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Question 1
Incorrect
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A 50-year-old man with a history of hypertension, psoriasis, and bipolar disorder visits his doctor complaining of a thick scaly patch on his right knee that appeared after starting a new medication.
Which of the following drugs is most likely responsible for exacerbating his rash?Your Answer: Methotrexate
Correct Answer: Lithium
Explanation:Lithium has been found to potentially worsen psoriasis symptoms.
Psoriasis can be worsened by various factors, including trauma, alcohol consumption, and certain medications such as beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs, ACE inhibitors, and infliximab. Additionally, the sudden withdrawal of systemic steroids can also exacerbate psoriasis symptoms. 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 steps to avoid or manage them as needed.
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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 16-year-old girl comes to your clinic complaining of cracked and peeling feet for the past 3 weeks. Her soles appear shiny and glazed, but her heels are not affected. The web spaces between her toes are also spared. What is the probable diagnosis?
Your Answer:
Correct Answer: Juvenile plantar dermatosis
Explanation:It is crucial to correctly diagnose juvenile plantar dermatosis as it can be misidentified as athlete’s foot, and therefore requires different treatment.
Juvenile plantar dermatosis is a prevalent condition that causes dry skin on the feet in children and adolescents, typically affecting those aged 3 to 14, although it can occur in individuals of any age. One key distinguishing factor is that juvenile plantar dermatosis spares the web spaces, whereas tinea pedis (athlete’s foot) commonly affects these areas.
The initial treatment for juvenile plantar dermatosis involves using moisturizing cream at night and barrier cream during the day. Additionally, patients can be advised to reduce friction by wearing well-fitting shoes, two pairs of cotton socks, and changing socks frequently.
Eczema typically presents as scaly, red patches in flexor creases, such as the elbow or knee.
Contact dermatitis may appear similar to juvenile plantar dermatosis, but there would be a history of exposure to a potential trigger.
In summary, accurately diagnosing juvenile plantar dermatosis is crucial to ensure appropriate treatment is provided, as it can be mistaken for other conditions such as athlete’s foot.
Understanding Athlete’s Foot
Athlete’s foot, medically known as tinea pedis, is a common fungal infection that affects the skin on the feet. It is caused by fungi in the Trichophyton genus and is characterized by scaling, flaking, and itching between the toes. The condition is highly contagious and can spread through contact with infected surfaces or people.
To treat athlete’s foot, clinical knowledge summaries recommend using a topical imidazole, undecenoate, or terbinafine as a first-line treatment. These medications work by killing the fungi responsible for the infection and relieving symptoms. It is important to maintain good foot hygiene and avoid sharing personal items such as socks and shoes to prevent the spread of the infection. With proper treatment and prevention measures, athlete’s foot can be effectively managed.
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This question is part of the following fields:
- Dermatology
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Question 3
Incorrect
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The community midwife has approached you regarding a patient she saw for her booking appointment that morning. The patient is a 22-year-old student who did not plan on becoming pregnant and is currently taking multiple prescribed medications. The midwife has requested that you review the medication list to determine if any of them need to be discontinued. The patient is taking levothyroxine for hypothyroidism, beclomethasone and salbutamol inhalers for asthma, adapalene gel for acne, and occasionally uses metoclopramide for migraines. She also purchases paracetamol over the counter for her migraines. She is believed to be approximately 8 weeks pregnant but is waiting for her dating scan.
Which of her medications, if any, should be stopped?Your Answer:
Correct Answer: Adapalene gel
Explanation:During pregnancy, it is not recommended to use topical or oral retinoids, including Adapalene gel, due to the risk of birth defects. Benzoyl peroxide can be considered as an alternative. Levothyroxine may need to be adjusted to meet the increased metabolic demands of pregnancy, and consultation with an endocrinologist may be necessary. beclomethasone inhaler should be continued to maintain good asthma control, unless there is a specific reason not to. Metoclopramide is generally considered safe during pregnancy and can be used if needed.
