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Question 1
Correct
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A 27-year-old man has come back from a vacation at the beach in Tenerife with a fresh rash on his neck and arms. The rash consists of patches that are coppery brown in color and lighter than the surrounding skin. There is no itching or pain associated with the rash. When examined with a Wood's light, the affected areas show yellow-green fluorescence.
What is the recommended initial treatment for this skin condition?Your Answer: Ketoconazole shampoo
Explanation:Ketoconazole shampoo is the recommended first-line therapy for treating pityriasis versicolor, a fungal infection caused by Malassezia furfur that commonly affects the trunk, neck, and arms following sun exposure. While the rash is usually asymptomatic, an emollient may help with any associated itch or irritation, but it is not sufficient to treat the underlying fungal infection. Oral antifungals like itraconazole may be necessary for extensive or unresponsive cases, but for limited non-extensive disease, ketoconazole shampoo is the preferred treatment. Topical steroids and vitamin D analogues are not effective in treating pityriasis versicolor.
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.
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This question is part of the following fields:
- Dermatology
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Question 2
Incorrect
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A 35-year-old woman in her third trimester of pregnancy reports an itchy rash around her belly button during an antenatal check-up. She had no such issues during her previous pregnancy. Upon examination, blistering lesions are observed in the peri-umbilical area and on her arms. What is the probable diagnosis?
Your Answer: Polymorphic eruption of pregnancy
Correct Answer: Pemphigoid gestationis
Explanation:Blistering is not a characteristic of polymorphic eruption of pregnancy.
Skin Disorders Associated with Pregnancy
During pregnancy, women may experience various skin disorders. The most common one is atopic eruption of pregnancy, which is characterized by an itchy red rash. This condition does not require any specific treatment. Another skin disorder is polymorphic eruption of pregnancy, which is a pruritic condition that usually appears during the last trimester. The lesions often first appear in abdominal striae, and management depends on the severity of the condition. Emollients, mild potency topical steroids, and oral steroids may be used. Pemphigoid gestationis is another skin disorder that causes pruritic blistering lesions. It usually develops in the peri-umbilical region and later spreads to the trunk, back, buttocks, and arms. This condition is rarely seen in the first pregnancy and usually presents in the second or third trimester. Oral corticosteroids are usually required for treatment.
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This question is part of the following fields:
- Dermatology
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Question 3
Incorrect
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A 25-year-old man presents to his General Practitioner with a 1-week history of an itchy rash on the inner aspect of his elbows on either side. He states that this came on suddenly and that he has had similar episodes in the past, the first of which occurred when he was around seven years old. He claims to only suffer from generally dry skin and asthma, which he controls with emollient creams and inhalers, respectively.
Given the likely diagnosis, which of the following is the best next step?Your Answer: Skin patch testing before starting treatment
Correct Answer: No further testing required; start treatment
Explanation:Diagnosis and Testing for Atopic Eczema
Atopic eczema is a common skin condition that can cause significant physical and psychological distress to patients. Diagnosis is usually made based on clinical presentation and history, with no further testing required. The UK Working Party Diagnostic Criteria can be used to aid in diagnosis. Treatment options include emollients, topical steroids, and other medications in severe cases.
Radioallergosorbent testing (RAST) and skin patch testing are not useful in diagnosing atopic eczema, as they are mainly used for other types of hypersensitivity reactions. Skin prick testing may be used to diagnose allergies that could be exacerbating the eczema. However, it is important to note that atopic eczema is a clinical diagnosis and testing is not always necessary.
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This question is part of the following fields:
- Dermatology
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Question 4
Correct
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A 42-year-old man with a history of psoriasis develops plaques on his scalp. What is the most suitable treatment option among the following choices?
Your Answer: Hydrocortisone 1%
Explanation:It’s a challenging question, especially since the decision on psoriasis treatment often involves the patient and doctor’s preference. While vitamin D analogues can be an option, calcipotriol is not advisable due to its potential to cause irritation. Instead, calcitriol and tacalcitol can be considered. For facial psoriasis, mild potency topical steroids can be effective. However, coal tar may not be well-tolerated for facial application due to its unpleasant odor and messiness.
NICE recommends a step-wise approach for chronic plaque psoriasis, starting with regular emollients and then using a potent corticosteroid and vitamin D analogue separately, followed by a vitamin D analogue twice daily, and then a potent corticosteroid or coal tar preparation if there is no improvement. Phototherapy, systemic therapy, and topical treatments are also options for management. Topical steroids should be used cautiously and vitamin D analogues may be used long-term. Dithranol and coal tar have adverse effects but can be effective.
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This question is part of the following fields:
- Dermatology
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Question 5
Correct
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A 20-year-old individual comes in with a 1 cm golden, crusted lesion on the border of their left lower lip. They have previously tried topical hydrogen peroxide for a similar episode without success. What is the best course of action for management?
Your Answer: Topical fusidic acid
Explanation:If hydrogen peroxide is not appropriate, topical fusidic acid can be used for impetigo.
Understanding Impetigo: Causes, Symptoms, and Management
Impetigo is a common bacterial skin infection that affects both children and adults. It is caused by either Staphylococcus aureus or Streptococcus pyogenes and can develop anywhere on the body, but lesions tend to occur on the face, flexures, and limbs not covered by clothing. The infection can be a primary infection or a complication of an existing skin condition such as eczema, scabies, or insect bites. Impetigo is highly contagious and can spread through direct contact with discharges from the scabs of an infected person or indirectly through toys, clothing, equipment, and the environment.
The symptoms of impetigo include ‘golden’, crusted skin lesions typically found around the mouth. The infection can be managed with limited, localized disease by using hydrogen peroxide 1% cream or topical antibiotic creams such as fusidic acid or mupirocin. However, if the disease is extensive, oral flucloxacillin or oral erythromycin may be prescribed. It is important to note that MRSA is not susceptible to either fusidic acid or retapamulin, so topical mupirocin should be used in this situation.
Children with impetigo should be excluded from school until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment. It is also important to practice good hygiene, such as washing hands regularly and avoiding close contact with infected individuals, to prevent the spread of impetigo. By understanding the causes, symptoms, and management of impetigo, individuals can take steps to prevent and treat this common bacterial skin infection.
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This question is part of the following fields:
- Dermatology
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Question 6
Incorrect
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A 65-year-old female is referred for management of a chronic ulcer above the left medial malleolus. The ankle-brachial pressure index readings are as follows:
Right 0.95
Left 0.95
The ulcer has been treated with standard dressings by the District Nurse. What is the best course of action to increase the chances of healing the ulcer?Your Answer: Intermittent pneumatic compression
Correct Answer:
Explanation:Compression bandaging is recommended for the management of venous ulceration, as the ankle-brachial pressure index readings suggest that the ulcers are caused by venous insufficiency rather than arterial issues.
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.
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This question is part of the following fields:
- Dermatology
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Question 7
Incorrect
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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: Pretibial myxoedema
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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This question is part of the following fields:
- Dermatology
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Question 8
Correct
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You are examining a 7-month-old infant who has a capillary haemangioma located on the right cheek that is beginning to interfere with their vision. Following a conversation with the parents, you have decided to initiate treatment for this area due to the potential impact on eyesight.
What is the primary treatment option for capillary haemangioma?Your Answer: Propranolol
Explanation:When it comes to capillary haemangiomas that require intervention, the preferred treatment is propranolol. Other options include laser therapy or systemic steroids, but topical steroids are unlikely to be effective. Surgery is generally not recommended for most cases.
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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This question is part of the following fields:
- Dermatology
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Question 9
Incorrect
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A 16-year-old female comes in for a follow-up. Three days ago she visited her physician with complaints of a severe sore throat, fatigue, and headache. The doctor prescribed amoxicillin to treat an upper respiratory tract infection. However, two days ago she developed a pruritic maculopapular rash that has spread throughout her body. Additionally, her initial symptoms have not improved. What is the probable diagnosis?
Your Answer: Beta-lactamase producing streptococcal sore throat
Correct Answer: Infectious mononucleosis
Explanation:Patients with infectious mononucleosis should not be prescribed amoxicillin. Instead, supportive treatment is recommended for their care.
Understanding Infectious Mononucleosis
Infectious mononucleosis, also known as glandular fever, is a viral infection caused by the Epstein-Barr virus (EBV) in 90% of cases. It is most commonly seen in adolescents and young adults. The classic triad of symptoms includes sore throat, pyrexia, and lymphadenopathy, which are present in around 98% of patients. Other symptoms include malaise, anorexia, headache, palatal petechiae, splenomegaly, hepatitis, lymphocytosis, haemolytic anaemia, and a maculopapular rash. The symptoms typically resolve after 2-4 weeks.
The diagnosis of infectious mononucleosis is confirmed through a heterophil antibody test (Monospot test) in the second week of the illness. Management is supportive and includes rest, drinking plenty of fluids, avoiding alcohol, and taking simple analgesia for any aches or pains. It is recommended to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture.
Interestingly, there is a correlation between EBV and socioeconomic groups. Lower socioeconomic groups have high rates of EBV seropositivity, having frequently acquired EBV in early childhood when the primary infection is often subclinical. However, higher socioeconomic groups show a higher incidence of infectious mononucleosis, as acquiring EBV in adolescence or early adulthood results in symptomatic disease.
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This question is part of the following fields:
- Dermatology
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Question 10
Correct
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A 28-year-old law student visits his primary care physician complaining of ear pain. He suspects that this is related to the same issue causing dryness in his scalp and beard, as well as eczema-like patches in his nasolabial folds. He has been using non-prescription topical treatments to manage these symptoms but seeks guidance for his earache. What is the probable diagnosis that connects all of this patient's symptoms?
Your Answer: Seborrhoeic dermatitis
Explanation:Seborrhoeic dermatitis can lead to common complications such as otitis externa and blepharitis. The patient is experiencing eczema-like plaques and dry skin in areas rich in sebum, which he has been treating with over-the-counter antifungal shampoos. However, his complaint of earache may be due to otitis externa, which is associated with seborrhoeic dermatitis. A full ear examination should be performed to rule out other diagnoses. Contact dermatitis is unlikely to present in this distribution and would not cause otalgia. Eczema herpeticum is a severe primary infection by herpes-simplex-virus 1 or 2, commonly seen in children with atopic eczema. Guttate psoriasis commonly affects children after Streptococcal upper respiratory tract infection and will clear over the course of ,3 months without treatment. Irritant dermatitis is unlikely to cause such focal areas of irritation.
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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This question is part of the following fields:
- Dermatology
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Question 11
Incorrect
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A 36-year-old woman presents to her GP with concerns about facial flushing. She reports experiencing random episodes of redness on her face, particularly after consuming alcohol. She also mentions an increase in the number of spots on her cheeks and wonders if these symptoms are related. During the examination, the GP observes two small telangiectasia on the nose and left cheek, as well as a few small papules on each cheek. What management options should the GP suggest to alleviate the patient's symptoms?
