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QUIZ 4

1. A 27-year-old woman attends the clinic for review. She is pale skinned
and lived in Australia prior to moving to the UK. She is extremely
concerned about a mole on her back.
Which of the following features would make you most concerned about
a possible melanoma?
o

Uniform pigmentation

Diameter 7mm

Smoothly raised lesion

Regular border

Blue-black in colour

Correct

The ABCDE criteria were developed as an educational tool about


melanomas and they neatly summarise the features which raise the
possibility of a malignant melanoma. They are :
o
o
o
o
o

asymmetry
border irregularity
colour variability
diameter>5mm
evolving lesion with changes over time.

A 12-year-old girl is admitted to the hospital with a history of an


epileptic fit. The admitting doctor has documented
hypopigmented macules on her abdomen and acne-like eruption
on her face.

Examination of her fingers shows small periungal fibrous papules. She


is also known to have learning disabilities.
What is the most likely diagnosis?
o

Refsums disease

Neurofibromatosis

Tuberous sclerosis

Oslers disease

Blooms syndrome

Correct

Tuberous sclerosis (Bournevilles disease) is an autosomal-dominant


disorder with variable expression. Epilepsy in infancy or childhood is
often the presenting feature. Mental deficiency is commonly seen.
Elongated hypopigmented macules (ash-leaf patches) are commonly
seen. Adenoma sebaceum is an acne-like eruption present on the face.
Periungal fibromas arise as pink projections from the nail folds. The

shagreen patch is an angiofibromatous raised plaque usually on the


lower back.

A 35-year-old male runner has thickened, discoloured toenails on


three toes with onycholysis and subungual hyperkeratosis.

What is the most likely diagnosis?


o

Darier's disease

Onychomycosis

Lichen planus

Alopecia areata

Psoriasis

Incorrect

The clinical signs are consistent with onychomycosis (fungal nail


infection). These clinical signs could also be seen in psoriasis but there
is usually additional pitting and involvement of fingernails. Pitting does
not occur in onychomycosis.
Being a runner, he is at risk of tinea pedis (athletes foot), which is
commonly seen in association with onychomycosis and is caused by
the same organisms.

A patient presents with hyperkeratotic plaques on the skin,


especially at the scalp margin. Mycology of hair pullings no
growth.

What is the likely diagnosis?


o

Psoriasis

Seborrhoeic dermatitis

Tinea capitis

Lichen simplex

Discoid eczema

Correct

The diagnosis is Psoriasis. Chronic plaque psoriasis is characterised by


pinkish-red hyperkeratotic plaques, which occur especially on extensor
surfaces such as knees and elbows. The lower back, ears and scalp are
also commonly involved.

In the treatment of psoriasis, which of the following statements is


correct?

Infliximab is associated with tuberculosis

Retinoids are the most useful monotherapy in psoriatic

patients
o

PUVA is ineffective

Etanercept is not effective in psoriatic arthritis

Vitamin D analogues are associated with cutaneous atrophy

Correct

Psoralen and ultraviolet light (PUVA) is an effective treatment for


psoriasis but has been related to increased risk of squamous cell
carcinoma, and possibly malignant melanoma.
Retinoids are most effective in combination therapy especially with
ultraviolet B (UVB) phototherapy and PUVA. Part of the attraction of
vitamin D analogues over steroids is that they do not cause cutaneous
atrophy whereas steroids do.
Infliximab is associated with tuberculosis by reactivation of latent
disease.

A 55-year-old man has a squamous-cell carcinoma of his lower


lip. Which of the following is most likely to be a feature of this
type of carcinoma?

It is unrelated to sun exposure

5 year survival is poor

It is capable of metastasising via the lymphatics

It commonly spreads to distant sites by venous channels

It is commonly seen in patients under 45 years of age

Correct

Squamous-cell carcinoma (SCC) spreads to distant sites by the


lymphatic channels. Foremost among the factors influencing
metastatic risk are the size and location of the tumour and, to a lesser
extent, a rapid growth rate.Excision biopsy is essential for accurate
diagnosis.
Radical surgery and radiotherapy are the treatment of choice, with a
95% cure rate being possible if prompt and complete excision can be
carried out; however, patients who develop one SCC have a 40% risk of
developing additional SCCs within the next 2 years and should remain
under surveillance.
Combined use of surgery and adjuvant radiotherapy for patients with
nodal metastasis increase the 5-year survival rate to 73%.

