Day 5 Derm

Question 1

A 45-year-old man presents to his general practitioner with a one-week history of a rash. He has recently returned from a holiday in Spain. He does not have any significant past medical history and does not take any regular medications.

On examination, there is a rash affecting his trunk, consisting of multiple hypopigmented patches, which are slightly scaly.

Based on the likely diagnosis, what is the appropriate treatment?

Answer 1

Ketoconazole shampoo is used to treat pityriasis versicolor

Question 2

A 72-year-old woman is diagnosed with a number of erythematous, rough lesions on the back of her hands.

What is the diagnosis?

What is the management?

Answer 2

actinic keratoses

Topical fluorouracil cream

Question 3

A 43-year-old woman comes for review. A few months ago she developed redness around her nose and cheeks. This is worse after drinking alcohol. She is concerned as one of her work colleagues asked her if she had a drink problem despite her drinking 10 units per week.

Answer 3

Acne rosacea features:

nose, cheeks and forehead

flushing, erythema, telangiectasia → papules and pustules

Question 4

A 36-year-old female with a history of ulcerative colitis She presented 4 days ago with a 3 cm lesion on her right shin which rapidly ulcerated and is now painful:

Answer 4

pyoderma gangrenosum

Oral prednisolone

Question 5

A 20-year-old lady is referred to the vascular clinic. She has been feeling generally unwell for the past six weeks. She works as a typist and has noticed increasing pain in her forearms whilst working.

• On examination she has absent upper limb pulses.
• Her ESR is measured and mildly elevated.

Answer 5

The correct answer is: Takayasu’s arteritis

Takayasus arteritis may be divided into acute systemic phases and the chronic pulseless phase.

In the latter part of the disease process the patient may complain of symptoms such as upper limb claudication.

In the later stages of the condition the vessels will typically show changes of intimal proliferation, together with band fibrosis of the intima and media.

Question 6

A 28-year-old Caucasian male presents with itchy red spots on is abdomen, back and arms, which he reports appeared quite suddenly.

He has no significant past medical history, but states he had a sore throat a few weeks ago.

On examination, you notice he has a white pus-like discharge over his palatine tonsils.

He states that he a similar rash last winter, when he had a sore throat.

Answer 6

Streptococcal throat infection may precipitate psoriasis (particularly guttate psoriasis). Patients with frequent exacerbations of guttate psoriasis due to streptococcal throat infections may benefit from tonsillectomy

Question 7

A 32-year-old female presents to her general practitioner with worsening blistering of the fingers and palms of both hands. She has a past history of blistering and fissuring of her hands and recently returned from a holiday in a foreign country with a hot, humid environment. Examination identifies numerous areas of irritable, erythematous vesicles on the palms of both hands.

What is the most likely diagnosis?

Answer 7

Pompholyx eczema may be precipitated by humidity (e.g. sweating) and high temperatures

Question 8

A 68-year-old farmer presents with a skin lesion on his forehead.

It has been present for the past 6 months and has grown slightly in size during that time.

On examination he has an ulcerated lesion with pearly white raised edges that measures 2cm in diameter.

Answer 8

The correct answer is: Basal cell carcinoma

The raised pearly edges in an ulcerated lesion at a sun exposed site makes BCC most likely.

Question 9

A 25-year-old man presents with a pruritic skin rash. This has been present for the past few weeks and has responded poorly to an emollient cream. The pruritus is described as ‘intense’ and has resulted in him having trouble sleeping. On inspecting the skin you notice a combination of papules and vesicles on his buttocks and the extensor aspect of the knees and elbows. What is the most likely diagnosis?

Answer 9

Dermatitis herpetiformis

Dermatitis herpetiformis is an autoimmune blistering skin disorder associated with coeliac disease. It is caused by deposition of IgA in the dermis.

Question 10

A 79-year-old woman presents with an itchy, blistering rash. Examination of her mouth is unremarkable.

Answer 10

Bullous pemphigoid

Blisters/bullae

• no mucosal involvement (in exams at least*): bullous pemphigoid
• mucosal involvement: pemphigus vulgaris

Question 11

What is Wegeners?

Answer 11

It is an autoimmune condition associated with necrotizing granulomatous vasculitis, affecting both the upper and lower respiratory tract as well as the kidneys.

Granulomatosis with polyangiitis is now the preferred term for Wegener’s granulomatosis.

Question 12

A 30-year-old man presents with a two-week history of a productive cough.

Whilst examining him you notice a large number of atypical naevi over his torso.

On his back you count between 20-25 moles. He reports no change in any of his moles, no bleeding and no itch.

One particular mole is noted due to the irregular border. It is 6 * 4 mm in size.

Answer 12

This is very likely to be a melanoma and the patient should be fast-tracked to dermatology.

Due to the location and the number of moles he has it is unlikely that he would have noticed any change

Question 13

A 52-year-old Afro-Caribbean woman presents to the dermatology department.

She has noticed a patch of pigmented skin on her toe, which has been slowly enlarging over the past five months.

On examination, she has pigmentation of the nail bed of her great toe, affecting the adjacent cuticle and proximal nail fold.

Which subtype of melanoma would you expect to present in this manner?

Answer 13

Acral lentiginous melanoma: Pigmentation of nail bed affecting proximal nail fold suggests melanoma (Hutchinson’s sign)

Question 14

A 35-year-old male presents with the rash shown below, which has been over the past 2 months.

It is intensely itchy.

Answer 14

This patient has an itchy rash that most closely resembles dermatitis herpetiformis. Dermatitis herpetiformis is most commonly caused by coeliac disease; therefore, is treated with a gluten-free diet.

Question 15

A 40-year-old woman visits the GP with a two-month history of unintentional weight loss. She reports feeling more fatigued than usual but otherwise has no localising signs or symptoms. On examination, hyperpigmentation and thickening of the skin in her groin and axilla are noted; the patient believes this has also been present for approximately 2 months.

Which malignancy is most associated with this presentation?

Answer 15

The most common malignancy associated with acanthosis nigricans
is gastrointestinal adenocarcinoma

Question 16

A 48-year-old male presents after a month after a holiday to Morocco with a burn across his cheeks and nose which he says is not getting any better. He says that he wore sun-screen on holiday and does not usually get sun-burnt.

On examination there is a uniform area of erythema across the bridge of his nose and extending across his cheeks. Upon this erythema you note there are about a dozen small pustules and papules. Lastly, you note the presence of superficial telangiectasia across the bridge of the nose and a small amount around the labia of the nose.

What treatment is indicated here?

Answer 16

Acne rosacea treatment:

mild/moderate: topical metronidazole

severe/resistant: oral tetracycline

Question 17

What is the most likely diagnosis?

Answer 17

Plaque psoriasis

the most common sub-type resulting in the typical well-demarcated red, scaly patches affecting the extensor surfaces, sacrum and scalp

Question 18

A 34-year-old man who is known to have HIV presents with a non-itchy skin eruption on his lower abdomen. He feels otherwise well and has had no similar ‘rashes’ previously.

Answer 18

Molluscum contagiosum is a common skin infection caused by molluscum contagiosum virus (MCV), a member of the Poxviridae family.

Transmission occurs directly by close personal contact, or indirectly via fomites (contaminated surfaces) such as shared towels and flannels.

The majority of cases occur in children (often in children with atopic eczema), with the maximum incidence in preschool children aged 1-4 years.

Question 19

What is the diagnosis?

Which medication is contraindicated?

Answer 19

Perioral dermatitis can be made worse by topical steroids

Question 20

A 63-year-old gentleman presents to his general practitioner.

He has recently been diagnosed with melanoma after being referred to the dermatologist with a suspicious red lump on his face.

He is awaiting further imaging to see if the melanoma has metastasised.

After being told his subtype of melanoma, he researched further online.

He is now very concerned as he has read that his subtype is the most aggressive subtype and that it metastasises early. Which subtype of melanoma is he likely to have?

Answer 20

Nodular melanoma: Invade aggressively and metastasise early

• Sun exposed skin, middle-aged people
• Red or black lump or lump which bleeds or oozes
• Second commonest

Question 21

A 42-year-old man is reviewed by his dermatologist for ongoing psoriasis. He was diagnosed several years ago and has had recurrent bouts since then. Recently, he has just completed a 4-week course of topical betamethasone and calcipotriol to bring the latest flare-up under control.

Given the frequency of flare-ups, the dermatologist suggests starting a long-term regime to keep his psoriasis under control.

Which of the following would be suitable long-term?

Answer 21

Calcipotriol may be used on a long-term basis for psoriasis

Question 22

Most important factor affecting rognosis of melanoma

Answer 22

The invasion depth of a tumour (Breslow depth) is the single most important factor in determining prognosis of patients with malignant melanoma

Question 23

A 47-year-old woman is brought into the Emergency Department with an erythematous rash that has come on over the last 2 days. On examination, the rash covers an extensive area of her body and has a red, ‘scalded’ appearance. She has ulcerations in her mouth. She looks very unwell and her temperature is 38.2ºC.

She is currently too unwell to give a good history, but her brother is with her and gives you her current medications from her bag.

Given the likely diagnosis, what medication is the most likely cause?

Answer 23

Toxic epidermal necrolysis is a rare but important side effect of which to be aware of penicillins

This woman has toxic epidermal necrolysis (TEN). Over 100 drugs have been noted as causes of TEN/Steven Johnson syndrome,

but the ones that most commonly cause it include penicillins, quinolones, sulfonamides, corticosteroids and NSAIDs.

Question 24

A 7-year-old girl is admitted to the emergency department with several partial thickness burns on her left foreman, abdomen and right thigh.

She is stable. Analgesia is given, and the wounds are cleaned and dressed.

What is the most accurate way to asses the percentage body surface area affected of the girl?

Answer 24

Lund and Browder chart is the most accurate way to asses the burns area

Question 25

A 41-year-old woman requests a repeat prescription for citalopram. She also mentions she is constantly itchy and bruises easily. On examination she has reddened palms and a distended abdomen

Answer 25

Iron deficiency anaemia

Question 26

Different types of melanoma | (4)

Answer 26

Superficial spreading Nodular Lentigo maligna Acral lentiginous

Question 27

A 29-year-old man presents with a rash on his trunk. Around two weeks ago he describes developing a patch of 'eczema' on his torso the size of 50 pence piece. Around a week later a number of smaller, red patches started to appear as well: He feels systemically well and has no history of note. What is the most likely diagnosis?

