next step in this woman's treatment?

      Your Answer: Arrange hospital admission

      Explanation:

      Urgent Hospital Admission Required for Erythrodermic Psoriasis

      Erythrodermic psoriasis is a severe dermatological emergency that requires urgent hospital admission. This is evident in a patient who presents with a drop in blood pressure, tachycardia, borderline pyrexia, and rigors. While the patient’s psoriasis needs more intensive management, it is not appropriate to manage erythroderma in the community.

      The treatment for erythrodermic psoriasis includes supportive care, such as intravenous fluids, cool, wet dressings, and a systemic agent. The choice of a systemic agent depends on the patient and may involve rapid-acting therapies like ciclosporin or slower agents like methotrexate. However, it is important to note that starting any systemic agent requires investigations, including baseline blood tests and a viral screen, to ensure it is not contraindicated.

      It is crucial to differentiate erythrodermic psoriasis from other dermatological emergencies like Stevens-Johnson syndrome/toxic epidermal necrolysis (TEN), which is a severe drug reaction associated with amoxicillin and anti-epileptic therapies. However, in this case, the patient’s history features a slow deterioration of pre-existing psoriasis, and the rash is not desquamating, and there are no oral lesions. Therefore, hospital admission is required for erythrodermic psoriasis.

      It is essential to avoid repeating phototherapy in a patient with erythrodermic psoriasis as it can worsen the condition. In a well patient, phototherapy would not be reattempted six months after a poor response, and an alternate approach would most likely be sought.

    • This question is part of the following fields:

      • Dermatology
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  • Question 15 - During a routine General Practitioner (GP) clinic, a mother attends with her 8-year-old...

    Correct

    • During a routine General Practitioner (GP) clinic, a mother attends with her 8-year-old daughter who has worsening dry, itchy skin, mainly affecting the flexor surfaces, particularly on the legs. She has tried regular liberal use emollient cream with limited success.
      What would be the most appropriate next step in the management of the child’s eczema?

      Your Answer: Prescribe hydrocortisone cream 1%

      Explanation:

      Managing Eczema in Children: Treatment Options and Considerations

      Eczema is a common condition in children that can be effectively managed with the right treatment approach. When a child presents with eczema symptoms, the first step is often to use emollient cream to moisturize the affected area. However, if the symptoms persist or worsen, a topical corticosteroid cream may be prescribed to help manage the flare-up. It is important to use this medication sparingly and in conjunction with emollients.

      If the eczema symptoms continue to be troublesome despite these measures, it may be appropriate to refer the child to a dermatology clinic. However, it is important to note that oral corticosteroids should be used with caution in children and only under the direction of a dermatologist.

      While emollient creams are often effective, in some cases, an emollient ointment may be more moisturizing and helpful. However, if the eczema flare-up is not resolving with emollients alone, a short course of topical corticosteroid is likely necessary.

      Watchful waiting is not appropriate in this situation, as the child has already presented to the GP and symptoms are worsening despite reasonable management by the mother. By understanding the various treatment options and considerations for managing eczema in children, healthcare providers can help ensure the best possible outcomes for their patients.

    • This question is part of the following fields:

      • Dermatology
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  • Question 16 - A 45-year-old woman presents to her General Practitioner with right lower-limb pain. This...

    Correct

    • A 45-year-old woman presents to her General Practitioner with right lower-limb pain. This is mainly localised over a red patch that has recently developed on the inner part of her thigh.
      On examination, there is a well-demarcated area of erythematous skin on the patient’s thigh, which is warm and tender to touch. There are no other rashes or skin changes present in the rest of her body. Her temperature is 37.5°C and the rest of her parameters are within normal limits.
      Which of the following is the most likely diagnosis?