Your Answer: Topical fusidic acid
Correct Answer: Topical metronidazole
Explanation:For the treatment of mild to moderate acne rosacea, topical metronidazole is recommended. This patient’s symptoms, including flushing and papules, suggest acne rosacea, and as they only have a few telangiectasia and papules, topical metronidazole would be the most appropriate treatment. Laser therapy may be considered for persistent telangiectasia, but it is not necessary at this stage and would likely be arranged by a specialist. Oral isotretinoin is not used to treat acne rosacea and is reserved for severe acne vulgaris, and can only be prescribed by a specialist due to potential harmful side effects. Oral oxytetracycline would be appropriate for more severe cases of acne rosacea with troublesome papules and pustules. Topical fusidic acid is not used to treat acne rosacea but can be used for impetigo.
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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This question is part of the following fields:
- Dermatology
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Question 12
Correct
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A 25-year-old male patient comes to you with concerns about changes in his axillary skin. He reports feeling otherwise healthy and denies any other symptoms. Upon examination, you observe thickened and darkened skin in the axillary creases. The patient's BMI is 38 kg/m² and his blood pressure is within normal limits. What is the probable diagnosis?
Your Answer: Acanthosis nigricans
Explanation:A thickened brown velvety patch of skin, often accompanied by skin tags, is a common sign of Acanthosis nigricans (AN). This condition is typically found in the axilla, groin, and back of the neck. However, AN is not a standalone condition, but rather a cutaneous sign of underlying disease. The most common type of AN is associated with obesity and insulin resistance. Other underlying conditions linked to AN include Cushing’s syndrome, polycystic ovary syndrome, and certain medications such as nicotinic acid, insulin, and systemic corticosteroids. In rare cases, AN may indicate an underlying malignancy, particularly stomach cancer. Therefore, it is crucial to consider this possibility when making a diagnosis.
Acanthosis nigricans is a condition characterized by the presence of symmetrical, brown, velvety plaques on the neck, axilla, and groin. This condition can be caused by various factors such as type 2 diabetes mellitus, gastrointestinal cancer, obesity, polycystic ovarian syndrome, acromegaly, Cushing’s disease, hypothyroidism, familial factors, Prader-Willi syndrome, and certain drugs like the combined oral contraceptive pill and nicotinic acid. The pathophysiology of acanthosis nigricans involves insulin resistance, which leads to hyperinsulinemia. This, in turn, stimulates the proliferation of keratinocytes and dermal fibroblasts through interaction with insulin-like growth factor receptor-1 (IGFR1).
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This question is part of the following fields:
- Dermatology
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Question 13
Incorrect
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A 24-year-old pregnant woman visits her General Practitioner with a rapidly growing lesion on the tip of her index finger. It began as a small spot but has rapidly increased in size over the past five days. It is dark red in colour and causes discomfort and easy bleeding when working in her café.
What is the most probable diagnosis?
Choose the ONE most likely diagnosis from the options below.Your Answer: Haemangioma
Correct Answer: Pyogenic granuloma
Explanation:Differentiating Skin Lesions: Pyogenic Granuloma, BCC, Haemangioma, Melanoma, and Viral Wart
Skin lesions can be caused by various factors, and it is important to differentiate them to determine the appropriate treatment. Here are some common skin lesions and their characteristics:
Pyogenic Granuloma
Pyogenic granulomas are benign vascular lesions that grow rapidly and bleed easily. They appear as a fleshy nodule and can be polyploid. They commonly occur in children, young adults, and pregnancy and are often found on the fingers and hands.Basal Cell Carcinoma (BCC)
BCC is a slow-growing, locally invasive lesion that appears on sun-exposed skin. It has a characteristic rolled edge and is more prevalent in elderly patients with fair skin and a history of sun exposure. BCC can be skin-colored, pink, or pigmented.Haemangioma
Haemangiomas are benign lesions caused by a collection of blood vessels under the skin. They commonly occur in infants and are known as strawberry marks. A new lesion that grows rapidly is unlikely to be a haemangioma.Melanoma
Melanoma is a malignant tumour that arises from the over-proliferation of cutaneous melanocytes. It can occur anywhere on the body and has characteristic asymmetry, border irregularity, color variation, and large diameter. The ABCDE criteria of melanoma can help in identifying it.Viral Wart
Viral warts are benign skin lesions caused by human papillomavirus infection. They commonly occur in school-aged children and have a rough, hyperkeratotic surface.In conclusion, identifying the characteristics of different skin lesions can help in determining the appropriate treatment and management. It is important to seek medical advice if there is any doubt about the nature of a skin lesion.
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This question is part of the following fields:
- Dermatology
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Question 14
Correct
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A 35-year-old man presents to his General Practitioner. He has noticed a few patches of pale skin on his arms over the past few weeks. He is not particularly worried about these but wants to know what it could be and what he needs to do about it.
On examination, a few depigmented patches on the arms are noted. His medical history includes asthma, for which he takes inhalers.
Given the likely diagnosis, which of the following treatments should he be started on?Your Answer: Daily sunscreen to the affected areas
Explanation:Managing Vitiligo: Recommended Treatments and Precautions
Vitiligo is a skin condition that requires careful management to prevent further damage and reduce the risk of skin cancer. Daily application of sunscreen to affected areas is crucial due to increased susceptibility to UV-light-induced damage. Camouflaging makeup can also help alleviate psychological distress. Topical steroids are recommended for up to two months, and if there is no response, a referral to a dermatologist is necessary. Emollients and oral antihistamines are not useful in vitiligo management. Oral steroids are rarely used, and topical clotrimazole and dapsone are not first-line treatments. Topical tacrolimus and phototherapy may have a role, but caution is needed for light-skinned patients. Overall, early intervention and precautionary measures are key to managing vitiligo effectively.
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This question is part of the following fields:
- Dermatology
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Question 15
Correct
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A 28-year-old patient presents to you with an itchy rash on both elbows that has been getting worse over the past week. Upon examination, you observe multiple flat-topped papular lesions that are polygonal and measure 5mm in diameter on the flexural surface of her elbows bilaterally. There are no other rashes on the rest of her body. What is the most probable diagnosis?
Your Answer: Lichen planus
Explanation: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.
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This question is part of the following fields:
- Dermatology
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Question 16
Incorrect
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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: Commence methotrexate orally
Correct 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.
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This question is part of the following fields:
- Dermatology
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Question 17
Incorrect
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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 erythromycin
Correct 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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This question is part of the following fields:
- Dermatology
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Question 18
Incorrect
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A 29-year-old man presents to the emergency department with a 3-day history of fever, fatigue, and a tingling sensation in the lateral aspect of his left thigh. The tingling was initially tolerable but has become increasingly painful over the past 24 hours. Upon examination, the area described is erythematous with a macular rash appearing. The patient has a history of HIV and is currently taking antiretroviral therapy with an undetectable viral load. He denies any cough, coryzal symptoms, focal neurological signs, or trauma to the site.
What is the appropriate management for this patient, given the likely diagnosis? Choose from the options provided.Your Answer:
Correct Answer: Aciclovir
Explanation:Patients suspected of having shingles should receive antiviral treatment within 72 hours of symptom onset, as this can help reduce the risk of post-herpetic complications. In the case of this patient, who is experiencing symptoms of shingles within the 72-hour window and has an immunosuppressive condition, antivirals such as aciclovir should be prescribed. Amitriptyline, which is used to manage post-herpetic neuralgia, would not be appropriate at this stage. Chlorphenamine is typically used to manage itching associated with chickenpox, but as this patient is only experiencing symptoms in one dermatome, it is more likely to be shingles. Flucloxacillin, an antibiotic used to treat bacterial skin infections, would not be appropriate in this case as the patient’s symptoms are consistent with herpes zoster infection.
Shingles is a painful blistering rash caused by reactivation of the varicella-zoster virus. It is more common in older individuals and those with immunosuppressive conditions. The rash is well demarcated by the affected dermatome and may be accompanied by fever and lethargy. Treatment includes analgesia, antivirals, and potentially oral corticosteroids. Complications include post-herpetic neuralgia, ocular and ear complications. Antivirals should be used within 72 hours to reduce the risk of post-herpetic neuralgia.
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This question is part of the following fields:
- Dermatology
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Question 19
Incorrect
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Which of the following characteristics is least commonly associated with rosacea?
Your Answer:
Correct Answer: Pruritus
Explanation:It is uncommon for pruritus to be present in cases of acne rosacea.
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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This question is part of the following fields:
- Dermatology
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Question 20
Incorrect
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A 30-year-old male patient comes to you with a rash that has spread all over his body. He has multiple erythematous lesions less than 1 cm in diameter on his torso and limbs, some of which are covered by a fine scale. Two weeks ago, he had exudative tonsillitis when he was seen with a sore throat. Apart from asthma, he has no other medical history. What is the probable diagnosis?
Your Answer:
Correct Answer: Guttate psoriasis
Explanation:Tear-drop scaly papules suddenly appearing on the trunk and limbs may indicate guttate psoriasis.
Guttate psoriasis is a type of psoriasis that is more commonly seen in children and adolescents. It is often triggered by a streptococcal infection that occurred 2-4 weeks prior to the appearance of the lesions. The name guttate comes from the Latin word for drop, as the lesions appear as small, tear-shaped papules on the trunk and limbs. These papules are pink and scaly, and the onset of the condition is usually acute, occurring over a few days.
In most cases, guttate psoriasis will resolve on its own within 2-3 months. There is no clear evidence to support the use of antibiotics to treat the underlying streptococcal infection. Treatment options for guttate psoriasis include topical agents commonly used for psoriasis and UVB phototherapy. In cases where the condition recurs, a tonsillectomy may be necessary.
It is important to differentiate guttate psoriasis from pityriasis rosea, another skin condition that can present with similar symptoms. Guttate psoriasis is often preceded by a streptococcal sore throat, while pityriasis rosea may be preceded by a respiratory tract infection. The appearance of guttate psoriasis is characterized by tear-shaped papules on the trunk and limbs, while pityriasis rosea presents with a herald patch followed by multiple oval lesions with a fine scale. While guttate psoriasis resolves within a few months, pityriasis rosea typically resolves after around 6 weeks.
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This question is part of the following fields:
- Dermatology
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Question 21
Incorrect
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A 62-year-old man visits his primary care physician with worries about a growth on his right lower eyelid. The lesion has been there for at least 3 months and has not increased in size. During examination, you observe a 3 mm lesion with rolled, pearly edges. Your suspicion is a basal cell carcinoma.
What would be the best course of action for management?Your Answer:
Correct Answer: Urgent referral for surgical excision
Explanation:When it comes to basal cell carcinoma, surgical excision is typically recommended and can be referred routinely. However, for high-risk areas such as the eyelids and nasal ala, urgent referral under the 2-week wait is necessary to prevent potential damage from delay.
Basal cell carcinoma (BCC) is a type of skin cancer that is commonly found in the Western world. It is one of the three main types of skin cancer and is characterized by slow growth and local invasion. BCC lesions are also known as rodent ulcers and rarely metastasize. The majority of BCC lesions are found on sun-exposed areas, particularly the head and neck. The most common type of BCC is nodular BCC, which initially appears as a pearly, flesh-colored papule with telangiectasia. As the lesion progresses, it may ulcerate, leaving a central crater. If BCC is suspected, a routine referral should be made. Management options include surgical removal, curettage, cryotherapy, topical cream such as imiquimod or fluorouracil, and radiotherapy.