A 55-year-old female is referred to dermatology due to a lesions


over both shins. On examination symmetrical erythematous
lesions are found with an orange peel texture.

What is the likely diagnosis?

Pretibial myxoedema

Pyoderma gangrenosum

Erythema nodosum

Syphilis

Necrobiosis lipoidica diabeticorum

Correct

Pretibial myxoedema is symmetrical erythematous shiny, orange peel


skin lesion seen in Graves disease .

A middle aged female patient presented an anaesthetic plaque


on the face of three months duration.

What is the most likely diagnosis?


o

Granuloma annulare

Tertiary syphilis

Leprosy

Urticaria

Sarcoidosis

Correct

Leprosy is the correct option here. It classically produces reddish


patches or hypopigmented areas of skin, with reduced sensation.
These are required for the disease to be diagnosed.

A 17-year-old girl presents with a two week history of urticaria.


Over the last couple of days she has been aware of new lesions
occurring on a daily basis.

Which one of the following statements is most likely to be correct?


o

The lesions will be present for at least 24 hours

She is likely to have an associated asthma

There is likely to be a nut allergy

She is unlikely to have any identifiable trigger factor

She is likely to have taken penicillin recently

Incorrect

The commonest form of urticaria is idiopathic and there is no


identifiable trigger. Peanut allergy and penicillin may cause urticarial
rashes but there is usually an associated specific history of contact
with the allergen.

A 20-year-old woman presented with sudden onset of swelling of


the lips and tongue. She also had abdominal pain and vomiting.
Her mother confirmed that her daughter had similar attacks over
the years and even as a child. A brother and older sister have the
same disorder.

Which of the following statements about this disease is accurate?


o

Animal allergen is often identified in the house

Antinuclear antibodies (ANA) is often positive

Serum C4 levels are often low

It has sex-linked inheritance

Raised IgE helps differentiate it from other immune disorders

Incorrect

Hereditary angioneurotic oedema is an autosomal dominantly inherited


condition caused by a deficiency of C1 esterase inhibitor. This results in
intermittent episodes of spontaneous complement activation.
Clinically the patient suffers oedema of the skin and mucosal surfaces.
Fatalities may occur if the airway is compromised. C4 levels are
typically low during an attack; they may be normal in between attacks.

A 17-year-old pregnant female attends antenatal clinic and is


noted to have scattered small, raised lesions on her trunk and
axillary freckles. She was not aware of any of her family
members having these lesions.

What is the likely mode of inheritance of this condition?


o

Trinucleotide repeating

X linked recessive

Autosomal recessive

Autosomal dominant

X linked dominant

Correct

This patient has neurofibromatosis with axillary freckling and


neurofibromas. This is usually inherited as autosomal dominant.

A 22-year-old woman presents with unsightly skin over her chest


and scapular area. She noticed it while recently sunbathing on
holiday in Spain.

On examination she has a number of greasy brown papules on her


chest and scapular area.
What diagnosis fits best with this clinical picture?
o

Dariers disease

Pityriasis rosea

Pityriasis rubra pilaris

Lichen planus

Lichen aureus

Incorrect

Dariers disease is a genetic skin condition that has an autosomaldominant mode of inheritance. It is characterised by abnormal
keratinisation mainly around hair follicles, resulting in a greasy, red
brown papular eruption. The rash most commonly presents on the
chest and scapular area and is aggravated by sunburn or tanning.
Small pits may occur on the skin of the palm of the hand, and nail
abnormalities may also be associated. The rash may occur as an

abnormal reaction to local skin infection, though the exact pathological


trigger is unknown.
Salicylic acid preparations were the mainstay of treatment in the past,
but these have now been largely replaced by retinoids. Of course, in
this age group, adequate contraception is essential in patients taking
retinoic acid preparations.

A 7-year-old black male presents with enlarged cervical lymph


nodes and scaly patches in the scalp. What is the MOST likely
diagnosis?

Non-Hodgkins lymphoma

Tinea capitis

Psoriasis

Rubella

Seborrhoeic dermatitis

Incorrect

Tinea capitis is more commonly seen in black children than other races
and there have been inner city epidemics. Regional lymphadenopathy
often occurs.

Caf-au-lait spots are seen in each of the following, except:

Neurofibromatosis

Tuberous sclerosis

McCune-Albright syndrome

Fanconi anaemia

Friedreich's ataxia

Incorrect

Caf-au-lait spots is hyperpigmented lesions that vary in colour from


light brown to dark brown, with borders that may be smooth or
irregular .
Causes include neurofibromatosis type I & II ,tuberous sclerosis
,Fanconi anaemia and McCune-Albright syndrome.

