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QUIZ 5 MRCPA 15-year-old girl presents with an itchy rash around her umilicus at
the site o! her "eans stud# $he is patch tested and !ound to e allergic to nic%el#
&hich o! the !ollowing is '() true*
$he is li%ely to ecome desensitised to nic%el i! she a+oids it !or a long time
)opical steroids will impro+e the rash
$he has a type-, allergy to nic%el
Painting the stud with nail +arnish may impro+e the rash
'ic%el allergy is the most common patch test nding in women
Incorrect
Contact dermatitis is a type-, allergy that can e treated with topical steroids# 'ail
+arnish can reduce contact o! studs with the s%in and impro+e this prolem
.although suse/uent allergy to the nail +arnish has een reported0#
(nce type-, allergy to a sustance has de+eloped it is usually li!e-long e+en i! the
allergen is strictly a+oided#
An 2,-year-old woman with a history o! ischaemic heart disease is re+iewed in the
dermatology clinic# 3er current medication includes aspirin sim+astatin isoprolol
ramipril and isosoride mononitrate#
$he has de+eloped tense listering lesions on her legs# 4ach lesion is around 1 to
cm in diameter and she reports that they are slightly pruritic# 46amination o! her
mouth and +ul+a is unremar%ale#
&hat is the most li%ely diagnosis*
7ullous pemphigoid
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Pemphigus
8rug reaction to aspirin
4pidermolysis ullosa
$caies
Correct
7ullous pemphigoid is an autoimmune condition causing su-epidermal listering o!
the s%in# )his is secondary to the de+elopment o! antiodies against
hemidesmosomal proteins 7P129 and 7P:9 #
;eatures include itchy tense listers typically around <e6ures the listers usually
heal without scarring#
A :=-year-old newly /ualied nurse presents as she has de+eloped a ilateral
erythematous rash on oth hands# $he has recently emigrated !rom the Philippines
and has no past medical history o! note# A diagnosis o! contact dermatitis is
suspected#
&hat is the most suitale to test to identi!y the underlying cause*
$%in patch test
Radioallergosorent test .RA$)0
>ate6 IgM le+els
$%in pric% test
Urinary porphyrins
Correct
$%in patch testing Use!ul !or contact dermatitis# Around 9-,9 allergens are placed
on the ac%# Irritants may also e tested !or# )he patches are remo+ed ,2 hours
later with the results eing read y a dermatolois ugist a!ter a !urther ,2 hours#
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A =:-year-old hea+y smo%er with a long history o! sel!neglect presents to his ?P
with se+ere leg pain# (n e6amination there are multiple small punched-out ulcers
situated on the lower third o! oth legs# 7oth dorsalis paedis and posterior tiial
pulses appear asent#
&hat diagnosis ts est with this clinical picture*
)raumatic s%in damage
Multiple arterial ulcers
;lea in!estation
@asculitis
Multiple +enous ulcers
Correct
)his is the typical picture o! arterial ulceration in a smo%er# Associated ischaemic leg
pain may e particularly intense on ele+ating the legs and cause sleep inter!erence#
As well as peripheral +ascular disease as e+idenced y the asent !oot pulses
ilaterally#
An 12-year-old woman attends antenatal clinic 1: wee%s into her pregnancy where
the doctor incidentally notes numerous small lumps o+er her trun% and !rec%les in
her a6illae# $he reported that none o! her relati+es had any similar !eatures#
&hat is the most li%ely diagnosis*
'euroromatosis
)uerous sclerosis
Acanthosis nigricans
8ysplastic nae+us syndrome
Mastocytosis
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Correct
)he patient is li%ely to ha+e neuroromatosis .';10 with two or more
neuroromas or a ple6i!orm neuroroma and !rec%les under the arm or in the
groin region#
A =,-year-old woman presents with se+ere mucosal ulceration associated with the
de+elopment o! listering lesions o+er her torso and arms#
(n e6amination the listers are <accid and easily ruptured when touched#
&hat is the most li%ely diagnosis*
8ermatitis herpeti!ormis
Pemphigoid
Pemphigus +ulgaris
4pidermolysis ullosa
Psoriasis
Correct
Pemphigus +ulgaris is an autoimmune disease caused y antiodies directed
against desmoglein a cadherintype epithelial cell adhesion molecule# It is more
common in the Ash%enai Bewish population #
Mucosal ulceration is common and o!ten the presenting symptom# (ral in+ol+ement
is seen in 59-9D o! patients # $%in listering E <accid easily ruptured +esicles and
ullae# >esions are typically pain!ul ut not itchy# )hese may de+elop months a!ter
the initial mucosal symptoms#
'i%ols%yFs descries the spread o! ullae !ollowing application o! horiontal
tangential pressure to the s%in
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A =:-year-old woman has recently een diagnosed as suGering !rom lentigo maligna
on her !ace#
&hich !actor is most important in determining her prognosis*