      Your Answer: Cellulitis

      Explanation:

      Differential Diagnosis for a Lower Limb Rash: Cellulitis, Atopic Dermatitis, Contact Dermatitis, Necrobiosis Lipoidica, and Pretibial Myxedema

      The patient in question is most likely suffering from cellulitis, as evidenced by the presence of erythema, warmth, tenderness, and swelling in the affected area. Cellulitis typically presents as a unilateral rash in the lower limbs, with a well-defined margin and potential skin breakdown or ulceration in severe cases. Localized lymph node swelling may also occur, and systemic symptoms such as tachycardia, fever, confusion, or respiratory distress may be present in more severe cases. It is important to examine the skin carefully for potential points of entry for pathogens, such as wounds, local skin infections, or recent injection sites.

      Atopic dermatitis, on the other hand, typically presents as an itchy rash in a flexural distribution, with a history of atopy and episodic flares starting from a young age. Contact dermatitis, which can be either irritant or allergic, is characterized by erythema and may present with crusting or vesicles in rare cases. Necrobiosis lipoidica is a condition that typically occurs in diabetic patients, presenting as shiny, painless areas of yellow or red skin on the shins, often with telangiectasia. Pretibial myxedema, which occurs in patients with Graves’ disease, presents as a shiny, waxy, orange-peel texture on the shins.

      In summary, a lower limb rash can have various causes, and a careful examination of the skin and consideration of the patient’s medical history can help narrow down the differential diagnosis.

    • This question is part of the following fields:

      • Dermatology
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  • Question 17 - A 26-year-old presents with a rash that developed after a camping trip. He...

    Correct

    • A 26-year-old presents with a rash that developed after a camping trip. He mentions being bitten by a tick during the trip. He explains that the rash is red, not itchy, and began at the site of the bite before spreading outward. The center of the rash has now cleared, resulting in a bulls-eye appearance. What is the name of this rash?

      Your Answer: Erythema migrans

      Explanation:

      Lyme Disease: Symptoms and Progression

      Lyme disease is a bacterial infection that is transmitted through the bite of an infected tick. The disease progresses in two stages, with early and later features. The early features of Lyme disease include erythema migrans, which is a small papule that often appears at the site of the tick bite. This papule develops into a larger annular lesion with central clearing, resembling a bulls-eye. This occurs in 70% of patients and is accompanied by systemic symptoms such as malaise, fever, and arthralgia.

      In the later stages of Lyme disease, patients may experience cardiovascular symptoms such as heart block and myocarditis. Neurological symptoms may also occur, including cranial nerve palsies and meningitis. Additionally, patients may develop polyarthritis, which is inflammation in multiple joints. It is important to seek medical attention if any of these symptoms occur after a tick bite, as early treatment can prevent the progression of the disease.

    • This question is part of the following fields:

      • Dermatology
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  • Question 18 - A 25-year-old woman in her first trimester of pregnancy presents for a check-up....

    Correct

    • A 25-year-old woman in her first trimester of pregnancy presents for a check-up. She is experiencing a resurgence of her chronic acne and is interested in finding a solution. What should she steer clear of?

      Your Answer: Topical isotretinoin

      Explanation:

      Acne vulgaris is a common skin condition that typically affects adolescents, with the face, neck, and upper trunk being the most commonly affected areas. It is characterized by the obstruction of hair follicles with keratin plugs, leading to the formation of comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the presence and extent of inflammatory lesions, papules, and pustules.

      The management of acne vulgaris typically involves a step-up approach, starting with single topical therapy such as topical retinoids or benzoyl peroxide. If this is not effective, topical combination therapy may be used, which includes a topical antibiotic, benzoyl peroxide, and topical retinoid. Oral antibiotics such as tetracyclines may also be prescribed, but they should be avoided in pregnant or breastfeeding women and children under 12 years of age. Erythromycin may be used in pregnancy, while minocycline is now considered less appropriate due to the possibility of irreversible pigmentation. Oral antibiotics should be used for a maximum of three months and always co-prescribed with a topical retinoid or benzoyl peroxide to reduce the risk of antibiotic resistance.

