DERMATOLOGY MCQs

Q-1 ANSWER:
A 43-year-old man comes for review. A few months ago he Pyoderma gangrenosum
developed redness around his nose and cheeks. This is worse
after drinking alcohol. He is concerned as one of his work EXPLANATION:
colleagues asked him if he had a drink problem despite him This patient is likely to have ulcerative colitis, which has a
drinking 14 units per week. On examination he has erythema known association with large-joint arthritis, sacroilitis and
as described above with some pustules on the nose and pyoderma gangrenosum
telangiectasia on the cheeks. What is the most likely
diagnosis? PYODERMA GANGRENOSUM
Features
A. Mitral stenosis
• typically on the lower limbs
B. Seborrhoeic dermatitis
• initially small red papule
C. Alcohol-related skin changes
• later deep, red, necrotic ulcers with a violaceous border
D. Acne rosacea
• may be accompanied systemic symptoms e.g. Fever,
E. Systemic lupus erythematosus
myalgia
ANSWER:
Acne rosacea Causes*
• idiopathic in 50%
EXPLANATION:
• inflammatory bowel disease: ulcerative colitis, Crohn's
This is a typical history of acne rosacea
• rheumatoid arthritis, SLE
ACNE ROSACEA • myeloproliferative disorders
Acne rosacea is a chronic skin disease of unknown aetiology • lymphoma, myeloid leukaemias
• monoclonal gammopathy (IgA)
Features
• primary biliary cirrhosis
• typically affects nose, cheeks and forehead
• flushing is often first symptom Management
• telangiectasia are common • the potential for rapid progression is high in most
• later develops into persistent erythema with papules and patients and most doctors advocate oral steroids as first-
pustules line treatment
• rhinophyma • other immunosuppressive therapy, for example
• ocular involvement: blepharitis ciclosporin and infliximab, have a role in difficult cases

Management *note whilst pyoderma gangrenosum can occur in diabetes

• topical metronidazole may be used for mild symptoms mellitus it is rare and is generally not included in a differential
(i.e. Limited number of papules and pustules, no plaques) of potential causes
• more severe disease is treated with systemic antibiotics
e.g. Oxytetracycline
• recommend daily application of a high-factor sunscreen
• camouflage creams may help conceal redness
• laser therapy may be appropriate for patients with
prominent telangiectasia

Q-2
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?

A. Systemic Shigella infection

B. Syphilis
C. Metastatic colon cancer
D. Erythema nodosum
E. Pyoderma gangrenosum
 A. Porphyria cutanea tarda
B. Pustular psoriasis
C. Pompholyx
D. Bullous pemphigoid
E. Pemphigus

ANSWER:
Pompholyx

EXPLANATION:
POMPHOLYX
Pompholyx is a type of eczema which affects both the hands
(cheiropompholyx) and the feet (pedopompholyx). It is also
known as dyshidrotic eczema

Features
• small blisters on the palms and soles
• pruritic, sometimes burning sensation
• once blisters burst skin may become dry and crack

Management
• cool compresses
• emollients
• topical steroids

Q-4
A 60-year-old man is admitted to hospital with acute
pneumonia. He has a past medical history of chronic
obstructive pulmonary disease, alcohol excess and
hypertension, and has been homeless for the last 12 years.
On the post-take ward round, you notice that he has a
brown-red discolouration of his face, neck, forearms and
lower legs, with scaling and cracking of the skin. He
complains that he is struggling to eat and drink and has
persistent vomiting and diarrhoea. He seems a little
disorientated. Which vitamin deficiency is most likely to be
causing these symptoms?

A. B2 (riboflavin)
B. B3 (niacin)
C. B6 (pyridoxine)
D. B1 (thiamine)
E. B12 (cyanocobalamin)

ANSWER:
B3 (niacin)

EXPLANATION:
Deficiency of niacin (B3) causes pellagra
Q-3 The correct answer is B3- niacin. The patient has some of the
A 43-year-old presents with itchy lesions on the soles of both symptoms of pellagra, which is classically characterised by
feet. These have been present for the past two months. On the triad of dermatitis, diarrhoea and dementia. The
examination small blisters are seen with surrounding dry and 'dementia' more commonly presents subtly with low mood,
cracked skin. What is the most likely diagnosis? irritability, apathy and anxiety, progressing to delusions,
psychosis, drowsiness and coma.
PELLAGRA Management
Pellagra is a caused by nicotinic acid (niacin) deficiency. The • topical steroids and emollients
classical features are the 3 D's - dermatitis, diarrhoea and
dementia Follow-up:
• increased risk of vulval cancer
Pellagra may occur as a consequence of isoniazid therapy
(isoniazid inhibits the conversion of tryptophan to niacin) and *the RCOG advise the following
it is more common in alcoholics.
Skin biopsy is not necessary when a diagnosis can be made on
Features clinical examination. Biopsy is required if the woman fails to
• dermatitis (brown scaly rash on sun-exposed sites - respond to treatment or there is clinical suspicion of VIN or
termed Casal's necklace if around neck) cancer.
• diarrhoea
• dementia, depression and the British Association of Dermatologists state the
• death if not treated following:

Q-5 A confirmatory biopsy, although ideal, is not always practical,

An 85-year-old lady presents to dermatology clinic particularly in children. It is not always essential when the
complaining of itchy white plaques affecting her vulva. There clinical features are typical. However, histological examination
is no history of vaginal discharge or bleeding. A similar is advisable if there are atypical features or diagnostic
plaque is also seen on her inner thigh. What is the likely uncertainty and is mandatory if there is any suspicion of
diagnosis? neoplastic
change. Patients under routine follow-up will need a biopsy if:
A. Candida (i) there is a suspicion of neoplastic change, i.e. a persistent
B. Lichen planus area of hyperkeratosis, erosion or erythema, or new warty or
C. Lichen sclerosus papular lesions;
D. Herpes simplex (ii) the disease fails to respond to adequate treatment;
E. Seborrhoeic dermatitis (iii) there is extragenital LS, with features suggesting an
overlap with morphoea;
ANSWER: (iv) there are pigmented areas, in order to exclude an
Lichen sclerosus abnormal melanocytic proliferation;
and
EXPLANATION: (v) second-line therapy is to be used.
Lichen
• planus: purple, pruritic, papular, polygonal rash on Q-6
flexor surfaces. Wickham's striae over surface. Oral A 36-year-old woman is reviewed. She presented 4 weeks
involvement common ago with itchy dry skin on her arms and was diagnosed as
• sclerosus: itchy white spots typically seen on the vulva of having atopic eczema. She was prescribed hydrocortisone 1%
elderly women cream with an emollient. Unfortunately there has been no
The correct answer is lichen sclerosus. Candida may cause improvement in her symptoms. What is the next step in
pruritus and white plaques but lesions would not also be management, alongside continued regular use of an
seen on her inner thigh emollient?

LICHEN SCLEROSUS A. Betamethasone valerate 0.1%

Lichen sclerosus was previously termed lichen sclerosus et B. Clobetasone butyrate 0.05%
atrophicus. It is an inflammatory condition which usually C. Clobetasol propionate 0.05%
affects the genitalia and is more common in elderly females. D. Topical tetracycline
Lichen sclerosus leads to atrophy of the epidermis with white E. Regular wet wraps
plaques forming
ANSWER:
Features Clobetasone butyrate 0.05%
• itch is prominent
EXPLANATION:
The diagnosis is usually made on clinical grounds but a biopsy Topical steroids
may be performed if atypical features are present* • moderate: Clobetasone butyrate 0.05%
• potent: Betamethasone valerate 0.1%
• very potent: Clobetasol propionate 0.05%
Clobetasone butyrate 0.05% is a moderately potent topical A. Roseola infantum
steroid and would be the most suitable next step in B. Molluscum contagiosum
management. It is important to note the potency difference C. Kawasaki disease
between two very similar sounding steroids - Clobetasone D. Viral warts
butyrate 0.05% (moderate) and Clobetasol propionate 0.05% E. Pityriasis rosea
(very potent)
ANSWER:
ECZEMA: TOPICAL STEROIDS Molluscum contagiosum
Use weakest steroid cream which controls patients symptoms
EXPLANATION:
The table below shows topical steroids by potency MOLLUSCUM CONTAGIOSUM
Molluscum contagiosum is a common skin infection caused by
Mild Moderate Potent Very potent molluscum contagiosum virus (MCV), a member of the
Hydrocortisone Betamethasone Fluticasone Clobetasol Poxviridae family. Transmission occurs directly by close
0.5-2.5% valerate 0.025% propionate propionate 0.05% personal contact, or indirectly via fomites (contaminated
(Betnovate RD) 0.05% (Cutivate) (Dermovate) surfaces) such as shared towels and flannels. The majority of
cases occur in children (often in children with atopic eczema),
Clobetasone Betamethasone with the maximum incidence in preschool children aged 1-4
butyrate 0.05% valerate 0.1%
years.
(Eumovate) (Betnovate)
Typically, molluscum contagiosum presents with characteristic
Finger tip rule pinkish or pearly white papules with a central umbilication,
• 1 finger tip unit (FTU) = 0.5 g, sufficient to treat a skin which are up to 5 mm in diameter. Lesions appear in clusters
area about twice that of the flat of an adult hand in areas anywhere on the body (except the palms of the hands
and the soles of the feet). In children, lesions are commonly
Topical steroid doses for eczema in adults seen on the trunk and in flexures, but anogenital lesions may
also occur. In adults, sexual contact may lead to lesions
Area of skin Fingertip units per dose developing on the genitalia, pubis, thighs, and lower
Hand and fingers (front and back) 1.0 abdomen. Rarely, lesions can occur on the oral mucosa and on
A foot (all over) 2.0 the eyelids.
Front of chest and abdomen 7.0
Self care advice:
Back and buttocks 7.0
Face and neck 2.5
• Reassure people that molluscum contagiosum is a self-
limiting condition.
An entire arm and hand 4.0
• Spontaneous resolution usually occurs within 18 months
An entire leg and foot 8.0
• Explain that lesions are contagious, and it is sensible to
avoid sharing towels, clothing, and baths with uninfected
The BNF makes recommendation on the quantity of topical
people (e.g. siblings)
steroids that should be prescribed for an adult for a single
daily application for 2 weeks: • Encourage people not to scratch the lesions. If it is
problematic, consider treatment to alleviate the itch
• Exclusion from school, gym, or swimming is not necessary
Area Amount
Face and neck 15 to 30 g Treatment is not usually recommended. If lesions are
Both hands 15 to 30 g troublesome or considered unsightly, use simple trauma or
Scalp 15 to 30 g cryotherapy, depending on the parents' wishes and the child's
Both arms 30 to 60 g age:
Both legs 100 g • Squeezing (with fingernails) or piercing (orange stick)
Trunk 100 g lesions may be tried, following a bath. Treatment should
Groin and genitalia 15 to 30 g be limited to a few lesions at one time
• Cryotherapy may be used in older children or adults, if
Q-7 the healthcare professional is experienced in the
A 3-year-old girl is taken to her doctor due to a rash on the procedure
right upper arm. On examination multiple raised lesions of • Eczema or inflammation can develop around lesions prior
about 2 mm in diameter are seen. On close inspection a to resolution. Treatment may be required if:
central dimple is present in the majority of lesions. What is • → Itching is problematic; prescribe an emollient and a
the likely diagnosis? mild topical corticosteroid (e.g. hydrocortisone 1%)
• → The skin looks infected (e.g. oedema, crusting);
prescribe a topical antibiotic (e.g. fusidic acid 2%)
 EXPLANATION:
Referral may be necessary in some circumstances: Blisters/bullae
• For people who are HIV-positive with extensive lesions • no mucosal involvement: bullous pemphigoid
urgent referral to a HIV specialist • mucosal involvement: pemphigus vulgaris
• For people with eyelid-margin or ocular lesions and
associated red eye urgent referral to an ophthalmologist PEMPHIGUS VULGARIS
• Adults with anogenital lesions should be referred to Pemphigus vulgaris is an autoimmune disease caused by
genito-urinary medicine, for screening for other sexually antibodies directed against desmoglein 3, a cadherin-type
transmitted infections epithelial cell adhesion molecule. It is more common in the
Ashkenazi Jewish population

