Integrated Specialties C - Dermatology Pre and Post block Assessment

Question 1

A 66 year old farmer has developed a large flat patch of erythema on the right trunk over the past 2 weeks which continues to enlarge. The patch is smooth, asymptomatic and not particularly hot. He is systemically well. large flat patch of erythema What is the most likely diagnosis?

Answer 1

Cutaneous manifestation of Lyme disease (erythema chronicum migrans) is a distinct possibility here, and 2 weeks of doxycycline would be indicated The correct answer is: Erythema chronicum migrans ( Lyme disease)- looks like a bullseye lesion

Question 2

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Answer 2

IM adrenaline Then give * IV steroids (hydrocortisone) * IV antihistamine (chlorphenamine) * IV fluids

Question 3

A 42 year man with known coeliac disease has developed an itchy vesicular eruption over elbows and buttocks. Which investigation would confirm the suspected diagnosis? Select one: * a. Specific IgE for wheat * b. Diagnostic biopsy with immunofluorescence * c. Patch testing * d. Viral culture of vesicle fluid * e. Diagnostic biopsy with PAS stain

Answer 3

The likely diagnosis here is dermatitis herpetiformis, an itchy vesicular rash often affecting extensor surfaces. Diagnosis is confirmed by the presence of granular deposits of IgA in the dermal papillae on direct immunofluorescence of skin biopsy (and blood testing for IgA antibodies to tissue transglutaminase may also be checked). The correct answer is: Diagnostic biopsy with immunofluorescence

Question 4

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Answer 4

The diagnosis is lichen planus and the correct answer is 4; Potent topical steroids are the mainstay of therapy. Scalp involvement is recognised but not common, and mouth involvement with Wickham’s striae is often evident on the buccal mucosa. Though it typically spontaneously resolves this may take 1 – 2 years so treatment with topical steroids, topical tacrolimus, phototherapy and only occasionally oral steroids / immunosuppression is usually required to suppress it. There are no known associated systemic diseases.

Question 5

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Answer 5

This presentation suggests polymorphic light eruption, fairly common in females of this age and often helped with desensitisation phototherapy. The correct answer is: This is most likely polymorphic light eruption. Sun protection is indicated and desensitisation phototherapy could help

Question 6

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Answer 6

The combination of hirsutism ( male-pattern hair growth) and acne may indicate polycystic ovaries The correct answer is: Menstrual history and hormone profile is indicated

Question 7

Which of the following statements is FALSE regarding connective tissue disease and the skin? Select one: * a. CDLE is a recognised cause of scarring alopecia * b. Potent or very potent steroids are used to treat facial chronic discoid lupus erythematosus (CDLE) * c. Phototherapy is used in the management of diffuse scleroderma * d. Screening for underlying malignancy is indicated in older patients presenting with dermatomyositis * e. Heliotrope rash is seen as a cutaneous feature of systemic sclerosis

Answer 7

Statement 4 is false – heliotrope rash is seen in dermatomyositis

Question 8

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Answer 8

UVB phototherapy

Question 9

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Answer 9

SCC is the commonest skin cancer seen in the immunosuppressed population, and presents as an obviously enlarging, often tender lesion as in this case. The correct answer is: Squamous cell carcinoma

Question 10

A child aged 5 presents with an itchy patch of alopecia measuring 3cm in diameter. On examination there is scaling and erythema on the scalp as well as hair loss. What investigation would be most helpful in diagnosis in this case: Select one: * a. Skin scrapings * b. Viral swab * c. Connective tissue disease screen * d. Bacterial swab * e. Skin biopsy

Answer 10

The most likely diagnosis here is tinea capitis, which is diagnosed with skin scraping The correct answer is: Skin scrapings

Question 11

Which of the following statements regarding acne is correct? Select one: * a. Staphylococcus aureus is the main bacteria implicated in acne development * b. Acne is a result of poor hygiene * c. Acne does not present over the age of 25 * d. Ductal hypercornification causes obstruction to the pilosebaceous unit * e. There is a decreased sebum production in those with acne