Initial sie o! the lesion
Colour o! the lesion
)hic%ness o! the lesion
PatientFs age
(ther comoridities
Correct
>entigo maligna represents an increased numer o! melanocytes at the
epidermodermal "unction# It egins as a <at !rec%le-li%e lesion which can change
into a malignant melanoma# It occurs on the !acial or sune6posed s%in o! patients in
their si6ties or older#
Malignant change should e suspected with a change in sie outline colour
sur!ace or ele+ation o! the lesion# It spreads +ia the lymphatics and satellite lesions
are commonly seen#
)he prognosis is directly related to the thic%ness o! the tumour assessed at
histological e6amination# )he prognosis is also related to the site#
A 1H-year-old student presents !or re+iew# 3e has "ust returned to uni+ersity !or the
start o! the $pring term#
3e gi+es a history o! a red patch o! s%in on his chest surrounded y an area o! s%in
scaling which was !ollowed aout days later y the de+elopment o! o+al macules
o+er the rest o! his trun% arms and thighs# 3e is otherwise well#
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&hat diagnosis ts est with this clinical picture*
>i%ely drug reaction
8arierFs disease
Pityriasis rosea
Pityriasis rura pilaris
Pityriasis +ersicolor
Correct
)he rst clinical lesion to appear in pityriasis rosea is the so-called herald patchF an
isolated erythematous patch appearing on the trun% surrounded y a ring o!
scaling s%in# A numer o! o+al macules appear on the upper arms remainder o! thetrun% and upper thighs some :E, days later#
In+ol+ement o! the hands !eet or scalp is rare# $e+ere itching is uncommon#
Pityriasis rosea normally remits within ,E 2 wee%s#
$ystemic antihistamines or calamine lotion may e use!ul to relie+e itching# )opical
steroids do not shorten the duration o! the disease and systemic steroids ha+e no
+alue in disease modication#
&hich o! the !ollowing is true regarding psoriasis*
)he main anormality is increased epidermal proli!eration due to e6cessi+e
di+ision o! cells in the asal layers and a shorter cell-cycle time
It suggests underlying adominal malignancy
It may commonly e the presenting !eature o! 3odg%inFs lymphoma
It aGects 15-:9D o! the population
Psoriatic arthropathy occurs in o+er 9D o! people with psoriasis
Correct
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Psoriasis may e associated with an increased ris% o! certain malignacies notaly
non-3odg%inFs lymphoma# 3owe+er the treatments o! psoriasis .e#g# methotre6ate
)'; alpha inhiitors0 pose a greater ris% o! associated malignancy than the
condition itsel!#
Psoriasis aGects 1- D o! the population and an arthropathy occurs in aout 5D o!
patients# )rauma eta-haemolytic streptococcal throat in!ections U@ rays
antimalarials and lithium can cause <are-ups#
&hich o! the !ollowing is true o! cutaneous anthra6*
>esions are associated with mar%ed oedema
>esions are usually pain!ul and tender
Mortality is appro6imately :9D despite antiiotic therapy
Is +ery li%ely to occur in su"ects e6posed to anthra6 spores
Causes a lac% eschar which o+erlies pus
Incorrect
Anthra6 is caused y 7acillus anthracis a ?ram positi+e rod# Cutaneous anthra6 is
caused y direct contact o! the acteria into an open wound .usually touching an
in!ected animal0#
Cutaneous anthra6 is associated with a lac% eschar without pus tends to e
painless and to ha+e widespread oedema#
&ithout antiiotics mortality is o! the order o! :9D ut with antiiotics mortality is
low which contrasts with pulmonary anthra6#
A patient with psoriatic arthritis has acti+e "oints and troulesome pla/ue psoriasis#
&hich o! the !ollowing will impro+e oth the "oint and s%in prolems*
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Methotre6ate
Penicillamine
$ulphasalaine
3ydro6ychloro/uine
?old
Correct
3ydro6ychloro/uine can e6acerate psoriasis# $ulphasalaine tends to only impro+e
"oint symptoms and not impro+e the psoriasis# ?old and penicillamine are not
commonly used to treat this condition#
A 9-year-old woman presents with an intermittent pruritic eruption which has eenoccurring !or se+eral months# >esions last a !ew hours only and disappear lea+ing no
mar% suggesting a diagnosis o! urticaria# $he is atopic and had a nut allergy as a
child#
&hich one o! the !ollowing is true*
Most patients with chronic urticaria do not ha+e an e6ogenous trigger
$%in pric% tests are not use!ul in diagnosis o! the causes o! urticaria
Acute urticaria typically responds to topical steroids
In!ant nut allergy persists into adult li!e in most patients
Chronic urticaria is strongly associated with atopy
Incorrect
Most indi+iduals with chronic long-term urticaria do not ha+e an e6ogenous trigger#
Ig4-mediated urticarial reactions to !oods usually !ollow a clear pattern and can ein+estigated y s%in-pric% tests or serum Ig4 /uantication#
A :,-year-old theatre nurse presents !or re+iew# $he has red scaling pla/ues that