Features
• mucosal ulceration is common and often the presenting
symptom. Oral involvement is seen in 50-70% of patients
• skin blistering - flaccid, easily ruptured vesicles and
bullae. Lesions are typically painful but not itchy. These
may develop months after the initial mucosal symptoms.
Nikolsky's describes the spread of bullae following
application of horizontal, tangential pressure to the skin
• acantholysis on biopsy

Mucosal ulceration is common with pemphigus

Q-8
A 64-year-old woman presents with severe mucosal
ulceration associated with the development of blistering
lesions over her torso and arms. On examination the blisters
are flaccid and easily ruptured when touched. What is the
most likely diagnosis?

A. Pemphigus vulgaris
B. Pemphigoid
C. Dermatitis herpetiformis
D. Psoriasis
E. Epidermolysis bullosa

ANSWER:
Pemphigus vulgaris
 ACNE VULGARIS: MANAGEMENT
Acne vulgaris is a common skin disorder which usually occurs
in adolescence. It typically affects the face, neck and upper
trunk and is characterised by the obstruction of the
pilosebaceous follicles with keratin plugs which results in
comedones, inflammation and pustules.

Acne may be classified into mild, moderate or severe:

• mild: open and closed comedones with or without sparse
inflammatory lesions
• moderate acne: widespread non-inflammatory lesions
and numerous papules and pustules
• severe acne: extensive inflammatory lesions, which may
include nodules, pitting, and scarring

A simple step-up management scheme often used in the

treatment of acne is as follows:
• single topical therapy (topical retinoids, benzoyl peroxide)
• topical combination therapy (topical antibiotic, benzoyl
peroxide, topical retinoid)
• oral antibiotics: e.g. Oxytetracycline, doxycycline.
Improvement may not be seen for 3-4 months.
Minocycline is now considered less appropriate due to
the possibility of irreversible pigmentation. Gram
negative folliculitis may occur as a complication of long-
term antibiotic use - high-dose oral trimethoprim is
effective if this occurs
• oral isotretinoin: only under specialist supervision
Management
There is no role for dietary modification in patients with acne
• steroids
• immunosuppressants
Q-10
An 18-year-old female is reviewed in the dermatology clinic
Q-9
complaining of scalp hair loss. Which one of the following
A 17-year-old female presents with multiple comedones,
conditions is least likely to be responsible?
pustules and papules on her face. Which one of the following
is least likely to improve her condition?
A. Porphyria cutanea tarda
B. Discoid lupus
A. Topical retinoids
C. Tinea capitis
B. Dietary advice
D. Alopecia areata
C. Washing her face using a mild soap with lukewarm
E. Telogen effluvium
water twice a day
D. Oral trimethoprim
ANSWER:
E. Ethinylestradiol with cyproterone acetate
Porphyria cutanea tarda
ANSWER:
EXPLANATION:
Dietary advice
Porphyria cutanea tarda is a recognised cause of
hypertrichosis
EXPLANATION:
There is no role for dietary modification in patients with acne
ALOPECIA
vulgaris. Ethinylestradiol with cyproterone acetate
Alopecia may be divided into scarring (destruction of hair
(Dianette) is useful in some female patients with acne
follicle) and non-scarring (preservation of hair follicle)
unresponsive to standard treatment. Oral trimethoprim is
useful in patients on long-term antibiotics who develop Gram
Scarring alopecia
negative folliculitis
• trauma, burns
• radiotherapy
• lichen planus
• discoid lupus EXPLANATION:
• tinea capitis* KELOID SCARS
Keloid scars are tumour-like lesions that arise from the
Non-scarring alopecia connective tissue of a scar and extend beyond the dimensions
• male-pattern baldness of the original wound
• drugs: cytotoxic drugs, carbimazole, heparin, oral
contraceptive pill, colchicine Predisposing factors
• nutritional: iron and zinc deficiency • ethnicity: more common in people with dark skin
• autoimmune: alopecia areata • occur more commonly in young adults, rare in the elderly
• telogen effluvium (hair loss following stressful period e.g. • common sites (in order of decreasing frequency):
surgery) sternum, shoulder, neck, face, extensor surface of limbs,
• trichotillomania trunk

*scarring may develop in untreated tinea capitis if a kerion Keloid scars are less likely if incisions are made along relaxed
develops skin tension lines*

Q-11 Treatment
Which of the following conditions is least likely to exhibit the • early keloids may be treated with intra-lesional steroids
Koebner phenomenon? e.g. triamcinolone
• excision is sometimes required
A. Vitiligo
B. Molluscum contagiosum *Langer lines were historically used to determine the optimal
C. Lichen planus incision line. They were based on procedures done on
D. Psoriasis cadavers but have been shown to produce worse cosmetic
E. Lupus vulgaris results than when following skin tension lines

Q-13
ANSWER:
A 31-year-old woman develops with painful, purple lesions
Lupus vulgaris
on her shins. Which one of the following medications is most
likely to be responsible?
EXPLANATION:
Lupus vulgaris is not associated with the Koebner A. Montelukast
phenomenon B. Lansoprazole
C. Combined oral contraceptive pill
KOEBNER PHENOMENON D. Sodium valproate
The Koebner phenomenon describes skin lesions which E. Carbimazole
appear at the site of injury. It is seen in:
• psoriasis ANSWER:
• vitiligo Combined oral contraceptive pill
• warts
EXPLANATION:
• lichen planus
ERYTHEMA NODOSUM
• lichen sclerosus
Overview
• molluscum contagiosum
• inflammation of subcutaneous fat
• typically causes tender, erythematous, nodular lesions
Q-12
• usually occurs over shins, may also occur elsewhere (e.g.
A 34-year-old man presents for the removal of a mole.
forearms, thighs)
Where on the body are keloid scars most likely to form?
• usually resolves within 6 weeks
A. Sternum • lesions heal without scarring
B. Lower back Causes
C. Abdomen • infection: streptococci, TB, brucellosis
D. Flexor surfaces of limbs • systemic disease: sarcoidosis, inflammatory bowel
E. Scalp
disease, Behcet's
• malignancy/lymphoma
ANSWER:
• drugs: penicillins, sulphonamides, combined oral
Keloid scars are most common on the sternum
contraceptive pill
• pregnancy
 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

Management
• permethrin 5% is first-line
• malathion 0.5% is second-line
• give appropriate guidance on use (see below)
• pruritus persists for up to 4-6 weeks post eradication

Patient guidance on treatment (from Clinical Knowledge

Summaries)
• avoid close physical contact with others until treatment is
complete
• all household and close physical contacts should be
treated at the same time, even if asymptomatic
• launder, iron or tumble dry clothing, bedding, towels,
etc., on the first day of treatment to kill off mites.