Answer 27

The earlier lesion represents a **classical herald patch**. **Guttate psoriasis** is generally has a more homogenic, 'teardrop' appearance with a more pronounced scale. This image demonstrates the 'fir tree' appearance often seen in patients with pityriasis rosea.

Question 28

A woman who is 24 weeks pregnant presents with a rash:

Answer 28

* Pemphigoid gestationis * The blistering lesions are clearly visible on this image

Question 29

A 52-year-old man asks you to look at the side of his tongue. The white patches have been present for the past few months and are asymptomatic. He is a smoker who is known to have type 2 diabetes mellitus.

Answer 29

Leukoplakia is a premalignant condition which presents as white, hard spots on the mucous membranes of the mouth. It is more common in smokers.

Question 30

What is excoriation?

Answer 30

Skin picking

Question 31

A 43-year-old lady presents to the dermatology department with an evolving lesion on her right lower leg. She first noticed the lesion 4 months ago, and it has increased in size and changed in colour during this time. On examination, she has a 2cm by 1.5 cm asymmetrical pigmented lesion, comprised of several shades of brown. She has Fitzpatrick skin type II and uses sunbeds approximately every 4 months. What is this lesion most likely to be?

Answer 31

Superficial spreading melanoma: Most common type of melanoma that has the typical diagnostic features of a changing mole

Question 32

You are seeing a 32 week pregnant woman in the GP surgery. She has widespread rash on her body with periumbilical sparing. What is the most likely diagnosis?

Answer 32

One of the main clinical features of polymorphic eruption in pregnancy is periumbilical sparing

Question 33

What is Bowen's disease

Answer 33

Bowen's disease is a type of precancerous dermatosis that is a precursor to squamous cell carcinoma. It is more common in elderly patients. There is around a 5-10% chance of developing invasive skin cancer if left untreated.

Question 34

You review a 24-year-old man who has recently presented with large psoriatic plaques on his elbows and knees. He has no history of skin problems although his mother has psoriasis. You recommend that he uses an emollient to help control the scaling. What is the most appropriate further prescription to use as a first-line treatment on his plaques?

Answer 34

Topical steroid + topical calcipotriol

Question 35

Venous ulceration is most characteristically seen above the:

Answer 35

Medial malleolus

Question 36

An 11-year-old girl is brought to the Emergency Department by her parents after the sudden appearance of widespread blistering, sore mouth and skin tenderness. She also has a three-day history of high fevers and malaise. She has no past medical history except amoxicillin for an ear infection two weeks ago. She appears systemically unwell with a temperature 39.2ºC, heart rate 187 bpm, blood pressure 100/54 mmHg, respiratory rate 22 /min and SpO2 98%. On examination, there are widespread erythematous bullae and vesicles covering almost half the body surface. Lesions are also present on the oral mucosa and beginning to affect the eyes. Nikolsky's sign is positive. What is the most likely diagnosis?

Answer 36

Toxic epidermal necrolysis is a rare but important side effect of which to be aware of penicillins

Question 37

A 56-year-old gentleman presents to the dermatology clinic. Over the last few weeks, he has noticed a new, enlarging lesion on his cheek which sometimes bleeds. On examination, he has Fitzpatrick skin type I, multiple melanocytic naevi over his body, and the lesion in question is a large, black, dome-shaped lump, of 1cm diameter, located on his right cheek. What is this lesion most likely to represent?

Answer 37

Nodular melanoma: Red or black lump, oozes or bleeds, sun-exposed skin

Question 38

A 25-year-old woman presents to her GP with **chronic shortness of breath**. She **occasionally coughs up small quantities of blood** and **small quantities of clear sputum**. She has no chest pain and denies feeling feverish. On examination, her heart rate is 70/min, respiratory rate 20/min, sats 93%, blood pressure 120/80mmHg and temperature 36.8ºC. **There are a number of very small telangiectases on the lips.** Which of the following symptoms is she most likely to have experienced?

Answer 38

Hereditary haemorrhagic telangiectasia: can cause pulmonary, hepatic, cerebral and spinal AVMs Epistaxis

Question 39

A 4-year-old girl is brought to surgery by her mother who has noticed a number of small 'spots' and 'bruises' on her legs that have developed over the past 2-3 days. She initially thought this was due to an allergy but it has not gone away. Her daughter is described as being well apart from a cough she's had for the past 2 weeks. On examination, she is apyrexial with a heart rate of 96/min. Examination of her ears, throat and chest is normal. There is no neck stiffness or abdominal masses. A number of petechiae are seen around her chest area as well as purpura on her lower legs and arms. What is the most appropriate action?

Answer 39

Children with new-onset purpura should be referred immediately for investigations to exclude ALL and meningococcal disease

Question 40

A 78-year-old man presents to the GP with a very painful ulcer on his leg, which began as a tender, raised nodule some time before. On examination, the GP notes a large ulcer on the calf, which has an **overhanging blue edge** and a **purulent appearance** on its surface. It is exquisitely tender to gentle palpation. He has had several episodes of illness over the last few months. He has also noticed some weight loss, and that his dentures no longer fit as his gums are swollen. His wife agrees that her husband has been looking pale and 'under the weather' for about a month, and is eating less at mealtimes.

Answer 40

**Pyoderma gangrenosum** is associated not only with IBD and RA but also with myeloproliferative disorders and AML

Question 41

A 32-year-old female enters the clinic with a 3-week history of a mild rash on her face. She explains how it is very sensitive to the sunlight and has been wearing hats for protection. She is two months postpartum and has no past medical history of note. On examination, there is an erythematous rash with superficial pustules affecting the forehead, nose and cheeks. Which of the following would best treat the underlying condition?

Answer 41

Acne rosacea features: ## Footnote nose, cheeks and forehead flushing, erythema, telangiectasia → papules and pustules

Question 42

A 21-year-old female has been suffering from well demarcated red, scaly lesions on her elbow and knees for the past few years. She is treated for her condition with corticosteroids and vitamin D. What is the condition? Which of the following drugs would most likely exacerbate her underlying condition?

Answer 42

plaque psoriasis

Question 43

A 47-year-old man presents to the general practitioner with a 6-month history of a chronic erythematous rash of the central face associated with papules. The rash is aggravated by sun exposure. He has a past medical history of gastro-oesophageal reflux disease, no allergies and has never sought medical assistance for this condition before. Which management option would be considered first-line in this patient?

Answer 43

Acne rosacea treatment: ## Footnote mild/moderate: topical metronidazole severe/resistant: oral tetracycline

Question 44

You are working in general practice and see a 24-year-old male with a likely diagnosis of pityriasis rosea. What most commonly precedes this condition?

Answer 44

Pityriasis rosea often follows a viral infection

Question 45

A 62-year-old man presents with a lesion on the right side of his nose. He is unsure how long it has been there.

Answer 45

The rolled, pearly edges with telangiectasia surrounding a central crater make basal cell carcinoma the most likely diagnosis.

Question 46

A 27-year-old man comes to see you as he has just returned from a beach holiday in Turkey and has noticed pale white patches on his neck and back. They are circular in shape and slightly itchy. Which one of the following is the most likely diagnosis?

Answer 46

Pityriasis versicolor is a superficial cutaneous fungal infection caused by Malassezia furfur which usually presents on the trunk or back and is scaly is appearance.

Question 47

A 3-year-old girl is taken to the GP due to a rash on her upper arm. On examination multiple raised lesions of about 2 mm in diameter are seen. On close inspection a central dimple is present in the majority of lesions. What is the likely diagnosis?

Answer 47

Molluscum contagiosum is a common skin infection caused by molluscum contagiosum virus (MCV), a member of the Poxviridae family.

Question 48

A 60-year-old man asks you to have a look at a 'sore' on his right ear. It has been present for around 6 months and is not painful. What is the most likely diagnosis?

Answer 48

Actinic keratoses * small, crusty or scaly, lesions * may be pink, red, brown or the same colour as the skin * typically on sun-exposed areas e.g. temples of head * multiple lesions may be present

Question 49

The parents of an 8-year-old girl have noticed a small growth on the sole of her foot for the last 3 months that has become painful. On examination, there is a small, firm, hyperkeratotic growth with tiny overlying black dots.

Answer 49

The correct answer is: Salicylic acid This child has a plantar wart, also known as a verruca. The tiny black dots are caused by thrombosed capillaries. They often self-resolve, but if treatment is desired, topical salicylic acid (15–50%) applied daily for up to 12 weeks can be tried.

Question 50

A 67-year-old man presents in general practice with a new itchy rash that he has had for a 'couple of weeks'. On examination, **the rash is purple, raised, and has fine white lines** on the surface. Inside the mouth, the patient has white striae on the oral mucosa which you identify as **Wickham striae**. Given the likely diagnosis, what medication is the first-line management for this?

Answer 50

Potent topical steroids are the first-line treatment for **lichen planus**

Question 51

A 19-year-old female who has just started work as a **cleaner presents with a rash on her hands.** On examination there is a **generalised erythematous rash on the dorsum of both hands.** There is no evidence of scaling or vesicles. What is the most likely diagnosis?

Answer 51

The strong alkalis and acids found in cleaning solutions are common triggers of **irritant contact dermatitis**

Question 52

A 23-year-old woman presents to the general practitioner with a worsening rash on her face and upper back which is causing a significant impact on her self confidence. She is currently five months pregnant and describes experiencing similar lesions during her teenage years. She is otherwise well with no allergies. The rash has not responded to topical benzoyl peroxide. Examination identifies numerous erythematous papules and pustules distributed across the patient's face and upper back. Which of the following management options is most appropriate?

Answer 52

Acne vulgaris in pregnancy - use oral erythromycin if treatment needed

Question 53

An 84-year-old woman with a history of ischaemic heart disease is reviewed in a nursing home. She has developed tense blistering lesions on her legs. Each lesion is around 1 to 3 cm in diameter and she reports that they are slightly pruritic. Examination of her mouth and vulva is unremarkable. What is the most likely diagnosis?