are worse on her hands ut are also present on the <e6or sur!aces o! her arms and
legs#
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3er past history o! note includes coeliac disease# )here is a mildly raised lood
eosinophil count# &
hat diagnosis ts est with this clinical picture*
Atopic ecema
8ermatitis herpeti!ormis
Psoriasis
Photosensiti+ity
3istiocytosis-J
Incorrect
4cema characteristically occur on the <e6ural sur!aces# Chronic in<ammation may
result in s%in lichenication constant scratching in hypopigmentation# In this case
late6 sensitisation may ha+e played a role in worsening the clinical picture#
A 15-year-old oy was treated with permethrin cream !or scaies in!estation# (n
!ollow-up three wee%s later he was !ound to ha+e continuing in!estation#
&hat is the most li%ely reason !or this*
'on-disposal o! underwear
(ther household memers were not treated
)he treatment was not repeated as prescried
)he organism is resistant to permethrin
;acial s%in was not treated
Correct
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)reatment !ailures are uncommon# Recurrence o! the eruption usually means re-
in!ection has occurred#
A :-year-old man presents with a , day history o! an itchy and sore right ear# 3e
has recently returned !rom holiday in $pain# (n e6amination the right ear canal is
in<amed ut no deris is seen# )he tympanic memrane is clearly +isile and is
unremar%ale#
&hat is the most appropriate management*
(ral <uclo6acillin
Re!er to 4')
)opical corticosteroid K clotrimaole
)opical corticosteroid
)opical corticosteroid K aminoglycoside
Incorrect
)his patient has otitis e6terna which commonly de+elops a!ter swimming on
holiday# )he rst line management is either a topical antiiotic or a comined
topical antiiotic and steroid#
A ,5-year-old woman presents !or re+iew# $he has noticed a numer o! patches o!
pale s%inF on her hands o+er the past !ew wee%s# )he patient has tried using an
emollient and topical hydrocortisone with no result#
(n e6amination you note a numer o! hypopigmented patches on the dorsum o!
oth hands# 3er past medical history includes thyroto6icosis !or which she ta%escarimaole and thyro6ine#
&hat is the most li%ely causes o! her symptoms*
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Carimaole-induced hypopigmentation
Addison disease
@itiligo
>eu%opaenia-induced !ungal in!ection
Idiopathic guttate hypomelanosis
Correct
@itiligo is more common in patients with %nown autoimmune conditions such as
thyroto6icosis#
A =9-year-old lady presents with a ,-wee% history o! generalised rash# $he
complains o! areas o! erythema and listering although only e6coriations are +isiletoday# (n !urther /uestioning she also admits to diLculty swallowing and pain on
passing urine#
3er past medical history includes angina and coeliac disease# 3er medication
includes aspirin atenolol and hydralaine#
$he is suse/uently re+iewed y the dermatologists who per!orm a s%in iopsy# )he
immuno<uorescence results show immunogloulin ? .Ig?0 staining in the
intercellular sustance#
&hat is the most li%ely diagnosis*
Pemphigus
Pemphigoid
8ermatitis herpeti!ormis
Allergic reaction
4pidermolysis ullosa
Correct
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Pemphigus occurs in middle age etween the ages o! ,9 and =9 years# It is common
in eastern countries and also in Bewish populations# It is characterised y <accid
listers that rupture easily as compared with the tense listers seen in pemphigoid#
Pemphigus also tends to in+ol+e the mucus memranes and patients may complain
o! pain on eating#
)he diagnosis is conrmed with immuno<uorescence which shows antiodies to the
cells in the epidermis while pemphigoid will show antiodies directed at the
asement memrane#
A 5-year-old woman is admitted to the 4mergency 8epartment at 95#99h with
oro!acial angio-oedema ha+ing eaten a prawn curry the pre+ious e+ening# $he has
a past history o! hypertension and hypothyroidism and has recently een treated
!or a chest in!ection# 3er regular medications include endro<umethiaide lisinopril
and le+othyro6ine# $he has a history o! penicillin allergy#
(n admission she is com!ortale at rest and has no urticaria# (ser+ations are as
!ollows temperature NC pulse 29 pm respiratory rate 1=Ominute and 7P
19O199 mm3g#
&hat is the most li%ely diagnosis*
Idiopathic anaphyla6is
Penicillin allergy
Angiotensin-con+erting enyme inhiitor-induced angio-oedema
Anaphyla6is due to prawns
8iuretic allergy
Incorrect
Angio-oedema may e related to use o! an angiotensin-con+erting enyme inhiitor
and may occur e+en a!ter apparent tolerance o! the drug !or many months# In this
case the drug should e stopped or sustituted#
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Allergic angio-oedema is usually o+ious y its !ast onset typically within a !ew
minutes o! contact with the allergen#