      Combined oral contraceptives (COCP) are an alternative to oral antibiotics in women, and Dianette (co-cyrindiol) may be used as it has anti-androgen properties. However, it has an increased risk of venous thromboembolism compared to other COCPs, so it should generally be used second-line and for only three months. Oral isotretinoin is a potent medication that should only be used under specialist supervision, and it is contraindicated in pregnancy. Finally, there is no evidence to support dietary modification in the management of acne vulgaris.

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      • Dermatology
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  • Question 19 - A concerned parent brings her 4-month-old to your clinic with a bright red...

    Correct

    • A concerned parent brings her 4-month-old to your clinic with a bright red lump on their scalp that has been gradually increasing in size over the past 6 weeks. What is the probable diagnosis?

      Your Answer: Capillary haemangioma

      Explanation:

      Port wine stain and naevus flammeus are two different conditions that are often confused with each other. While they both present as red or purple birthmarks, port wine stains are caused by a malformation of blood vessels in the skin, while naevus flammeus is a type of capillary malformation.

      Understanding Strawberry Naevus

      Strawberry naevus, also known as capillary haemangioma, is a type of skin condition that usually develops in infants within the first month of life. It is characterized by raised, erythematous, and multilobed tumours that commonly appear on the face, scalp, and back. While it is not present at birth, it can grow rapidly and reach its peak size at around 6-9 months before regressing over the next few years. In fact, around 95% of cases resolve before the child reaches 10 years of age. However, there are potential complications that may arise, such as obstructing visual fields or airway, bleeding, ulceration, and thrombocytopaenia.

      Capillary haemangiomas are more common in white infants, particularly in female and premature infants, as well as those whose mothers have undergone chorionic villous sampling. In cases where treatment is necessary, propranolol is now the preferred choice over systemic steroids. Topical beta-blockers like timolol may also be used. It is important to note that there is a deeper type of capillary haemangioma called cavernous haemangioma. Understanding the nature of strawberry naevus is crucial in managing its potential complications and providing appropriate treatment.

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      • Dermatology
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  • Question 20 - A middle-aged woman comes to you with concerns about skin lesions on her...

    Correct

    • A middle-aged woman comes to you with concerns about skin lesions on her chest. Upon examination, you notice two small red papules with visible fine vessels surrounding them. The lesions blanch when pressure is applied. What commonly used medication could be causing these lesions?

      Your Answer: Combined oral contraceptive

      Explanation:

      Spider naevi are a type of skin angioma that are typically found in the distribution of the superior vena cava. While they can occur without any apparent cause, the presence of multiple lesions may indicate an excess of oestrogen in the body. This is often associated with liver cirrhosis, as the liver is responsible for processing oestrogens. However, it can also occur during pregnancy or as a side effect of oestrogen-containing medications.

      Understanding Spider Naevi

      Spider naevi, also known as spider angiomas, are characterized by a central red papule surrounded by capillaries. These lesions can be identified by their ability to blanch upon pressure. Spider naevi are typically found on the upper part of the body and are more common in childhood, affecting around 10-15% of people.

      To differentiate spider naevi from telangiectasia, one can press on the lesion and observe how it fills. Spider naevi fill from the center, while telangiectasia fills from the edge. It is important to note that spider naevi may be associated with liver disease, pregnancy, and the use of combined oral contraceptive pills.

      In summary, understanding spider naevi is important for proper diagnosis and management. By recognizing their distinct characteristics and potential associations, healthcare professionals can provide appropriate care for their patients.

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      • Dermatology
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  • Question 21 - A 65-year-old man with a history of Parkinson's disease comes to the clinic...

    Correct

    • A 65-year-old man with a history of Parkinson's disease comes to the clinic complaining of an itchy, red rash on his neck, behind his ears, and around the nasolabial folds. He experienced a similar outbreak last year but did not seek medical attention. What is the probable diagnosis?