A 64-year-old female is referred to dermatology due to a nonhealing skin ulcer on her lower leg. This has been present for
around 6 weeks and the appearance didnt improve following a
course of oral flucloxacillin. What is the

most important investigation to perform first?


o

MRI

Ankle-brachial pressure index

Rheumatoid factor titres

X-ray

Swab of ulcer for culture and sensitivity

Incorrect

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.
If the ulcer fails to heal with active management (e.g. Compression
bandaging) then referral for consideration of biopsy to exclude a
malignancy should be made.

A 28-year-old woman presents with an enlarging mole on her


calf. Excision biopsy shows a superficial spreading melanoma of
0.5mm thickness.

Subsequent treatment should be:


o

Wide excision and sentinel node biopsy

Wide excision and adjuvant immunotherapy

Wide excision with 1 cm margin

Wide excision and elective inguinal node dissection

Wide excision with 5 cm margin

Correct

This is a low risk melanoma. Excision margins greater than 1-2 cm


have no advantage and the role of adjuvant immunotherapy is
debatable even in high risk patients, although it may prolong diseasefree survival.

A 51-year-old male presents with a rash that has been present


intermittently over the last two years. On examination there is a
symmetrical rash over the cheeks, nose and chin, with multiple
papules and pustules.

What is the most appropriate therapy for this patient?


o

Flucloxacillin

Oxytetracycline

Prednisolone

Hydroxychloroquine

Isotretinoin

Correct

The description is that of acne rosacea particularly in view of the


distribution, duration and absence of any other features. The most
appropriate treatment is a tetracycline.
Isotretinoin although effective in rosacea is reserved for recalcitrant or
fulminant cases. Prednisolone is administered in rosacea fulminans.

A 31-year-old woman develops with painful, purple lesions on her


shins. Which one of the following medications is most likely to be
responsible?

Carbimazole

Combined oral contraceptive pill

Lansoprazole

Sodium valproate

Montelukast

Correct

Erythema nodosum drug causes include penicillins, sulphonamides and


combined oral contraceptive pill.

Which of the following concerning pityriasis rosea is correct?

May be preceded by intense itching

It is frequently associated with oro-genital itching

It is due to a fungal infection

It is characterised by flat scaly patches

Tends to recur after apparent cure

Incorrect

Pityriasis rosea may be set off by a viral infection but does not appear
to be contagious; herpes viruses 6 and 7 have most often been
associated with pityriasis rosea. It is not caused by a fungus. It is not
related to foods, medicines, or stress. It most often affects teenagers
or young adults.
The condition often begins as a large single pink patch on the chest or
back. This patch may be scaly and is called a herald or mother
patch. Within a week or two, more pink patches, sometimes hundreds
of them, appear on the body and on the arms and legs. Patches may
also occur on the neck, and though rare, the face. The oval patches

follow the line of the ribs like a fir tree. They have a dry surface and
may have an inner circlet of scaling.

A 25-year-old man gives a 2-week history of painful joints


affecting his lower limbs. He returned from a holiday in SE Asia 3
weeks ago. During this holiday he had developed loose bowel
motions followed by eye irritation, for which he had consulted a
local doctor. He has a psoriasiform rash on his lower limbs and
soles.

What is the most likely diagnosis?


o

Reactive arthritis

Guttate psoriasis

Lichen planus

Mastocytosis

Porphyria

Correct

Reactive arthritis is characterised by non-suppurative polyarthritis


following a lower urogenital or enteric infection. It usually affects
young men carrying the HLA-B27 antigen. Inflammatory eye disease
and mucocutaneous manifestations are common.

A 23-year-old homosexual man visits a local GP while on holiday


in the UK from Australia. He has noted a lesion on his penis that
was initially nodular and painless, but has progressed over a time
to form a heaped-up ulcer.

Sampling from the lesion reveals large infected mononuclear cells


containing many Donovan bodies.
What diagnosis fits best with this clinical picture?
o

Chancroid

Lymphogranuloma venereum

Granuloma inguinale

Penile carcinoma

Genital herpes

Incorrect

Calymmatobacterium granulomatis is a Gramnegative bacillus that


reproduces within neutrophils, plasma cells and histiocytes, causing
the infected white cells to rupture with the release of 2030 organisms.
The key features are a primary, painless indurated nodule that
progresses to a heaped-up ulcer, and the presence of infected
mononuclear cells containing many Donovan bodies.