The BNF advises to apply the insecticide to all areas, including

the face and scalp, contrary to the manufacturer's
recommendation. Patients should be given the following
Q-14 instructions:
Which one of the following statements regarding scabies is • apply the insecticide cream or liquid to cool, dry skin
false? • pay close attention to areas between fingers and toes,
under nails, armpit area, creases of the skin such as at the
A. All members of the household should be treated
wrist and elbow
B. Typically affects the fingers, interdigital webs and flexor
• allow to dry and leave on the skin for 8-12 hours for
aspects of the wrist in adults
permethrin, or for 24 hours for malathion, before
C. Scabies causes a delayed type IV hypersensitivity
washing off
reaction
• reapply if insecticide is removed during the treatment
D. Patients who complain of pruritus 4 weeks following
period, e.g. If wash hands, change nappy, etc
treatment should be retreated
• repeat treatment 7 days later
E. Malathion is suitable for the eradication of scabies
ANSWER: Crusted (Norwegian) scabies
Patients who complain of pruritus 4 weeks following Crusted scabies is seen in patients with suppressed immunity,
treatment should be retreated especially HIV.

EXPLANATION:
It is normal for pruritus to persist for up to 4-6 weeks post
eradication
SCABIES
Scabies is caused by the mite Sarcoptes scabiei and is spread
by prolonged skin contact. It typically affects children and
young adults.
The crusted skin will be teeming with hundreds of thousands • typically occur on the dorsal surfaces of the hands and
of organisms. feet, and on the extensor aspects of the arms and legs

Ivermectin is the treatment of choice and isolation is essential A number of associations have been proposed to conditions
such as diabetes mellitus but there is only weak evidence for
Q-15 this
Which of the following skin disorders is least associated with
tuberculosis? Q-17
A 54-year-old woman with a history of type 1 diabetes
A. Scrofuloderma mellitus presents with unsightly toenails affecting the lateral
B. Erythema nodosum three nails of the left foot. On examination the nails and
C. Lupus vulgaris brown and break easily. Nail scrapings demonstrate
D. Verrucosa cutis Trichophyton rubrum infection. What is the treatment of
E. Lupus pernio choice?

ANSWER: A. Oral terbinafine for 12 weeks

Lupus pernio B. Oral itraconazole for 4 weeks
C. Topical itraconazole for 2 weeks
EXPLANATION: D. Topical amorolfine for 6 weeks
Lupus pernio is sometimes seen in sarcoidosis but is not E. Oral itraconazole for 1 weeks
associated with tuberculosis
ANSWER:
SKIN DISORDERS ASSOCIATED WITH TUBERCULOSIS Oral terbinafine for 12 weeks
Possible skin disorders
• lupus vulgaris (accounts for 50% of cases) EXPLANATION:
• erythema nodosum Dermatophyte nail infections - use oral terbinafine
• scarring alopecia
• scrofuloderma: breakdown of skin overlying a FUNGAL NAIL INFECTIONS
tuberculous focus Onychomycosis is fungal infection of the nails. This may be
• verrucosa cutis caused by
• gumma • dermatophytes - mainly Trichophyton rubrum, accounts
for 90% of cases
Lupus vulgaris is the most common form of cutaneous TB seen • yeasts - such as Candida
in the Indian subcontinent. It generally occurs on the face and • non-dermatophyte moulds
is common around the nose and mouth. The initial lesion is an
erythematous flat plaque which gradually becomes elevated Risk factors include for fungal nail infections include diabetes
and may ulcerate later mellitus andincreasing age.

Q-16 Features
A 63-year-old man who is known to have type 2 diabetes • 'unsightly' nails are a common reason for presentation
mellitus presents with a number of lesions over his shins. On • thickened, rough, opaque nails are the most common
examination there are a number of 3-4 mm smooth, firm, finding
papules which are hyperpigmented and centrally depressed.
What is the most likely diagnosis? Differential diagnosis
A. Lupus vulgaris • psoriasis
B. Necrobiosis lipoidica diabeticorum • repeated trauma
C. Guttate psoriasis • lichen planus
D. Granuloma annulare • yellow nail syndrome
E. Pyoderma gangrenosum
Investigation
ANSWER:
• nail clippings
Granuloma annulare
• scrapings of the affected nail
EXPLANATION: • the false negative rate for cultures are around 30%, so
GRANULOMA ANNULARE repeat samples may need to be sent if the clinical
Basics suspicion is high
• papular lesions that are often slightly hyperpigmented
and depressed centrally
Management ALLERGY TESTS
• treatment is successful in around 50-80% of people
• diagnosis should be confirmed by microbiology before Most commonly used test as easy to perform and
starting treatment inexpensive. Drops of diluted allergen are placed
• dermatophyte infection: oral terbinafine is currently on the skin after which the skin is pierced using a
needle. A large number of allergens can be tested
recommended first-line with oral itraconazole as an
in one session. Normally includes a histamine
alternative. Six weeks - 3 months therapy is needed for (positive) and sterile water (negative) control. A
fingernail infections whilst toenails should be treated for wheal will typically develop if a patient has an
3 - 6 months allergy. Can be interpreted after 15 minutes
• Candida infection: mild disease should be treated with
topical antifungals (e.g. Amorolfine) whilst more severe Skin prick test Useful for food allergies and also pollen
infections should be treated with oral itraconazole for a Radioallergosorbent Determines the amount of IgE that reacts specifically
period of 12 weeks test (RAST) with suspected or known allergens, for example IgE to
egg protein. Results are given in grades from 0
(negative) to 6 (strongly positive)
Q-18
Which one of the following conditions is least likely to be Useful for food allergies, inhaled allergens (e.g. Pollen)
associated with pyoderma gangrenosum? and wasp/bee venom

A. Ulcerative colitis Blood tests may be used when skin prick tests are not
B. Syphilis suitable, for example if there is extensive eczema or if
the patient is taking antihistamines
C. Lymphoma
Skin patch testing Useful for contact dermatitis. Around 30-40 allergens
D. IgA monoclonal gammopathy
are placed on the back. Irritants may also be tested for.
E. Rheumatoid arthritis The patches are removed 48 hours later with the
results being read by a dermatologist after a further 48
ANSWER: hours
Syphilis
Q-20
EXPLANATION: You review a 24-year-old man who has recently presented
Syphilis is not commonly associated with pyoderma with large psoriatic plaques on his elbows and knees. He has
gangrenosum no history of skin problems although his mother has
psoriasis. You recommend that he uses an emollient to help
Please see Q-2 for Pyoderma Gangrenosum control the scaling. What is the most appropriate further
prescription to use as a first-line treatment on his plaques?
Q-19
A 25-year-old man presents with bloating and alteration in A. Topical steroid
his bowel habit. He has been keeping a food diary and feels B. Topical steroid + topical calcipotriol
his symptoms may be secondary to a food allergy. Blood C. Topical coal tar
tests show a normal full blood count, ESR and thyroid D. Topical calcipotriol
function tests. Anti-endomysial antibodies are negative. E. Topical dithranol
What is the most suitable test to investigate possible food
allergy? ANSWER:
Topical steroid + topical calcipotriol
A. Total IgE levels
B. Hair analysis EXPLANATION:
C. Skin patch testing NICE recommend a potent corticosteroid applied once daily
D. Skin prick test plus vitamin D analogue applied once daily (applied
E. Jejunal biopsy separately, one in the morning and the other in the evening)
for up to 4 weeks as initial treatment.
ANSWER:
Skin prick test PSORIASIS: MANAGEMENT
NICE released guidelines in 2012 on the management of
EXPLANATION: psoriasis and psoriatic arthropathy. Please see the link for
Skin prick testing would be first-line here as it is inexpensive more details.
and a large number of allergens can be investigated. Whilst
there is a role for IgE testing in food allergy it is in the form Management of chronic plaque psoriasis
of specific IgE antibodies rather than total IgE levels. • regular emollients may help to reduce scale loss and
reduce pruritus
• first-line: NICE recommend a potent corticosteroid
applied once daily plus vitamin D analogue applied once
daily (applied separately, one in the morning and the
other in the evening) for up to 4 weeks as initial
treatment
• second-line: if no improvement after 8 weeks then offer a
vitamin D analogue twice daily
• third-line: if no improvement after 8-12 weeks then offer
either: a potent corticosteroid applied twice daily for up
to 4 weeks or a coal tar preparation applied once or twice
daily
• short-acting dithranol can also be used

Using topical steroids in psoriasis

• as we know topical corticosteroid therapy may lead to
skin atrophy, striae and rebound symptoms
• systemic side-effects may be seen when potent
corticosteroids are used on large areas e.g. > 10% of the
body surface area
• NICE recommend that we aim for a 4 week break before
starting another course of topical corticosteroids
• they also recommend using potent corticosteroids for no
longer than 8 weeks at a time and very potent
corticosteroids for no longer than 4 weeks at a time

What should I know about vitamin D analogues?