A ,-year-old woman who is a recent immigrant !rom Moami/ue is re!erred to the
dermatology outpatient clinic# $he has de+eloped a numer o! hypopigmented o+al
shaped lesions on her ody which are associated with reduced sensation#
)hese are mainly located on the e6tensor sur!aces o! her lims# $he has no past
medical history o! note other than suGering !rom malaria as a child#
&hat is the most li%ely diagnosis*
Chagas disease
3I@
>eprosy
Pityriasis +ersicolor
)uerculosis
Correct
>eprosy causes patches o! hypopigmented s%in typically aGecting the uttoc%s
!ace and e6tensor sur!aces o! lims and sensory loss#
A ,-year-old patient who is %nown to ha+e psoriasis presents with erythematous
s%in in the groin and genital area# 3e also has erythematous s%in in the a6illa# In the
past he has e6pressed a disli%e o! messy or cumersome creams#
&hat is the most appropriate treatment*
)opical clotrimaole
)opical steroid
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)opical calcipotriol
)opical dithranol
Coal tar
Incorrect
)his patient has <e6ural psoriasis which responds well to topical steroids# )opical
calcipotriol is usually irritant in <e6ures# Mild tar preparations are an option ut may
e messy and cumersome#
&hich one o! the !ollowing conditions is least li%ely to e associated with pyoderma
gangrenosum*
>ymphoma
Ulcerati+e colitis
$yphilis
Rheumatoid arthritis
IgA monoclonal gammopathy
Incorrect
Pyoderma gangrenosum causes include
idiopathic in 59D
in<ammatory owel disease ulcerati+e colitis CrohnFs
rheumatoid arthritis $>4
myeloproli!erati+e disorders
lymphoma myeloid leu%aemias
monoclonal gammopathy .IgA0
primary iliary cirrhosis
&hich is true regarding ecema herpeticum*
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(nly a single crop o! +esicles usually appear
Is more se+ere in reacti+ation disease
Is in+arialy !atal i! untreated
Usually has an indolent onset
Is typically associated with a high !e+er !or o+er a wee%
Incorrect
4cema herpeticum is the result o! primary in!ection o! ecematous s%in with
3erpes simple6 +irus .3$@0# )he se+erity +aries !rom mild to !atal#
)here is usually an arupt onset with crops appearing o+er se+en to nine days#
)hese may ecome coalesced# )ypically the child has a high !e+er !or se+en days
and recurrent attac%s can occur#
8eath can result !rom physiological disturances .loss o! <uid electrolytes and
protein through the s%in0 or dissemination o! the +irus to rain and other organs or
!rom secondary acterial sepsis#
A -year-old woman is re+iewed in the dermatology clinic with patchy well
demarcated hair loss on the scalp# )his is aGecting around :9D o! her total scalp
and causing signicant psychological distress# A diagnosis o! alopecia areata is
suspected#
&hich one o! the !ollowing is an appropriate management plan*
Autoimmune screen
)opical corticosteroid
)opical 5-;U cream
Autoimmune screen K topical %etoconaole
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)opical %etoconaole
Correct
3air will regrow in 59D o! patients y 1 year and in 29-H9D e+entually# Care!ul
e6planation is there!ore suLcient in many patients# )opical or intralesional
corticosteroids is the management o! choice#
A :5-year-old male presents with e6tensi+e patches o! altered pigmentation on his
!ront ac% !ace and thighs# )here is mild pruritus# A diagnosis o! e6tensi+e
pityriasis +ersicolor is made#
&hat is the most appropriate management*
(ral itraconaole
)opical terinane
(ral metronidaole
(ral terinane
)opical selenium sulphide
Incorrect
Pityriasis +ersicolor management y topical anti!ungal e#g# terinane or selenium
sulphide i! e6tensi+e disease or !ailure to respond to topical treatment then
consider oral itraconaole#
A 5,-year-old Bewish woman consults her ?P ecause o! recurrent oral ulceration
and the appearance o! listers on her trun%#
$%in iopsy re+eals a supercial intraepidermal split "ust ao+e the asal layer with
e+idence o! acantholysis#
&hat diagnosis ts est with this clinical picture*
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4pidermolysis ullosa
8ermatitis herpeti!ormis
Pemphigus +ulgaris
>inear IgA disease
7ullous pemphigoid
Correct
Pemphigus +ulgaris is characterised y mucosal in+ol+ement with ulceration
.presenting sign in up to 59D0 this is then !ollowed y the appearance o! <accid
listers on the trun% in particular#
Patients tend to complain o! soreness !rom the listers as these rapidly denude the
appearance is o!ten one o! weeping erosions#
)he listers can e e6tended with gentle pressure .'i%ols%yFs sign0# )he s%in iopsy
is o! the typical appearance descried in the clinical scenario#
A =5-year-old !emale who has a history o! long-standing psoriasis and hea+y alcoholinta%e presents with a se+ere e6aceration o! psoriasis# $he was admitted and
recei+ed topical therapy and o+er the month o! her admission her gamma-?)