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This question is part of the following fields:
- Dermatology
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Question 22
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Dermatology
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Question 23
Incorrect
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A 63-year-old man with a recent diagnosis of congestive cardiac failure and a history of psoriasis visits his GP complaining of a deterioration in his psoriatic plaques. He has been prescribed multiple medications by his cardiologist to alleviate his cardiac symptoms.
Which of the following newly prescribed medications is the probable cause of this man's psoriasis exacerbation?Your Answer:
Correct Answer: Bisoprolol
Explanation:Psoriatic plaques can be worsened by beta-blockers like bisoprolol, but not by calcium channel blockers like amlodipine or antiplatelet agents like clopidogrel. However, NSAIDs like aspirin can exacerbate psoriasis symptoms. Furosemide, a loop diuretic, has no impact on psoriasis.
Psoriasis can be worsened by various factors. These include physical trauma, consumption of alcohol, and certain medications such as beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, and infliximab. Additionally, stopping the use of systemic steroids can also exacerbate psoriasis. It is important to note that streptococcal infection can trigger guttate psoriasis, a type of psoriasis characterized by small, drop-like lesions on the skin. Therefore, individuals with psoriasis should be aware of these exacerbating factors and take necessary precautions to manage their condition.
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This question is part of the following fields:
- Dermatology
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Question 24
Incorrect
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A 47-year-old woman was prescribed carbamazepine for trigeminal neuralgia. After a few days, she experiences a prodromal illness with symptoms of sore throat, malaise, and conjunctivitis. She then develops a rash that initially presents as erythematous macules on her torso and progresses to blisters, covering less than 10% of her body surface area. Additionally, she has painful ulcers in her mouth, stomatitis, and worsening conjunctivitis. What is the probable diagnosis?
Your Answer:
Correct Answer: Stevens-Johnson syndrome
Explanation:Erythema multiforme is a skin condition that is characterized by a rash that affects a small area of the body or the entire body surface. It can be caused by drugs or other factors. The exact cause of this condition is unknown. The rash typically appears on the hands and feet and is often raised. In some cases, the rash may also affect the mucous membranes. This is known as the major form of erythema multiforme.
Understanding Stevens-Johnson Syndrome
Stevens-Johnson syndrome is a severe reaction that affects both the skin and mucosa. It is usually caused by a drug reaction and is considered a separate entity from erythema multiforme. Common causes of Stevens-Johnson syndrome include penicillin, sulphonamides, lamotrigine, carbamazepine, phenytoin, allopurinol, NSAIDs, and oral contraceptive pills. The rash associated with this syndrome is typically maculopapular with target lesions, which may develop into vesicles or bullae. A positive Nikolsky sign is observed in erythematous areas, where blisters and erosions appear when the skin is gently rubbed. Mucosal involvement and systemic symptoms such as fever and arthralgia may also occur. Hospital admission is required for supportive treatment.
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This question is part of the following fields:
- Dermatology
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Question 25
Incorrect
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Which one of the following statements regarding scabies is untrue?
Your Answer:
Correct Answer: Patients who complain of pruritus 4 weeks following treatment should be retreated
Explanation:It is typical for itching to continue for a period of 4-6 weeks after elimination.
Scabies: Causes, Symptoms, and Treatment
Scabies is a skin condition caused by the Sarcoptes scabiei mite, which is spread through prolonged skin contact. It is most commonly seen in children and young adults. The mite burrows into the skin and lays its eggs in the stratum corneum, leading to intense itching. This itching is caused by a delayed-type IV hypersensitivity reaction to the mites/eggs, which occurs about 30 days after the initial infection. Symptoms of scabies include widespread itching, linear burrows on the fingers, interdigital webs, and flexor aspects of the wrist. In infants, the face and scalp may also be affected. Scratching can lead to secondary features such as excoriation and infection.
The first-line treatment for scabies is permethrin 5%, while malathion 0.5% is second-line. Patients should be advised to avoid close physical contact with others until treatment is complete. All household and close physical contacts should be treated at the same time, even if asymptomatic. Clothing, bedding, and towels should be laundered, ironed, or tumble-dried on the first day of treatment to kill off mites. The insecticide should be applied to all areas, including the face and scalp, contrary to the manufacturer’s recommendation. Patients should apply the insecticide cream or liquid to cool, dry skin, paying close attention to areas between fingers and toes, under nails, armpit area, and creases of the skin such as at the wrist and elbow. The insecticide should be left on the skin for 8-12 hours for permethrin or 24 hours for malathion before washing off. Treatment should be repeated 7 days later.
Crusted scabies, also known as Norwegian scabies, is seen in patients with suppressed immunity, especially HIV. The crusted skin will be teeming with hundreds of thousands of organisms. Isolation is essential, and ivermectin is the treatment of choice.
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This question is part of the following fields:
- Dermatology
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Question 26
Incorrect
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A 55-year-old woman comes to see her general practitioner complaining of a progressively worsening erythematous rash on her nose, forehead, and cheeks accompanied by telangiectasia and papules for the past year. The rash is exacerbated by exposure to sunlight and consumption of hot and spicy foods. She has previously sought medical attention for this condition and has been treated with topical metronidazole, but her symptoms persist. She has no allergies and is otherwise healthy.
What is the most suitable course of action for managing this patient's condition?Your Answer:
Correct Answer: Oral doxycycline
Explanation:The patient has an erythematous rash on the nose, forehead, and cheeks with telangiectasia and papules, worsened by sun exposure and spicy food, suggesting a diagnosis of rosacea. The first-line treatment for mild to moderate cases is topical metronidazole, while severe or resistant cases require oral tetracycline. However, in this case, oral doxycycline should be given instead of metronidazole as it has been ineffective. Oral clarithromycin, erythromycin, and flucloxacillin are not appropriate treatments for rosacea.
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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This question is part of the following fields:
- Dermatology
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Question 27
Incorrect
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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:
Correct 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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This question is part of the following fields:
- Dermatology
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Question 28
Incorrect
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You are conducting an 8-week examination on a baby with a prominent purplish birthmark. The mother was informed that it may not disappear on its own and could be linked to other vascular issues. What is the probable diagnosis?
Your Answer:
Correct Answer: Port wine stain
Explanation:Understanding Port Wine Stains
Port wine stains are a type of birthmark that are characterized by their deep red or purple color. Unlike other vascular birthmarks, such as salmon patches and strawberry hemangiomas, port wine stains do not go away on their own and may even become more prominent over time. These birthmarks are typically unilateral, meaning they only appear on one side of the body.
Fortunately, there are treatment options available for those who wish to reduce the appearance of port wine stains. Cosmetic camouflage can be used to cover up the birthmark, while laser therapy is another option that requires multiple sessions. It’s important to note that while these treatments can help reduce the appearance of port wine stains, they may not completely eliminate them. Understanding the nature of port wine stains and the available treatment options can help individuals make informed decisions about managing these birthmarks.
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This question is part of the following fields:
- Dermatology
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Question 29
Incorrect
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A 25-year-old man visits his GP complaining of a rash that has spread across his trunk over the last 4 days. He is worried about the appearance of the rash. The patient has no significant medical history except for completing a course of phenoxymethylpenicillin for tonsillitis last week and takes no other regular medications. Upon examination, the doctor observes multiple scaly papules on the patient's trunk and upper limbs. The lesions are small and have a teardrop shape. What is the most probable diagnosis?
Your Answer:
Correct Answer: Guttate psoriasis
Explanation:The tear-drop scaly papules that have suddenly appeared on the patient’s trunk and limbs suggest guttate psoriasis. This type of psoriasis is commonly seen in children and young adults who have recently had a Streptococcus infection, such as the tonsillitis infection that this patient had. The rash is characterized by multiple small scaly and red patches that have a teardrop shape.
Disseminated varicella zoster, pityriasis rosea, and pityriasis versicolor are not likely diagnoses for this patient. Disseminated varicella zoster causes a different type of rash that includes macular, papular, and vesicular lesions that crust over time. Pityriasis rosea presents with a large round herald patch on the chest, abdomen, or back, and is thought to be triggered by viral or bacterial infections. Pityriasis versicolor is a fungal infection that causes patches that are paler than the surrounding skin, and is commonly found on the upper limbs and neck. However, exposure to heat and moisture can increase the risk of developing this rash.
Guttate psoriasis is a type of psoriasis that is more commonly seen in children and adolescents. It is often triggered by a streptococcal infection that occurred 2-4 weeks prior to the appearance of the lesions. The name guttate comes from the Latin word for drop, as the lesions appear as small, tear-shaped papules on the trunk and limbs. These papules are pink and scaly, and the onset of the condition is usually acute, occurring over a few days.
In most cases, guttate psoriasis will resolve on its own within 2-3 months. There is no clear evidence to support the use of antibiotics to treat the underlying streptococcal infection. Treatment options for guttate psoriasis include topical agents commonly used for psoriasis and UVB phototherapy. In cases where the condition recurs, a tonsillectomy may be necessary.
It is important to differentiate guttate psoriasis from pityriasis rosea, another skin condition that can present with similar symptoms. Guttate psoriasis is often preceded by a streptococcal sore throat, while pityriasis rosea may be preceded by a respiratory tract infection. The appearance of guttate psoriasis is characterized by tear-shaped papules on the trunk and limbs, while pityriasis rosea presents with a herald patch followed by multiple oval lesions with a fine scale. While guttate psoriasis resolves within a few months, pityriasis rosea typically resolves after around 6 weeks.
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This question is part of the following fields:
- Dermatology
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Question 30
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Dermatology
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Question 31
Incorrect
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A 50-year-old female patient visits the clinic complaining of an itchy rash. During the examination, the doctor observes several purple papular rashes on the flexural surface of her wrists. Additionally, a similar rash is present at the edges of a laceration wound she suffered a week ago. What is the recommended initial treatment for this condition?
Your Answer:
Correct Answer: Hydrocortisone cream
Explanation:Lichen planus is present in this woman, but it appears to be limited in scope. The initial treatment for lichen planus is potent topical steroids. Oral azathioprine or prednisolone is only prescribed if the condition is widespread. Coal tar cream and calcitriol ointment are not effective treatments for lichen planus.
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.
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This question is part of the following fields:
- Dermatology
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Question 32
Incorrect
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A 45-year-old female patient complains of painful erythematous lesions on her shins. Which of the following is not commonly associated with this presentation?
Your Answer:
Correct Answer: Syphilis
Explanation:Erythema nodosum caused by syphilis is uncommon.
Understanding Erythema Nodosum
Erythema nodosum is a condition characterized by inflammation of the subcutaneous fat, resulting in tender, erythematous, nodular lesions. These lesions typically occur over the shins but may also appear on other parts of the body such as the forearms and thighs. The condition usually resolves within six weeks, and the lesions heal without scarring.
There are several possible causes of erythema nodosum, including infections such as streptococci, tuberculosis, and brucellosis. Systemic diseases like sarcoidosis, inflammatory bowel disease, and Behcet’s can also lead to the condition. In some cases, erythema nodosum may be associated with malignancy or lymphoma. Certain drugs like penicillins, sulphonamides, and the combined oral contraceptive pill, as well as pregnancy, can also trigger the condition.
Overall, understanding the causes and symptoms of erythema nodosum is important for prompt diagnosis and treatment.