Acne vulgaris is a common skin condition that usually affects teenagers and is characterized by the obstruction of hair follicles with keratin plugs, resulting in comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the number and type of lesions present. Treatment for acne typically involves a step-up approach, starting with single topical therapy and progressing to combination therapy or oral antibiotics if necessary. Tetracyclines are commonly used but should be avoided in certain populations, and a topical retinoid or benzoyl peroxide should always be co-prescribed to reduce the risk of antibiotic resistance. Combined oral contraceptives can also be used in women, and oral isotretinoin is reserved for severe cases under specialist supervision. Dietary modification has no role in the management of acne.
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This question is part of the following fields:
- Dermatology
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Question 4
Incorrect
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A 14-year-old girl presents to the clinic with concerns about hair loss on her scalp. She has a history of atopic eczema and has depigmented areas on her hands. What is the most probable diagnosis?
Your Answer:
Correct Answer: Trichotillomania
Explanation:Co-Existence of Vitiligo and Alopecia Areata
This girl is experiencing a combination of vitiligo and alopecia areata, two conditions that can co-exist and have a similar autoimmune cause. Alopecia areata is highly suggested by the presence of discrete areas of hair loss and normal texture on the scalp. These conditions can cause significant emotional distress and impact a person’s self-esteem.
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This question is part of the following fields:
- Dermatology
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Question 5
Incorrect
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In what year was the shingles vaccination added to the routine immunisation schedule, and at what age is it typically administered?
Your Answer:
Correct Answer: Age 70
Explanation:The recommended age for receiving the shingles vaccine is 70, with only one dose required. Shingles is more prevalent and can have severe consequences for individuals over the age of 70, with a mortality rate of 1 in 1000.
Varicella-Zoster Vaccination: Protection Against Chickenpox and Shingles
Varicella-zoster is a herpesvirus that causes Chickenpox and shingles. There are two types of vaccines available to protect against these infections. The first type is a live attenuated vaccine that prevents primary varicella infection or Chickenpox. This vaccine is recommended for healthcare workers who are not immune to VZV and for individuals who are in close contact with immunocompromised patients.
The second type of vaccine is designed to reduce the incidence of herpes zoster or shingles caused by reactivation of VZV. This live-attenuated vaccine is given subcutaneously and is offered to patients aged 70-79 years. The vaccine is also available as a catch-up campaign for those who missed out on their vaccinations in the previous two years of the program. However, the shingles vaccine is not available on the NHS to anyone aged 80 and over because it seems to be less effective in this age group.
The main contraindication for both vaccines is immunosuppression. Side effects of the vaccines include injection site reactions, and less than 1 in 10,000 individuals may develop Chickenpox. It is important to note that vaccination is the most effective way to prevent varicella-zoster infections and their complications.
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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 68-year-old male is referred to dermatology for evaluation of a non-healing skin ulcer on his lower leg that has persisted for 8 weeks despite a course of oral flucloxacillin. What is the initial investigation that should be prioritized?
Your Answer:
Correct Answer: Ankle-brachial pressure index
Explanation:To rule out arterial insufficiency as a potential cause, it would be beneficial to conduct an ankle-brachial pressure index measurement. If the results are abnormal, it may be necessary to refer the patient to vascular surgeons.
If the ulcer doesn’t respond to active management, such as compression bandaging, it may be necessary to consider a biopsy to rule out malignancy and a referral should be made.
It is uncommon for non-healing leg ulcers to be caused by persistent infection.
Venous ulceration is a type of ulcer that is commonly found above the medial malleolus. To determine the cause of non-healing ulcers, it is important to conduct an ankle-brachial pressure index (ABPI) test. A normal ABPI value is between 0.9 to 1.2, while values below 0.9 indicate arterial disease. However, values above 1.3 may also indicate arterial disease due to arterial calcification, especially in diabetic patients.
The most effective treatment for venous ulceration is compression bandaging, specifically four-layer bandaging. Oral pentoxifylline, a peripheral vasodilator, can also improve the healing rate of venous ulcers. While there is some evidence supporting the use of flavonoids, there is little evidence to suggest the benefit of hydrocolloid dressings, topical growth factors, ultrasound therapy, and intermittent pneumatic compression.
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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 25-year-old male presents with a new skin rash, which appeared during his summer vacation spent hiking. He displays several pale brown patches on his neck, upper back, and chest. The patches seem slightly flaky but are not causing any discomfort. He is generally healthy. What is the most suitable initial treatment for this condition?