concentration had !allen !rom ,99 UO> to 159 UO> .,-50#
$i6 wee%s a!ter discharge she was seen in outpatients where her psoriasis remained
under control ut she complained o! generalised hair loss#
&hat is the most li%ely cause !or her hair loss*
Iron deciency
)elogen eu+ium
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Alopecia areata
)hiamine deciency
)richotillomania
Correct
In a normal healthy personFs scalp aout 25D o! the hair !ollicles are acti+ely
growing hair and 15D are resting# I! there is some shoc% to the system as many as
9D o! the scalp hairs can e precipitated into a resting state thus re+ersing the
usual ratio# )ypical precipitants include illnesses operations accidents and
childirth#
A 5,-year-old man is re!erred to the dermatology outpatient department due to a
!acial rash which has persisted !or the past 1: months#
(n e6amination there is a symmetrical rash consisting o! e6tensi+e pustules and
papules which aGects his nose chee%s and !orehead#
&hat is the most appropriate treatment*
3ydro6ychloro/uine
Cipro<o6acin
(6ytetracycline
Isotretinoin
Prednisolone
Incorrect
)his case o! acne rosacea # As there is e6tensi+e in+ol+ement oral o6ytetracyclineshould proaly e used rather than topical metronidaole#
A =:-year-old !emale is re!erred due to a long-standing ulcer ao+e the right medial
malleolus# An%le-rachial pressure inde6 readings are as !ollows
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Right 9#H5
>e!t 9#H5
)o date it has een managed y the 8istrict 'urse with standard dressings#
&hat is the most appropriate management to ma6imie the li%elihood o! the ulcer
healing*
Intermittent pneumatic compression
Re!er to +ascular surgeon
Compression andaging
3ydrocolloid dressings
)opical <uclo6acillin
Correct
)he an%le-rachial pressure inde6 readings indicate a reasonale arterial supply and
suggest the ulcers are +enous in nature#
Compression andaging usually !our layer .only treatment shown to e o! real
enet0 oral pento6i!ylline a peripheral +asodilator impro+es healing rate#
A :1-year-old woman who is 1= wee%s pregnant present with worsening acne which
she is nding distressing# $he is currently using topical enyl pero6ide with limited
eGect# (n e6amination there is widespread nonin<ammatory lesions and pustules
on her !ace#
&hat is the most appropriate ne6t management step*
(ral erythromycin
)opical retinoid
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(ral do6ycycline
(ral trimethoprim
(ral lymecycline
Correct
(ral erythromycin may e used !or acne in pregnancy# )he other drugs are
contraindicated#
A 9-year-old man gi+es a history o! recurrent ullous eruption on his hands
!orearms and trun% whene+er he is on holiday and mentions that these lesions
de+elop whene+er he +isits sunny places# 3e has numerous scars on his hands
!orearms and chest wall#
&hat is the diagnosis*
Pemphigous
$unurn
Pemphigoid
Porphyria cutanea tarda
Polymorphic light eruption
Correct
Porphyria cutanea tarda presents with ullous eruptions on e6posure to sunlight#
)he eruptions heal with scarring#
8iagnosis depends on the presence o! increased le+els o! urinary uroporphyrin#
Remission can e induced y +enesection# Chloro/uine promotes the urinarye6cretion o! uroporphyrin#
A ,-year-old presents with itchy lesions on the soles o! oth !eet# )hese ha+e een
present !or the past two months# (n e6amination small listers are seen with
surrounding dry and crac%ed s%in#
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&hat is the most li%ely diagnosis*
Pompholy6
7ullous pemphigoid
Porphyria cutanea tarda
Pustular psoriasis
Pemphigus
Incorrect
Pompholy6 is a type o! ecema which aGects oth the hands .cheiropompholy60 andthe !eet .pedopompholy60# It is also %nown as dyshidrotic ecema #
;eatures include small listers on the palms and soles pruritic sometimes urning
sensation once listers urst s%in may ecome dry and crac%#
A 9-year-old male presents with a =-month history o! a recurring itchy rash#
Clinically you suspect chronic idiopathic urticaria#
&hich o! the !ollowing is '() appropriate management !or him*
Ad+ising %eeping cool and a+oiding e6cess alcohol when the rash is present
Prescriing oral antihistamines
Re!erring !or patch testing
Ad+ising a+oidance o! aspirin and '$AI8$
Reassuring patient that it should e sel!-limiting
Incorrect
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)hose cases o! urticaria which are allergic in aetiology are thought to e type 1