      Your Answer: Seborrhoeic dermatitis

      Explanation:

      Patients with Parkinson’s disease are more likely to experience seborrhoeic dermatitis.

      Understanding Seborrhoeic Dermatitis in Adults

      Seborrhoeic dermatitis is a chronic skin condition that affects around 2% of the general population. It is caused by an inflammatory reaction related to the overgrowth of a fungus called Malassezia furfur, which is a normal inhabitant of the skin. The condition is characterized by eczematous lesions that appear on the sebum-rich areas of the body, such as the scalp, periorbital, auricular, and nasolabial folds. It can also lead to the development of otitis externa and blepharitis.

      Seborrhoeic dermatitis is often associated with other medical conditions, such as HIV and Parkinson’s disease. The management of the condition depends on the affected area. For scalp disease, over-the-counter preparations containing zinc pyrithione and tar are usually the first-line treatment. If these are not effective, ketoconazole is the preferred second-line agent. Selenium sulphide and topical corticosteroids may also be useful.

      For the face and body, topical antifungals such as ketoconazole and topical steroids are often used. However, it is important to use steroids for short periods only to avoid side effects. Seborrhoeic dermatitis can be difficult to treat, and recurrences are common. Therefore, it is important to work closely with a healthcare provider to manage the condition effectively.

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      • Dermatology
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  • Question 22 - A 70-year-old man is seen on a home visit by his General Practitioner...

    Correct

    • A 70-year-old man is seen on a home visit by his General Practitioner as his wife is concerned about an ulcer on his lower leg, which has been present for a couple of weeks. It is starting to leak clear fluid. He has a history of chronic congestive cardiac failure and chronic obstructive pulmonary disease. A diagnosis of a venous ulcer is suspected.
      Which of the following examination findings would best support this diagnosis?

      Your Answer: Atrophie blanche

      Explanation:

      Signs and Symptoms of Leg Ulcers: Differentiating Arterial, Venous, and Inflammatory Causes

      Leg ulcers can have various causes, including arterial, venous, and inflammatory conditions. Here are some signs and symptoms that can help differentiate between these causes:

      Atrophie Blanche: This is a white atrophic scar surrounded by areas of hyperpigmentation, which is a sign of severe venous insufficiency.

      Ankle Brachial Pressure Index (ABPI) of 0.4: ABPI is the ratio of systolic blood pressure in the ankle compared with the arm. An ABPI < 0.5 indicates severe arterial disease, suggesting that the ulcer is most likely arterial, rather than venous, in nature. Hairless and Pale Skin on the Lower Legs: Pallor of the skin and a lack of hair growth on the lower legs is a sign of arterial disease, pointing towards a diagnosis of an arterial ulcer rather than a venous ulcer. Necrobiosis Lipoidica: This is a rare granulomatous condition that usually affects people with insulin-dependent diabetes. Plaques are present on the shins, often with telangiectasia in the center and may ulcerate. The cause for the leg ulcer is, therefore, inflammatory rather than venous in origin. Reduced Light-Touch Sensation in Both Feet: Reduced sensation in the feet could be neuropathic in nature (diabetes, multiple sclerosis) or the result of severe arterial disease. Venous insufficiency does not usually affect sensation, so this finding on examination would support a diagnosis of arterial or neuropathic ulcer. By recognizing these signs and symptoms, healthcare professionals can better diagnose and treat leg ulcers based on their underlying causes.

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  • Question 23 - A 67-year-old woman presents with blistering lesions on her leg and is suspected...

    Correct

    • A 67-year-old woman presents with blistering lesions on her leg and is suspected to have bullous pemphigoid. What would be the most suitable course of action for management?

      Your Answer: Refer to secondary care

      Explanation:

      Understanding Bullous Pemphigoid

      Bullous pemphigoid is an autoimmune disease that causes blistering of the skin due to the development of antibodies against hemidesmosomal proteins BP180 and BP230. This condition is more common in elderly patients and is characterized by itchy, tense blisters that typically appear around flexures. However, the blisters usually heal without scarring, and there is usually no mucosal involvement.