• examples of vitamin D analogues include calcipotriol
(Dovonex), calcitriol and tacalcitol
• they work by reducing cell division and differentiation
• adverse effects are uncommon
• unlike corticosteroids they may be used long-term
• unlike coal tar and dithranol they do not smell or stain
• they tend to reduce the scale and thickness of plaques example, a shampoo or mousse) and/or a topical agents
but not the erythema to remove adherent scale (for example, agents containing
• they should be avoided in pregnancy salicylic acid, emollients and oils) before application of
• the maximum weekly amount for adults is 100g the potent corticosteroid

Face, flexutal and genital psoriasis

• NICE recommend offering a mild or moderate potency
corticosteroid applied once or twice daily for a maximum
of 2 weeks

Secondary care management

Phototherapy
• narrow band ultraviolet B light is now the treatment of
choice. If possible this should be given 3 times a week
• photochemotherapy is also used - psoralen + ultraviolet A
light (PUVA)
• adverse effects: skin ageing, squamous cell cancer (not
melanoma)

Systemic therapy
• oral methotrexate is used first-line. It is particularly useful
if there is associated joint disease
• ciclosporin
• systemic retinoids
• biological agents: infliximab, etanercept and adalimumab
• ustekinumab (IL-12 and IL-23 blocker) is showing promise
in early trials

Mechanism of action of commonly used drugs:

• coal tar: probably inhibit DNA synthesis
• calcipotriol: vitamin D analogue which reduces epidermal
proliferation and restores a normal horny layer
• dithranol: inhibits DNA synthesis, wash off after 30 mins,
SE: burning, staining
A 'before and after' image showing the effect of 6 weeks of calcipotriol therapy on
a large plaque. Note how the scale has improved but the erythema remains
Q-21
Each of the following drugs may be used in psoriasis, except:
Steroids in psoriasis
• topical steroids are commonly used in flexural psoriasis A. Interferon alpha
and there is also a role for mild steroids in facial psoriasis. B. Infliximab
If steroids are ineffective for these conditions vitamin D C. Retinoids
analogues or tacrolimus ointment should be used second D. Methotrexate
line E. Ciclosporin
• patients should have 4 week breaks between course of
topical steroids ANSWER:
• very potent steroids should not be used for longer than 4 Interferon alpha
weeks at a time. Potent steroids can be used for up to 8
weeks at a time EXPLANATION:
Please see Q-20 for Psoriasis: Management
• the scalp, face and flexures are particularly prone to
steroid atrophy so topical steroids should not be used for
Q-22
more than 1-2 weeks/month
A 34-year-old man attends the emergency department with
Scalp psoriasis a rash on his legs which he says has been getting worse over
• NICE recommend the use of potent topical corticosteroids the past two weeks. His GP started him on flucloxacillin one
used once daily for 4 weeks week ago. At the weekend he visited the emergency
• if no improvement after 4 weeks then either use a department as the rash was spreading; he was discharged
different formulation of the potent corticosteroid (for with the addition of clarithromycin.
He has a past medical history of well-controlled asthma. He Pretibial myxoedema
suffers occasional aches and pains in multiple joints but has • symmetrical, erythematous lesions seen in Graves'
never had any formal investigations for this problem. He disease
takes no regular medications. • shiny, orange peel skin

On examination his observations are stable and he is Pyoderma gangrenosum

afebrile. He has a series of raised purple-red lumps on the • initially small red papule
anterior aspect of both his shins. They are painful and tender • later deep, red, necrotic ulcers with a violaceous border
to touch. • idiopathic in 50%, may also be seen in inflammatory
bowel disease, connective tissue disorders and
The results of investigations are as follows: myeloproliferative disorders

Hb 144 g/l Necrobiosis lipoidica diabeticorum

Platelets 301 * 109/l • shiny, painless areas of yellow/red skin typically on the
WBC 9.6 * 109/l shin of diabetics
CRP 15 mg/L • often associated with telangiectasia
Na+ 139 mmol/l
K+ 4.5 mmol/l Q-23
Ca2+ 2.5 mmol/l A 33-year-old male patient with a history of recurrent nose
bleeds, iron-deficiency anaemia and dyspnoea is found to
The on call radiologist has authorised this report: have a pulmonary AV malformation on pulmonary
angiography. What is the likely underlying diagnosis?
Chest X-ray No focal consolidation seen, clear lung
fields. Some bilateral hilar lymphadenopathy. A. Haemophilia A
B. Hereditary haemorrhagic telangiectasia
What is the most likely diagnosis? C. Mantle cell lymphoma
D. Wegener's granulomatosis
A. Sarcoidosis E. Down's syndrome
B. Cellulitis caused by MRSA
C. Necrotising fasciitis ANSWER:
D. Scrofuloderma (cutaneous tuberculosis) Hereditary haemorrhagic telangiectasia
E. Erysipelas

ANSWER: EXPLANATION:
Sarcoidosis HEREDITARY HAEMORRHAGIC TELANGIECTASIA
Also known as Osler-Weber-Rendu syndrome, hereditary
EXPLANATION: haemorrhagic telangiectasia (HHT) is an autosomal dominant
The description of this gentleman's rash is a classic picture of condition characterised by (as the name suggests) multiple
erythema nodosum. Together with bilateral hilar telangiectasia over the skin and mucous membranes. Twenty
lymphadenopathy, this makes sarcoid the most plausible percent of cases occur spontaneously without prior family
diagnosis. history.

SHIN LESIONS There are 4 main diagnostic criteria. If the patient has 2 then
The differential diagnosis of shin lesions includes the following they are said to have a possible diagnosis of HHT. If they meet
conditions: 3 or more of the criteria they are said to have a definite
• erythema nodosum diagnosis of HHT:
• pretibial myxoedema • epistaxis : spontaneous, recurrent nosebleeds
• pyoderma gangrenosum • telangiectases: multiple at characteristic sites (lips, oral
• necrobiosis lipoidica diabeticorum cavity, fingers, nose)
• visceral lesions: for example gastrointestinal
Below are the characteristic features:
telangiectasia (with or without bleeding), pulmonary
Erythema nodosum arteriovenous malformations (AVM), hepatic AVM,
• symmetrical, erythematous, tender, nodules which heal cerebral AVM, spinal AVM
without scarring • family history: a first-degree relative with HHT
• most common causes are streptococcal infections,
sarcoidosis, inflammatory bowel disease and drugs
(penicillins, sulphonamides, oral contraceptive pill)
 ANSWER:
Trichophyton tonsurans

EXPLANATION:
TINEA
Tinea is a term given to dermatophyte fungal infections. Three
main types of infection are described depending on what part
of the body is infected
• tinea capitis - scalp
• tinea corporis - trunk, legs or arms
• tinea pedis - feet

Tinea capitis (scalp ringworm)

• a cause of scarring alopecia mainly seen in children
• if untreated a raised, pustular, spongy/boggy mass called
a kerion may form
• most common cause is Trichophyton tonsurans in the UK
and the USA
• may also be caused by Microsporum canis acquired from
cats or dogs
• diagnosis: lesions due to Microsporum canis green
fluorescence under Wood's lamp*. However the most
useful investigation is scalp scrapings
• management (based on CKS guidelines): oral antifungals:
terbinafine for Trichophyton tonsurans infections and
griseofulvin for Microsporum infections. Topical
ketoconazole shampoo should be given for the first two
weeks to reduce transmission

The chest x-ray shows multiple pulmonary nodules representing arteriovenous

malformations, the largest in the right mid-zone. The CT scan shows multiple
hepatic arteriovenous malformations

Q-24
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? Tinea corporis (ringworm)
• causes include Trichophyton rubrum and Trichophyton
A. Trichophyton tonsurans verrucosum (e.g. From contact with cattle)
B. Microsporum distortum • well-defined annular, erythematous lesions with pustules
C. Trichophyton verrucosum and papules
D. Microsporum audouinii • may be treated with oral fluconazole
E. Microsporum canis
 ANSWER:
Erythema ab igne

EXPLANATION:
This is a classic presentation of erythema ab igne. Despite
the name, pretibial myxoedema is associated with
hyperthyroidism rather than hypothyroidism.

Hypothyroidism can make patients feel cold and hence more

likely to sit next a heater / fire.

ERYTHEMA AB IGNE
Erythema ab igne is a skin disorder caused by over exposure
to infrared radiation. Characteristic features include
reticulated, erythematous patches with hyperpigmentation
and telangiectasia. A typical history would be an elderly
women who always sits next to an open fire.
Image showing tinea corporis

If the cause is not treated then patients may go on to develop

squamous cell skin cancer.

Image showing tinea corporis. Note the well defined border

Tinea pedis (athlete's foot)

• characterised by itchy, peeling skin between the toes
• common in adolescence

*lesions due to Trichophyton species do not readily fluoresce

under Wood's lamp

Q-25
A 74-year-old lady with a history of hypothyroidism presents
in January with a rash down the right side of her body. On
examination an erythematous rash with patches of
hyperpigmentation and telangiectasia is found. What is the
likely diagnosis?

A. Erythema marginatum
B. Herpes zoster
C. Pretibial myxoedema
D. Erythema ab igne
E. Xanthomata
Q-26
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?

A. Polyurethane dermatitis
B. Fibreglass exposure
C. Cimex lectularius infestation (Bed-bugs)
D. Scabies
E. Langerhans cell histiocytosis

ANSWER:
Scabies

EXPLANATION: Q-28
Please see Q-14 for Scabies A 72-year-old man is investigated for oral ulceration. A
biopsy suggests pemphigus vulgaris. This is most likely to be
Q-27 caused by antibodies directed against:
A 54-year-old man presents with a two month history of a
rapidly growing lesion on his right forearm. The lesion A. Hemidesmosomal BP180
initially appeared as a red papule but in the last two weeks B. Occludin-2
has become a crater filled centrally with yellow/brown C. Hemidesmosomal BP230
material. On examination the man has skin type II, the lesion D. Desmoglein
is 4 mm in diameter and is morphologically as described E. Adherens
above. What is the most likely diagnosis?
ANSWER:
A. Seborrhoeic keratosis Desmoglein
B. Keratoacanthoma
C. Pyoderma gangrenosum EXPLANATION:
D. Basal cell carcinoma Please see Q-8 for Pemphigus Vulgaris
E. Malignant melanoma
Q-29
ANSWER: A 67-year-old retired gardener presents to the dermatology
Keratocanthoma department with a suspicious evolving freckle on his face,
which he first noticed 10 years ago. On examination, he has
EXPLANATION: a 3cm asymmetric pigmented patch on his cheek, comprised
KERATOACANTHOMA of multiple shades of brown and black, and with
Keratoacanthoma is a benign epithelial tumour. They are asymmetrical thickening of the lesion. Which subtype of
more common with advancing age and rare in young people. melanoma is this gentleman most likely to have?