hypersensiti+ity reactions ut patch testing identies type , delayed
hypersensiti+ity reactions#
A :-year-old woman de+elops diLculty reathing and her lips and tongue swell
aout +e minutes a!ter starting to eat a curry# $he is rought to the accident and
emergency department y amulance# $he is cyanosed and wheeing#
Aside !rom high <ow o6ygen +ia a reser+oir ag which o! the !ollowing treatments
would e your top priority*
4pinephrine .adrenaline0 - 9#5 ml o! 1O1999 solution intramuscularly
$alutamol 5 mg neulied
3ydrocortisone :99 mg intra+enously
Chlorpheniramine 19 mg intra+enously
4pinephrine .adrenaline0 - 9#5 ml o! 1O1999 solution intra+enously
Incorrect
)he history clearly suggests anaphyla6is and treatment with intramuscular
epinephrine .9#5 ml o! 1O19990 is re/uired#
A :9-year-old woman %nown to suGer !rom acne +ulgaris has een started on
isotretinoin#
&hich o! the !ollowing statements est applies to treatment with isotretinoin*
It can cause hirsutism
Pregnancy should e a+oided during and 1 month a!ter treatment
It may cause haemoptysis
It is contraindicated in patients with renal artery stenosis
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It can cause hyper%alaemia and hence electrolytes should e chec%ed e+ery month
Correct
Isotretinoin is indicated !or the treatment o! se+ere in<ammatory acne# 3owe+er it
causes mar%ed dryness o! the s%in and mucous memranes especially the lips and
can result in minor noseleeds#
8ue to its teratogenicity pregnancy must e e6cluded prior to its initiation and
during treatment as well as !or 1 month a!ter treatment#
Anormalities o! serum lipids and li+er !unction tests should e e6cluded e!ore
treatment
A 1H-year-old student presents with a three day history o! a 1 cm golden crusted
lesion on the order o! her lower lip#
&hat is the most suitale management*
(ral penicillin
(ral co-amo6icla+
)opical !usidic acid
(ral <uclo6acillin
(ral <uclo6acillin K penicillin
Correct
)his history is typical o! impetigo# As the lesion is small and localised topical !usidic
acid is recommended#
&hich o! the !ollowing is true regarding diaetic !oot ulceration*
$%in in!ection is the most common initiating e+ent in ulceration
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Callus !ormation at pressure areas is an important predictor o! ulceration
Autonomic neuropathy results in reduced peripheral lood <ow
Plantar ulceration is most commonly due to atherosclerosis
Radiography can readily distinguish etween Charcots "oint and osteomyelitis
Correct
Callus !ormation at pressure areas is an important predictor o! potential ulceration#
Plantar ulceration is usually a conse/uence o! neuropathy# Minor s%in trauma is
proaly the most common initiating e+ent#
It is diLcult to distinguish radiographically etween CharcotFs "oint and
osteomyelitis as neither ha+e specic signs in their early stages#
A ,:-year-old man with a history o! ulcerati+e colitis attends the gastroenterology
clinic !or re+iew# 3e has noticed a deep ulcerating lesion on his leg and is concerned
as to what it may e#
(n e6amination he has a deep ulcer on the le!t lower leg which has a +iolet order#
In+estigations show
3 1:#9 gOdl
&CC 5#1 619HOl
P>) :, 619HOl
'aK 1,1 mmolOl
K ,# mmolOl
Creatinine 195 SmolOl
4$R 15 mmOhr
&hich o! the !ollowing would e the most appropriate in+estigation to conrm the
diagnosis*
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Angiography and +enous 8oppler studies
7iopsy and culture !rom the ulcerated tissue
Chest 6-ray
;asting plasma glucose
Autoimmune prole
Incorrect
)his patient has a clinical history which is suggesti+e o! pyoderma granulosum a
condition which may e associated with +asculitis haematological malignancy or
in<ammatory owel disease as seen here#
7iopsy o! the ulcerated tissue re+eals intense neutrophilic inltration haemorrhage
and necrosis o! the o+erlying epidermis# Culture is important to rule out in!ection as
a cause o! the presentation#
An elderly man presented with a lump on his temple that is shiny and is gradually
increasing in sie#
&hat is the most li%ely diagnosis*
$eorrhoeic wart
7asal cell carcinoma
>entigo maligna
$/uamous cell carcinoma
Amelanotic melanoma
Incorrect
7asal cell carcinomas are the most common malignant s%in tumour and are related
to e6cessi+e sun e6posure# )hey are common later in li!e and may present as a