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This question is part of the following fields:
- Dermatology
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Question 33
Incorrect
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Which of the following is not typically associated with hirsutism in individuals?
Your Answer:
Correct Answer: Porphyria cutanea tarda
Explanation:Hypertrichosis is the result of Porphyria cutanea tarda, not hirsutism.
Understanding Hirsutism and Hypertrichosis
Hirsutism and hypertrichosis are two conditions that involve excessive hair growth in women. Hirsutism is typically caused by androgen-dependent hair growth, while hypertrichosis is caused by androgen-independent hair growth. The most common cause of hirsutism is polycystic ovarian syndrome, but it can also be caused by other conditions such as Cushing’s syndrome, congenital adrenal hyperplasia, and obesity. Hypertrichosis, on the other hand, can be caused by drugs like minoxidil and ciclosporin, as well as congenital conditions like hypertrichosis lanuginosa and terminalis.
To assess hirsutism, doctors use the Ferriman-Gallwey scoring system, which assigns scores to nine different body areas. A score of over 15 is considered to indicate moderate or severe hirsutism. Management of hirsutism typically involves weight loss if the patient is overweight, as well as cosmetic techniques like waxing and bleaching. Combined oral contraceptive pills like co-cyprindiol and ethinylestradiol and drospirenone may also be used, but co-cyprindiol should not be used long-term due to the increased risk of venous thromboembolism. For facial hirsutism, topical eflornithine may be used, but it is contraindicated in pregnancy and breastfeeding.
Overall, understanding the causes and management of hirsutism and hypertrichosis is important for women who experience excessive hair growth. By working with their doctors, they can find the best treatment options to manage their symptoms and improve their quality of life.
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This question is part of the following fields:
- Dermatology
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Question 34
Incorrect
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A toddler is brought to your clinic as the mother has noticed some skin lesions on the child's face. Upon examination, you observe multiple small white papules on the nose. What is the probable diagnosis?
Your Answer:
Correct Answer: Milia
Explanation:Milia, which are often found on the face of newborns, are a normal occurrence and can be seen in up to 50% of babies. They typically disappear on their own within a few weeks.
Understanding Milia: Small, Benign Cysts on the Face
Milia are small cysts that are filled with keratin and are typically found on the face. These cysts are benign and are not harmful to one’s health. Although they can appear at any age, they are more commonly found in newborns. Milia are often described as small, white bumps that are painless and do not cause any discomfort.
While the exact cause of milia is unknown, they are thought to occur when dead skin cells become trapped in the skin’s surface. They can also develop as a result of using heavy skin care products or as a side effect of certain medications. In most cases, milia will disappear on their own without any treatment. However, if they persist or become bothersome, a dermatologist may recommend treatment options such as extraction or chemical peels.
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This question is part of the following fields:
- Dermatology
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Question 35
Incorrect
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A 35-year-old man comes to his General Practitioner complaining of an itchy rash on the flexural surface of both his arms that has been present for 1 week. On examination, the rash appears polygonal and shiny with a white lines pattern on the surface. What is the most appropriate next step?
Your Answer:
Correct Answer: No further testing required, start treatment
Explanation:Diagnostic Testing for Lichen Planus: Understanding Skin Patch Testing, Skin Prick Testing, and RAST
Lichen planus is a clinical diagnosis that can be made based on the characteristic appearance of the rash. However, in some cases, a biopsy may be helpful if the presentation is atypical. The diagnosis is typically made without the need for further testing, and treatment can be started promptly.
Skin patch testing and skin prick testing are not useful for diagnosing lichen planus, as they are mainly used for different types of hypersensitivity reactions. Skin patch testing is used for contact dermatitis and other type IV hypersensitivity reactions, while skin prick testing is used for type I hypersensitivity reactions, such as food allergies and pollen allergies.
Radioallergosorbent testing (RAST) is also unsuitable for diagnosing lichen planus, as it is used to determine the amount of immunoglobulin E (IgE) that reacts specifically with suspected or known allergens. RAST is useful for food allergies, inhaled allergens (such as pollen), and wasp/bee venom.
In summary, diagnostic testing is not typically required for lichen planus, as it can be diagnosed clinically. Skin patch testing, skin prick testing, and RAST are not useful for diagnosing lichen planus and are mainly used for different types of hypersensitivity reactions.
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This question is part of the following fields:
- Dermatology
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Question 36
Incorrect
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A 16-year-old high school student visits his doctor because he is struggling with his self-esteem due to skin problems. During the examination, you observe multiple open and closed comedones mainly on his chin and cheeks. He also reports experiencing painful papules on his back. About six weeks ago, your colleague prescribed him topical benzoyl peroxide and topical fusidic acid, but he feels that they have not been effective. He has no medical history and is not taking any other medications. What is the most suitable treatment to initiate?
Your Answer:
Correct Answer: Oral oxytetracycline
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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This question is part of the following fields:
- Dermatology
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Question 37
Incorrect
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A 45-year-old man visits his GP with a lump on the side of his head. During the examination, the GP suspects that the lump may be a basal cell carcinoma. What characteristic is most indicative of this diagnosis?
Your Answer:
Correct Answer: Telangiectasia
Explanation:Understanding Basal Cell Carcinomas: Symptoms and Diagnosis
Basal cell carcinomas are the most common type of non-melanocytic skin carcinoma, typically found in sun-exposed areas of the skin such as the face and neck. They can be familial and associated with certain syndromes. Symptoms of basal cell carcinomas include a slow-growing, skin-colored, pearly nodule with surface telangiectasia, an ulcerated lesion with rolled edges, and crusted edges. Pigmentation is not a predominant feature, but bleeding may occur. Size is not a specific feature of malignancy, but sudden changes in size should be referred to a dermatologist for further assessment and investigation. Diagnosis is confirmed with a biopsy, and treatment involves excision with a clear margin. Recurrence is possible, but basal cell carcinomas rarely metastasize.
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This question is part of the following fields:
- Dermatology
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Question 38
Incorrect
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You are examining a 65-year-old individual with acanthosis nigricans. You suggest screening for diabetes. Due to the widespread skin alterations, including some oral changes, what other potential underlying condition should be taken into account?
Your Answer:
Correct Answer: Internal malignancy
Explanation:While acanthosis nigricans may occur on its own in individuals with dark skin, it is typically a sign of insulin resistance and associated conditions such as type 2 diabetes, polycystic ovarian syndrome, Cushing’s syndrome, and hypothyroidism. Certain medications, including corticosteroids, insulin, and hormone medications, can also cause this condition. If acanthosis nigricans appears suddenly and in unusual areas such as the mouth, it may indicate the presence of an internal malignancy, particularly gastric cancer.
Acanthosis nigricans is a condition characterized by the presence of symmetrical, brown, velvety plaques on the neck, axilla, and groin. This condition can be caused by various factors such as type 2 diabetes mellitus, gastrointestinal cancer, obesity, polycystic ovarian syndrome, acromegaly, Cushing’s disease, hypothyroidism, familial factors, Prader-Willi syndrome, and certain drugs like the combined oral contraceptive pill and nicotinic acid. The pathophysiology of acanthosis nigricans involves insulin resistance, which leads to hyperinsulinemia. This, in turn, stimulates the proliferation of keratinocytes and dermal fibroblasts through interaction with insulin-like growth factor receptor-1 (IGFR1).
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This question is part of the following fields:
- Dermatology
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Question 39
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Dermatology
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Question 40
Incorrect
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A 70-year-old man comes in to discuss the results of laboratory tests for nail clippings taken 8 weeks ago. He had previously presented with thickening and discoloration of all the nails on his right foot. He has a medical history of type 2 diabetes and hypertension. He is currently in good health and taking metformin, simvastatin, and ramipril. The lab report confirms the presence of onychomycosis. What treatment options should be offered to him?
Your Answer:
Correct Answer: Oral terbinafine
Explanation:Oral terbinafine is recommended for treating dermatophyte nail infections.
Understanding Fungal Nail Infections
Fungal nail infections, also known as onychomycosis, can affect any part of the nail or the entire nail unit. However, toenails are more susceptible to infection than fingernails. The primary cause of fungal nail infections is dermatophytes, with Trichophyton rubrum being the most common. Yeasts, such as Candida, and non-dermatophyte moulds can also cause fungal nail infections. Risk factors include increasing age, diabetes mellitus, psoriasis, and repeated nail trauma.
The most common symptom of fungal nail infections is unsightly nails, which can be thickened, rough, and opaque. Other conditions, such as psoriasis, repeated trauma, lichen planus, and yellow nail syndrome, can mimic fungal nail infections. To confirm a diagnosis, nail clippings and scrapings of the affected nail should be examined under a microscope and cultured.
Asymptomatic fungal nail infections do not require treatment unless the patient is bothered by the appearance. However, if a dermatophyte or Candida infection is confirmed, treatment is necessary. Topical treatment with amorolfine 5% nail lacquer is recommended for limited involvement, while oral terbinafine is the first-line treatment for more extensive dermatophyte infections. Candida infections are best treated with oral itraconazole using a pulsed weekly therapy approach. It is important to note that cultures have a false-negative rate of around 30%, so repeat samples may be necessary if clinical suspicion is high.
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This question is part of the following fields:
- Dermatology
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Question 41
Incorrect
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A 32-year-old male presents to his GP with a complaint of rectal bleeding and black stool. He reports experiencing this issue more than six times in the past four months. The patient denies any other symptoms such as weight loss, abdominal pain, or changes in bowel habits. During the examination, no masses or apparent causes of bleeding are found in his abdomen or rectum. However, the GP notices some red spots on the patient's lips and tongue. When questioned about them, the patient dismisses them as insignificant and claims that everyone in his family has them. What is the most probable reason for the bleeding?
Your Answer:
Correct Answer: Hereditary haemorrhagic telangiectasia
Explanation:Rectal bleeding can have various causes, and it is crucial to differentiate between them as the treatments and prognosis can differ significantly. By utilizing signs and examinations, one can eliminate possibilities. If there are no masses, weight loss, or changes in bowel habits, rectal or colon cancer is less probable. Similarly, if there are no changes in bowel habits, abdominal pain, or weight loss, Crohn’s disease is less likely. This narrows down the possibilities to Louis-Bar syndrome and hereditary haemorrhagic telangiectasia. Louis-Bar syndrome, also known as ataxia telangiectasia, is a rare neurodegenerative disorder that typically manifests in early childhood with severe ataxia and other neurological symptoms.
Understanding Hereditary Haemorrhagic Telangiectasia
Hereditary haemorrhagic telangiectasia, also known as Osler-Weber-Rendu syndrome, is a genetic condition that is inherited in an autosomal dominant manner. It is characterized by the presence of multiple telangiectasia on the skin and mucous membranes. While 80% of cases have a family history, 20% occur spontaneously without prior family history.
There are four main diagnostic criteria for HHT. If a patient has two of these criteria, they are said to have a possible diagnosis of HHT. If they meet three or more of the criteria, they are said to have a definite diagnosis of HHT. These criteria include spontaneous, recurrent nosebleeds (epistaxis), multiple telangiectases at characteristic sites such as the lips, oral cavity, fingers, and nose, visceral lesions such as gastrointestinal telangiectasia (with or without bleeding), pulmonary arteriovenous malformations (AVM), hepatic AVM, cerebral AVM, and spinal AVM, and a first-degree relative with HHT.