      To diagnose bullous pemphigoid, a skin biopsy is necessary, and immunofluorescence shows IgG and C3 at the dermoepidermal junction. Treatment for this condition involves referral to a dermatologist for biopsy and confirmation of diagnosis, as well as the use of oral corticosteroids as the mainstay of treatment. Topical corticosteroids, immunosuppressants, and antibiotics may also be used.

      It is worth noting that while mucosal involvement is seen in some patients, it is not a classic feature of bullous pemphigoid and is therefore not always mentioned in exam questions. Overall, understanding the symptoms, diagnosis, and treatment of bullous pemphigoid is crucial for healthcare professionals to provide appropriate care for patients with this condition.

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      • Dermatology
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  • Question 24 - A 16-year-old boy presents to you with complaints of excessive sweating in his...

    Correct

    • A 16-year-old boy presents to you with complaints of excessive sweating in his hands. He reports feeling embarrassed in social situations, particularly when he has to shake hands with someone. He is also concerned about how this may impact his upcoming A-level exams.

      Which of the following is the most appropriate initial management approach for this condition?

      Your Answer: Aluminium chloride

      Explanation:

      Hyperhidrosis is not treated with beta blockers like propranolol or calcium channel blockers like nifedipine.

      Hyperhidrosis is a condition characterized by the excessive production of sweat. To manage this condition, there are several options available. The first-line treatment is the use of topical aluminium chloride preparations, although it may cause skin irritation as a side effect. Iontophoresis is another option that is particularly useful for patients with palmar, plantar, and axillary hyperhidrosis. Botulinum toxin is also licensed for axillary symptoms. Surgery, such as Endoscopic transthoracic sympathectomy, is another option, but patients should be informed of the risk of compensatory sweating. Overall, there are various management options available for hyperhidrosis, and patients should discuss with their healthcare provider to determine the best course of action.

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      • Dermatology
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  • Question 25 - A 3-year-old child with a history of atopic eczema presents to the clinic....

    Correct

    • A 3-year-old child with a history of atopic eczema presents to the clinic. The child's eczema is typically managed well with emollients, but the parents are worried as the facial eczema has worsened significantly overnight. The child now has painful blisters clustered on both cheeks, around the mouth, and on the neck. The child's temperature is 37.9ºC. What is the best course of action for management?

      Your Answer: Admit to hospital

      Explanation:

      IV antivirals are necessary for the treatment of eczema herpeticum, which is a severe condition.

      Understanding Eczema Herpeticum

      Eczema herpeticum is a serious skin infection caused by herpes simplex virus 1 or 2. It is commonly observed in children with atopic eczema and is characterized by a rapidly progressing painful rash. The infection can be life-threatening, which is why it is important to seek medical attention immediately.

      During examination, doctors typically observe monomorphic punched-out erosions, which are circular, depressed, and ulcerated lesions that are usually 1-3 mm in diameter. Due to the severity of the infection, children with eczema herpeticum should be admitted to the hospital for intravenous aciclovir treatment. It is important to understand the symptoms and seek medical attention promptly to prevent any complications.

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      • Dermatology
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  • Question 26 - A 28-year-old woman with a history of thyroid disorder presents to the clinic...

    Correct

    • A 28-year-old woman with a history of thyroid disorder presents to the clinic with concerns about darkened skin on her neck.
      Which of the following is the most probable cause?

      Your Answer: Acanthosis nigricans

      Explanation:

      Common Skin Conditions: A Brief Overview

      Acanthosis Nigricans: A condition characterized by darkened patches of thickened skin, often described as velvet-like. It is usually benign but can sometimes be associated with underlying autoimmune conditions or gastric cancer.