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slow-growing nodule or papule# 7asal cell carcinomas grow slowly and may cause
local erosion ut they almost ne+er metastasise#
)reatment is with surgical e6cision although radiotherapy may e used !or large
supercial lesions# @ery supercial small asal cell carcinomas may e managed
with cryotherapy although regular !ollow-up to e6amine !or recurrence is
recommended#
A =-year-old man who is %nown to ha+e type : diaetes mellitus presents with a
numer o! lesions o+er his shins#
(n e6amination there are a numer o! -, mm smooth rm papules which arehyperpigmented and centrally depressed#
&hat is the most li%ely diagnosis*
>upus +ulgaris
Pyoderma gangrenosum
?uttate psoriasis
?ranuloma annulare
'ecroiosis lipoidica diaeticorum
Incorrect
?ranuloma annulare is papular lesions that are o!ten slightly hyperpigmented and
depressed centrally # It is typically occur on the dorsal sur!aces o! the hands and
!eet and on the e6tensor aspects o! the arms and legs#
A =-year-old !emale presents with raised erythematous tender lesions on oth legs
which ha+e de+eloped since she had a throat in!ection two wee%s ago#
&hich one o! the !ollowing in+estigations is most li%ely to estalish the diagnosis*
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Anti-streptolysin-( titre .A$()0
Mantou6 test
Chest 6 ray
)hroat swa cultured !or +iruses
)hroat swa cultured !or acteria
Correct
)his lady presents with tender lesions two wee%s a!ter a sore throat# )his is most
li%ely to e post-streptococcal erythema nodosum and A$() is most li%ely to
conrm this#
A =:-year-old with a history o! acne rosacea presents !or ad+ice regarding
treatment#
&hich one o! the !ollowing inter+entions has the least role in management*
>ow-dose topical corticosteroids
Camou<age creams
Use o! high-!actor sun loc%
>aser therapy
)opical metronidaole
Incorrect
)opical metronidaole may e used !or mild symptoms .i#e# >imited numer o!
papules and pustules no pla/ues0 more se+ere disease is treated with systemicantiiotics e#g# (6ytetracycline
Recommend daily application o! a high-!actor sunscreen camou<age creams may
help conceal redness laser therapy may e appropriate !or patients with prominent
telangiectasia#
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A 9-year-old woman de+elops a systemic reaction characteried y hypotension
ronchospasm and widespread urticaria soon a!ter induction o! anaesthesia !or
cholecystectomy#
&hich o! the !ollowing lood test results would suggest that her reaction was
associated with mast cell degranulation*
3ypernatraemia
4le+ated plasma tryptase
3ypo%alaemia
3ypocomplementaemia
3ypergammagloulinaemia
Incorrect
)he constellation o! acute symptoms in this case is highly suggesti+e o! a systemic
allergic reaction either anaphyla6is .i! Ig4 mediated0 or an anaphylactoid reaction
.i! non-Ig4 mediated0# 7oth o! these reactions are due to e6tensi+e mast cell
degranulation leading to release o! large amounts o! tryptase in to the circulation#
A =H-year-old woman with a history o! learning diLculties is re+iewed in clinic# $he
is %nown to ha+e erythema a igne on her legs ut according to her carer still
spends long hours in !ront o! her electric re#
&hich one o! the !ollowing s%in lesions is she at ris% o! de+eloping*
Cutaneous )-cell lymphoma o! the s%in
$/uamous cell carcinoma
8ermatorosarcoma protuerans
7asal cell carcinoma
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Malignant melanoma
Correct
I! 4rythema a igne is not treated then patients may go on to de+elop s/uamous
cell s%in cancer#
A ,5-year-old man who presented with itchy lesions on his hands is diagnosed with
scaies# It is decided to treat him with permethrin 5D# Tou ha+e e6plained the need
to treat all memers o! the household and hot wash all edding and clothes#
&hat ad+ice should e gi+en aout applying the cream*
;rom nec% down K lea+e !or 1: hours
;rom nec% down K lea+e !or , hours
;rom nec% down K lea+e !or 1: hours K retreat in days
All s%in including scalp K lea+e !or 1: hours K retreat in days
All s%in including scalp K lea+e !or 1: hours K retreat in : days
Incorrect
)he 7'; ad+ises to apply the insecticide to all areas including the !ace and scalp
contrary to the manu!acturerFs recommendation# Allow to dry and lea+e on the s%in
!or 2-1: hours !or permethrin or !or :, hours !or malathion e!ore washing oG #
Repeat treatment days later#
A :2-year-old ;rench woman presents complaining o! increasingly dar% areas o!