Answer 11

Ductal hypercornification and follicular obstruction are seen in acne, in combination with inflammation and infection of the pilosebaceous unit with Proprionobacterium acnes The correct answer is: Ductal hypercornification causes obstruction to the pilosebaceous unit

Question 12

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Answer 12

This presentation suggests rosacea, with rhinophyma development seen in the image. Initial treatment would consist of prolonged course of oral anitibiotics, usually a tetracycline. Initial treatment in mild cases is to usually prescribe topical metronidazole

Question 13

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Answer 13

Dermatomal distribution is typical of herpes zoster The correct answer is: Distribution of rash

Question 14

Which one of the following clinical features is not associated with a diagnosis of Neurofibromatosis? Select one: * a. Lisch nodules * b. Axillary freckling * c. Multiple café au lait macules * d. Sphenoid bone dysplasia * e. Ash leaf macules

Answer 14

Ash leaf macules are associated with tuberous sclerosis, the other features are used in diagnosing neurofibromatosis The correct answer is: Ash leaf macules

Question 15

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Answer 15

Tinea incognito is the name given when fungal infection has been misdiagnosed, treated with topical steroids, which through local immunosuppression allows the infection to flourish and often results in quite atypical appearance. The correct answer is: Tinea incognito

Question 16

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Answer 16

This presentation is in keeping with fungal nail infection. With this degree of nail involvement, oral anti-fungal treatment would be required, but diagnosis should be confirmed initially with nail clippings to avoid inappropriate prescribing of oral treatment. Psoriatic nails can have a similar appearance, however this is less likely as the patient has no other skin issues. The correct answer is: Take nail clippings

Question 17

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Answer 17

The correct answer is: c - Soap subsitute, twice daily liberal application of emollients plus as required use, moderate potency topical steroid daily if needed

Question 18

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Answer 18

The diagnosis is vitiligo; cosmetic camouflage is of limited benefit in fair skin but can be useful in darker skin types when lesions are more obvious. This is an autoimmune condition but there is no diagnostic blood test available. Prognosis is variable and unpredictable, systemic immunosuppression is not advised due to risks outweighing benefits and cosmetic camouflage is often helpful. The correct answer is: Cosmetic camouflage is particularly helpful in darker skin types

Question 19

What would be the main histological feature seen on a biopsy of acute dermatitis? Select one: * a. Apoptotic keratinocytes * b. Spongiosis * c. Vasodilatation * d. Neutrophil microabscesses * e. Parakeratosis

Answer 19

Spongiosis is typically seen in acute dermatitis (fluid accumulation between keratinocytes) The correct answer is: Spongiosis

Question 20

What are the cells most involved in the pathogenesis of urticaria? Select one: * a. Neurons * b. Mast cells * c. Langerhans’ cells * d. Lymphocytes * e. Keratinocytes

Answer 20

Mast cells, found in the dermis, are responsible for the release of histamine and other mediators that result in urticaria The correct answer is: Mast cells

Question 21

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Answer 21

This is pityriasis versicolor, a common yeast infection of the skin which can affect melanocyte function leading to variable pigmentation The correct answer is: Pityriasis versicolor

Question 22

A 67-year old man has had a generalised itch for 2 years. After initial assessment he was found to have severe kidney disease and this is considered to be the underlying cause for his symptoms . Which of the following is the most appropriate symptomatic relief treatment for his itch? Select one: * a. Ursodeoxycholic acid * b. A leukotriene receptor antagonist * c. Ultraviolet B phototherapy * d. Hospital haemodialysis * e. A non-sedating antihistamine

Answer 22

If able to comply, UVB is likely to be the most beneficial treatment of these options. The correct answer is: Ultraviolet B phototherapy (sounds like he has uraemic pruritus) UVB phototherapy is the mainstay of treatment for severe uraemic pruritus. Oral antihistamines and systemic steroids are generally not effective

Question 23

Which of the following correctly describes skin type III? Select one: a. Only burns b. Burns easily but eventually tans c. Dark brown skin d. Primarily tans but can burn e. Only tans

Answer 23

d. Primarily tans but can burn

Question 24

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Answer 24

Dermatitis, psoriasis, drug eruption, cutaneous lymphoma and idiopathic are all recognised causes of erythroderma. contact dermatitis would present as a more localised rash The correct answer is: Contact allergic dermatitis