In summary, HHT is a genetic condition that is characterized by multiple telangiectasia on the skin and mucous membranes. It can be diagnosed based on the presence of certain criteria, including nosebleeds, telangiectases, visceral lesions, and family history.
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This question is part of the following fields:
- Dermatology
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Question 42
Incorrect
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A 60-year-old woman comes to the doctor's office with concerns about small spots on her shoulder. She reports that the lesions are accompanied by several tiny blood vessels that radiate from the center. During the examination, you observe that applying pressure to the spots causes them to turn white and then refill from the center. What condition is typically associated with this type of lesion?
Your Answer:
Correct Answer: Liver failure
Explanation:When differentiating between spider naevi and telangiectasia, it is important to note that spider naevi fill from the centre when pressed, while telangiectasia fill from the edge. A woman presenting with a small lesion surrounded by tiny blood vessels radiating from the middle that refills from the centre is likely to have a spider naevus. This condition is commonly associated with liver failure, making it the most likely diagnosis.
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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This question is part of the following fields:
- Dermatology
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Question 43
Incorrect
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A 25-year-old man comes to his General Practitioner complaining of an itchy rash on both his wrists that has been present for 1 week. Upon examination, the doctor notes small purplish papules on the flexural aspect of both wrists with a flat top and small white lines on the surface. The patient also has areas of hyperpigmentation on the inner aspect of his elbows. What is the most probable diagnosis?
Your Answer:
Correct Answer: Lichen planus
Explanation:The patient’s symptoms and medical history suggest a diagnosis of lichen planus, a skin condition with an unknown cause that is likely immune-mediated. The rash is typically itchy and appears as papules with a shiny, purplish color in areas such as the palms, soles, genitalia, and flexor surfaces of the arms. The rash often has a polygonal shape and may have white lines known as Wickham’s striae. Over time, the papules flatten and are replaced by hyperpigmentation. Oral involvement is common, with a white-lace pattern on the buccal mucosa. Management usually involves topical steroids, but more severe cases may require oral steroids or immunosuppressants. Atopic eczema, irritant eczema, molluscum contagiosum, and psoriasis are different skin conditions that do not fit the patient’s symptoms.
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This question is part of the following fields:
- Dermatology
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Question 44
Incorrect
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A 14-year-old girl, who is a keen dancer, visits her General Practitioner with a painful rash on her foot. She says that it started several weeks ago and often stings. Examination reveals a red rash in the interdigital spaces, with small fissures and white exudate.
What is the most appropriate treatment option?Your Answer:
Correct Answer: Topical miconazole
Explanation:Understanding Topical Treatments for Skin Conditions
Athlete’s foot is a common fungal infection that affects the toe webs and is often caused by excess moisture. The first-line treatment for this condition is a topical antifungal such as miconazole or terbinafine cream, which should be used twice daily for four weeks. If there is no improvement, further investigations may be required, and oral antifungals may be prescribed. It is important to advise patients on foot hygiene and to avoid walking barefoot in communal areas.
Dithranol is a topical treatment for psoriasis, a condition that presents as large, scaly plaques with a symmetrical distribution. This is different from athlete’s foot, which is characterized by a moist, peeling rash between the toes. Emollients, which are topical moisturizers, are used for atopic eczema management and have no role in treating athlete’s foot.
Oral terbinafine is reserved for severe or extensive fungal infections that cannot be treated with topical antifungal agents. Finally, while an antifungal/topical steroid combination may reduce symptoms more rapidly in cases of inflamed tissue, it has no overall benefit. Moderately potent topical steroids such as eumovate are more appropriate for managing atopic eczema.
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This question is part of the following fields:
- Dermatology
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Question 45
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Dermatology
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Question 46
Incorrect
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A typically healthy 68-year-old man visits the doctor's office complaining of feeling unwell. He mentions experiencing a sharp ache in his right groin. After three days, he develops a strip of painful, red blisters on the top of his right foot.
What is the most probable diagnosis?Your Answer:
Correct Answer: Herpes zoster
Explanation:This individual is experiencing shingles, which is caused by the herpes zoster virus and is characterized by a unique distribution along a specific dermatome.
Shingles is a painful blistering rash caused by reactivation of the varicella-zoster virus. It is more common in older individuals and those with immunosuppressive conditions. The rash is well demarcated by the affected dermatome and may be accompanied by fever and lethargy. Treatment includes analgesia, antivirals, and potentially oral corticosteroids. Complications include post-herpetic neuralgia, ocular and ear complications. Antivirals should be used within 72 hours to reduce the risk of post-herpetic neuralgia.
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This question is part of the following fields:
- Dermatology
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Question 47
Incorrect
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A 67-year-old woman presents to General Practitioner with a 2-day history of fever and pain in her right shin.
On examination, she was found to have a tender erythematous skin swelling in the anterior aspect of her right shin. This measured around 10 cm × 4 cm. Her temperature was 38.2°C and the rest of her parameters included a heart rate of 120 bpm, respiratory rate of 21 bpm and oxygen saturation of 99%.
What is the most appropriate next investigation?
Select the SINGLE best option from the list below.
Select ONE option only.Your Answer:
Correct Answer: Full blood count, urea and electrolytes and C-reactive protein (CRP)/erythrocyte sedimentation rate (ESR)
Explanation:Diagnostic Tests for Cellulitis: Which Ones are Necessary?
Cellulitis is a clinical diagnosis, but certain tests may be necessary in patients with a systemic response. A full blood count, urea and electrolytes, and CRP/ESR are recommended to assess the severity of the infection. A wound swab and blood cultures may also be considered. An ABPI measurement is indicated in patients with suspected lower-limb arterial disease. A chest X-ray is not necessary unless co-existing lung pathology is suspected. In stable patients with no systemic upset, no further investigations are needed. A punch biopsy is not necessary for diagnosis but may be considered in other skin conditions.
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This question is part of the following fields:
- Dermatology
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Question 48
Incorrect
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A 32-year-old woman presents with worries about hair loss. She reports experiencing hair loss in small patches on her scalp. During examination, you observe distinct patches of hair loss with some ‘broken exclamation mark’ hairs at the edges.
What is the most probable diagnosis?Your Answer:
Correct Answer: Alopecia areata
Explanation:Understanding Hair Loss: Causes and Symptoms
Hair loss is a common concern for many individuals, causing anxiety and worry. There are various causes of hair loss, each with their own unique symptoms. Alopecia areata is a chronic inflammatory disease that affects the hair follicles, resulting in patchy, non-scarring hair loss on the scalp. Androgenic alopecia, on the other hand, is more common in men and causes a receding hairline and loss of hair from the top and front of the head. Fungal infections, such as tinea capitis, can also cause hair loss accompanied by scaling, itching, and pain. Scalp psoriasis can range from mild scaling to severe crusted plaques covering the entire scalp, while erosive pustular dermatosis of the scalp affects elderly individuals with scarring and yellow-brown crusts. It is important to understand the various causes and symptoms of hair loss in order to properly diagnose and treat the condition.
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This question is part of the following fields:
- Dermatology
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Question 49
Incorrect
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A 26-year-old male patient visits his GP complaining of a firm, round swelling over the angle of his jaw that has been growing for two years. The patient is having difficulty shaving his beard due to the size of the swelling. The GP suspects a sebaceous cyst and the patient is eager for treatment to alleviate his symptoms. What is the best course of action to prevent further discomfort?
Your Answer:
Correct Answer: Surgical excision
Explanation:To prevent the sebaceous cyst from recurring, it is necessary to surgically remove the entire structure. This can be done by a general practitioner or a surgical team, but funding for the procedure may be limited due to its lower clinical priority. Patients may opt to have the surgery done privately. Incision and drainage or fine needle aspiration may provide temporary relief, but the cyst is likely to return. Intralesional steroids are not recommended in this case, as there is no infection present. Oral antibiotics are also unnecessary. Complete surgical excision offers the best chance for long-term resolution of the patient’s symptoms.
Understanding Sebaceous Cysts
Sebaceous cysts refer to a group of cysts that include both epidermoid and pilar cysts. However, the term is not entirely accurate and should be avoided if possible. Epidermoid cysts occur when there is an overgrowth of epidermal cells in the dermis, while pilar cysts, also known as trichilemmal cysts or wen, originate from the outer root sheath of the hair follicle. These cysts can appear anywhere on the body, but are most commonly found on the scalp, ears, back, face, and upper arm, and will typically have a punctum.
To prevent recurrence, it is essential to remove the entire cyst wall during excision. While sebaceous cysts are generally harmless, they can become infected and cause discomfort or pain.
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This question is part of the following fields:
- Dermatology
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Question 50
Incorrect
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A 56-year-old man with a history of type 2 diabetes mellitus and benign prostatic hyperplasia presents to dermatology with multiple lesions on his shin. Upon examination, symmetrical, tender, erythematous nodules are observed. The lesions are healing without scarring. What is the probable diagnosis?
Your Answer:
Correct Answer: Erythema nodosum
Explanation:The relevant diagnosis for this question relies solely on the description of the lesions, as the patient’s medical history is not a factor. Specifically, the tender shin lesions are indicative of erythema nodosum.
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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This question is part of the following fields:
- Dermatology
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Question 51
Incorrect
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You assess a 23-year-old male patient who has newly developed extensive psoriatic plaques on his elbows and knees. He has no prior history of skin issues, but his mother has a history of psoriasis. You suggest using an emollient to manage the scaling. What would be the most suitable initial prescription for treating his plaques?
Your Answer:
Correct Answer: Topical steroid + topical calcipotriol
Explanation:As a first-line treatment, NICE suggests using a strong corticosteroid and a vitamin D analogue separately, once a day for up to four weeks. The corticosteroid should be applied in the morning and the vitamin D analogue in the evening.
NICE recommends a step-wise approach for chronic plaque psoriasis, starting with regular emollients and then using a potent corticosteroid and vitamin D analogue separately, followed by a vitamin D analogue twice daily, and then a potent corticosteroid or coal tar preparation if there is no improvement. Phototherapy, systemic therapy, and topical treatments are also options for management. Topical steroids should be used cautiously and vitamin D analogues may be used long-term. Dithranol and coal tar have adverse effects but can be effective.
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This question is part of the following fields:
- Dermatology
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Question 52
Incorrect
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A 65-year-old woman comes to see her GP for a skin condition that has been slowly progressing over the years. She has had dry patches of skin that eventually turned into plaques, which have been treated as psoriasis. However, the lesions have continued to worsen and now have nodules. Some of these nodules have become painful and have discharged fluid. A biopsy is taken to further assess the lesions, and the pathology report shows lymphocytic and atypical T-cell infiltrates in the dermis and epidermis, with some Pautrier microabscesses. Based on this information, what is the most likely diagnosis?
Your Answer:
Correct Answer: Mycosis fungoides
Explanation:Mycosis fungoides, a severe form of T-cell lymphoma that mimics eczema or psoriasis, is a rare but concerning skin condition. The patient’s atypical medical history, previous diagnostic uncertainty, and laboratory results suggest that they may have cutaneous T-cell lymphoma. Biopsy results showing Pautrier microabscesses are a common feature of mycosis fungoides. Harlequin ichthyosis is a genetic disorder that manifests from birth, making it an unlikely diagnosis. Although syphilis can cause various skin symptoms, the biopsy findings do not support this diagnosis. Discoid eczema, also known as nummular dermatitis, has a different clinical course than the patient’s condition, and the biopsy results do not indicate it.