Features - said to look like a volcano or crater A. Superficial spreading melanoma

B. Desmoplastic melanoma
• initially a smooth dome-shaped papule
C. Lentigo maligna melanoma
• rapidly grows to become a crater centrally-filled with
D. Acral lentiginous melanoma
keratin
E. Nodular melanoma
Spontaneous regression of keratoacanthoma within 3 months
is common, often resulting in a scar. Such lesions should
ANSWER:
however be urgently excised as it is difficult clinically to
Lentigo maligna melanoma
exclude squamous cell carcinoma. Removal also may prevent
scarring.
EXPLANATION:
Lentigo maligna melanoma: Suspicious freckle on face or
scalp of chronically sun-exposed patients
Lentigo maligna is a precursor to lentigo maligna melanoma.
It begins as a suspicious flat freckle which can grow over 5-
20 years to develop into melanoma. It typically occurs in can make subsequent histopathological assessment
older people on chronically sun-exposed skin (e.g. with a difficult.
career in gardening) and develops the characteristics of • Once the diagnosis is confirmed the pathology report
typical melanoma (asymmetry, border irregularity, colour should be reviewed to determine whether further re-
variation, diameter>6mm, evolving). Once it has become excision of margins is required (see below):
melanoma, parts of the lesion may thicken as occurred in this
gentleman, there may be increasing numbers of colours, Margins of excision-Related to Breslow thickness
ulceration, bleeding, itching and stinging. Lesions 0-1mm thick 1cm
Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological
Whilst nodular melanoma also presents on the face and features)
neck, it is less likely given the presentation and the slow Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological
growth of the lesion. features)
Lesions >4 mm thick 3cm
Superficial spreading melanoma would also be a differential
to consider in this gentleman, however, the location of the Q-30
lesion and the chronic mild nature of the sun exposure better A 24-year-old female with a history of anorexia nervosa
fits lentigo maligna. presents with red crusted lesions around the corner of her
mouth and below her lower lip. What is she most likely to be
(DermNet NZ) deficient in?

MALIGNANT MELANOMA A. Zinc

There are four main subtypes of melanoma. Nodular B. Tocopherol
melanoma is the most aggressive whilst the other forms C. Pantothenic acid
spread more slowly. D. Thiamine
E. Magnesium
Superficial Lentigo
spreading Nodular maligna Acral lentiginous ANSWER:
Frequency 70% of Second Less Rare form Zinc
cases commonest common
Typically Arms, legs, Sun Chronically Nails, palms or soles, EXPLANATION:
affects back and exposed sun-exposed African Americans or
Vitamin B2 (riboflavin) deficiency may also cause angular
chest, young skin, skin, older Asians
people middle- people cheilosis.
aged
people ZINC DEFICIENCY
Appearance A growing Red or A growing Subungual Features
moles with black lump mole with pigmentation • perioral dermatitis: red, crusted lesions
diagnostic or lump diagnostic (Hutchinson's sign) • acrodermatitis
features which features or of palms or feet
• alopecia
listed above bleeds or listed above
oozes • short stature
• hypogonadism
There are other rare forms of melanoma including • hepatosplenomegaly
desmoplastic melanoma, amelanotic melanoma, or melanoma • geophagia (ingesting clay/soil)
arising in other parts of the body such as ocular melanoma. • cognitive impairment

The main diagnostic features (major Secondary features (minor

Q-31
criteria): criteria)
A 34-year-old patient who is known to have psoriasis
presents with erythematous skin in the groin and genital
area. He also has erythematous skin in the axilla. In the past
• Change in size • Diameter >6mm
he has expressed a dislike of messy or cumbersome creams.
• Change in shape • Inflammation
What is the most appropriate treatment?
• Change in colour • Oozing or bleeding
• Altered sensation
A. Topical steroid
B. Topical dithranol
Treatment C. Topical clotrimazole
D. Coal tar
• Suspicious lesions should undergo excision biopsy. The
E. Topical calcipotriol
lesion should be removed in completely as incision biopsy
ANSWER: Malassezia furfur (formerly known as Pityrosporum ovale). It
Topical steroid is common, affecting around 2% of the general population

EXPLANATION: Features
Flexural psoriasis - topical steroid • eczematous lesions on the sebum-rich areas: scalp (may
This patient has flexural psoriasis which responds well to cause dandruff), periorbital, auricular and nasolabial folds
topical steroids. Topical calcipotriol is usually irritant in • otitis externa and blepharitis may develop
flexures. Mild tar preparations are an option but may be
messy and cumbersome. Associated conditions include
• HIV
Please see Q-20 for Psoriasis: Management • Parkinson's disease

Q-32 Scalp disease management

Which one of the following statements regarding allergy • over the counter preparations containing zinc pyrithione
testing is incorrect? ('Head & Shoulders') and tar ('Neutrogena T/Gel') are
first-line
A. Both irritants and allergens may be tested for using skin • the preferred second-line agent is ketoconazole
patch testing • selenium sulphide and topical corticosteroid may also be
B. The radioallergosorbent test determines the level of IgE useful
to a specific allergen
C. Skin prick testing is easy to perform and inexpensive Face and body management
D. Skin prick testing should be read after 48 hours • topical antifungals: e.g. Ketoconazole
E. Skin prick testing normally includes a histamine control • topical steroids: best used for short periods
• difficult to treat - recurrences are common
ANSWER:
Skin prick testing should be read after 48 hours
Q-34
A 23-year-old man presents as he is concerned over recent
EXPLANATION:
hair loss. Examination reveals a discrete area of hair loss on
Skin prick testing can be read after 15-20 minutes. Skin patch
the left temporal region with no obvious abnormality of the
testing is read after 48 hours
underlying scalp. What is the most likely diagnosis?
Please see Q-19 for Allergy Tests
A. Telogen effluvium
B. Alopecia areata
Q-33
C. Tinea capitis
A 67-year-old man with a history of Parkinson's disease
D. Male-pattern baldness
presents due to the development of an itchy, red rash on his
E. Discoid lupus erythematous
neck, behind his ears and around the nasolabial folds. He
had a similar flare up last winter but did not seek medical
ANSWER:
attention. What is the most likely diagnosis?
Alopecia areata
A. Levodopa associated dermatitis
EXPLANATION:
B. Seborrhoeic dermatitis
ALOPECIA AREATA
C. Flexural psoriasis
Alopecia areata is a presumed autoimmune condition causing
D. Acne rosacea
localised, well demarcated patches of hair loss. At the edge of
E. Fixed drug reaction to ropinirole
the hair loss, there may be small, broken 'exclamation mark'
hairs
ANSWER:
Seborrhoeic dermatitis
Hair will regrow in 50% of patients by 1 year, and in 80-90%
eventually. Careful explanation is therefore sufficient in many
EXPLANATION:
patients. Other treatment options include:
Seborrhoeic dermatitis is more common in patients with
• topical or intralesional corticosteroids
Parkinson's disease
• topical minoxidil
• phototherapy
SEBORRHOEIC DERMATITIS IN ADULTS
Seborrhoeic dermatitis in adults is a chronic dermatitis • dithranol
thought to be caused by an inflammatory reaction related to a • contact immunotherapy
proliferation of a normal skin inhabitant, a fungus called • wigs
Q-35 A. Camouflage creams
A 78-year-old woman asks you for cream to treat a lesion on B. Topical metronidazole
her left cheek. It has been present for the past nine months C. Low-dose topical corticosteroids
and is asymptomatic. On examination you find a 2 * 3 cm D. Laser therapy
area of flat brown pigmentation with a jagged, irregular E. Use of high-factor sun block
edge. The pigmentation on the anterior aspect of the lesion
is a darker brown. What is the most likely diagnosis? ANSWER:
Low-dose topical corticosteroids
A. Solar lentigo
B. Dermatofibroma EXPLANATION:
C. Lentigo maligna Please see Q-1 for Acne Rosacea
D. Bowen's disease
E. Seborrhoeic keratosis Q-38
A 50-year-old man presents with shiny, flat-topped papules
ANSWER: on the palmar aspect of the wrists. He is mainly bothered by
Lentigo maligna the troublesome and persistent itching. A diagnosis of lichen
planus is suspected. What is the most appropriate
EXPLANATION: treatment?
These lesions often present a diagnostic dilemma. The
asymmetrical nature of the lesion would however point A. Refer for punch biopsy
away from a diagnosis of solar lentigo. B. Emollients + oral antihistamine
LENTIGO MALIGNA C. Topical dapsone
Lentigo maligna is a type of melanoma in-situ. It typically D. Topical clotrimazole
progresses slowly but may at some stage become invasive E. Topical clobetasone butyrate
causing lentigo maligna melanoma.
ANSWER:
Q-36 Topical clobetasone butyrate
Which of the following conditions is most associated with
onycholysis? EXPLANATION:
LICHEN PLANUS
A. Bullous pemphigoid Lichen planus is a skin disorder of unknown aetiology, most
B. Raynaud's disease probably being immune mediated.
C. Osteogenesis imperfecta
D. Oesophageal cancer Features
E. Scabies • itchy, papular rash most common on the palms, soles,
ANSWER: genitalia and flexor surfaces of arms
Raynaud's disease • rash often polygonal in shape, 'white-lace' pattern on the
surface (Wickham's striae)
EXPLANATION: • Koebner phenomenon may be seen (new skin lesions
Raynaud's disease causes onycholysis, as can any cause of appearing at the site of trauma)
impaired circulation • oral involvement in around 50% of patients
ONYCHOLYSIS • nails: thinning of nail plate, longitudinal ridging
Onycholysis describes the separation of the nail plate from
the nail bed
Causes
• idiopathic
• trauma e.g. Excessive manicuring
• infection: especially fungal
• skin disease: psoriasis, dermatitis
• impaired peripheral circulation e.g. Raynaud's
• systemic disease: hyper- and hypothyroidism