Question 25

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Answer 25

This presentation suggests impetigo, a bacterial infection common in children. The correct answer is: Skin swab for bacterial culture and sensitivity

Question 26

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Answer 26

b - ABPI = 0.75, treat the venous ulcer with reduced compression ABPI is calculated by dividing the highest ankle pressure by the highest arm pressure. Normal range is 0.8-1.3 (other sources state 0.9-1.2)

Question 27

A 45 year old female had a pigmented mole removed from her leg, which histology shows to be a malignant melanoma. What is the most important prognostic marker? Select one: \* a. A history of previous melanoma \* b. Skin type of the patient \* c. Depth of the melanoma \* d. Age of the patient \* e. Diameter of the melanoma

Answer 27

Breslow thickness, which measures the depth of invasion, is the most important prognostic indicator in melanoma The correct answer is: Depth of the melanoma

Question 28

Which one of the following statements regarding UV radiation are true? Select one: \* a. UV irradiation causes local skin immunosuppression \* b. UVA is primarily responsible for sunburn \* c. Only UVB exposure is associated with an increased risk of skin cancer development \* d. Window glass prevents the transmission of UVA \* e. The ozone layer blocks most UVA from reaching the earth’s surface

Answer 28

UV irradiation causes local skin immunosuppression- TRUE FALSE b. UVA is primarily responsible for sunburn - UVB c. Only UVB exposure is associated with an increased risk of skin cancer development - UVA&B d. Window glass prevents the transmission of UVA e. The ozone layer blocks most UVA from reaching the earth’s surface - BLOCKS UVC

Question 29

A 73 year old lady attends her GP with an ulcer at the left medial malleolus. The surrounding skin appears normal with no signs of infection, however she has severe varicose veins. She also has type 2 diabetes and has had an MI in the past. You plan to treat this lady with compression bandaging. What would be an acceptable ABPI measurement? Select one: \* a. 0.2 \* b. 1.1 \* c. 1.8 \* d. 0.4 \* e. 1.5

Answer 29

ABPI is essential before any pressure bandage can be applied. If an individual has evidence vascular disease, there is a risk of ischaemia and poor healing. ABPI measurements: 0.8-1.3 normal \>1.3 calcification The correct answer is: 1.1

Question 30

A genetic mutation in which protein is thought to contribute to the pathophysiology of atopic eczema? Select one: \* a. Keratin \* b. Filaggrin \* c. Myosin \* d. Collagen \* e. Fibrillin

Answer 30

Filaggrin

Question 31

A 23 year old female is under regular review for monitoring of atypical naevi. Which of the following is not a risk factor for melanoma development? Select one: \* a. Blistering sunburns in childhood \* b. Systemic immunosuppression \* c. Skin type 4 \* d. Giant congenital naevus \* e. Personal history of melanoma

Answer 31

Skin type 4 is not a risk factor

Question 32

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Answer 32

Multiple bilateral superficial ulcerations extending up to the knee would raise the possibility of vasculitis. Vasculitis is likely – refer for further assessment. The correct answer is: Vasculitis is likely – refer for further assessment

Question 33

A 28 year old woman presents as she is concerned about recent hair loss. She describes the loss as severe, and on examination has generalised thinning over the whole scalp, but no bald patches. She is 10 weeks postpartum and has no past medical history. What is the most likely diagnosis? \* a. Alopecia areata \* b. Androgenetic hair loss \* c. Tinea capitis \* d. Telogen effluvium \* e. Trichotillomania

Answer 33

Telogen effluvium, due to altered hair cycle and mass shedding, is a common transient problem after childbirth. The correct answer is: Telogen effluvium

Question 34

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Answer 34

This presentation is suggestive of scabies, so the most appropriate treatment is option 2, permethrin cream The correct answer is: Permethrin cream

Question 35

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Answer 35

This description is consistent with nodular BCC, best managed by routine surgical excision. The correct answer is: Routine excision

Question 36

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Answer 36

History of lesion arising at site of injury suggests pyogenic granuloma, an exaggerated healing response. The correct answer is: Pyogenic granuloma