Treatment is with tetracycline or ampicillin, and patients are advised to


refrain from sexual intercourse until the lesion has healed.

A 34-year-old man presents for the removal of a mole. Where on


the body are keloid scars most likely to form?

Sternum

Lower back

Abdomen

Scalp

Flexor surfaces of limbs

Incorrect

Keloid scars are tumour-like lesions that arise from the connective
tissue of a scar and extend beyond the dimensions of the original
wound Predisposing factors . It is more common in people with dark
skin . It occur more commonly in young adults, rare in the elderly .
Common sites (in order of decreasing frequency): sternum, shoulder,
neck, face, extensor surface of limbs, trunk.

A 32-year-old Turkish man presents with painful mouth sores, a


painful red eye and polyarthralgia. Ulcers on a yellow base with
erythematous edges are seen in the buccal mucosa.

He gives a history of painful genital ulcers in the past few months


which have now healed.
What is the most likely diagnosis?
o

Reactive arthritis

Erythema multiforme

Syphilis

Behets syndrome

Crohns disease

Incorrect

Behets syndrome is characterised by recurrent orogenital ulceration,


uveitis and arthritis and is more common in Turkish and Chinese
populations. It is an autoimmune disease associated with HLA-B12,
-B51 and -B5.

A 74-year-old man with a thirty year history of psoriasis


presented with generalised erythroderma of three days duration.

Examination reveals him to be shivering but otherwise well. He was


treated as an inpatient with emollients and attention to fluid
replacement and temperature control but failed to improve after five
days.

What is the most appropriate next treatment?


o

Oral hydroxychloroquine

Oral prednisolone

Oral methotrexate

Topical coal tar

Topical Dithranol

Correct

Erythroderma is an emergency as patients are susceptible to profound


dehydration, infection and hypothermia. Methotrexate would be the
only correct treatment for someone with erythrodermic psoriasis.
Steroids could lead to unstable pustular psoriasis and would not
generally work. Hydroxychloroquine has little effect on psoriasis.
Topical coal tar and Dithranol are good treatments for chronic plaque
psoriasis but are highly irritant and would make the erythroderma
much more inflamed and deteriorate his condition.

A 23-year-old woman who is 5 months pregnant presents to the


GP with concerns about changes in her skin appearance. She
reports that she has always had some light brown discolorations
on her skin, a lot of freckling and lumps on her skin, but that
these have worsened during the pregnancy.

On examination she has multiple light brown pigmented areas on her


skin, a number of friable cutaneous skin lesions and axillary freckling.
Which of the following is the most likely diagnosis?
o

Neurofibromatosis Type 1

MEN-1

Acanthosis nigricans

MEN-2

Neurofibromatosis Type 2

Correct

Neurofibromatosis results from a deletion or mutation in the NF-1 gene,


the product of which, neurofibromin acts a suppressor for CNS
tumours.
The disease is associated with less central CNS tumours than
neurofibromatosis Type 2, but is associated with a mixture of skin
features such as multiple caf-au-lait spots, axillary freckling and
cutaneous neurofibromas.
Skin features develop over a number of years, but the pace of
development may increase during puberty and pregnancy.

A 23-year-old man presents as he is concerned over recent hair


loss. Examination reveals a discrete area of hair loss on the left
temporal region with no obvious abnormality of the underlying
scalp.

What is the most likely diagnosis?


o

Male-pattern baldness

Alopecia areata

Telogen effluvium

Tinea capitis

Discoid lupus erythematous

Correct

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 .
Hair will regrow in 50% of patients by 1 year, and in 80-90% eventually.
Careful explanation is therefore sufficient in many patients.

A 34-year-old man comes for review. Over the past two weeks he
has developed a number of painful, erythematous lesions on his

shins. He has no dermatological history of note and is usually fit


and well.
On examination the lesions are consistent with erythema nodosum. You
arrange some baseline investigations. He asks what is likely to happen.
What is the most appropriate response?
o

Heal without scarring if steroids are given within 2 weeks

Heal without scarring within 1-2 months

Heal with scarring within 6-12 months

Heal with scarring within 1-2 months

Heal without scarring within 6-12 months

Correct

Erythema nodosum usually resolves within 6 weeks without scarring.