Answer 53

Blisters/bullae ## Footnote no mucosal involvement (in exams at least\*): bullous pemphigoid mucosal involvement: pemphigus vulgaris

Question 54

A 40-year-old man complains of widespread pruritus for the past two weeks. The itching is particularly bad at night. He has no history of note and works in the local car factory. On examination he has noted to have a number of linear erythematous lesions in between his fingers. What is the most likely diagnosis?

Answer 54

Scabies

Question 55

A 54-year-old lady attends with a rash. She describes a facial rash present for several weeks associated with flushing. On examination, there is erythematous **papulopustular** rash with telangiectasia across both cheeks and nose. Given the likely diagnosis, which associated complication may she also have?

Answer 55

Acne rosacea * chronic skin condition which causes persistent facial flushing, erythema, telangiectasia, pustules, papules and rhinophyma * It can also affect the eyes causing **blepharitis, keratitis, conjunctivitis** * It is treated with topical antibiotics e.g. metronidazole gel or oral tetracycline (especially if ocular symptoms).

Question 56

A 29-year-old woman who is 24 weeks pregnant presents to the antenatal clinic with a **worsening rash on her legs**. She had initially noticed multiple small red rounded lumps on both her lower legs. **The lesions initially measured 3cm in diameter and have been slowly growing in size over the past two weeks.** The lesions now range between **6-9cm nodules** on both her shins which were becoming painful. This is her second pregnancy and she denied experiencing a similar rash before. **What is the likely cause for the rash in this case?**

Answer 56

**Erythema nodosum** may be caused by pregnancy

Question 57

A 30-year-old male develops an intensely itchy rash over his shins and knees over a course of 3 months. He has also noticed some weight loss recently but reports no other symptoms.

Answer 57

This patient has characteristic **dermatitis herpetiformis**. This is characterised by intense itchy bumps and blisters in a rash-like form. This condition is closely related to **coeliac disease**, a potential cause of this patient's weight loss. Dermatitis herpetiformis rash is diagnosed by skin biopsy which shows a granular pattern of **IgA deposition**.

Question 58

A 58-year-old woman presents with facial redness. This has been worsening since her holiday to Spain but she is otherwise asymptomatic. She has a background of hypertension and takes amlodipine 5mg OD. She has no allergies and has not started any new medications recently. On examination, telangiectasia are present with papules and pustules clustered around her nose and cheeks. She is afebrile. What is the most likely diagnosis?

Answer 58

Acne rosacea features: ## Footnote nose, cheeks and forehead flushing, erythema, telangiectasia → papules and pustules

Question 59

Features of guttate psoriasis | (3)

Answer 59

* Classically preceded by a streptococcal sore throat 2-4 weeks * 'Tear drop', scaly papules on the trunk and limbs * Most cases resolve spontaneously within 2-3 months

Question 60

Features of BCC | (3)

Answer 60

* sun-exposed sites, especially the head and neck account for the majority of lesions * initially a pearly, flesh-coloured papule with telangiectasia * may later ulcerate leaving a central 'crater' Basal cell carcinoma (BCC) is one of the **three main types of skin cancer.** Lesions are also known as **rodent ulcers** and are characterised by **slow-growth and local invasion.** **Metastases are extremely rare**. BCC is the most common type of cancer in the Western world.

Question 61

What is the most common malignancy associated with acanthosis nigricans?

Answer 61

The most common malignancy associated with acanthosis nigricans is **gastrointestinal adenocarcinoma**

Question 62

A 32-year-old man is involved in a house fire and sustains extensive partial thickness burns to his torso and thigh. Two weeks post operatively he develops oedema of both lower legs. The most likely cause of this is:

Answer 62

Loss of plasma proteins is the most common cause of oedema developing in this time frame.

Question 63

A 72 year-old woman presents to the GP with an itchy, sore white plaque on her vulva. The patient has a past medical history of type 1 diabetes and no personal or family history of cancer. What is the most likely diagnosis?

Answer 63

This patient has the characteristic description of lichen sclerosus which is more commonly seen in elderly women. Diagnosis is made on clinical findings. Lichen sclerosus is associated with other autoimmune conditions and as such the history of type 1 diabetes is relevant. **Management** * topical steroids and emollients

Question 64

A 68-year-old Caucasian man presents with a lesion on his scalp for the last 6 weeks. It has gradually increased in size and is associated with discomfort and some bleeding. He has a history of a renal transplant 10 years ago, type 2 diabetes mellitus and hypertension. There is no family history of skin cancer. On examination, there is a non-pigmented indurated plaque on the scalp with surrounding inflammation. What is the most likely diagnosis?

Answer 64

Renal transplant patients - skin cancer (particularly squamous cell) is the most common malignancy secondary to immunosuppression

Question 65

A 72-year-old man presents with a large nodule on his face. It is friable. There is no regional lymphadenopathy. He is lost to follow up and re-attends several months later. On this occasion the lesion has been noted to resolve with scarring.

Answer 65

The correct answer is: Keratoacanthoma Keratoacanthomas may reach a considerable size prior to sloughing off and scarring.

Question 66

A 76-year-old man has a longstanding patch of rough, itchy skin on his scalp which has not changed in size. On examination, there is a 1cm area of erythema and some scaling which is rough in texture, with evidence of surrounding sun damage. There is no ulceration or bleeding.

Answer 66

The correct answer is: Diclofenac This man likely has an actinic keratosis, a common hyperkeratotic lesion that arises on areas of skin that have had long-term cumulative sun exposure. There are no features to suggest that it has transformed into a squamous cell carcinoma. There are a variety of topical treatments, of which diclofenac is the only available option from the list above. Alternatives include 5-fluorouracil and imiquimod.

Question 67

You are working in general practice and see a 17-year-old girl with a 8-day history of a lesion on her lower torso. This is a single 3cm oval plaque, pink in colour, with a scale trailing just inside the edge of the lesion. She has then had a subsequent 2-day history of generalised, non-pruritic, rash down her torso. This rash consists of lots of fine scales patches and plaques which follow the pattern of langer's lines. What is the most likely diagnosis?

Answer 67

Pityriasis can initially present with a herald patch

Question 68

A 39-year-old woman presents to her GP with a history of painful fingers and ankles. These symptoms have come on steadily and she didn't want to come to the GP, but now is worried as her left ring finger has become swollen 'like a sausage' and is very painful. She otherwise feels well. Past medical history includes polycystic ovarian syndrome, psoriasis, depression and a previous excision of a Wilms' tumour as a child. On examination of her hands, she has tender swellings at the distal interphalangeal joints. Her left ring finger is diffuse swollen downs it length and is tender to touch. Given the most likely diagnosis, which of the following is most likely to be present?

Answer 68

The vast majority of patients with psoriatic arthropathy will have nail changes such as onycholysis

Question 69

A 54-year-old man presents with a lesion on his forearm. This has been slowly developing over the past 2-3 months and has bled on one occasion. His past medical history includes Alport syndrome for which he had a renal transplant ten years ago. He currently takes ciclosporin as immunosuppression. He also takes ramipril and amlodipine for hypertension. The lesion is shown below:

Answer 69

The clue here is immunosuppression. Patients on ciclosporin and other immunosuppressants have a much higher risk of **squamous cell carcinoma**.

Question 70

A 25-year-old man presents with a widespread rash over his body. The torso and limbs are covered with multiple erythematous lesions less than 1 cm in diameter which in parts are covered by a fine scale. You note that two weeks earlier he was seen with a sore throat when it was noted that he had exudative tonsillitis. Other than a history of asthma he is normally fit and well. What is the most likely diagnosis?

Answer 70

Guttate psoriasis is more common in children and adolescents. It may be precipitated by a streptococcal infection 2-4 weeks prior to the lesions appearing. **Features** ## Footnote tear drop papules on the trunk and limbs

Question 71

A 22-year-old man presents to the GP with a mass on his lower back. On examination, there is a 6cm mobile rubbery mass on his lower back just lateral and superior to the sacrum. The mass is not painful and there are no accompanying symptoms. **Which of the following is the next best step in the management of this patient?** **What is the most likely diagnosis?**

Answer 71

**lipoma** Ultrasound is not neccesary in a **lipoma** diagnosis unless \> 5cm

Question 72

A 72-year-old man is investigated for weight loss. On examination he is deeply jaundiced and cachectic. He also has a dark velvety lesion coating his tongue.

Answer 72

The correct answer is: Acanthosis nigricans Acanthosis nigricans may be associated with GI malignancies such as gastric and pancreatic cancer.

Question 73

A 62-year-old man asks you to look at a lesion on his face:

Answer 73

Keratoacanthoma is a benign epithelial tumour. They are more common with advancing age and rare in young people. Features - said to look like a volcano or crater ## Footnote initially a smooth dome-shaped papule rapidly grows to become a crater centrally-filled with keratin

Question 74

This 17-year-old man has a history of asthma and eczema but is normally fit and well. Yesterday he developed a rash on face which extends down to his torso. He feels generally unwell with flu-like symptoms.

Answer 74

**Eczema herpeticum** describes a severe primary infection of the skin by herpes simplex virus 1 or 2.

Question 75

A 59-year-old patient presents to dermatology outpatients clinic with a three-month history of discolouration of the skin on his back. On examination, there are patchy areas of mild hypopigmentation covering large areas of the back. You suspect a diagnosis of pityriasis versicolor. What is the likely causative organism?

Answer 75

Pityriasis versicolor is caused by Malassezia furfur

Question 76

A 23-year-old woman is seen in the dermatology clinic with a 3-month history of an intensely itchy rash over her hands and feet. She has been working as a veterinarian’s assistant for the last 9 months and there is no clear trigger for her symptoms. She finds the itching is exacerbated on hot days, particularly during her holiday to Spain 4 weeks ago. There is no past medical history of note and she has no known allergies. There is a family history of atopic eczema. On examination, she has sweaty palms. There is a vesicular rash over her plantar and palmar surfaces. The surrounding skin is erythematous. What is the most likely diagnosis?