      Dermatitis: Inflammation of the skin that can cause blistering, oozing, crusting, or flaking. Examples include eczema, dandruff, and rashes caused by contact with certain substances.

      Hidradenitis Suppurativa: A chronic condition that affects the apocrine glands in skin folds, causing painful nodules that can develop into pustules and eventually rupture. Scarring is common.

      Intertrigo: An inflammatory condition of skin folds caused by friction, often leading to secondary bacterial or fungal infections. Commonly found in the groin, axillae, and inframammary folds.

      Cowden’s Syndrome: An autosomal dominant condition characterized by hair follicle tumors, a cobblestone appearance of the oral epithelium, oral papillomas, and multiple skin tags. Associated with a high incidence of breast, thyroid, and gastrointestinal cancers.

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      • Dermatology
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  • Question 27 - A 35-year-old man presents to his General Practitioner (GP) with concerns about a...

    Correct

    • A 35-year-old man presents to his General Practitioner (GP) with concerns about a mole on his leg. He has noticed over the past few months that it has increased in size. On examination, the mole is 7 mm in diameter and has an irregular border but is a consistent colour.
      What is the most appropriate management option for this patient?

      Your Answer: 2-week wait referral to dermatology

      Explanation:

      Understanding Referral Guidelines for Suspicious Pigmented Lesions

      When assessing pigmented lesions, the National Institute of Health and Care Excellence (NICE) recommends using the 7-point scoring system.
      The 7-point checklist includes:
      Major features (2 points each):
      change in size
      irregular shape or border
      irregular colour.
      Minor features (1 point each):
      > 7 mm at greatest diameter
      inflammation
      oozing or crusting
      change in sensation including itch.

      Lesions scoring 3 or more or with other suspicious features of melanoma should be referred urgently via the cancer fast-track pathway to dermatology.

      For lesions with a low suspicion of melanoma, a photo should be taken with a ruler and the patient advised to return in eight weeks for review. However, lesions scoring 5 on the checklist, like those with a change in size, irregular shape or border, and irregular color, should be referred urgently to a dermatologist to avoid any delay in diagnosis and subsequent treatment.

      Excision of lesions suspicious of melanoma should be avoided in primary care as this can delay treatment, and incomplete excision is more common. Routine referral to dermatology would be suitable for a pigmented lesion which scores less than 3 on the 7-point checklist if there are no other features to suggest melanoma. Referral to genetics is recommended if three or more family members have been diagnosed with melanoma.

      It is important to understand these referral guidelines to ensure timely and appropriate management of suspicious pigmented lesions.

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      • Dermatology
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  • Question 28 - A 56-year-old Caucasian man presents with a rash on the face. He first...

    Correct

    • A 56-year-old Caucasian man presents with a rash on the face. He first noticed this six months ago when he experienced episodes of flushing on the face. This has often occurred after he had alcohol or in situations where he felt stressful. A month ago, he started noticing a rash on his cheeks which came on intermittently until three weeks ago when the rash has become permanent. There has been no pain or itch associated with the rash. He is otherwise fit and well. He does not smoke.

      On examination of the face, there is marked erythema with papules, pustules and telangiectasia. There are no comedones seen. The rash is distributed across the cheeks and nose. There is no per-oral or peri-orbital involvement.

      What is the most likely diagnosis?

      Your Answer: Acne rosacea

      Explanation:

      The features described suggest acne rosacea, with episodic flushing, papules and pustules with telangiectasia on the nose, cheeks and forehead. Other conditions such as acne vulgaris, systemic lupus erythematosus, seborrhoeic dermatitis and shingles are unlikely based on the described symptoms.

      Understanding Rosacea: Symptoms and Management

      Rosacea, also known as acne rosacea, is a chronic skin condition that has no known cause. It typically affects the nose, cheeks, and forehead, and the first symptom is often flushing. Over time, telangiectasia (visible blood vessels) may appear, followed by persistent redness with papules and pustules. In some cases, rhinophyma (enlarged nose) may develop, and there may be ocular involvement, such as blepharitis. Sunlight can exacerbate symptoms.