A 22-year-old male is referred to dermatology clinic with a


longstanding problem of bilateral excessive axillary sweating. He
is otherwise well but the condition is affecting his confidence and
limiting his social life.

What is the most appropriate management?

Trial of desmopressin

Non-sedating antihistamine

Perform thyroid function tests

Topical aluminium chloride

Topical hydrocortisone 1%

Correct

Hyperhidrosis describes the excessive production of sweat


Management options include:
o

topical aluminium chloride preparations are first-line. Main side

effect is skin irritation


o
iontophoresis: particularly useful for patients with palmar,
plantar and axillary hyperhidrosis
o
botulinum toxin: currently licensed for axillary symptoms
o
surgery: e.g. Endoscopic transthoracic sympathectomy. Patients
should be made aware of the risk ofcompensatory sweating
A 71-year-old obese woman presents for review. Her past history
has been unremarkable apart from a deep venous thrombosis
suffered some years ago.
On examination there is an ulcer over the left medial malleolus with
fibrosis and purpura of the surrounding skin.

What is the diagnosis that fits best with this particular clinical picture?
o

Trauma to the medial malleolus

An arterial ulcer

A neuropathic ulcer

A venous ulcer

A vasculitic ulcer

Correct

The incidence of venous leg ulceration is higher in obese patients,


those with a history of varicose veins and where there is a history of
deep vein thrombosis.
Ulcers occur due to venous stasis, secondary increase in capillary
pressure, fibrosis, and poorly nourished skin particularly over areas
such as the medial malleolus. This process, coupled with minor trauma,
then results in venous ulceration.

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?
o

Chronic plaque psoriasis

Scabies

Dermatitis herpetiformis

Lichen planus

Henoch-Schonlein purpura

Correct

Dermatitis herpetiformis is an autoimmune blistering skin disorder


associated with coeliac disease. It is caused by deposition of IgA in the
dermis.
It is featured by itchy, vesicular skin lesions on the extensor surfaces
(e.g. elbows, knees buttocks).

Which one of these features is typical of dermatomyositis?


Gottron's papules over knuckles of fingers

Sclerotic digital skin

Heliotrope rash around external auditory meatus

Distal muscle weakness

Rare association with malignancy in the elderly

Correct

The lilac heliotrope discolouration around the eyes can be associated


with a malar erythema and oedema. Gottrons papules are slightly
atropihic lilac-coloured papules over the knuckles of the hands and can
be associated with linear streaks of erythema over the extensor
tendons.
Most patients have clinical muscle involvement with a predominantly
proximal pattern. Internal malignancy occurs in up to 66% of males
over 40 years.

A 78-year-old nursing home resident is reviewed due to the


development of an intensely itchy rash.

On examination red linear lesions are seen on the wrists and elbows,
and red papules are present on the penis.
What is the most appropriate management?
o

Referral to GUM clinic

Topical permethrin

Topical betnovate

Topical selenium sulphide

Topical ketoconazole

Incorrect

Lichen planus may give a similar picture but the intense itching is more
characteristic of scabies. It is also less common for lichen planus to
present in the elderly it typical affects patients aged 30-60 years.
Permethrin 5% is first-line management , malathion 0.5% is secondline.

A 72-year-old woman is diagnosed with a number of


erythematous, rough lesions on the back of her hands. A
diagnosis of actinic keratoses is made.

What is the most appropriate management?


o

Topical betnovate

Review in 3 months

Reassurance

Topical fluorouracil cream

Urgent referral to a dermatologist

Incorrect

Actinic, or solar, keratoses (AK) is a common premalignant skin lesion


that develops as a consequence of chronic sun exposure. Management
include prevention of further risk: e.g. sun avoidance, sun cream .
Fluorouracil cream: typically a 2 to 3 week course. The skin will
become red and inflamed sometimes topical hydrocortisone is given
following fluorouracil to help settle the inflammation , topical
diclofenac: may be used for mild AKs. Moderate efficacy but much
fewer side-effects.

An elderly woman is referred with mildly itchy vulval skin.


Examination shows an atrophic white plaque affecting the vulva.
There is a similar plaque on her abdomen.

Which of the following is the most likely diagnosis?


o

Lichen sclerosus

Vitiligo

Lichen simplex

Lichen planus

Morphea

Correct

This would be an unusual site for morphea. Vitiligo is not generally an


atrophic condition. Lichen planus and lichen simplex tend to be very
itchy.