Understanding Mycosis Fungoides
Mycosis fungoides is a rare type of T-cell lymphoma that primarily affects the skin. It is characterized by the presence of itchy, red patches that may appear in different colors, unlike eczema or psoriasis where the lesions are more uniform in color. These patches may progress to form plaques, which can be seen in the later stages of the disease.
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This question is part of the following fields:
- Dermatology
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Question 53
Incorrect
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You see a 4-year-old child in surgery with his mother. He has been diagnosed with molluscum contagiosum and she is keen to have him treated.
Which of the following statements about molluscum contagiosum is true?Your Answer:
Correct Answer: The condition resolves spontaneously
Explanation:Molluscum Contagiosum: Myths and Facts
Molluscum contagiosum is a common skin infection caused by a poxvirus. However, there are several myths surrounding this condition that need to be debunked. Firstly, it is not true that the condition resolves spontaneously. While most cases do clear up on their own within 6-9 months, some can last up to 4 years. Secondly, molluscum contagiosum is highly infectious and can be transmitted through contact with infected persons or objects, including swimming pools. Sexual transmission is also possible.
Another myth is that patients can treat themselves by squeezing the spots. This is not recommended as it can lead to scarring. Additionally, molluscum contagiosum is not limited to children. While it does present mainly in young children, there is also a later peak in young adults, some of which is attributable to sexual transmission.
Finally, piercing the lesions with an orange stick dipped in phenol is not the treatment of choice. In fact, the condition usually requires no treatment and resolves on its own. Treatment may be recommended for adults or older children with particularly unsightly spots or in the immunosuppressed, where it can take several years to resolve. Topical applications such as benzyl peroxide or potassium hydroxide, as well as curettage and cryotherapy, can be used to treat the condition.
In conclusion, it is important to separate fact from fiction when it comes to molluscum contagiosum. While it is a common and often harmless condition, it is important to seek medical advice if you have concerns or if the spots are causing discomfort or affecting your quality of life.
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This question is part of the following fields:
- Dermatology
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Question 54
Incorrect
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A 21-year-old woman presents with a rash on her trunk that developed a few weeks after a sore throat. On examination, small, drop-shaped, salmon-pink plaques are observed. What is the most probable cause of this rash?
Your Answer:
Correct Answer: Guttate psoriasis
Explanation:Understanding Different Skin Conditions: Guttate Psoriasis, Dermatitis, Hand, Foot and Mouth Disease, Pityriasis Rosea, and Pustular Psoriasis
Skin conditions can be uncomfortable and sometimes even painful. Here are some common skin conditions and their characteristics:
Guttate psoriasis is a type of psoriasis that causes small, drop-shaped plaques on the chest, arms, legs, and scalp. It is usually caused by a streptococcal infection and can last for up to three months. Topical agents, such as steroids or calcipotriol, can be used to treat it.
Dermatitis, also known as eczema, results in rough patches of skin that are dry and itchy, particularly with exposure to irritants. In children and adults with long-standing disease, eczema is often localised to the flexure of the limbs.
Hand, foot and mouth disease (HFMD) is an acute viral illness characterised by vesicular eruptions in the mouth and papulovesicular lesions of the distal limbs. It should not be confused with foot and mouth disease of animals, which is caused by a different virus.
Pityriasis rosea is a skin rash that is characterised by distinctive, scaly, erythematous lesions. It is thought to be a reaction to exposure to infection.
Pustular psoriasis is a rarer type of psoriasis that causes pus-filled blisters (pustules) to appear on your skin. Different types of pustular psoriasis affect different parts of the body.
It is important to consult a healthcare professional for proper diagnosis and treatment of any skin condition.
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This question is part of the following fields:
- Dermatology
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Question 55
Incorrect
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A 65-year-old woman comes to the clinic with a similar concern as the previous patient. She has noticed a volcano-like spot on her left arm that has been present for the past 3 months. Initially, she thought it was a simple spot, but it has not gone away. Upon examination, a 5 mm red, raised lesion with a central keratin-filled crater is observed. The doctor suspects a probable keratoacanthoma. What is the most appropriate course of action?
Your Answer:
Correct Answer: Urgent referral to dermatology
Explanation:Keratoacanthoma is a benign lesion, but urgent excision is advised due to difficulty in clinically excluding squamous cell carcinoma.
Understanding Keratoacanthoma
Keratoacanthoma is a type of non-cancerous tumor that affects the epithelial cells. It is more commonly found in older individuals and is rare in young people. The tumor is characterized by a dome-shaped papule that resembles a volcano or crater. As it grows, it becomes filled with keratin and develops a central crater. While spontaneous regression of keratoacanthoma is common within three months, it often results in scarring. Therefore, it is important to urgently remove such lesions as it is difficult to clinically differentiate them from squamous cell carcinoma. Removal may also prevent scarring.
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This question is part of the following fields:
- Dermatology
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Question 56
Incorrect
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A 45-year-old man presents to the Emergency Department with a rash and feeling generally unwell. He has a history of epilepsy and recently started taking phenytoin three weeks ago. He developed mouth ulcers, malaise, and a cough about a week ago. Two days ago, he developed a widespread red rash that has now formed large fluid-filled blisters, covering approximately 30% of his body area. The lesions separate when slight pressure is applied. Upon examination, his temperature is 38.3ºC and pulse is 126/min. Blood results reveal:
Na+ 144 mmol/l
K+ 4.2 mmol/l
Bicarbonate 19 mmol/l
Urea 13.4 mmol/l
Creatinine 121 µmol/l
What is the most likely diagnosis?Your Answer:
Correct Answer: Toxic epidermal necrolysis
Explanation:Understanding Toxic Epidermal Necrolysis
Toxic epidermal necrolysis (TEN) is a severe skin disorder that can be life-threatening and is often caused by a reaction to certain drugs. It is characterized by extensive scalding of the skin, and is considered by some experts to be the most severe form of a range of skin disorders that includes erythema multiforme and Stevens-Johnson syndrome. Symptoms of TEN include fever, rapid heartbeat, and a positive Nikolsky’s sign, which means that the epidermis separates easily with slight lateral pressure.
The most effective way to manage TEN is to stop the use of the drug that caused the reaction. Supportive care is also necessary, and patients are often treated in an intensive care unit to monitor for potential complications such as electrolyte imbalances and fluid loss. Intravenous immunoglobulin is a commonly used first-line treatment for TEN, and has been shown to be effective. Other treatment options include immunosuppressive agents like ciclosporin and cyclophosphamide, as well as plasmapheresis.
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This question is part of the following fields:
- Dermatology
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Question 57
Incorrect
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A 27-year-old man of black African-Caribbean origin with a history of eczema visits his GP complaining of red, itchy, dry skin behind his knees. The GP prescribes a course of betamethasone and advises the patient to use emollients as well. The patient is warned to follow the instructions carefully and not to apply the betamethasone for more than one week. What is the most probable adverse effect that the patient may experience from this treatment?
Your Answer:
Correct Answer: Skin depigmentation
Explanation:Topical corticosteroids can lead to patchy depigmentation in patients with darker skin, which is a potential adverse effect. These medications are commonly used to reduce inflammation in skin conditions like psoriasis and eczema. However, if used for an extended period or in high doses, they can cause local side effects such as skin thinning, excessive hair growth, and depigmentation. Therefore, the correct answer is depigmentation. Dry skin is not a typical side effect of topical steroid use, but it can occur with other topical preparations like benzoyl peroxide and topical retinoids. While systemic side effects like weight gain, hyperglycemia, hypertension, and mood changes are possible with corticosteroids, they are rare with topical use. Hyperglycemia is therefore an incorrect answer. Reduced hair growth at the application site is also incorrect, as corticosteroids can actually increase hair growth and may be used to treat alopecia.
Topical Steroids for Eczema Treatment
Eczema is a common skin condition that causes red, itchy, and inflamed skin. Topical steroids are often used to treat eczema, but it is important to use the weakest steroid cream that effectively controls the patient’s symptoms.
To determine the appropriate amount of topical steroid to use, the finger tip rule can be used. One finger tip unit (FTU) is equivalent to 0.5 g and is sufficient to treat an area of skin about twice the size of an adult hand.
The British National Formulary (BNF) recommends specific quantities of topical steroids to be prescribed for a single daily application for two weeks. These recommendations vary depending on the area of the body being treated. It is important to follow these guidelines to ensure safe and effective use of topical steroids for eczema treatment. -
This question is part of the following fields:
- Dermatology
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Question 58
Incorrect
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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:
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.
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This question is part of the following fields:
- Dermatology
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Question 59
Incorrect
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A 58-year-old with a history of acne rosacea seeks guidance on treatment options. Which of the following interventions is least helpful in managing the condition?
Your Answer:
Correct Answer: Low-dose topical corticosteroids
Explanation: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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This question is part of the following fields:
- Dermatology
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Question 60
Incorrect
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An itchy rash over the extensor surfaces in a patient with gluten intolerance:
Your Answer:
Correct Answer: Dermatitis herpetiformis
Explanation:Dermatitis herpetiformis is the correct answer, which is a skin rash that is closely linked to coeliac disease. This is a persistent skin condition that causes blisters, but it is not caused by or related to the herpes virus. It is important to note that dapsone is an effective treatment for Dermatitis herpetiformis, which is a common question in exams. Additionally, a gluten-free diet can also help alleviate symptoms.
Understanding Dermatitis Herpetiformis
Dermatitis herpetiformis is a skin condition that is linked to coeliac disease and is caused by the deposition of IgA in the dermis. It is an autoimmune blistering disorder that is characterized by itchy, vesicular skin lesions that appear on the extensor surfaces of the body, such as the elbows, knees, and buttocks.
To diagnose dermatitis herpetiformis, a skin biopsy is required, which will show the deposition of IgA in a granular pattern in the upper dermis. This condition can be managed by following a gluten-free diet and taking dapsone medication.
It is important to understand the symptoms and management of dermatitis herpetiformis to ensure that proper treatment is given. By following a gluten-free diet and taking medication, individuals with this condition can manage their symptoms and improve their quality of life.
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This question is part of the following fields:
- Dermatology
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Question 61
Incorrect
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A 63-year-old woman presents to her General Practitioner concerned about a lesion to her right temple. It has been there for several months. Examination reveals a round lesion, 1 cm in diameter, with rolled edges and a pearly appearance.
Which of the following, from the history, is the most likely diagnosis?
Select the SINGLE most likely diagnosis from the list below. Select ONE option only.Your Answer:
Correct Answer: Basal cell carcinoma (BCC)
Explanation:Skin cancer can take on different forms, including basal cell carcinoma (BCC), actinic keratosis, herpes zoster infection, melanoma, and squamous cell carcinoma (SCC). BCCs can appear on any part of the body and often produce a bloody crust. AKs are scaly or hyperkeratotic lesions that can become malignant and are common in individuals over 60 years old. Herpes zoster infection causes a rash that is usually unilateral and follows a dermatomal distribution. Melanoma is a malignant tumour that arises from cutaneous melanocytes and can take on different types. SCC is the second most common type of skin cancer and arises from the keratinocytes of the epidermis. It predominantly affects sun-exposed sites and has a firm, indurated appearance with surrounding inflammation. BCCs are commonly found in sun-exposed areas and have a pearly appearance with rolled edges and surrounding telangiectasia. Management for skin cancer varies depending on the type and severity, but removal through curettage or excision is common for BCCs.