Your Answer:
Correct Answer: Ketoconazole shampoo
Explanation:Pityriasis versicolor is a skin condition caused by an overgrowth of Malassezia yeast, which commonly affects young males. It results in multiple patches of discolored skin, mainly on the trunk, which can appear pale brown, pink, or depigmented. The condition often occurs after exposure to humid, sunny environments.
According to NICE guidelines, the first-line treatment for pityriasis versicolor is either ketoconazole shampoo applied topically for five days or selenium sulphide shampoo for seven days (off-label indication). While topical antifungal creams like clotrimazole are effective, they are not typically used as first-line treatment unless the affected area is small due to their higher cost.
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 are commonly found on the trunk area. These patches may appear hypopigmented, pink, or brown, and may become more noticeable after sun exposure. Scaling is also a common feature, and mild itching may occur.
Pityriasis versicolor can affect healthy individuals, but it may also occur in people with weakened immune systems, malnutrition, or Cushing’s syndrome. Treatment for this condition typically involves the use of topical antifungal agents. According to NICE Clinical Knowledge Summaries, ketoconazole shampoo is a cost-effective option for treating large areas. If topical treatment fails, alternative diagnoses should be considered, and oral itraconazole may be prescribed.
In summary, pityriasis versicolor is a fungal infection that affects the skin’s surface. It is characterized by patches that may appear hypopigmented, pink, or brown, and scaling is a common feature. Treatment typically involves the use of topical antifungal agents, and oral itraconazole may be prescribed if topical treatment fails.
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This question is part of the following fields:
- Dermatology
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Question 8
Incorrect
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You are assessing a 28-year-old woman who has chronic plaque psoriasis. Despite trying various combinations of potent corticosteroids, vitamin D analogues, coal tar and dithranol over the past two years, she has seen limited improvement. Light therapy was attempted last year but the psoriasis returned within a month. The patient is feeling increasingly discouraged, especially after a recent relationship breakdown. As per NICE guidelines, what is a necessary requirement before considering systemic therapy for this patient?
Your Answer:
Correct Answer: It has a significant impact on physical, psychological or social wellbeing
Explanation:Referral Criteria for Psoriasis Patients
Psoriasis is a chronic skin condition that affects a significant number of people. According to NICE guidelines, around 60% of psoriasis patients will require referral to secondary care at some point. The guidance provides some general criteria for referral, including diagnostic uncertainty, severe or extensive psoriasis, inability to control psoriasis with topical therapy, and major functional or cosmetic impact on nail disease. Additionally, any type of psoriasis that has a significant impact on a person’s physical, psychological, or social wellbeing should also be referred to a specialist. Children and young people with any type of psoriasis should be referred to a specialist at presentation.
For patients with erythroderma or generalised pustular psoriasis, same-day referral is recommended. erythroderma is characterized by a generalised erythematous rash, while generalised pustular psoriasis is marked by extensive exfoliation. These conditions require immediate attention due to their severity. Overall, it is important for healthcare professionals to be aware of the referral criteria for psoriasis patients to ensure that they receive appropriate care and management.
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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 26-year-old female patient visits her general practitioner with a concern about excessive hair growth on her arms. She has a slim build and olive skin with dark brown hair. The patient shaves the hair to remove it. Her menstrual cycles are regular, occurring every 33 days, and she reports no heavy bleeding or pain. What is the probable diagnosis?
Your Answer:
Correct Answer: Genetic phenotype
Explanation:Excessive hair growth on the arms may be noticeable in this woman due to her genetic makeup, as she has olive skin and dark hair. However, hirsutism, which is characterized by excessive hair growth on the face and body, is often associated with polycystic ovarian syndrome. Although her menstrual cycle is regular at 33 days, it is important to note that a normal cycle can range from 24 to 35 days. A cycle variation of 8 days or more is considered moderately irregular, while a variation of 21 days or more is considered very irregular. Additionally, this patient has light periods and a slim physique.