Answer 76

Pompholyx eczema is a subtype of eczema characterised by an intensely pruritic rash on the palms and soles

Question 77

A 33-year-old patient comes to see you as she has noticed an itchy rash on both elbows. It has been worsening for the past week. On examination, you see a multiple polygonal, flat-topped papular lesions that each measure 5mm diameter on the flexural surface of her elbows, bilaterally. She has no other rash on the rest of her body. Which one of the following is the most likely diagnosis?

Answer 77

**Lichen planus** is an itchy, papular rash which most commonly occurs on the palms, soles, genitalia and flexor surfaces of the arms.

Question 78

A 15-year-old female presents to ambulatory care with a painful pruritic rash that has rapidly worsened over the last 10 hours. Her past medical history includes atopic dermatitis treated with emollients and hayfever. On examination, she has a monomorphic rash with punched out erosions over her cheeks and bilateral dorsal wrists. Which of the following is the most likely implicated pathogen?

Answer 78

She should be admitted for IV antivirals and observation. HSV, Eczema herpeticum

Question 79

A 52-year-old woman presents with pruritus and lethargy. She has recently put on weight and is complaining about dry skin

Answer 79

Hypothyroidism

Question 80

Features of allergic contact dermatitis | (4)

Answer 80

* type IV hypersensitivity reaction. * Uncommon - often seen on the head following hair dyes. * Presents as an acute weeping eczema which predominately affects the margins of the hairline rather than the hairy scalp itself. * Topical treatment with a potent steroid is indicated

Question 81

You are on the morning ward round with your consultant on the labour ward. You come across a patient who has just given birth to a healthy baby boy. You notice several excoriated nodules on her face and neck. What is the likely cause of the presented dermatosis?

Answer 81

The most common dermatosis in pregnancy is atopic eruption of pregnancy

Question 82

During a 6-week baby check, you notice a flat, 30x20mm, pink-coloured, vascular skin lesion over the nape of the baby's neck, which blanches on pressure. On further questioning, this area has been present since birth and has not changed significantly. They are developing normally. What is the most likely underlying diagnosis?

Answer 82

Salmon patches are a vascular birthmark which usually self resolve

Question 83

A 4-year-old boy develops multiple tear-drop papules on his trunk and limbs. He is otherwise well. What is the most likely diagnosis? What is the most appropriate management?

Answer 83

guttate psoriasis *guttate - ressembling drops* Reassurance + topical treatment if lesions are symptomatic

Question 84

A 32 year-old builder presents with sore and itchy skin on his hands and wrists. He has noticed it gets better when he is not in work and wonders if it is something he is coming into contact with at work causing the irritation. Which of the following tests could best further investigate this theory?

Answer 84

Contact dermatitis

Question 85

Features of squamous cell carcinoma

Answer 85

Chronic exposure to ultraviolet rays is the most important risk factor. It can appear as thick, rough, scaly patches that may crust or bleed. They can also resemble warts or open sores that don’t completely heal. This description does not match the patient's presentation, additionally, the fact that in the beginning, it appeared as a pearly, flesh-coloured papule with telangiectasia, point more towards a basal cell carcinoma.

Question 86

An 8-year-old boy is brought to the GP by his father following a 2-week history of persistent itch. On examination, you note that the child is scratching his wrists, and you can see linear burrows present on the flexor aspects of his left wrist. Given the likely diagnosis, what is the most appropriate first-line treatment?

Answer 86

Permethrin is the treatment of choice for scabies

Question 87

These skin lesions have been present for the past year. What is the most likely diagnosis?

Answer 87

Actinic keratoses Actinic, or solar, keratoses (AK) is a common premalignant skin lesion that develops as a consequence of chronic sun exposure

Question 88

A 61-year-old man presents with pruritus. He has had recurrent episodes of painful swelling in the MTP joints and a history of peptic ulcer disease. On examination he has a 'ruddy' complexion

Answer 88

Polycythaemia

Question 89

Features of Pityriasis rosea

Answer 89

* Many patients report recent respiratory tract infections but this is not common in questions * Herald patch followed 1-2 weeks later by multiple erythematous, slightly raised oval lesions with a fine scale confined to the outer aspects of the lesions. * May follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer. This may produce a 'fir-tree' appearance * Self-limiting, resolves after around 6 weeks

Question 90

A 75-year-old man presents with a 'sore' on his lip. This has been present for around four months and has been getting slowly worse. His past medical history includes ischaemic heart disease and chronic obstructive pulmonary disease. He still smokes around 20 cigarettes per day

Answer 90

**Squamous cell carcinoma** Squamous cell carcinoma is a common variant of skin cancer. Metastases are rare but may occur in 2-5% of patients.

Question 91

A mother brings her 2-week-old baby girl into the surgery for review. She has noted a bright red, well-circumscribed and lobulated lesion developing on her right temple. This wasn't noted at birth but is now 5 mm in diameter. What is the most appropriate management?

Answer 91

This baby has a strawberry naevus. Treatment is only usually required if the lesion is causing a mechanical problem or bleeding. Starting treatment such as propranolol would also clearly not be appropriate at 2 weeks of age.

Question 92

A 29-year-old man presents with a lump in his scalp. It feels smooth and slightly fluctuant and has a centrally located small epithelial defect. What is the most likely underlying diagnosis?

Answer 92

Sebaceous cysts are most frequently located in the scalp and have an associated central punctum.

Question 93

A 17-year-old girl comes to see you at the GP surgery. She complains of excess hair. On examination she has a very fine layer of s**oft un-pigmented hair that covers her entire body**, apart from her palmar and plantar surfaces. From the list below, what is the most likely cause?

Answer 93

**Malnutrition** This question provides an example of a patient with '**lanugo hair**'. This is generally found in newborn babies and those with chronic malnutrition. It is an important sign to remember as it can be found in patients with anorexia nervosa.

Question 94

An 82-year-old patient attends her GP surgery due to a rash that has developed over her anterior thighs in the past 3 weeks. She states that it is not painful or itchy but she is concerned as it does not blanch with the application of the 'glass test'. She states that she has had some flu-like symptoms recently so has spent much of her time in her chair under many blankets and with a hot water bottle on her lap. On examination, you notice that the patient has a well-demarcated area of mottled erythema which appears net-like across her anterior thighs. The area is non-tender and non-blanching. What is the most likely diagnosis of this lesion?

Answer 94

Erythema ab igne is caused by infrared radiation and is commonly associated with hot water bottles or open fires

Question 95

A 2-year-old girl develops a rash on her legs. The next day she is brought to surgery, by which time the rash has spread to the rest of her body.

Answer 95

The classic 'target' lesions of erythema multiforme can be seen clearly on this image.

Question 96

A 20-year-old man presents with acute gingivitis associated with oral ulceration. A diagnosis of primary herpes simplex infection is suspected. Which rash is he most likely to go on to develop?

Answer 96

Erythema multiforme Erythema multiforme is a hypersensitivity reaction which is most commonly triggered by infections. It may be divided into minor and major forms.

Question 97

A 34-year-old man presents with an itchy rash on his genitals and palms. He has also noticed the rash around the site of a recent scar on his forearm. Examination reveals papules with a white-lace pattern on the surface. What is the diagnosis?

Answer 97

Lichen ## Footnote planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham's striae over surface. Oral involvement common

Question 98

Clinical features of hidradenitis suppurativa

Answer 98

1. Initial manifestation involves recurrent, painful, and inflamed nodules. 2. HS occurs most commonly on intertriginous skin. The axilla is the most common site 3. The nodules may rupture, discharging purulent, malodorous material. 4. Coalescence of nodules can result in plaques, sinus tracts and 'rope-like’ scarring.

Question 99

An 85-year-old lady presents to her GP complaining of itchy white plaques affecting her vulva. There is no history of vaginal discharge or bleeding. A similar plaque is also seen on her inner thigh. What is the likely diagnosis?

Answer 99

Lichen sclerosus: itchy white spots typically seen on the vulva of elderly women

Question 100

A 18-year-old female has presented with pustule and nodules in her neck and axillae with a narrow tract visible in the skin. She has noted that they can become swollen, painful and have a small amount of yellow discharge at times. Given the presentation, what is the most likely diagnosis?

Answer 100

Hidradenitis suppurativa is a chronic, painful, inflammatory skin disorder is characterized by nodules, pustules, sinus tracts, and scars in intertriginous areas

Question 101

Your next patient is a 21-year-old fire-eater in training, who presents with pale pink, painful and blistered burns to both of his palms and the anterior aspect of his right forearm. He burnt himself approximately 1 hour ago. In this time he had washed the burn under cool water for 20 minutes and a friend had layered his hands and arm in clingfilm. What is the most appropriate next stage of his treatment?

Answer 101

Superficial dermal burns covering \>3% TBSA in adults must be referred to secondary care

Question 102

A 5-year-old boy is brought to the surgery by his mother. She is worried about her son who has been unwell the past 2 days with a fever and general malaise. She has also noticed a rash on his face. On examination you note multiple yellow-crusted lesions on his cheeks. His mother comments that these began as small red spots. His temperature is 38.6ºC. All other examinations are normal. What is the most likely diagnosis?

Answer 102

**Impetigo** is a reasonable common condition in young children and is very infectious. The classical clinical features are yellow crusted lesions in the affected area (usually around the mouth), that begin as red macules.

Question 103

A 8-year-old boy attends the GP surgery with his mother. He recently injured his shin playing football and his mother is concerned it may be infected. The initial injury was 2 weeks previously and described as a graze. On examination you see a well healed superficial abrasion on the skin, with multiple small, raised pink papules with a central dimple around the graze. The skin is otherwise not flushed and cool to touch around the wound. You also notice a crop of similar lesions on his stomach. His mother says these lesions have been present for about 6 months. What is the likely diagnosis?

Answer 103

**Koebner phenomenon** can cause **molluscum contagiosum** lesions to appear at areas of injury

Question 104

A 78-year-old man asks you to look at a **lesion on the right side of nose which has been getting slowly bigger over the past 2-3 months**. On **examination you observe a round, raised, flesh coloured lesion which is 3mm** in diameter and has a **central depression**. The edges of the lesion appear rolled and contain some telangiectasia. What is the single most likely diagnosis?

Answer 104

This is a classic description of a basal cell carcinoma.