A 85-year-old lady presents to dermatology clinic 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?


o

Herpes simplex

Seborrhoeic dermatitis

Lichen planus

Lichen sclerosus

Candida

Incorrect

Lichen sclerosus is an inflammatory condition which usually affects the


genitalia and is more common in elderly females. Lichen sclerosus
leads to atrophy of the epidermis with white plaques forming.
Candida may cause pruritus and white plaques but lesions would not
also be seen on her inner thigh.

Which of the following would be expected to produce alopecia


(hair loss) if there was scalp involvement?

Seborrhoeic dermatitis

Rosacea

Psoriasis

Discoid lupus erythematosus

Bullous pemphigoid

Correct

Discoid lupus erythematosus produces hair loss which may be


permanent because of scarring of the hair follicles (a scarring
alopecia).
Psoriasis and seborrhoeic dermatitis commonly involve the scalp but
do not produce hair loss.

A 75-year-old ex-soldier presents to his GP complaining of a


dome-shaped lesion on his nose.

There are prominent telangiectatic vessels on the surface of the lesion.


The border of the lesion is translucent, looks pearly-white and is
slightly raised.
What diagnosis fits best with this clinical picture?
o

Sebaceous hyperplasia

Nodular basal-cell carcinoma

Superficial basal-cell carcinoma

Keratoacanthoma

Melanoma

Correct

This lesion has the typical appearance of an early basal-cell carcinoma


of the nodular type. Nodular BCCs are the commonest type (21%)
The major risk factor for BCC is sun exposure. BCC is the commonest
cutaneous neoplasm in humans, 85% of cases are on the head and
neck region.
Morpheaform lesions present with a yellowish or white appearance
similar to localised scleroderma.

A 69-year-old woman with a history of learning difficulties is


reviewed in clinic. She is known to have erythema ab igne on her
legs but according to her carer still spends long hours in front of
her electric fire.

Which one of the following skin lesions is she at risk of developing?


o

Cutaneous T-cell lymphoma of the skin

Basal cell carcinoma

Squamous cell carcinoma

Malignant melanoma

Dermatofibrosarcoma protuberans

Incorrect

If Erythema ab igne is not treated then patients may go on to develop


squamous cell skin cancer.

A 39-year-old female has a pigmented mole removed from her


leg which histology shows to be a malignant melanoma.

What is the single most important prognostic marker?


o

Mutation in the MC1R gene

Depth of melanoma

Number of episodes of sunburn before the age of 18 years

Age of patient

Diameter of melanoma

Correct

The invasion depth of a tumour is the single most important factor in


determining prognosis of patients with malignant melanoma.

A 70-year-old woman complains of swollen, red, itchy legs. Which


is the most likely diagnosis?

Varicose eczema

Cellulitis

Lymphedema

Necrobiosis lipoidica

Lipodermatosclerosis

Incorrect

Varicose eczema is a common problem, particularly in elderly patients


with peripheral edema, which tends to exacerbate the problem. It is
often mistaken for cellulitis, but cellulitis is rarely bilateral and is
painful rather than itchy.

Which one of the following antibiotics is most associated with the


development of Stevens-Johnson syndrome?

Ethambutol

Co-trimoxazole

Chloramphenicol

Gentamicin

Ciprofloxacin

Correct

Drugs causing Stevens-Johnson syndrome : penicillin, sulphonamides,


carbamazepine, allopurinol, NSAIDs, oral contraceptive pill

A 16-year-old male is given amoxycillin for a sore throat. Five


days later, he develops a rash consisting of erythematous
papules and plaques. Individual lesions come and go over
several hours, leaving no trace.

What is the most likely diagnosis?


o

Cutaneous vasculitis

Epstein Barr virus (EBV) infection

Scarlet fever

Urticaria

Drug hypersensitivity syndrome

Incorrect

Lesions which come and resolve without trace, typically within 24


hours, are characteristic of urticaria. The other diagnoses would all fit
the clinical scenario but individual lesions would take several days
minimum to resolve.

A 14-year-old male is reviewed due to a patch of scaling and hair


loss on the right side of his head. A skin scraping is sent which
confirms a diagnosis of tinea capitis.

Which organism is most likely to be responsible?


o

Microsporum audouinii

Microsporum distortum

Microsporum canis

Trichophyton tonsurans

Trichophyton verrucosum

Incorrect

Most common cause of Tinea capitis is Trichophyton tonsurans in the


UK and the USA . It may also be caused by Microsporum canis acquired
from cats or dogs.