Understanding Hirsutism and Hypertrichosis
Hirsutism is a term used to describe excessive hair growth in women that is dependent on androgens, while hypertrichosis refers to hair growth that is not androgen-dependent. Polycystic ovarian syndrome is the most common cause of hirsutism, but other factors such as Cushing’s syndrome, obesity, and certain medications can also contribute to this condition. To assess hirsutism, the Ferriman-Gallwey scoring system is often used, which assigns scores to nine different body areas. Management of hirsutism may involve weight loss, cosmetic techniques, or the use of oral contraceptive pills or topical medications.
Hypertrichosis, on the other hand, can be caused by a variety of factors such as certain medications, congenital conditions, and even anorexia nervosa. It is important to identify the underlying cause of excessive hair growth in order to determine the most appropriate treatment approach. By understanding the differences between hirsutism and hypertrichosis, individuals can better manage these conditions and improve their quality of life.
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This question is part of the following fields:
- Dermatology
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Question 10
Incorrect
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A 36-year-old woman presents with a 3-year history of recurrent painful pustules and nodules in both axillae. She frequently goes to the gym and initially attributed her symptoms to deodorant use, although there have been no signs of improvement since stopping these.
She doesn't take any regular medication and is allergic to macrolides.
Upon examination, there are numerous lesions in both axillae consisting of pustules and nodules, as well as sinus tract formation. Mild scarring is also evident.
What is the most suitable course of treatment?Your Answer:
Correct Answer: 3-6 month course of lymecycline
Explanation:To manage her hidradenitis suppurativa, which is a chronic follicular occlusive disorder affecting intertriginous areas, such as the axillae, groin, perineal and infra-mammary areas, long-term topical or oral antibiotics may be used. As she is experiencing severe symptoms with nodules, sinuses, and scarring, it would be appropriate to offer her long-term systemic antibiotics. Tetracycline is the first-line antibiotic, making lymecycline the correct answer. Macrolides, such as clarithromycin, can be offered as a second-line option, but she is allergic to this antibiotic. Oral fluconazole and ketoconazole shampoo are used to treat various fungal skin conditions, but hidradenitis suppurativa is not related to a fungal infection. Topical clindamycin can be effective in mild localised hidradenitis suppurativa, but this woman requires systemic treatment due to her severe bilateral symptoms.
Understanding Hidradenitis Suppurativa
Hidradenitis suppurativa (HS) is a chronic skin disorder that causes painful and inflammatory nodules, pustules, sinus tracts, and scars in intertriginous areas. It is more common in women and typically affects adults under 40. HS occurs due to chronic inflammatory occlusion of folliculopilosebaceous units that obstructs the apocrine glands and prevents keratinocytes from properly shedding from the follicular epithelium. Risk factors include family history, smoking, obesity, diabetes, polycystic ovarian syndrome, and mechanical stretching of skin.
The initial manifestation of HS involves recurrent, painful, and inflamed nodules that can rupture and discharge purulent, malodorous material. The axilla is the most common site, but it can also occur in other areas such as the inguinal, inner thighs, perineal and perianal, and inframammary skin. Coalescence of nodules can result in plaques, sinus tracts, and ‘rope-like’ scarring. Diagnosis is made clinically.
Management of HS involves encouraging good hygiene and loose-fitting clothing, smoking cessation, and weight loss in obese patients. Acute flares can be treated with steroids or antibiotics, and surgical incision and drainage may be needed in some cases. Long-term disease can be treated with topical or oral antibiotics. Lumps that persist despite prolonged medical treatment are excised surgically. Complications of HS include sinus tracts, fistulas, comedones, scarring, contractures, and lymphatic obstruction.
HS can be differentiated from acne vulgaris, follicular pyodermas, and granuloma inguinale. Acne vulgaris primarily occurs on the face, upper chest, and back, whereas HS primarily involves intertriginous areas. Follicular pyodermas are transient and respond rapidly to antibiotics, unlike HS. Granuloma inguinale is a sexually transmitted infection caused by Klebsiella granulomatis and presents as an enlarging ulcer that bleeds in the inguinal area.
Overall, understanding HS is crucial for early diagnosis and effective management of this chronic and painful skin disorder.
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This question is part of the following fields:
- Dermatology
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