Question 105

A 53-year-old woman presents to the general practitioner with a 1-year history of worsening erythematous rash on the nose, forehead and cheeks associated with telangiectasia and papules. The rash is aggravated by sun exposure and hot and spicy food. She has previously sought medical help for this condition before, and despite treatment with topical metronidazole, her symptoms remain uncontrolled. She is otherwise well with no allergies. Which of the following management options would be most appropriate for this patient?

Answer 105

**Acne rosacea treatment:** ## Footnote mild/moderate: topical metronidazole severe/resistant: oral tetracycline

Question 106

Features of Actinic keratoses | (4)

Answer 106

**Features** ## Footnote small, crusty or scaly, lesions may be pink, red, brown or the same colour as the skin typically on sun-exposed areas e.g. temples of head multiple lesions may be present

Question 107

A 5-year-old child presents with his mother to his GP. His mum is concerned as she has noticed some skin changes which started last week. The lesions are itchy but not painful. There is no past medical history of note except asthma. On examination, you see the following skin lesion behind the child's knee:

Answer 107

This child has **molluscum contagiosum**. This skin condition is caused by a pox virus and can be identified by its raised, pearly white, and umbilicated lesions. Supportive care is the mainstay of treatment for this condition, although specialist treatment may be required if the patient is immunocompromised. This condition normally clears up on its own within 18 months. Time off school is not necessary but, as the condition is infectious, it is advised to avoid sharing baths, towels, or clothing with others to prevent transmission.

Question 108

A 2-year-old child with a history of atopic eczema is brought to the local GP surgery. Her eczema is usually well controlled with emollients but her parents are concerned as the facial eczema has got significantly worse overnight. She now has painful clustered blisters on both cheeks, around her mouth on her neck. Her temperature is 37.9ºC. What is the most appropriate management?

Answer 108

**Eczema herpeticum** is a serious condition that requires IV antivirals

Question 109

A 75-year-old patient complains of right-sided severe chest pain, fever, and malaise which started 3 days ago. You note nothing of concern in his respiratory, cardiovascular and neurological examinations. There are closely grouped **red papules and vesicles on the right side of his chest**. The patient reports this as the site of the pain. **What is the most appropriate management of this patient?** **What is the most likely diagnosis**

Answer 109

People with **shingles** should be advised that they are **infectious until the vesicles have crusted over,** usually **5-7 days** following onset Advise the patient that he is infectious until the vesicles have crusted over and prescribe a course of antivirals

Question 110

A 23-year-old female boxer presents to her GP practice with itchy feet/toes and scaling of the skin between her toes. A positive culture of skin scrapings taken when she first presented 4 weeks ago confirmed athlete's foot and she has now completed a 4 week course of topical imidazole without resolution of her symptoms. What treatment is now indicated?

Answer 110

If initial topical treatment for athlete's foot fails, oral antifungal treatment is indicated Prescribe a course of oral terbinafine

Question 111

You are the GP reviewing an 81-year-old man with **varicose veins**. When he removes his right sock, you notice an **ill-defined area of ulceration** in the region of the medial malleolus. There is also **pedal oedema** to the mid-shins and some cutaneous changes of chronic venous insufficiency. Pulses are present. You decide to refer to vascular surgery. Alongside surgery for his varicose veins, which treatment would be most appropriate?

Answer 111

Management of venous ulceration - compression bandaging **Charing Cross 4-layer compression bandaging** is the most appropriate initial treatment for venous ulcers - although without surgery for the underlying varicose veins the ulcers are likely to either fail to heal or recur.

Question 112

A 35-year-old female presents with tender, erythematous nodules over her forearms. Blood tests reveal: Calcium - 2.78 mmol/l What is the most likely diagnosis?

Answer 112

The likely underlying diagnosis is sarcoidosis Erythema nodosum

Question 113

A 59-year-old man complains of pruritus and lethargy. On examination he has spoon shaped nails and a smooth tongue

Answer 113

The correct answer is: Iron deficiency anaemia

Question 114

The parents of a 6-year-old girl have noticed that she has been scratching her hair excessively for the past 1 week. Detection combing has revealed live lice.

Answer 114

The correct answer is: Malathion Malathion is an insecticide that poisons head lice by chemical means. Note that resistance to malathion has been reported, and hence it may be appropriate to try a physical insecticide (such as dimeticone) instead.

Question 115

A 62-year-old female is referred to dermatology by her GP due to a lesion over her shin. It initially started as a small red papule which later became a deep, red, necrotic ulcer with a violaceous border. What is the likely diagnosis?

Answer 115

Pyoderma gangrenosum

Question 116

A 72 year-old woman presents to the GP with a large itchy, sore white plaque on her vulva. What is the most likely diagnosis? What is the treatment plan?

Answer 116

Lichen sclerosis is a dermatological condition that affects the vulva. The first line treatment is a strong topical steroid thus the answer is topical clobetasol propionate.

Question 117

Which complication is most associated with psoralen + ultraviolet A light (PUVA) therapy?

Answer 117

Squamous cell cancer

Question 118

A 34-year-old man presents with a three week history of an intensely itchy rash just below his knees. On examination he has a symmetrical vesicular rash as shown below and also some early lesions on the back of his arms.

Answer 118

Dermatitis herpetiformis is an autoimmune blistering skin disorder associated with coeliac disease. It is caused by deposition of IgA in the dermis.

Question 119

A 62-year-old woman presents to her GP with an itchy rash of several weeks' duration. She describes the rash as being present on her hands and around the elbows. She is otherwise well and has no past medical history except for hypertension. On examination, a papular, polygonal, violaceous, flat-topped rash is present on the palms, in her elbow creases and on the soles of her feet. Given the likely diagnosis, what is the first-line treatment?

Answer 119

**Potent topical steroids** are the first-line treatment for **lichen planus**

Question 120

A 55-year-old man presents with the following lesions on his forearm. He complains that they itch and has tried over the counter creams without any success. The patient is worried and would like to know how this condition can be treated.

Answer 120

This patient has purple, polygonal, pruritic papules which are consistent with lichen planus.

Question 121

A 69-year-old woman asks you to have a look at her feet. She lives out in Spain most of the year but comes back to the UK periodically to see her family.

Answer 121

Actinic keratoses Actinic, or solar, keratoses (AK) is a common premalignant skin lesion that develops as a consequence of chronic sun exposure

Question 122

Release of epidermal toxins A and B is seen in which skin condition?

Answer 122

staphylococcal scalded skin syndrome (SSSS) This is far more common in children and causes a widespread blistering rash

Question 123

Please look at this skin lesion below a patient's eye:

Answer 123

spider naevi

Question 124

A lesion that may occur in a 32-year-old man with long standing Crohns disease.

Answer 124

Pyoderma gangrenosum

Question 125

An 18-year-old man presents due a number of itchy skin lesions on his arms and trunk. On examination, the lesions are coppery brown in colour and scaly. Which diagnosis is suspected? What is the most appropriate treatment?

Answer 125

A diagnosis of pityriasis versicolor is suspected. Ketoconazole shampoo is used to treat pityriasis versicolor

Question 126

A 65-year-old lady presents to the GP as she has noticed some small spots on her shoulder. She describes small lesions with a number of tiny blood vessels radiating from the middle. On examination you can press down on them, causing them to go white and then refill from the centre. Which of the following conditions is this lesion associated with?

Answer 126

Spider naevi can be differentiated from telangiectasia by pressing on them and watching them fill. Spider naevi fill from the centre, telangiectasia from the edge

Question 127

There are 4 main diagnostic criteria for hereditary haemorrhagic telangiectasia

Answer 127

**epistaxis** : spontaneous, recurrent nosebleeds **telangiectases**: multiple at characteristic sites (lips, oral cavity, fingers, nose) **visceral lesions**: for example gastrointestinal telangiectasia (with or without bleeding), pulmonary arteriovenous malformations (AVM), hepatic AVM, cerebral AVM, spinal AVM **family history**: a first-degree relative with HHT

Question 128

A 17-year-old male presents with a new skin condition which his mum noticed when they were on holiday in Spain. On examination, he has skin type V, with multiple small patches of depigmentation to the upper back. The patches appear mildly flaky but they are asymptomatic. He is usually well and has never had this condition before.

Answer 128

This is a typical history of pityriasis versicolor, a skin condition caused by an overgrowth of Malassezia yeast.

Question 129

A 59-year-old man presents to the GP practice with his wife due to recent changes in his bowel habits. He reports that his stools have become very loose. He also mentions that he is losing some hair and on examination, the doctor notes numerous red rashes on the skin. The man is unable to recall when these rashes first appeared. He is currently taking rifampicin, isoniazid and pyrazinamide for **a recent tuberculosis infection.**

Answer 129

Isoniazid, an anti-TB medication, may induce **pellagra**

Question 130

Susan is a 30-year-old woman with a body mass index of **32kg/m²** who has presented with a **recurrence of boils in her axilla**. She has had this numerous times before requiring antibiotics and has even had an incision and drainage on one occasion. She also described one episode of such boils on her vulva a few years ago. On this occasion, you notice large red lumps in her right axilla. There is some scarring of the skin and you also notice a little hole with pus discharging out of it. What is the most likely diagnosis?

Answer 130

Sinus tracts and fistulas may develop as a complication of **hidradenitis suppurativa** Hidradenitis suppurativa is a painful skin condition which causes multiple abscesses in areas which contain apocrine sweat glands. Common areas involved are the armpits and groin region. Obesity is a risk factor. In the later stages, it can lead to fistula and sinus tract formation which discharge pus.

Question 131

A 32-year-old woman attends the GP with a rash. She has a bright red rash over her nose and cheeks. She reports that drinking alcohol makes her rash worse and this is really embarrassing for her. She reports occasional pustules. What is the most likely diagnosis?

Answer 131

Acne rosacea features: ## Footnote nose, cheeks and forehead flushing, erythema, telangiectasia → papules and pustules

Question 132

A 67-year-old man who is a retired builder presents following the development of a number of red, scaly lesions on his forehead. These were initially small and flat but are now erythematous and rough to touch.