A 25-year-old pregnant woman complains she has had painful


nodules on her shins for over 2 weeks. She suffers from asthma,
which is well controlled and is 32 weeks pregnant.

Examination shows painful nodules over her shins.


What is the most likely diagnosis?
o

Erythema nodosum

Erythema multiforme

Cellulitis

Drug eruption

Granuloma annulare

Incorrect

Erythema nodosum is an acute panniculitis that produces painful


nodules or plaques on the shin. It is commonly seen in sarcoidosis,
inflammatory bowel diseases, streptococcal infections, tuberculosis,
sulphonamide treatment and may be seen during pregnancy.

A 25-year-old female presents with a 3-week history of bald


patches in the scalp. On examination, there are several round
patches (2-3cm), of completely hairless skin. The skin looks
normal.

What is the most likely diagnosis?


o

Alopecia areata

Alopecia totalis

Tinea capitis

Lichen planus

Discoid lupus erythematosus

Correct

All of the above can cause loss of scalp hair. Discoid lupus
erythematosus and lichen planus are inflammatory skin diseases that
can cause permanent hair loss due to scarring of the hair follicles
(scarring alopecia). The scalp would look red and scaly in these two
conditions. Tinea capitis can produce patchy hair loss but the scalp
would not look normal.
Alopecia areata and alopecia totalis are believed to be organ-specific
autoimmune diseases targeting hair follicles. Alopecia areata
characteristically presents with round patches of complete hair loss
and the scalp looks normal.

Which one of the following statements regarding acne vulgaris is


incorrect?

Acne vulgaris affects at least 80% of teenagers

Beyond the age of 25 years acne vulgaris is more common in

males
o

Propionibacterium acnes is an anaerobic bacterium

Typical lesions include comedones and pustules

Follicular epidermal hyperproliferation results in obstruction

of the pilosebaceous follicle


Incorrect

Acne is actually more common in females after the age of 25 years

Which of the following conditions is least likely to exhibit the


Koebner phenomenon?

Molluscum contagiosum

Lupus vulgaris

Vitiligo

Lichen planus

Psoriasis

Incorrect

The Koebner phenomenon describes skin lesions which appear at the


site of injury. It is seen in:
psoriasis
vitiligo
warts
lichen planus
lichen sclerosus
molluscum contagiosum

o
o
o
o
o
o

A 43-year-old man comes for review. A few months ago he


developed redness around his nose and cheeks. This is worse
after drinking alcohol. He is concerned as one of his work
colleagues asked him if he had a drink problem despite him
drinking 14 units per week.

On examination he has erythema as described above with some


pustules on the nose and telangiectasia on the cheeks.
What is the most likely diagnosis?
o

Mitral stenosis

Systemic lupus erythematosus

Alcohol-related skin changes

Acne rosacea

Seborrhoeic dermatitis

Incorrect

This is a typical history of acne rosacea.

A 67-year-old heavy smoker presents to his GP for review. He has


developed a blueviolet rash on his face, particularly around the
eyes. There is also erythema on the back of his hands and feet,
and nailfold haemorrhages are present. On examination there is
mild proximal muscle weakness.

Past history of note includes hypertension, hypothyroidism, for which


he is taking thyroxine, and hypercholesterolaemia, for which he takes
simvastatin.
What diagnosis fits best with this clinical picture?
o

Hypothyroid proximal myopathy

Dermatomyositis

Cushings disease

Discoid lupus

Statin-related rhabdomyolysis

Incorrect

The typical rash of dermatomyositis is a macular erythema with a blue


violet (heliotrope) coloration around the eyes. There is also linear
erythema over the dorsum of the hands and feet, and nailfold
haemorrhages in some patients. In adults there is an association with
occult malignancy.

A 44-year-old woman has been admitted to hospital with atypical


pneumonia. She has now developed a rash with a purpuric
centre. There is no mucosal involvement.

What is the diagnosis?


o

Erythema multiforme

Fixed drug eruption

Hereditary pemphigus

Toxic epidermal necrolysis

Erythema nodosum

Correct

Erythema multiforme is an urticaria-like rash with purpura or vesicles


in the centre (Target lesions or bulls eye). It may follow a herpes
simplex flare, orf, mycoplasma, bacterial infections, sulphonamides,
penicillins, barbiturates and internal malignancy.