pigmentation on her !ace which ha+e appeared o+er the past !ew wee%s#
$he has noticed weight increase o+er the past !ew months and has not had a period
!or 5 months#
&hat is the diagnosis that ts est with this clinical picture*
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Chloasma
@itiligo
Prolactinoma
>upus
4cema
Incorrect
Chloasma is a hormonally stimulated increase in melanogenesis that mainly
appears on the !ace it aGects oth pregnant women and those who are ta%ing the
comined oral contracepti+e pill# )he pigment is augmented y sunlight hence the
more pronounced appearance on the !ace# )he pigmentation may ta%e many
months to resol+e a!ter parturition or pill discontinuation#
&hich o! the !ollowing s%in conditions is not associated with diaetes mellitus*
$weets syndrome
?ranuloma annulare
>ipoatrophy
@itiligo
'ecroiosis lipoidica
Incorrect
$weetFs syndrome is also %nown as acute !erile neutrophilic dermatosis has a
strong association with acute myeloid leu%aemia# It is not associated with diaetes
mellitus#
A 55-year-old man %nown to suGer !rom alcohol-induced li+er disease gi+es a history
o! a listering rash on his hands a!ter a holiday in ?reece#
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46amination shows estalished listers as well as scar mar%s# 3e says he de+eloped
a similar rash last year !ollowing a holiday in Ma"orca which healed with the
!ormation o! scars# 3e also has patches o! scarring alopecia#
&hich o! the !ollowing in+estigations might est estalish the diagnosis*
$%in iopsy
Plasma and urinary uroporphyrins
C) scan o! the li+er
>i+er !unction tests
>i+er iopsy
Correct
)his patient has porphyria cutanea tarda# )his is due to a deciency o!
uroporphyrinogen decaro6ylase which leads to the accumulation o!
uroporphyrinogen III# )he anormality can e ac/uired as a result o! alcoholinduced
li+er disease or it may e inherited#
46posure to sun results in lister !ormation which heal with scarring# 3ypertrichosis
may occur especially o+er temporal and malar !acial areas and sometimes in+ol+es
arms and legs#
&hich is not a poor prognostic !actor !or outcome in patients with malignant
melanoma*
$ur!ace ulceration
8iameter o! melanoma = mm
Microsatellite metastasis
7reslow thic%ness mm
Clar%eFs le+el I@
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Incorrect
Malignant melanoma is staged according to the 7reslow thic%ness which is
measured in millimetres !rom the dermoepidermal "unction# )he deeper the 7reslow
thic%ness the poorer the prognosis#
)he Clar%eFs le+el is measured !rom I to I@ and re<ects the le+el o! in+asion through
the dermis#
Clar%eFs le+el I represents melanomas that ha+e not in+aded past the asement
memrane
Clar%eFs le+el II represents in+ol+ement o! the supercial dermis
Clar%eFs le+el III in+ol+ement o! the deep dermis
Clar%eFs le+el I@ in+ol+ement o! the sucutis# An increasing
Clar%eFs le+el is associated with a poorer prognosis#
Malignant melanoma tends to grow radially e!ore entering a +ertical growth phase#
)he diameter it reaches has not een !ound to e a prognostic !actor#
Microsatellite metastases are cutaneous metastases around the primary melanoma
and are a poor prognostic !eature# $ur!ace ulceration is also a poor prognostic
!eature#
A si6-month-old ay is re!erred with a recurrent itchy eruption aGecting his trun%
and soles# 46amination shows a diGuse ecema on the trun% and pin%-red papules
on oth soles#
&hich o! the !ollowing is the most li%ely diagnosis*
)inea pedis
$caies
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@iral warts
Atopic dermatitis
Pustular psoriasis
Incorrect
$caies can present with an itchy dermatitic-loo%ing rash on the ody ut the clues
are at certain sites .soles genitalia uttoc%s0#
It is unli%ely that the child has pustular psoriasis as there are no pustules in the
history# )inea pedis and +iral warts do not generally gi+e rise to dermatitis on the
trun%# Atopic dermatitis presents with a dermatitis aGecting the <e6ures or the !ace
in aies without papules on the soles#
A 1,-year-old male is re+iewed due to a patch o! scaling and hair loss on the right
side o! his head# A s%in scraping is sent which conrms a diagnosis o! tinea capitis#
&hich organism is most li%ely to e responsile*
Microsporum distortum
)richophyton tonsurans
Microsporum audouinii
Microsporum canis
)richophyton +errucosum
Correct
Most common cause o! )inea capitis is )richophyton tonsurans in the U and the
U$A # It may also e caused y Microsporum canis ac/uired !rom cats or dogs#