Answer 132

Actinic keratoses Actinic, or solar, keratoses (AK) is a common premalignant skin lesion that develops as a consequence of chronic sun exposure

Question 133

A 30-year-old man is trapped in a house fire and sustains 30% partial and full thickness burns to his torso and limbs. Three days following admission he has a brisk haematemesis.

Answer 133

Stress ulcers in burns patients are referred to as **Curlings ulcers** and may cause haematemesis.

Question 134

Characteristics of scabies (4)

Answer 134

The scabies mite burrows into the skin, laying its eggs in the stratum corneum. The intense pruritus associated with scabies is due to a delayed-type IV hypersensitivity reaction to mites/eggs which occurs about 30 days after the initial infection. **Features** * widespread pruritus * linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist * in infants, the face and scalp may also be affected * secondary features are seen due to scratching: excoriation, infection

Question 135

Toby first presented 6 months ago when his mother was concerned about a birthmark on his face. Examination at the time noted that the birthmark was macular, red in colour and had a poorly defined border. On repeat examination today, the birthmark appears to have resolved. What is the most likely diagnosis for Toby's birthmark?

Answer 135

**Salmon patches** are a vascular birthmark which usually self resolve Salmon patches are congenital capillary malformations seen at birth. They are often small, flat patches of pink or red skin with poorly defined borders. These tend to resolve by 18 months of age.

Question 136

A 62-year-old male is referred to dermatology by his GP due to a lesion over his shin. On examination shiny, painless areas of yellow skin over the shin are found with abundant telangiectasia. What is the most likely diagnosis?

Answer 136

Diabetes, waxy yellow shin lesions - **necrobiosis lipoidica diabeticorum**

Question 137

You review a 31-year-old woman who has had Crohn's disease for the past 12 years.She is currently on infliximab therapy.

Answer 137

Pyoderma gangrenosum

Question 138

A 40-year-old woman presents with a painful 'rash' on her shins:

Answer 138

The likely diagnosis here is erythema nodosum (EN). All these tests may have a place but a chest x-ray is important as it helps exclude sarcoidosis and tuberculosis, two important cause of EN

Question 139

A 32-year-old woman has noticed painful lesions on both of her shins in the past 2 weeks. **She is currently 18 weeks pregnant** and reports that she was treated with a course of cefalexin for a urinary tract infection 3 weeks ago. She also has a history of hypothyroidism and increased her levothyroxine dose in her first trimester after her blood tests indicated she was undertreated. On examination, there are multiple erythematous nodular lesions distributed symmetrically on her lower legs, measuring between 1 and 5 cm in size. Which part of her medical history is most likely to have caused her dermatological condition?

Answer 139

Erythema nodosum may be caused by pregnancy

Question 140

A 36-year-old woman presents to clinic with a 4 month history of intermittent bloating and loose stools. She has never passed any blood but has lost a few kilograms in weight. Over the past week, she has noticed some itchy, vesicular rashes on her elbows that won't seem to go away. You send off some routine blood tests which come back as normal except for one positive result. **Anti-TTG Positive** What is the dermatological condition that she describes?

Answer 140

Dermatitis herpetiformis has a recognised association with coeliac disease

Question 141

A 22-year-old is admitted to the intensive care unit with an extensive blistering and necrotic skin rash affecting the whole body including the mucous membranes. The patient was treated for an infection by her GP the previous week. Given the diagnosis, which medication was she most likely to have been prescribed?

Answer 141

**Toxic epidermal necrolysis** is a rare but important side effect of which to be aware of penicillins The diagnosis here is **toxic epidermal necrolysis (TEN)**. Of all the antibiotics listed, co-amoxiclav (penicillins generally) have been implicated in the development of TEN. None of the others are known to be causes. Other medications are known to induce TEN - they are listed below.

Question 142

A 28-year-old man undergoes an ileocaecal resection and end ileostomy for Crohn's disease. One year later he presents with a deep painful ulcer at his stoma site. What is the most likely diagnosis?

Answer 142

Pyoderma gangrenosum is associated with inflammatory bowel disease (this patient had a stoma for Crohn's).

Question 143

A 32-year-old lady presents with hair-loss which she thinks started after the birth of her second child 7 months ago. She is normally fit and well and is not on any regular or over the counter medication. On examination, you notice patches of hair loss around her occiput. The skin looks normal and a few short broken hairs are obvious at the edges of two of the patches. What condition is most likely?

Answer 143

Alopecia areata Alopecia areata is a presumed autoimmune condition causing localised, well demarcated patches of hair loss. At the edge of the hair loss, there may be small, broken 'exclamation mark' hairs

Question 144

A one-year-old child presents to the GP with his mother for his vaccinations. His mother is pleased to note that his birthmark, which was a pink flat mark on his eyelids and on the nape of his neck has almost faded entirely. What is the most likely birthmark this child has?

Answer 144

Salmon patches are a vascular birthmark which usually self resolve

Question 145

A 28-year-old female presents with increasing concern about a lesion that has developed over her shin. She has never had any lesions like this before. Which of the following symptoms/signs would indicate this lesion is likely benign? What is the diagnosis?

Answer 145

Central dimple on squeezing This lesion looks characteristic for a **dermatofibroma**; a benign lesion that is characterised by a central dimple forming when the lesion is squeezed. This clinical sign would clinically confirm a diagnosis of dermatofibroma.

Question 146

A 30-year-old female in her third trimester of pregnancy mentions during an antenatal appointment that she has noticed an itchy rash around her umbilicus. This is her second pregnancy and she had no similar problems in her first pregnancy. Examination reveals blistering lesions in the peri-umbilical region and on her arms. What is the likely diagnosis?

Answer 146

**Pemphigoid gestationis** is the correct answer. Polymorphic eruption of pregnancy is not associated with blistering

Question 147

Hannah is a 13-year-old who has presented to her GP complaining of having too many ‘spots’. **On examination, she has a mix of open and closed comedones over her face.** What is the first line management of her mild acne? What stage of acne is this?

Answer 147

Use non-antibiotic topical treatment first line for the management of acne ## Footnote **mild**: open and closed comedones with or without sparse inflammatory lesions

Question 148

Characteristics of pityriasis versicolor (7)

Answer 148

1. an overgrowth of Malassezia yeast 2. It is most common in young people, especially males. 3. It causes multiple patches of skin discolouration, mainly to the trunk. 4. The patches may appear pale brown, pink, or may appear depigmented especially in patients with dark skin. 5. They may also be mildly flaky and itchy. 6. The condition can often present after spending time in sunny, humid environments. 7. It is treated with topical antifungals eg. ketoconazole shampoo.

Question 149

A 22-year-old woman presents due to hypopigmented skin lesions on her chest and back. She has recently returned from holiday in Spain and has tanned skin. On examination the lesions are slightly scaly. What is the most likely diagnosis?

Answer 149

Pityriasis versicolor

Question 150

What is the most likely diagnosis?

Answer 150

The patient has guttate psoriasis. The rash is often widespread on the torso, legs, and arms, often with \>100 individual lesions. It can be tear-drop-shaped.

Question 151

Define telangiectasia

Answer 151

a condition characterized by **dilatation of the capillaries** causing them to appear as s**mall red or purple clusters**, often spidery in appearance, on the skin or the surface of an organ.

Question 152

A 53-year-old man presents with a nodule on his chin. He is concerned because it has grown extremely rapidly over the course of the preceding week. On examination he has a swollen, red, dome shaped lesion with a central defect that contains a keratinous type material.

Answer 152

The correct answer is: **Keratoacanthoma** Keratoacanthomas are characterised by a **rapid growth** phase. This may mimic amelanotic melanoma (although such rapid growth is rare even in these lesions). The keratin core is the clue as to the true nature of the lesion.

Question 153

What is the most likely diagnosis?

Answer 153

Basal cell carcinoma

Question 154

A 65-year-old man presents with **worsening psoriasis**. He has been more stressed recently and feels like this may be contributing to his exacerbation. He has also started a new medication. On examination, he has scaly plaques on the extensor surfaces and his trunk which are erythematous. **Which one of the following medications may trigger exacerbations in his condition?**

Answer 154

* beta blockers * lithium * antimalarials (chloroquine and hydroxychloroquine) * NSAIDs and ACE inhibitors * infliximab * withdrawal of systemic steroids

Question 155

A 79-year-old female presents to her general practitioner with a lesion on her nose which she first noticed three months ago. She describes that it started as a white patch with some 'wide red vessels' around it. She reports no other lesions across her body.

Answer 155

basal cell carcinoma * un-exposed sites, especially the head and neck account for the majority of lesions * initially a pearly, flesh-coloured papule with telangiectasia * may later ulcerate leaving a central 'crater'

Question 156

You are examining the back of a 74-year-old man and notice the following:

Answer 156

This man has multiple seborrhoeic keratoses, also known as basal cell papillomas.

Question 157

What is tacrolimus?

Answer 157

immunosuppressant used in transplants and vitiligo treatment

Question 158

You are an FY2 in General Practice reviewing a 72-year-old woman with a background of Parkinson's disease. She has come in today with a 4-week history of sore, gritty eyes. She reports that both eyes are affected and that the symptoms are worst in the morning. On examination, she has inflamed skin with fine scaling around the nasolabial folds and eyelashes, and her ear canal is erythematous and obscured by debris. What is the most likely unifying diagnosis?

Answer 158

Otitis externa and blepharitis are common complications of seborrhoeic dermatitis

Question 159

A 15-year-old girl comes to see you as she has noticed that her hands become very sweaty. She says that this can become quite awkward in social situations for example if she has to shake hands with someone. She is also worried about how this may affect her upcoming GCSE exams. Which one of the following is most suitable for first line management of this condition?

Answer 159

Topical **aluminium chloride** preparations are first-line for hyperhidrosis

Question 160

A 34-year-old gardener presents with a lesion affecting the dorsum of his right hand. It has been present for the past 10 days and occurred after he had been pruning rose bushes. On examination he has a raised ulcerated lesion which bleeds easily on contact.

Answer 160

The correct answer is: Pyogenic granuloma Trauma is a common precipitant of pyogenic granuloma and contact bleeding and ulceration are common.

Question 161

A 64-year-old female is referred to dermatology due to a non-healing skin ulcer on her lower leg. This has been present for around 6 weeks and the appearance didn't improve following a course of oral flucloxacillin. What is the most important investigation to perform first?