      Mild cases of rosacea may be treated with topical metronidazole, while topical brimonidine gel may be used for patients with predominant flushing but limited telangiectasia. More severe cases may require systemic antibiotics like oxytetracycline. Patients are advised to apply high-factor sunscreen daily and use camouflage creams to conceal redness. Laser therapy may be appropriate for those with prominent telangiectasia, and patients with rhinophyma should be referred to a dermatologist.

      Overall, understanding the symptoms and management of rosacea can help individuals manage their condition and improve their quality of life.

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      • Dermatology
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  • Question 29 - A 76-year-old man, who lives alone, presents to his General Practitioner with an...

    Correct

    • A 76-year-old man, who lives alone, presents to his General Practitioner with an extensive itchy, red rash over the trunk, arms and legs, which has been worsening over the preceding three days. He has a past medical history of psoriasis, hypertension and high cholesterol.
      On examination, he has an extensive erythematous rash covering much of his body, with evidence of scaling. He has a normal temperature, a blood pressure (BP) of 110/88 mmHg and a pulse of 101 beats per minute.
      What is the most appropriate management for this patient, given the likely diagnosis?

      Your Answer: Admit to hospital

      Explanation:

      Management of Erythroderma in an Elderly Patient Living Alone

      Erythroderma is a dermatological emergency that requires urgent treatment. In elderly patients who are frail and live alone, hospital admission is necessary. This is the case for an 86-year-old man with a history of psoriasis who presents with erythroderma. Topical emollients and steroids are key in management, but this patient requires intravenous fluids and close monitoring for infection and dehydration. Oral antibiotics are not indicated unless there are signs of infection. A topical steroid with a vitamin D analogue may be appropriate for psoriasis, but urgent assessment by Dermatology in an inpatient setting is necessary. An outpatient appointment is not appropriate for this patient due to his age and living situation.

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      • Dermatology
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  • Question 30 - A 58-year-old male is referred to dermatology by his physician for evaluation of...

    Incorrect

    • A 58-year-old male is referred to dermatology by his physician for evaluation of a lesion on his shin. During the examination, the dermatologist observes shiny, painless areas of yellow skin with numerous telangiectasia. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Necrobiosis lipoidica diabeticorum

      Explanation:

      Necrobiosis lipoidica diabeticorum is a condition characterized by waxy yellow shin lesions that often occur in individuals with diabetes.

      Understanding Shin Lesions: Differential Diagnosis and Characteristic Features

      Shin lesions can be caused by a variety of conditions, and it is important to differentiate between them in order to provide appropriate treatment. The four most common conditions that can cause shin lesions are erythema nodosum, pretibial myxoedema, pyoderma gangrenosum, and necrobiosis lipoidica diabeticorum.

      Erythema nodosum is characterized by symmetrical, tender, erythematous nodules that heal without scarring. It is often caused by streptococcal infections, sarcoidosis, inflammatory bowel disease, or certain medications such as penicillins, sulphonamides, or oral contraceptive pills.

      Pretibial myxoedema, on the other hand, is seen in Graves’ disease and is characterized by symmetrical, erythematous lesions that give the skin a shiny, orange peel appearance.

      Pyoderma gangrenosum initially presents as a small red papule, which later develops into deep, red, necrotic ulcers with a violaceous border. It is idiopathic in 50% of cases, but may also be seen in inflammatory bowel disease, connective tissue disorders, and myeloproliferative disorders.

      Finally, necrobiosis lipoidica diabeticorum is characterized by shiny, painless areas of yellow/red skin typically found on the shin of diabetics. It is often associated with telangiectasia.

      In summary, understanding the differential diagnosis and characteristic features of shin lesions can help healthcare professionals provide appropriate treatment and improve patient outcomes.

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      • Dermatology
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