Q-37
A 62-year-old with a history of acne rosacea presents for
advice regarding treatment. Which one of the following
interventions has the least role in management?
Lichenoid drug eruptions - causes: A. Direct immunofluorescent staining
• gold B. Varicella antibodies
• quinine C. Urine uroporphyrinogen
• thiazides D. Serum porphobilinogen
E. Anti tissue transglutaminase antibodies
Management
• topical steroids are the mainstay of treatment ANSWER:
• benzydamine mouthwash or spray is recommended for Urine uroporphyrinogen
oral lichen planus
• extensive lichen planus may require oral steroids or EXPLANATION:
immunosuppression Hepatitis C may lead to porphyria cutanea tarda
This blistering condition is porphyria cutanea tarda (PCT). It
is associated with chronic hepatitis C and results in blisters
and erosions in sun exposed areas. High levels of urine
uroporphyrinogen are diagnostic. Serum (and urine)
porphobilinogen are useful for the diagnosis of acute
intermittent porphyria (AIP), an autosomal dominant
condition that is characterised by neurological symptoms
and abdominal pain.

Other conditions that can cause acantholysis include

pemphigus vulgaris (for which answer 1 is useful) and
dermatitis herpetiformis (for which answer 5 is useful).

PORPHYRIA CUTANEA TARDA

Porphyria cutanea tarda is the most common hepatic
porphyria. It is due to an inherited defect in uroporphyrinogen
decarboxylase or caused by hepatocyte damage e.g. alcohol,
hepatitis C, oestrogens

Features
• classically presents with photosensitive rash with
blistering and skin fragility on the face and dorsal aspect
of hands (most common feature)
• hypertrichosis
• hyperpigmentation

Investigations
• urine: elevated uroporphyrinogen and pink fluorescence
of urine under Wood's lamp
Management
• chloroquine
• venesection

Q-39
A 45-year-old man has been referred to dermatology clinic
due to a new rash. He is a keen gardener and has spent the
majority of the summer tending to his outdoor plants. His
background is notable for hepatitis C, COPD and
hypertension. He notes this rash is worst on his hands, face
and shoulders.

On examination you note blisters and erosions on his hands,

forehead and upper back.

Which of the following tests would be most helpful in

ascertaining a diagnosis?
Q-40 Pathophysiology
A 33-year-old woman is reviewed in the dermatology clinic • multifactorial and not yet fully understood
with patchy, well demarcated hair loss on the scalp. This is • genetic: associated HLA-B13, -B17, and -Cw6. Strong
affecting around 20% of her total scalp, and causing concordance (70%) in identical twins
significant psychological distress. A diagnosis of alopecia • immunological: abnormal T cell activity stimulates
areata is suspected. Which one of the following is an keratinocyte proliferation. There is increasing evidence
appropriate management plan? this may be mediated by a novel group of T helper cells
producing IL-17, designated Th17. These cells seem to be
A. Topical 5-FU cream
a third T-effector cell subset in addition to Th1 and Th2
B. Autoimmune screen
• environmental: it is recognised that psoriasis may be
C. Topical ketoconazole
worsened (e.g. Skin trauma, stress), triggered (e.g.
D. Topical corticosteroid
Streptococcal infection) or improved (e.g. Sunlight) by
E. Autoimmune screen + topical ketoconazole
environmental factors
ANSWER:
Topical corticosteroid Recognised subtypes of psoriasis
• plaque psoriasis: the most common sub-type resulting in
EXPLANATION: the typical well demarcated red, scaly patches affecting
Watchful waiting for spontaneous remission is another the extensor surfaces, sacrum and scalp
option. Neither the British Association of Dermatologists or • flexural psoriasis: in contrast to plaque psoriasis the skin
Clinical Knowledge Summaries recommend screening for is smooth
autoimmune disease • guttate psoriasis: transient psoriatic rash frequently
Please see Q-34 for Alopecia Areata triggered by a streptococcal infection. Multiple red,
teardrop lesions appear on the body
Q-41 • pustular psoriasis: commonly occurs on the palms and
A 29-year-old man presents due to the development of 'hard soles
skin' on his scalp. On examination he has a 9cm circular,
white, hyperkeratotic lesion on the crown of his head. He
has no past history of any skin or scalp disorder. Skin
scrapings are reported as follows:

No fungal elements seen

What is the most likely diagnosis?

A. Psoriasis
B. Dissecting cellulitis
C. Kerion Other features
D. Systemic lupus erythematous • nail signs: pitting, onycholysis
E. Seborrhoeic dermatitis • arthritis

ANSWER: Complications
Psoriasis • psoriatic arthropathy (around 10%)
• increased incidence of metabolic syndrome
EXPLANATION: • increased incidence of cardiovascular disease
As the skin scraping is negative for fungi the most likely • increased incidence of venous thromboembolism
diagnosis is psoriasis. Scalp psoriasis may occur in isolation in • psychological distress
patients with no history of psoriasis elsewhere. Please see
the link for more information.

The white appearance of the lesion is secondary to the 'silver

scale' covering the psoriatic plaque.

PSORIASIS
Psoriasis is a common (prevalence around 2%) and chronic
skin disorder. It generally presents with red, scaly patches on
the skin although it is now recognised that patients with
psoriasis are at increased risk of arthritis and cardiovascular
disease.
Q-42 Features
A 41-year-old man develops itchy, polygonal, violaceous • 'golden', crusted skin lesions typically found around the
papules on the flexor aspect of his forearms. Some of these mouth
papules have coalesced to form plaques. What is the most • very contagious
likely diagnosis?
Management
A. Lichen planus Limited, localised disease
B. Scabies • topical fusidic acid is first-line
C. Lichen sclerosus • topical retapamulin is used second-line if fusidic acid has
D. Morphea been ineffective or is not tolerated
E. Psoriasis • MRSA is not susceptible to either fusidic acid or
retapamulin. Topical mupirocin (Bactroban) should
ANSWER: therefore be used in this situation
Lichen planus
Extensive disease
EXPLANATION: • oral flucloxacillin
Please see Q-38 for Lichen Planus • oral erythromycin if penicillin allergic
• children should be excluded from school until the lesions
Q-43 are crusted and healed or 48 hours after commencing
A 19-year-old student presents with a three day history of a antibiotic treatment
1 cm golden, crusted lesion on the border of her lower lip.
What is the most suitable management?

A. Oral co-amoxiclav
B. Oral penicillin
C. Oral flucloxacillin
D. Oral flucloxacillin + penicillin
E. Topical fusidic acid

ANSWER:
Topical fusidic acid

EXPLANATION:
Impetigo - topical fusidic acid is first-line
This history is typical of impetigo. As the lesion is small and
localised topical fusidic acid is recommended

IMPETIGO
Impetigo is a superficial bacterial skin infection usually caused
by either Staphylcoccus aureus or Streptococcus pyogenes. It
can be a primary infection or a complication of an existing skin
condition such as eczema (in this case), scabies or insect bites.
Impetigo is common in children, particularly during warm
weather.

The infection can develop anywhere on the body but lesions

tend to occur on the face, flexures and limbs not covered by
clothing.
Q-44
A 25-year-old man presents with a widespread rash over his
Spread is by direct contact with discharges from the scabs of
body. The torso and limbs are covered with multiple
an infected person. The bacteria invade skin through minor
erythematous lesions less than 1 cm in diameter which in
abrasions and then spread to other sites by scratching.
parts are covered by a fine scale. You note that two weeks
Infection is spread mainly by the hands, but indirect spread
earlier he was seen with a sore throat when it was noted
via toys, clothing, equipment and the environment may occur.
that he had exudative tonsillitis. Other than a history of
The incubation period is between 4 to 10 days.
asthma he is normally fit and well. What is the most likely
diagnosis?
A. Pityriasis rosea
B. Pityriasis versicolor
C. Syphilis
D. Discoid eczema
E. Guttate psoriasis

ANSWER:
Guttate psoriasis

EXPLANATION:
PSORIASIS: GUTTATE
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. Management
• most cases resolve spontaneously within 2-3 months
Features • there is no firm evidence to support the use of antibiotics
• tear drop papules on the trunk and limbs to eradicate streptococcal infection
• topical agents as per psoriasis
• UVB phototherapy
• tonsillectomy may be necessary with recurrent episodes

Differentiating guttate psoriasis and pityriasis rosea

Guttate psoriasis Pityriasis rosea

Prodrome Classically preceded by a Many patients report recent
streptococcal sore throat respiratory tract infections but this is
2-4 weeks not common in questions
Appearance 'Tear drop', scaly papules Herald patch followed 1-2 weeks later
on the trunk and limbs 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
Treatment Most cases resolve Self-limiting, resolves after around 6
/ spontaneously within 2-3 weeks
natural months
history Topical agents as per
psoriasis
UVB phototherapy

Q-45
Each one of the following is associated with yellow nail
syndrome except:

A. Chronic sinus infections

B. Bronchiectasis
C. Azoospermia
D. Congenital lymphoedema
E. Pleural effusions

ANSWER:
Azoospermia
EXPLANATION:
YELLOW NAIL SYNDROME Please see Q-20 for Psoriasis: Management
Slowing of the nail growth leads to the characteristic
thickened and discoloured nails seen in yellow nail syndrome. Q-47
A 17-year-old man presents with a 2 week history of
Associations abdominal pain, diarrhoea and repeated episodes of
• congenital lymphoedema flushing. Examination reveals urticarial skin lesions on the
• pleural effusions trunk. What test is most likely to reveal the diagnosis?
• bronchiectasis
• chronic sinus infections A. Chest x-ray
B. Urinary catecholamines
Q-46 C. Serum amylase
A 54-year-old man with significant psoriasis and related D. Urinary 5-HIAA
arthritis comes to the rheumatology clinic for review. despite E. Urinary histamine
both NSAIDs and corticosteroids, his symptoms continue to
worsen. On examination you can see both extensive plaque ANSWER:
psoriasis, and deforming polyarthropathy leading to Urinary 5-HIAA
significant loss of function affecting both hands.
EXPLANATION:
Investigations Urinary histamine is used to diagnose systemic mastocytosis
Given the history of diarrhoea and flushing a diagnosis of
Hb 123 g/l Na+ 140 mmol/l carcinoid syndrome should be considered, which would be
Platelets 321 * 109/l K+ 4.2 mmol/l investigated with urinary 5-HIAA levels. This would not
WBC 10.1 * 109/l Urea 6.7 mmol/l however explain the urticarial skin lesions. In a young person
Neuts 6.1 * 109/l Creatinine 105 µmol/l a diagnosis of systemic mastocytosis should be considered.
Lymphs 1.9 * 109/l CRP 104 mg/l Another factor against carcinoid syndrome is the age of the
Eosin # * 109/l ESR 70 mm/hr patient - the average age of a patient with a carcinoid
tumour is 61 years
Which of the following is the most appropriate next step?
SYSTEMIC MASTOCYTOSIS
A. Azathioprine Systemic mastocytosis results from a neoplastic proliferation
B. Brodalumab of mast cells
C. Etanercept
D. Rituximab Features
E. Toclizumab • urticaria pigmentosa - produces a wheal on rubbing
(Darier's sign)
ANSWER: • flushing
Etanercept • abdominal pain
• monocytosis on the blood film
EXPLANATION:
In this situation with uncontrolled psoriasis and psoriatic Diagnosis
arthritis, early instigation of a biological is recommended. • raised serum tryptase levels
TNF alpha is a pro-inflammatory cytokine closely linked to • urinary histamine
the severity of psoriasis, and etanercept, a TNF alpha
antagonist is the most appropriate intervention. Tuberculosis Q-48
and viral hepatitis should be ruled out prior to starting A 20-year-old man presents with acute gingivitis associated
therapy. with oral ulceration. A diagnosis of primary herpes simplex
infection is suspected. Which one of the following types of
Although azathioprine does impact on disease severity in rash is he most likely to go an develop?
psoriasis, in this situation it's more important to gain disease
control early, and therefore etanercept is the preferred A. Erythema ab igne
intervention. Brodalumab is an anti-IL17 monoclonal B. Erythema nodosum
antibody which has completed registration trials for C. Erythema chronicum migrans
psoriasis. It's likely to be reserved however for patients who D. Erythema marginatum
fail to gain control on other interventions. Rituximab is an E. Erythema multiforme
anti-CD20 antibody more commonly used in the treatment of
rheumatoid arthritis, as is toclizumab which targets IL6.
ANSWER:
Erythema chronicum migrans

EXPLANATION:
ERYTHEMA MULTIFORME

Erythema multiforme is a hypersensitivity reaction which is

most commonly triggered by infections. It may be divided into
minor and major forms.

Previously it was thought that Stevens-Johnson syndrome

(SJS) was a severe form of erythema multiforme. They are
now however considered as separate entities.

Features
• target lesions
• initially seen on the back of the hands / feet before
spreading to the torso
• upper limbs are more commonly affected than the lower
limbs
• pruritus is occasionally seen and is usually mild

Causes
• viruses: herpes simplex virus (the most common cause),
Orf*
• idiopathic
• bacteria: Mycoplasma, Streptococcus
• drugs: penicillin, sulphonamides, carbamazepine,
allopurinol, NSAIDs, oral contraceptive pill, nevirapine
• connective tissue disease e.g. Systemic lupus
erythematosus
• sarcoidosis
• malignancy

Erythema multiforme major

The more severe form, erythema multiforme major is
associated with mucosal involvement.

Example of mucosal involvement in erythema multiforme major

*Orf is a skin disease of sheep and goats caused by a parapox

virus
Q-49
A 54-year-old woman is prescribed topical fusidic acid for a Management
small patch of impetigo around her nose. She has recently • gluten-free diet
been discharged from hospital following varicose vein • dapsone
surgery. Seven days after starting treatment there has been
no change in her symptoms. Examination reveals a
persistent small, crusted area around the right nostril. Whilst
awaiting the results of swabs, what is the most appropriate
management?

A. Oral vancomycin
B. Oral erythromycin
C. Topical metronidazole
D. Topical mupirocin
E. Oral flucloxacillin

ANSWER:
Topical mupirocin

EXPLANATION:
MRSA should be considered given the recent hospital stay
and lack of response to fusidic acid. Topical mupirocin is
therefore the most appropriate treatment.

Please see Q-43 for Impetigo

Q-50
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?

A. Lichen planus
B. Chronic plaque psoriasis
C. Henoch-Schonlein purpura
D. Dermatitis herpetiformis
E. Scabies Q-51
Pellagra is caused by a deficiency in:
ANSWER:
Dermatitis herpetiformis A. Vitamin B12
B. Thiamine
EXPLANATION: C. Nicotinic acid
DERMATITIS HERPETIFORMIS D. Vitamin B2
Dermatitis herpetiformis is an autoimmune blistering skin E. Vitamin B6
disorder associated with coeliac disease. It is caused by
deposition of IgA in the dermis. ANSWER:
Nicotinic acid
Features
• itchy, vesicular skin lesions on the extensor surfaces (e.g. EXPLANATION:
elbows, knees, buttocks) Please see Q-4 for Pellagra

Diagnosis
• skin biopsy: direct immunofluorescence shows deposition
of IgA in a granular pattern in the upper dermis
Q-52 A. Munchausen's syndrome
A 17-year-old male is reviewed six weeks after starting an B. Irritant contact dermatitis
oral antibiotic for acne vulgaris. He stopped taking the drug C. Pyoderma gangrenosum
two weeks ago due to perceived alteration in his skin colour, D. Dermatitis artefacta
and denies been exposed to strong sunlight for the past six E. Stomal granuloma
months. On examination he has generalised increased skin
pigmentation, including around the buttocks. Which one of ANSWER:
the following antibiotics was he likely to be taking? Pyoderma gangrenosum
A. Doxycycline EXPLANATION:
B. Oxytetracycline Pyoderma gangrenosum is associated with inflammatory
C. Tetracycline bowel disease and may be seen around the stoma site.
D. Erythromycin Treatment is usually with immunosuppressants as surgery
E. Minocycline may worsen the problem
ANSWER:
Minocycline A differential diagnosis would be malignancy and hence
lesions should be referred for specialist opinion to evaluate
EXPLANATION: the need for a biopsy. Irritant contact dermatitis is common
Minocycline can cause irreversible skin pigmentation and is but would not be expected to cause such a deep ulcer.
now considered a second line drug in acne. Photosensitivity
secondary to tetracycline/doxycycline is less likely given the Please see Q-2 for Pyoderma Gangrenosum
generalised distribution of the pigmentation and the failure
to improve following drug withdrawal Q-55
Which one of the following factors would predispose a
Please see Q-9 for Acne Vulgaris: Management patient to forming keloid scars?