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This question is part of the following fields:
- Dermatology
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Question 62
Incorrect
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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:
Correct 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
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This question is part of the following fields:
- Dermatology
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Question 63
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Dermatology
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Question 64
Incorrect
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A 5-year-old girl is brought to the pediatrician's office by her father, who is concerned about a red rash on her arms and chest. She has been feeling sick, with cold-like symptoms preceding the rash. The rash is erythematous, macular and symmetrical to both arms and chest and is non-blanching. She is currently without fever and appears to be in good health.
What is the most probable cause?Your Answer:
Correct Answer: Henoch–Schönlein purpura
Explanation:Distinguishing Between Different Skin Conditions: A Guide for Healthcare Professionals
Henoch–Schönlein purpura, eczema, intertrigo, meningococcal disease, and systemic lupus erythematosus are all skin conditions that can present with various rashes and symptoms. It is important for healthcare professionals to be able to distinguish between these conditions in order to provide appropriate treatment.
Henoch–Schönlein purpura is an autoimmune hypersensitivity vasculitis that presents with a non-blanching rash, joint and abdominal pain, and nephritis. Eczema is characterized by areas of erythema that are blanching, dry skin with fine scales, and excoriations. Intertrigo primarily affects the flexures with erythematous patches that may progress to intense inflammation. Meningococcal disease presents with a non-blanching rash that rapidly progresses to purpura and requires immediate treatment. Systemic lupus erythematosus is rare in children and presents with a malar or butterfly rash on the face, joint pain, fever, or weight loss.
By understanding the unique features of each condition, healthcare professionals can accurately diagnose and treat their patients.
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This question is part of the following fields:
- Dermatology
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Question 65
Incorrect
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A 5-year-old girl is presented to your GP clinic by her father with a complaint of erythematous sores on her face for the past 2 days. The lesions are limited to her face and have started to weep and progress to honey crusted lesions over the last 24 hours. The child is otherwise healthy. Previously, topical hydrogen peroxide was ineffective for a similar episode. What is the most appropriate treatment option?
Your Answer:
Correct Answer: Topical fusidic acid
Explanation:If hydrogen peroxide is not appropriate, topical fusidic acid can be used for impetigo.
Understanding Impetigo: Causes, Symptoms, and Management
Impetigo is a common bacterial skin infection that affects both children and adults. It is caused by either Staphylococcus aureus or Streptococcus pyogenes and can develop anywhere on the body, but lesions tend to occur on the face, flexures, and limbs not covered by clothing. The infection can be a primary infection or a complication of an existing skin condition such as eczema, scabies, or insect bites. Impetigo is highly contagious and can spread through direct contact with discharges from the scabs of an infected person or indirectly through toys, clothing, equipment, and the environment.
The symptoms of impetigo include ‘golden’, crusted skin lesions typically found around the mouth. The infection can be managed with limited, localized disease by using hydrogen peroxide 1% cream or topical antibiotic creams such as fusidic acid or mupirocin. However, if the disease is extensive, oral flucloxacillin or oral erythromycin may be prescribed. It is important to note that MRSA is not susceptible to either fusidic acid or retapamulin, so topical mupirocin should be used in this situation.
Children with impetigo should be excluded from school until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment. It is also important to practice good hygiene, such as washing hands regularly and avoiding close contact with infected individuals, to prevent the spread of impetigo. By understanding the causes, symptoms, and management of impetigo, individuals can take steps to prevent and treat this common bacterial skin infection.
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This question is part of the following fields:
- Dermatology
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Question 66
Incorrect
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A 28-year-old woman presents with a recurring, intensely itchy rash on the palms of her hands. She reports that these rashes tend to occur every summer. Despite trying over-the-counter emollients and antihistamines, there has been only marginal improvement. The patient is otherwise healthy with no other medical conditions and does not smoke.
During examination, bilateral vesicles are observed on the palms and sides of the fingers. The palms appear dry with areas of skin peeling, while the rest of her body is unaffected.
What is the most probable diagnosis?Your Answer:
Correct Answer: Pompholyx eczema
Explanation:Palmoplantar pustulosis is often accompanied by psoriasis on other areas of the body and is strongly linked to smoking. Unlike pompholyx eczema, the connection to high temperatures and humidity is not as significant. Scabies, which is caused by the parasite Sarcoptes scabiei, results in severe itching of the hands and web spaces but is typically not a recurring issue. Symptoms include linear burrows and erythematous papules rather than vesicles.
Understanding Pompholyx Eczema
Pompholyx eczema, also known as dyshidrotic eczema, is a type of skin condition that affects both the hands and feet. It is often triggered by high temperatures and humidity, such as sweating. The main symptom of pompholyx eczema is the appearance of small blisters on the palms and soles, which can be intensely itchy and sometimes accompanied by a burning sensation. Once the blisters burst, the skin may become dry and crack.
To manage pompholyx eczema, cool compresses and emollients can be used to soothe the affected areas. Topical steroids may also be prescribed to reduce inflammation and itching. It is important to avoid further irritation by wearing gloves or protective footwear and avoiding exposure to irritants. With proper management, the symptoms of pompholyx eczema can be controlled and minimized.
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This question is part of the following fields:
- Dermatology
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Question 67
Incorrect
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A 32-year-old man with a past medical history of polyarthralgia, back pain, and diarrhea presents with a 3 cm red lesion on his shin that is beginning to ulcerate. What is the probable diagnosis?
Your Answer:
Correct Answer: Pyoderma gangrenosum
Explanation:It is probable that this individual is suffering from ulcerative colitis, a condition that is commonly linked to arthritis in large joints, sacroiliitis, and pyoderma gangrenosum.
Understanding Pyoderma Gangrenosum
Pyoderma gangrenosum is a rare inflammatory disorder that causes painful skin ulceration. While it can affect any part of the skin, it is most commonly found on the lower legs. This condition is classified as a neutrophilic dermatosis, which means that it is characterized by the infiltration of neutrophils in the affected tissue. The exact cause of pyoderma gangrenosum is unknown in 50% of cases, but it can be associated with inflammatory bowel disease, rheumatological conditions, haematological disorders, and other diseases.
The initial symptoms of pyoderma gangrenosum may start suddenly with a small pustule, red bump, or blood-blister. The skin then breaks down, resulting in an ulcer that is often painful. The edge of the ulcer is typically described as purple, violaceous, and undermined. In some cases, systemic symptoms such as fever and myalgia may also be present. Diagnosis is often made by the characteristic appearance, associations with other diseases, the presence of pathergy, histology results, and ruling out other potential causes.
Management of pyoderma gangrenosum typically involves oral steroids as first-line treatment due to the potential for rapid progression. Other immunosuppressive therapies such as ciclosporin and infliximab may also be used in difficult cases. It is important to note that any surgery should be postponed until the disease process is controlled on immunosuppression to avoid worsening the condition. Understanding pyoderma gangrenosum and seeking prompt medical attention can help manage this rare and painful condition.
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This question is part of the following fields:
- Dermatology
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Question 68
Incorrect
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A 28-year-old woman presents to the general practice clinic with a history of itchy palms and soles for a few weeks. Examination reveals pitting to the nails and dry, scaly, fissured skin with areas of pustules on the palms and soles. She is a social drinker but has no other medical conditions.
Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Palmoplantar pustulosis
Explanation:Skin Conditions: Palmoplantar Pustulosis, Bullous Pemphigoid, Contact Dermatitis, Eczema, and Secondary Syphilis
Palmoplantar Pustulosis: A chronic inflammatory skin condition that affects the palms and soles, often associated with chronic plaque psoriasis and smoking. It presents with painful cracking, fissuring, and crops of sterile pustules that are severely itchy. Topical treatments and phototherapy can be used.
Bullous Pemphigoid: An autoimmune skin disease that forms large fluid-filled blisters, typically affecting people over 80 years old with underlying neurological or malignant conditions. The age and presenting features in this man are not typical for bullous pemphigoid.
Contact Dermatitis: A type of eczema triggered by contact with a particular substance, causing a red, dry, and scaly rash only in the areas that have been in contact with the irritant. Pustules are not a feature of this condition, and it would be unusual for an irritant to have been in contact with the palms and soles.
Eczema: A chronic, itchy, inflammatory skin condition that commonly begins in childhood and affects flexural areas such as behind the knees or in the antecubital fossae. The palms of hands and soles of feet are usually spared.
Secondary Syphilis: A rash that may appear as rough, red or reddish-brown papules or patches, typically occurring on the trunk but frequently affecting the palms and soles. The rash doesn’t itch and can appear more obvious with physical activity or heat. It resolves spontaneously within several weeks but can recur over the next two years.
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This question is part of the following fields:
- Dermatology
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Question 69
Incorrect
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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:
Correct 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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This question is part of the following fields:
- Dermatology
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Question 70
Incorrect
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Which of the following complications is most commonly associated with PUVA therapy in elderly patients?
Your Answer:
Correct Answer: Squamous cell cancer
Explanation:Squamous cell skin cancer is the most notable adverse effect of PUVA therapy in treating psoriasis.
NICE recommends a step-wise approach for chronic plaque psoriasis, starting with regular emollients and then using a potent corticosteroid and vitamin D analogue separately, followed by a vitamin D analogue twice daily, and then a potent corticosteroid or coal tar preparation if there is no improvement. Phototherapy, systemic therapy, and topical treatments are also options for management. Topical steroids should be used cautiously and vitamin D analogues may be used long-term. Dithranol and coal tar have adverse effects but can be effective.
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This question is part of the following fields:
- Dermatology
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Question 71
Incorrect
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A 55-year-old diabetic female patient comes in with bilateral erythematous lesions on her shins that have been present for four months. The lesions are surrounded by telangiectasia. What is the probable diagnosis?
Your Answer:
Correct Answer: Necrobiosis lipoidica
Explanation:There is no association between erythema nodosum and telangiectasia in the surrounding area.
Skin Disorders Linked to Diabetes
Diabetes mellitus is a chronic metabolic disorder that affects various organs in the body, including the skin. Several skin disorders are associated with diabetes, including necrobiosis lipoidica, infections such as candidiasis and staphylococcal, neuropathic ulcers, vitiligo, lipoatrophy, and granuloma annulare. Necrobiosis lipoidica is characterized by shiny, painless areas of yellow, red, or brown skin, typically on the shin, and is often associated with surrounding telangiectasia. Infections such as candidiasis and staphylococcal can also occur in individuals with diabetes. Neuropathic ulcers are a common complication of diabetes, and vitiligo and lipoatrophy are also associated with the condition. Granuloma annulare is a papular lesion that is often slightly hyperpigmented and depressed centrally, but recent studies have not confirmed a significant association between diabetes mellitus and this skin disorder. It is important for individuals with diabetes to be aware of these potential skin complications and to seek medical attention if they notice any changes in their skin.