Answer 161

An ankle-brachial pressure index measurement would help exclude arterial insufficiency as a contributing factor. If this was abnormal then a referral to the vascular surgeons should be considered.

Question 162

A 32-year-old man is seen at his GP for an erythematous rash in both axillae and his right groin crease. It is slightly scaly and flat and not itchy. Which of the following oral antibiotics should be used to treat this man's condition? What is the likely diagnosis?

Answer 162

Erythromycin is the oral antibiotic of choice to treat **erythrasma**

Question 163

Which of the following bacteria found on skin is known to contribute to the development of acne?

Answer 163

Propionibacterium acnes is the bacteria that contributes to the development of acne

Question 164

A 34-year-old man with a long history of back pain asks you to have a look at his back. His wife has noticed a rash.

Answer 164

erythema ab igne

Question 165

A 78 year-old woman presents with a poorly healing area of skin on her ankle. She has a history of deep vein thrombosis 20 years ago following a hip replacement. She currently takes Adcal D3, and no other medications. On examination there is a shallow ulcer anterior to the medial malleolus. She is otherwise very well. **What is the diagnosis?** **What investigation would be most useful in determining further management?**

Answer 165

This patient has the classic appearances of a venous ulcer. The most appropriate management of venous ulcers is with compression dressings, however it is important to make sure the patient's arterial supply is good enough to allow some compression.

Question 166

A woman who is 31 weeks pregnant presents with a rash on her abdomen and thighs: The rash is very itchy and she is having difficulty sleeping at night. What is the most likely diagnosis?

Answer 166

Polymorphic eruption of pregnancy * pruritic condition associated with last trimester * lesions often first appear in abdominal striae * management depends on severity: emollients, mild potency topical steroids and oral steroids may be used

Question 167

An 82-year-old Caucasian gentleman presents with a waxy, scar-like plaque over his left eyelid. He reports it to have been slowly increasing in size over the last two years. You diagnose morphoeic basal cell carcinoma (BCC). Which of the following is the best management option?

Answer 167

Morphoeic BCC usually is associated more extensive spread than nodular BCC as it is more aggressive and often presents later. Due to this, and to its poorly-defined edges, Mohs microgaphic surgery is the gold standard approach in managing morphoeic BCC

Question 168

A 19-year-old man presents with the following lesions on his leg. They are mildly pruritic. Two weeks later he develops numerous other lesions on his body. What is the most likely diagnosis?

Answer 168

**Pityriasis rosea** describes an acute, self-limiting rash which tends to affect young adults. The aetiology is not fully understood but is thought that herpes hominis virus 7 (HHV-7) may play a role.

Question 169

Features of Pyoderma gangrenosum | (4)

Answer 169

Features * typically on the lower limbs * initially small red papule * later deep, red, necrotic ulcers with a violaceous border * may be accompanied systemic symptoms e.g. Fever, myalgia

Question 170

A 24-year-old male presents with a lesion on the back of his hand. He is concerned that it is due to excessive sun exposure and could be serious. It has not bled and is not itchy. It is pictured below.

Answer 170

**Dermatofibroma** is conservatively managed with reassurance as it is benign.

Question 171

A 63-year-old man presents to his general practitioner with a three-week history of an itchy rash over the face and upper chest. His only past medical history is HIV for which he is poorly compliant with his anti-retroviral medications. On examination, areas of erythema over the eyebrows, nasolabial folds, and upper chest are noted. Excoriations surrounding the rash are present. What is the most appropriate initial treatment?

Answer 171

Seborrhoeic dermatitis - first-line treatment is topical ketoconazole This man has presented with a rash consistent with seborrhoeic dermatitis, which he is at particular risk of given his past medical history of HIV. The first-line treatment for this condition is topical ketoconazole.

Question 172

A 34-year-old man with a history of **polyarthralgia**, back pain and diarrhoea is found to have a 3 cm red lesion on his shin which is starting to ulcerate. What is the most likely diagnosis?

Answer 172

This patient is likely to have ulcerative colitis, which has a known association with large-joint arthritis, sacroilitis and **pyoderma gangrenosum**

Question 173

A 45-year-old man is admitted after his clothing caught fire. He suffers a full thickness circumferential burn to his lower thigh. He complains of increasing pain in lower leg and on examination there is parasthesia and severe pain in the lower leg. Foot pulses are normal

Answer 173

Compartment syndrome Circumferential burns may constrict the limb and cause a compartment syndrome to develop. Eshcarotomy is required, and compartmental decompression.

Question 174

What is the diagnosis?

Answer 174

Seborrhoeic keratosis Features large variation in colour from flesh to light-brown to black have a 'stuck-on' appearance keratotic plugs may be seen on the surface

Question 175

A 34-year-old lady visits her GP inquiring about a new rash. It arose on her shins 2 days ago and is described as red, round and slightly painful. On examination, the lesion appears consistent with erythema nodosum. She has no history of trauma however she states she gave birth 4 months ago. Past medical history includes type 1 diabetes mellitus (T1DM) and sarcoidosis. Currently, she is taking insulin, corticosteroids and paracetamol. What in this patient's history is the likely cause of her rash?

Answer 175

Sarcoidosis

Question 176

10-year-old child is admitted with severe 30% burns following a house fire. After wound cleaning and dressings he is admitted to critical care. 1 day following skin grafts he becomes tachycardic and hypotensive. He vomits twice and this shows evidence of haematemesis

Answer 176

Curlings Ulcer Stress ulcers may occur in the duodenum of burns patients and are more common in children

Question 177

A 30-year-old man is investigated for recurrent nose bleeds and iron deficiency anaemia. You notice a number of erythematous lesions on his skin:

Answer 177

Hereditary haemorrhagic telangiectasia

Question 178

A mother comes to see you with her 3-year-old son who suffers from eczema. She reports that his eczema has become a lot worse this week. He has developed widespread itchy blisters all over his body: including his face, torso, arms and legs. In addition to this, he is not acting like his usual self- eating and drinking less than usual and not playing with his favourite toys. He also has a temperature of 39ºC. Which one of the following is the most appropriate?

Answer 178

Eczema herpeticum is a serious condition that requires IV antivirals

Question 179

A 22-year-old woman is troubled by intensely itchy crops of blisters on her arms and legs. On examination she is malnourished and she has papulovesicular eruptions over her elbows and knees.

Answer 179

Dermatitis herpetiformis Dermatitis herpetiformis is seen in association with coeliac disease.

Question 180

Pemphigus mechanism of disease

Answer 180

antibodies target the desmosomes that connect the cells

Question 181

A 19-year-old man comes for review after burning himself with an iron. On examination he has a 4 by 3 cm area of pale pink skin the left forearm. In the middle of the area there are two small, fluid filled blisters. What is the most accurate description for this type of injury?

Answer 181

Partial-thickness (superficial dermal)Second degreePale pink, painful, blistered

Question 182

A 27-year-old man presents as he is feeling generally unwell. Around 5 days ago he started having a sore throat associated with myalgia and lethargy. Yesterday he developed a fever and over the course of the past 24 hours a rash has appeared. His past medical history includes anxiety and atopic eczema. On examination he has a widespread erythematous rash, with many of the lesions having a 'target' appearance. Some of the lesions are becoming bullous. His pulse is 120/min and temperature 38.4º. He also has conjunctivitis and some ulceration and sloughing around the mouth:

Answer 182

Erythema multiforme is a hypersensitivity reaction which is most commonly triggered by infections. It may be divided into minor and major forms.

Question 183

A 52-year-old woman presents to her GP with a persistent rash. She describes it as being itchy and being on the palms and inside the elbow creases. On examination, there are several violaceous, polygonal papules and plaques with some overlying white scale, on the palms and flexor surfaces of the arms. Close examination of the hands also reveals mild oncodystrophy. Given the likely diagnosis, what is the most appropriate management?

Answer 183

Potent topical steroids are the first-line treatment for lichen planus

Question 184

A 43-year-old man presents to his GP with a persistent skin lesion overlying the right second metacarpophalangeal joint:

Answer 184

Granuloma annulare * papular lesions that are often slightly hyperpigmented and depressed centrally * typically occur on the dorsal surfaces of the hands and feet, and on the extensor aspects of the arms and legs

Question 185

A 57-year-old woman presents with pruritus. She states she has been gaining weight despite eating less and complains of constant nausea. On examination she is pale

Answer 185

The correct answer is: Chronic kidney disease

Question 186

A 55-year-old man asks you to have a look at some 'red spots' on his torso. They have been present for about the past six months.

Answer 186

Cherry haemangioma Cherry haemangiomas (Campbell de Morgan spots) are benign skin lesions which contain an abnormal proliferation of capillaries. They are more common with advancing age and affect men and women equally.

Question 187

A 64-year-old man presents with a 'rash' on his legs which has developed over the past few days:

Answer 187

**Vasculitis** is commonly limited to the skin and may be caused by infections, drugs, autoimmune disorders and malignancy.

Question 188

You are working in a busy emergency department. A 52-year-old male is brought in to resus with extensive burns covering around 40% of his body surface area. Which of the following is used to calculate the volume of fluid required for resuscitation over the first 24 hours after the burn?

Answer 188

Parkland formula is used to calculate the volume of IV fluid required for resuscitation over the first 24 hours after the burn

Question 189

A middle aged man develops a non-pruritic rash after starting allopurinol therapy for gout. The rash develop within 24 hours and started on the back of his hands.

Answer 189

Erythema multiforme

Question 190

A 78-year-old man presents with a lesion on his right cheek. This has slowly been getting larger over the past 6-7 months. He has no history of skin problems and the only past medical history of note is osteoarthritis of the knee and depression.

Answer 190

Squamous cell carcinoma Don't be fooled into thinking this is a basal cell carcinoma (BCC) by the presence of telangiectasia near the lesion. With BCC's these are generally found on the rolled edges of the lesion rather than being scattered around the periphery

Question 191

A 36-year-old male presents to his GP with a raised, patchy rash on his elbows and knees. He tells you the lesions have come on slowly over the past few months and that they are itchy but not painful. On further questioning, he tells you he has recently been on holiday to Morocco where he noticed the rash improved slightly, and he got temporary relief from the itch. You examine the rash to find well-demarcated, red, scaly patches on his elbow and both knees. He has a past medical history of ankylosing spondylitis which is treated with naproxen and omeprazole. What is the most appropriate treatment for the rash?