Question 37

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Answer 37

Using ABCD method of assessment, this lesion is extremely likely to be a melanoma, with features in keeping with the superficial spreading variant. The correct answer is: Superficial spreading melanoma

Question 38

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Answer 38

This is a well-defined lesion with a stuck on appearance. Clinical features and reassuring history suggest this is a seborrheic wart (or seborrheic keratosis / basal cell papilloma) which is benign and requires no intervention. The correct answer is: This is a harmless lesion and no intervention is needed (cryotherapy can be given if troublesome)

Question 39

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Answer 39

Histology shows an intra-epidermal split consistent with pemphigus vulgaris, which presents with flaccid blisters and erosions. Tense blisters are seen in bullous pemphigoid which has sub-epidermal split on histology. Spongiosis is seen in dermatitis (in the acute phase), where fluid accumulates between the keratinocytes, and burrows would suggest scabies, which is a clinical diagnosis, although if biopsied may show mites in the upper epidermis. The correct answer is: Flaccid blisters and erosions

Question 40

A 63 year old man has had a biopsy of a new onset persistent rash. The pathology report describes epidermal thickening, absence of granular layer, presence of parakeratosis and Munro microabscesses. What is the diagnosis? Select one: \* a. Psoriasis \* b. Atopic eczema \* c. Bowens disease \* d. Lichen planus \* e. Eruptive squamous cell carcinomas

Answer 40

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Question 41

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Answer 41

Histology here confirms Bowens disease ( in-situ SCC) which can be managed non-surgically, commonly with topical treatment such as Efudix. The correct answer is: Topical Efudix ( 5 fluoro-uracil) (can use imiquimod)

Question 42

Which of the following is not a recognised presentation of psoriasis? Select one: \* a. Chronic plaque psoriasis \* b. Palmoplantar pustulosis \* c. Chronic discoid psoriasis \* d. Flexural psoriasis \* e. Guttate psoriasis

Answer 42

Option 3 is not a recognised presentation of psoriasis The correct answer is: Chronic discoid psoriasis Technically palmoplantar pustulosis is now considered a separate condition

Question 43

A 36 year old female is referred to dermatology with an intermittent very itchy rash. It’s not present when she comes for her appointment, but she clearly describes small red, slightly swollen areas which are not scaly and very itchy. They last a few hours each and can affect any body site. What is the most likely diagnosis given this description? \* a. Urticaria \* b. Insect bite reaction \* c. Lichen planus \* d. Dermatitis herpetiformis \* e. Erythema nodosum

Answer 43

The description of short lived itchy lesions suggests urticaria, with individual lesions lasting no more than 24 hours generally The correct answer is: Urticaria

Question 44

You see a 19 year old girl with nodulo-cystic acne vulgaris in the dermatology clinic and are considering starting her on oral isotretinoin. Which one of the following side effects would it be MOST important to counsel the patient about? Select one: \* a. Teratogenicity \* b. Photosensitivity \* c. Dry skin \* d. Development of high cholesterol/triglyceride levels \* e. Leucopenia

Answer 44

Dry skin, photosensitivity and altered lipids are all potential side-effects of oral isotretinoin, but the most important in females of child-bearing age is teratogenicity. Patients are advised to enrol on the pregnancy prevention programme, with 2 methods of contraception to be used during treatment and monthly pregnancy tests before prescriptions are issued. The correct answer is: Teratogenicity

Question 45

Which of the following is NOT a feature of plaque psoriasis: Select one: \* a. Koebnor phenomenon \* b. Nikolsky’s sign positive \* c. Symmetrical distribution \* d. Extensor surfaces affected \* e. Auspitz sign positive

Answer 45

Nikolsky’s sign is used in diagnosis of bullous disorders, and not a finding in psoriasis The correct answer is: Nikolsky’s sign positive

Question 46

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Answer 46

Targetoid lesions in association with herpes simplex is consistent with a diagnosis of erythema multiforme, which can be bullous. The correct answer is: Erythema multiforme (also seen in mycoplasma pneumonia infections and drug reaction)