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This question is part of the following fields:
- Dermatology
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Question 72
Incorrect
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A 32-year-old male patient comes in for mole removal. Which areas of the body are more prone to developing keloid scars?
Your Answer:
Correct Answer: Sternum
Explanation:Understanding Keloid Scars
Keloid scars are abnormal growths that develop from the connective tissue of a scar and extend beyond the boundaries of the original wound. They are more common in people with dark skin and tend to occur in young adults. Keloids are most frequently found on the sternum, shoulder, neck, face, extensor surface of limbs, and trunk.
To prevent keloid scars, incisions should be made along relaxed skin tension lines. However, if keloids do develop, early treatment with intra-lesional steroids such as triamcinolone may be effective. In some cases, excision may be necessary, but this should be approached with caution as it can potentially lead to further keloid scarring.
It is important to note that the historical use of Langer lines to determine optimal incision lines has been shown to produce worse cosmetic results than following skin tension lines. Understanding the predisposing factors and treatment options for keloid scars can help individuals make informed decisions about their care.
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This question is part of the following fields:
- Dermatology
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Question 73
Incorrect
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A 55-year-old man visits his doctor as he noticed a new spot on his arm while showering. Upon examination, there is a lesion that appears to be dark brown and has a raised appearance.
What is the most probable diagnosis?
Your Answer:
Correct Answer: Seborrhoeic keratosis
Explanation:Understanding Seborrhoeic Keratoses: A Common Benign Skin Condition in the Elderly
Seborrhoeic keratoses, also known as senile warts, are a benign overgrowth of epidermal keratinocytes that commonly present in individuals over the age of 60. These warty nodules are usually found on the trunk and can be light tan to black in color. While they can be unsightly, seborrhoeic keratoses are not harmful and do not require treatment. However, there is a small risk of infection if the lesion is picked at. If a growth becomes excessively itchy or irritated, it can be removed through various methods such as cryotherapy, curettage, shave biopsy, or excision biopsy. It is important to understand this common skin condition to avoid unnecessary worry or concern.
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This question is part of the following fields:
- Dermatology
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Question 74
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Dermatology
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Question 75
Incorrect
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A 60-year-old smoker presents with non-healing sores on his lower lip that have been gradually enlarging for several months. Upon examination, a lesion is found at the vermilion border of the lower lip. What is the most probable type of lesion?
Your Answer:
Correct Answer: Squamous cell carcinoma (SCC)
Explanation:Common Skin Lesions and Cancers: Characteristics and Clinical Presentations
Squamous cell carcinoma (SCC), actinic keratosis, Bowen’s disease, cold sores, and leukoplakia are common skin lesions and cancers that have distinct characteristics and clinical presentations.
SCC is a malignant tumour that commonly affects the backs of the hands and forearms, the upper part of the face, and the lower lip and pinna in men. The first clinical sign is induration, which may take on nodular, plaque-like, verrucous, or ulcerated characteristics. The limits of induration are not sharp and usually extend beyond the visible margins of the lesion. The surrounding tissue is often inflamed. SCCs rarely metastasize.
Actinic keratosis is a sun-induced scaly or hyperkeratotic lesion that has the potential to become malignant. It is characterized by multifocal, scaly, hyperpigmented or scaly lesions, usually brown with a scaly base, occurring on the head, neck, forearms, and hands.
Bowen’s disease is an intraepidermal (in situ) squamous cell carcinoma that arises in sun-exposed sites, especially the lower legs in women. It is characterized by well-defined pink and scaly patches or plaques that may become crusty, fissured, or ulcerated as lesions grow.
Cold sores are recurrent infections of orofacial herpes simplex that present as grouped vesicles, especially of the lips and perioral skin. The eruption is often preceded by a tingling, itching, or burning sensation. Over a few days, the vesicles form a crust, and the eruption resolves within 7–10 days.
Leukoplakia is a white patch or plaque of the oral mucosa that cannot be characterized clinically or pathologically as any other condition.
A non-healing lesion is also of concern, especially in patients with a history of smoking and advanced age, as it may indicate a malignant cause. Early detection and treatment are crucial in preventing the progression of these skin lesions and cancers.
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This question is part of the following fields:
- Dermatology
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Question 76
Incorrect
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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:
Correct 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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This question is part of the following fields:
- Dermatology
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Question 77
Incorrect
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A 28-year-old man presents to the emergency department with complaints of severe pain in his perineum and scrotum. He has type 2 diabetes that is currently well managed with dapagliflozin. Upon examination, a purple rash with bullae is observed covering the entire perineum and extending up the scrotum. The patient reports intense pain, but reduced sensation is noted upon palpation of the rash. Vital signs are as follows: BP 110/90 mmHg, heart rate 109bpm, respiration rate 21/minute, temperature 38.1ºC, and oxygen saturation 98% on room air. What is the likely diagnosis?
Your Answer:
Correct Answer: Necrotizing fasciitis
Explanation:The patient’s symptoms are consistent with necrotizing fasciitis, which often affects the perineum. The patient is experiencing severe pain, which may be causing his fever and rapid heart and breathing rates. As a type 2 diabetic taking dapagliflozin, an SGLT-2 inhibitor, his risk of developing necrotizing fasciitis is increased. While cellulitis can have similar symptoms in the early stages, the presence of bullae, purple discoloration, and severe pain in a patient with risk factors for necrotizing fasciitis make it less likely. Septic arthritis is not a likely diagnosis as it affects joint spaces, which is not the case in this patient. Pyoderma gangrenosum, which is associated with inflammatory conditions, is not a likely diagnosis as the rash is not ulcerated and the patient has no history of inflammatory bowel disease or rheumatoid arthritis.
Understanding Necrotising Fasciitis
Necrotising fasciitis is a serious medical emergency that can be difficult to identify in its early stages. It can be classified into two types based on the causative organism. Type 1 is the most common and is caused by mixed anaerobes and aerobes, often occurring post-surgery in diabetics. Type 2 is caused by Streptococcus pyogenes. There are several risk factors associated with necrotising fasciitis, including recent trauma, burns, or soft tissue infections, diabetes mellitus, intravenous drug use, and immunosuppression. The most commonly affected site is the perineum, also known as Fournier’s gangrene.
The features of necrotising fasciitis include an acute onset, pain, swelling, and erythema at the affected site. It often presents as rapidly worsening cellulitis with pain that is out of keeping with physical features. The infected tissue is extremely tender and may have hypoaesthesia to light touch. Late signs include skin necrosis and crepitus/gas gangrene. Fever and tachycardia may be absent or occur late in the presentation.
Management of necrotising fasciitis requires urgent surgical referral for debridement and intravenous antibiotics. The prognosis for this condition is poor, with an average mortality rate of 20%. It is important to be aware of the risk factors and features of necrotising fasciitis to ensure prompt diagnosis and treatment.
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This question is part of the following fields:
- Dermatology
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Question 78
Incorrect
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A 60-year-old man presents with blisters on his skin. He reports that some of the blisters have healed and left scars, but others are still growing, and new ones are appearing. Despite taking antibiotics prescribed by his doctor, the blisters have not improved. Upon examination, he has multiple superficial skin lesions and oral ulcers that easily slough off. A skin punch biopsy shows circular intra-epidermal deposits. What other condition is likely to be present in this patient?
Your Answer:
Correct Answer: Antibodies against desmosomes
Explanation:Understanding Autoimmune Blistering Conditions: Pemphigus Vulgaris and Bullous Pemphigoid
Pemphigus Vulgaris: Autoimmune Blistering Condition
Pemphigus vulgaris is an autoimmune blistering condition that primarily affects middle-aged patients. The condition is caused by Immunoglobulin G (IgG) autoantibodies against desmosomal components (desmogleins 1 and 3) of the superficial layers of the skin. This results in flaccid blisters that rupture easily, leading to erosions and scarring. The oral mucosa is often affected early, and Nikolsky’s sign is positive. Immunofluorescence reveals intra-epidermal circular deposits, and antibodies against desmosomes are usually positive. The condition requires aggressive treatment, with high-dose steroids initially used, and life-long maintenance doses often needed. Immunologicals are being trialled.
Bullous Pemphigoid: Another Autoimmune Blistering Condition
Bullous pemphigoid is another autoimmune blistering condition that typically affects older patients. The condition is caused by antibodies directed to the deeper basement membrane of the skin. This results in tense, firm, often haemorrhagic blisters that do not rupture easily. Oral lesions are rare, and Nikolsky’s sign is negative. Immunofluorescence reveals linear IgG and C3 deposits along the basement membrane of the skin, and antibodies against hemidesmosomes may be positive. The condition carries significantly less morbidity than pemphigus vulgaris, and topical steroid cream (ex: clobetasol propionate usually suffices).
No Link to Other Conditions
There is no link between pemphigus vulgaris or bullous pemphigoid and other conditions such as alopecia, positive HIV serology, or psoriasis. It is important to understand the differences between these autoimmune blistering conditions to ensure proper diagnosis and treatment.
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This question is part of the following fields:
- Dermatology
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Question 79
Incorrect
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A 4-year-old boy is brought to the doctor's office because of a rash on his upper arm. During the examination, the doctor observes several raised lesions that are approximately 2 mm in diameter. Upon closer inspection, a central dimple is visible in most of the lesions. What is the probable diagnosis?
Your Answer:
Correct Answer: Molluscum contagiosum
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.
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This question is part of the following fields:
- Dermatology
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Question 80
Incorrect
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A 50-year-old man is brought to the Emergency Department by his wife after developing a severe cutaneous hypersensitivity reaction. He has a history of rheumatoid arthritis for which he was taking non-steroidal anti-inflammatory drugs (NSAIDs). Still, his symptoms did not improve, and his rheumatologist prescribed him methotrexate a few days ago.
On examination, Nikolsky’s sign is present and affects 45% of his body’s surface area.
What is the underlying condition?Your Answer:
Correct Answer: Toxic epidermal necrolysis
Explanation:Common Skin Hypersensitivity Reactions and their Causes
Skin hypersensitivity reactions can range from mild to life-threatening. Here are some common types and their causes:
Toxic Epidermal Necrolysis: This is the most serious skin hypersensitivity reaction, with a high mortality rate. It is usually caused by drugs such as NSAIDs, steroids, methotrexate, allopurinol and penicillins.
Erythema Multiforme: This is a target-like lesion that commonly occurs on the palms and soles. It is usually caused by drugs such as penicillins, phenytoin, NSAIDs and sulfa drugs. Mycoplasma and herpes simplex infections can also cause erythema multiforme.
Erythema Nodosum: This is an inflammatory condition of subcutaneous tissue. The most common causes are recent streptococcal infection, sarcoidosis, tuberculosis and inflammatory bowel disease.
Fixed Drug Reaction: This is a localised allergic drug reaction that recurs at the same anatomic site of the skin with repeated drug exposure. It is most commonly caused by aspirin, NSAIDs, tetracycline and barbiturate.
Morbilliform Rash: This is a mild hypersensitivity skin reaction that manifests as a generalised maculopapular eruption that blanches with pressure. The rash can be caused by penicillin, sulfa drugs, allopurinol and phenytoin.
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This question is part of the following fields:
- Dermatology
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