Answer 191

Topical potent corticosteroid + vitamin D analogue is first-line for chronic **plaque psoriasis**

Question 192

A 24-year-old female in her third trimester of pregnancy mentions during a routine antenatal appointment that she has noticed an **itchy rash around her umbilicus**.

Answer 192

Polymorphic eruption of pregnancy * pruritic condition associated with last trimester * lesions often first appear in abdominal striae * management depends on severity: emollients, mild potency topical steroids and oral steroids may be used

Question 193

A 67-year-old man with a history of Parkinson's disease presents due to the development of an itchy, red rash on his neck, behind his ears and around the nasolabial folds. He had a similar flare up last winter but did not seek medical attention. What is the most likely diagnosis?

Answer 193

Seborrhoeic dermatitis is more common in patients with Parkinson's disease

Question 194

The lesion below started as a small red papule which grew in size before starting to ulcerate: ## Footnote **What is the condition?** **Wha is it commonly associated with?**

Answer 194

Pyoderma gangrenosum

Question 195

A 64-year-old diabetic patient presents with fevers, fatigue and generally feeling unwell for the past 48 hours. On examination she has a raised well-defined red rash with sharp borders on her legs. It is tender and warm to touch. Which is the most likely causative organism?

Answer 195

**Erysipelas** is localised skin infection caused by Streptococcus pyogenes

Question 196

A 64-year-old man presents with an ulcerated firm pink-coloured irregular lesion on his right leg. He reports that it has been growing in size slowly over the past 3 years. He also complains of left knee pain which has been getting worse for the past year. He has a past medical history of chronic kidney disease and underwent a kidney transplant 10 years ago. He has worked as a shopkeeper for several years. He smokes 10 cigarettes a day. What is the most likely diagnosis?

Answer 196

Renal transplant patients - skin cancer (particularly squamous cell) is the most common malignancy secondary to immunosuppression

Question 197

A 6-year-old boy is brought to his GP by his father with what he describes as 'red sores' around the mouth. You decide to prescribe an antibiotic. The father states that the boy is currently otherwise well but suffered with an asthma exacerbation three weeks previously. Topical hydrogen peroxide did not help for a similar episode previously. What would be the most appropriate treatment in this case? What is the diagnosis?

Answer 197

Impetigo - topical fusidic acid if hydrogen peroxide not suitable

Question 198

Causes of Puritis | (5)

Answer 198

* Liver disease * Iron deficiency anaemia * Polycythaemia * Chronic kidney disease * Lymphoma

Question 199

A 38-year-old woman visits her GP reporting episodes of 'flushing' affecting her face. She says that over the past few months she has noticed that her face might turn red at random, but that this particularly occurs after she has consumed alcohol. She also complains of an increased number of 'spots' over her cheeks recently and isn't sure if these symptoms are related. On examination, the GP notes two small telangiectases - one on the nose and one on the left cheek. There are also a couple of small papules on each cheek. What should the GP offer this patient to help manage her symptoms?

Answer 199

Acne rosacea treatment: ## Footnote mild/moderate: topical metronidazole severe/resistant: oral tetracycline

Question 200

An 8-year-old boy presents with his mother to the GP practice with a red macular rash covering his trunk and back. He has been feeling lethargic for the last two weeks. His mother recalls seeing a larger patch appear on his back initially a week ago, which was then followed by smaller red macules elsewhere on his trunk. His observations are all normal. What is the most likely diagnosis?

Answer 200

The mother had noticed the 'herald patch' of **pityriasis rosea** followed a week later by additional lesions. The symptoms of lethargy and limitation of lesions to the trunk are typical.

Question 201

A 47-year-old woman complains of an itchy neck and scalp:

Answer 201

Seborrhoeic dermatitis an inflammatory reaction to Malassezia furfur

Question 202

A 50-year-old man presents with shiny, flat-topped papules on the palmar aspect of the wrists. He is mainly bothered by the troublesome and persistent itching. Which condition is suspected? What is the most appropriate treatment?

Answer 202

Lichan Planus ## Footnote potent topical steroids are the mainstay of treatment itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms rash often polygonal in shape, with a 'white-lines' pattern on the surface (Wickham's striae) Koebner phenomenon may be seen (new skin lesions appearing at the site of trauma) oral involvement in around 50% of patients: typically a white-lace pattern on the buccal mucosa nails: thinning of nail plate, longitudinal ridging

Question 203

A 32-year-old man presents to the vascular clinic with symptoms of foot pain during exertion. He is a heavy smoker and has recently tried to stop smoking. On examination he has normal pulses to the level of the popliteal. However, foot pulses are absent. A diagnostic angiogram is performed which shows an abrupt cut off at the level of the anterior tibial artery, together with the formation of corkscrew-shaped collateral vessels distally.

Answer 203

**Buergers disease** Buergers disease is most common in young male smokers. This demographic is changing in those areas where young female smokers are more common. In the acute lesion the internal elastic lamina of the vessels is usually intact. As the disease progresses the changes progress to hypercellular occlusive thrombus. Tortuous corkscrew collaterals may reconstitute patent segments of the distal tibial or pedal vessels.

Question 204

A 41-year-old man develops itchy, polygonal, violaceous papules on the flexor aspect of his forearms. Some of these papules have coalesced to form plaques. What is the most likely diagnosis?

Answer 204

Lichen ## Footnote planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham's striae over surface. Oral involvement common

Question 205

A 21-year-old man presents to his GP with an itchy rash. This has been coming on for the past three months and is characterised by red, scaly patches of skin, most prominent on the back of his elbows and the front of his knees. He has suffered with dandruff for some time. He has no past medical or family history and is not taking any medication. What finding is most likely to be present in this patient?

Answer 205

Psoriasis commonly exhibits the Koebner phenomenon he Koebner phenomenon describes the tendency for new skin lesions to form at sites of cutaneous injury

Question 206

A 26-year-old electrician suffers a full thickness high voltage burn to his leg. On routine urine analysis he has + blood. His U+E's show mild hyperkalaemia and a CK of 3000

Answer 206

Rhabdomyolysis Electrical high voltage burns are associated with rhabdomyolysis. Acute tubular necrosis may occur. Aggressive IV fluids should be given

Question 207

Differences (3) and Similarities (3) between Wegener's and Churg-Strauss syndrome

Answer 207

Question 208

A 68-year-old patient presents to her GP with a 'rash' over her right deltoid. She got her COVID-19 vaccine last week and is concerned that she now has the disease. There was no bleeding from the injection site and she tolerated the vaccine well, with only mild fatigue for a few days. She has a past medical history of anxiety, psoriasis and mild irritable bowel syndrome. On examination, she is systemically well but has a small, silvery plaque over her injection site. What is the most likely diagnosis?

Answer 208

Psoriasis commonly exhibits the Koebner phenomenon The description of this patient's skin condition fits with psoriasis and, given the history of trauma the most likely answer is Koebner phenomenon.

Question 209

IgE is released from plasma cells is seen in which skin condition?

Answer 209

atopic dermatitis; however, this patient does not have a rash characteristic of atopic dermatitis.

Question 210

A 27-year-old man with a history of depression and coeliac disease presents with an itchy rash on his buttocks:

Answer 210

dermatitis herpetiformis

Question 211

A 22-year-old male comes to see you the GP. He explains that there are strange spots on his body that he first noticed over 2 months ago. The spots are slightly itchy and he assumed they would go away without treatment. He has no past medical history and states he leads an active life with regular exercise. On examination, there are 6 hypopigmented spots on the left posterior aspect of his neck. What is the most likely diagnosis?

Answer 211

Pityriasis versicolor presents with hypopigmented patches Pityriasis versicolour is a fungal infection that characteristically causes light patches on the trunk which can be mildly pruritic.

Question 212

Define curettage

Answer 212

scraping

Question 213

A 50-year-old man presents to the GP with a red spherical lesion that he would like looked at. Which of the following would point towards a diagnosis of a pyogenic granuloma over an amelanotic melanoma?

Answer 213

A pyogenic granuloma may mimic amelanotic melanoma but can be differentiated based on a history of trauma

Question 214

Which drug exacerbates plaque psoraisis?

Answer 214

beta blockers

Question 215

Answer 215

Bullous pemphigoid oral corticosteroids

Question 216

The lesion has been getting bigger for the past few weeks. There is no history of trauma. What is the most likely diagnosis?

Answer 216

Bowen's disease Bowen's disease is a type of precancerous dermatosis that is a precursor to squamous cell carcinoma. It is more common in elderly patients. There is around a 5-10% chance of developing invasive skin cancer if left untreated.

Question 217

A 20-year-old woman presents to her GP complaining of a persistent facial rash. On examination, you note erythema of the nose, cheeks and forehead. There are some scattered papules. She has not noticed any particular triggers but does think it is slightly worse in the summer. Given the likely diagnosis, which of the following is the most appropriate first-line treatment?

Answer 217

Acne rosacea treatment: ## Footnote mild/moderate: topical metronidazole severe/resistant: oral tetracycline

Question 218

Which drugs exacerbate plaque psoriasis? (2)

Answer 218

Beta blockers and aspirin

Question 219

A 78-year-old man presents with symptoms of headaches and deteriorating vision. He notices that there is marked pain on the right hand side of his face when he combs his hair.

Answer 219

Giant cell arteritis Temporal arteritis may present acutely with symptoms of headache and visual loss, or with a less acute clinical picture. Sight may be threatened and treatment with immunosupressants should be started promptly. The often requested temporal artery biopsy (which can be the bane of many surgeons) is often non diagnostic and unhelpful.

Question 220

A 45-year-old woman presents with itchy, violaceous papules on the flexor aspects of her wrists. She is normally fit and well and has not had a similar rash previously. Given the likely diagnosis, what other feature is she most likely to have?

Answer 220

Lichen ## Footnote planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham's striae over surface. Oral involvement common