Q-53 A. Having white skin

A 21-year-old woman who is 16 weeks pregnant present B. Incisions along relaxed skin tension lines
with worsening acne which she is finding distressing. She is C. Being aged 20-40 years
currently using topical benzyl peroxide with limited effect. D. Being female
On examination there is widespread non-inflammatory E. Having a wound on the lower back
lesions and pustules on her face. What is the most
appropriate next management step? ANSWER:
A. Oral trimethoprim Being aged 20-40 years
B. Oral lymecycline
C. Oral erythromycin EXPLANATION:
D. Topical retinoid Keloid scars - more common in young, black, male adults
E. Oral doxycycline
Please see Q-12 for Keloid Scars
ANSWER:
Oral erythromycin Q-56
A 22-year-old male sex worker comes to the Emergency
EXPLANATION: department with an erythematous skin rash. He tells you
Acne vulgaris in pregnancy - use oral erythromycin if that it began on his scalp, and is now spreading to involve his
treatment needed face, neck, and the flexor surfaces of his arms and legs. He
Oral erythromycin may be used for acne in pregnancy. The has no significant past medical history and takes no regular
other drugs are contraindicated medication. Blood pressure, pulse and temperature are all
normal. Respiratory and abdominal examination is
Please see Q-9 for Acne Vulgaris: Management
unremarkable. There are extensive erythematous scaly
Q-54 plaques, the overlying skin is greasy and there are areas of
A 50-year-old man with a history of ulcerative colitis comes yellow / brown crusted material.
for review. Six years ago he had an ileostomy formed which
has been functioning well until now. Unfortunately he is Which of the following tests is most important in this
currently suffering significant pain around the stoma site. On situation?
examination a deep erythematous ulcer is noted with a
ragged edge. The surrounding skin is erythematous and
swollen. What is the most likely diagnosis?
A. Autoimmune profile Q-58
B. Herpes PCR An 84-year-old woman with a history of ischaemic heart
C. HIV testing disease is reviewed in the dermatology clinic. Her current
D. Skin scrapings for microscopy and culture medication includes aspirin, simvastatin, bisoprolol, ramipril
E. Syphilis serology and isosorbide mononitrate. She has developed tense
blistering lesions on her legs. Each lesion is around 1 to 3 cm
ANSWER: in diameter and she reports that they are slightly pruritic.
HIV testing Examination of her mouth and vulva is unremarkable. What
is the most likely diagnosis?
EXPLANATION:
This man's presentation is consistent with seborrhoeic A. Pemphigus
dermatitis, and given his occupation as a male sex worker, B. Drug reaction to aspirin
there is a high risk this may be associated with HIV infection. C. Epidermolysis bullosa
p24 antigen testing may be useful in the early stages of HIV D. Scabies
infection for screening, in the later stages of infection E. Bullous pemphigoid
serology for anti-HIV antibodies is most useful.
ANSWER:
The extensive plaques count against this being a fungal Bullous pemphigoid
infection, which would usually be confined to one area,
ruling out taking skin scrapings as being useful. Seborrhoeic EXPLANATION:
dermatitis may be associated with autoimmune thyroid Blisters/bullae
disease, although we're given no evidence to support a • no mucosal involvement (in exams at least*): bullous
diagnosis of thyroid dysfunction here. Syphilis is unlikely pemphigoid
given there is no history of primary syphilis infection, and • mucosal involvement: pemphigus vulgaris
herpes PCR is not useful in determining the underlying cause
BULLOUS PEMPHIGOID
of seborrhoeic dermatitis.
Bullous pemphigoid is an autoimmune condition causing sub-
epidermal blistering of the skin. This is secondary to the
Please see Q-33 for Seborrhoeic Dermatitis in Adults
development of antibodies against hemidesmosomal proteins
BP180 and BP230
Q-57
A 26-year-old lady presents to you distressed due to the Bullous pemphigoid is more common in elderly patients.
presence of a rash over her thorax and abdomen for the last Features include
three weeks. On examination, you note numerous teardrop • itchy, tense blisters typically around flexures
lesions on her body. • the blisters usually heal without scarring
• mouth is usually spared*
She has no known past medical history and denies exposure
to any new irritants. She states that she is going to be Skin biopsy
married in 2 weeks and wants to know if there is anything • immunofluorescence shows IgG and C3 at the
that can be done to hasten the disappearance of her rash. dermoepidermal junction
Which therapy could this lady be commenced on? Management
A. Photochemotherapy (PUVA) A • referral to dermatologist for biopsy and confirmation of
B. Oral prednisolone diagnosis
C. Dermovate • oral corticosteroids are the mainstay of treatment
D. Ultraviolet B phototherapy • topical corticosteroids, immunosuppressants and
E. Methotrexate antibiotics are also used

ANSWER:
Ultraviolet B phototherapy

EXPLANATION:
This patient has a classic description of guttate psoriasis.
Whilst this will usually self-resolve, ultraviolet B
phototherapy has been known to accelerate resolution. The
other treatments have no role in the acute management of
guttate psoriasis.
Please see Q-44 for Psoriasis: Guttate
 EXPLANATION:
Acral lentiginous melanoma: Pigmentation of nail bed
affecting proximal nail fold suggests melanoma
(Hutchinson's sign)
Acral lentiginous melanoma is the rarest form of melanoma
overall, but the commonest form of melanoma in people
with darker skin. Hence it is important to be able to
recognise.

Acral lentiginous melanoma mostly affects people over the

age of 40 and is equally common in males and females. It is
not related to sun exposure. It typically presents as an
enlarging discoloured skin patch on the palms, fingers, soles
or toes with the characteristics of other flat forms of
melanoma. It can arise in the nail unit, appearing as general
discolouration or irregular pigmented bands running
longitudinally along the nail plate and is called subungual
melanoma when it arises in the matrix.

This patient has subungual acral lentiginous melanoma with

an important clinical clue of this called 'Hutchinson's nail
sign'. This sign is characterised by extension of the nail bed,
matrix and nail plate pigmentation to the adjacent cuticle
and proximal or lateral nail folds.

The other forms of melanoma are less likely to present in this

way and are described in more detail in the notes below

(DermNet NZ)

Please see Q-29 for Malignant Melanoma

*in reality around 10-50% of patients have a degree of
Q-60
mucosal involvement. It would however be unusual for an
Which one of the following side-effects is least recognised in
exam question to mention mucosal involvement as it is seen
patients taking isotretinoin?
as a classic differentiating feature between pemphigoid and
pemphigus.
A. Hypertension
B. Teratogenicity
Q-59
A 52-year-old African-American woman presents to the C. Nose bleeds
dermatology department. She has noticed a patch of D. Depression
E. Raised triglycerides
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 ANSWER:
Hypertension
adjacent cuticle and proximal nail fold. Which subtype of
melanoma would you expect to present in this manner?
EXPLANATION:
A. Superficial spreading melanoma Isotretinoin adverse effects
B. Acral lentiginous melanoma • teratogenicity - females MUST be taking contraception
C. Lentigo maligna melanoma • low mood
D. Nodular melanoma • dry eyes and lips
E. Amelanotic melanoma • raised triglycerides
• hair thinning
ANSWER: • nose bleeds
Acral lentiginous melanoma
Hypertension is not listed in the British National Formulary
as a side-effect
ISOTRETINOIN Management of hirsutism
Isotretinoin is an oral retinoid used in the treatment of severe • advise weight loss if overweight
acne. Two-thirds of patients have a long-term remission or • cosmetic techniques such as waxing/bleaching - not
cure following a course of oral isotretinoin. available on the NHS
• consider using combined oral contraceptive pills such as
Adverse effects co-cyprindiol (Dianette) or ethinylestradiol and
• teratogenicity: females should ideally be using two forms drospirenone (Yasmin). Co-cyprindiol should not be used
of contraception (e.g. Combined oral contraceptive pill long-term due to the increased risk of venous
and condoms) thromboembolism
• dry skin, eyes and lips/mouth: the most common side- • facial hirsutism: topical eflornithine - contraindicated in
effect of isotretinoin pregnancy and breast-feeding
• low mood*
• raised triglycerides Causes of hypertrichosis
• hair thinning • drugs: minoxidil, ciclosporin, diazoxide
• nose bleeds (caused by dryness of the nasal mucosa) • congenital hypertrichosis lanuginosa, congenital
• intracranial hypertension: isotretinoin treatment should hypertrichosis terminalis
not be combined with tetracyclines for this reason • porphyria cutanea tarda
• photosensitivity • anorexia nervosa

*whilst this is a controversial topic, depression and other Q-62

psychiatric problems are listed in the BNF A 24-year-old woman presents due to a rash on her neck and
forehead. She returned from a holiday in Cyprus 1 week ago
Q-61 and had her hair dyed 2 days ago. On examination there is a
Each one of the following is associated with hypertrichosis, weepy, vesicular rash around her hairline although the scalp
except: itself is not badly affected. What is the most likely diagnosis?

A. Anorexia nervosa A. Cutaneous leishmaniasis

B. Porphyria cutanea tarda B. Irritant contact dermatitis
C. Psoriasis C. Allergic contact dermatitis
D. Minoxidil D. Syphilis
E. Ciclosporin E. Photocontact dermatitis

ANSWER: ANSWER:
Psoriasis Allergic contact dermatitis

EXPLANATION: EXPLANATION:
HIRSUTISM AND HYPERTRICHOSIS CONTACT DERMATITIS
Hirsutism is often used to describe androgen-dependent hair There are two main types of contact dermatitis
growth in women, with hypertrichosis being used for • irritant contact dermatitis: common - non-allergic
androgen-independent hair growth reaction due to weak acids or alkalis (e.g. detergents).
Often seen on the hands. Erythema is typical, crusting
Polycystic ovarian syndrome is the most common causes of and vesicles are rare
hirsutism. Other causes include: • allergic contact dermatitis: type IV hypersensitivity
• Cushing's syndrome reaction. Uncommon - often seen on the head following
• congenital adrenal hyperplasia hair dyes. Presents as an acute weeping eczema which
• androgen therapy predominately affects the margins of the hairline rather
• obesity: due to peripheral conversion oestrogens to than the hairy scalp itself. Topical treatment with a
androgens potent steroid is indicated
• adrenal tumour
• androgen secreting ovarian tumour Cement is a frequent cause of contact dermatitis. The alkaline
• drugs: phenytoin, corticosteroids nature of cement may cause an irritant contact dermatitis
whilst the dichromates in cement also can cause an allergic
Assessment of hirsutism contact dermatitis
• Ferriman-Gallwey scoring system: 9 body areas are
assigned a score of 0 - 4, a score > 15 is considered to
indicate moderate or severe hirsutism
Q-63
You are working in dermatology. A 72-year-old lady has been
referred to you by the GP. She says she can feel a firm patch
of roughened skin overlying the left cheek which has been
getting gradually larger in size. She thinks it has been there
for at least a year. Her GP was not able to see any external
features of ulceration, but felt there was a rough area over
the left cheek. On examination there is a firm waxy area
about 3 x 3 cm in size overlying the left cheek with ill-defined
edges. How would you manage this lesion?

A. Mohs surgery
B. Radiotherapy
C. Excision biopsy
D. Reassure the patient and discharge her back to the GP
E. Monitor in clinic every six months

ANSWER:
Mohs surgery

EXPLANATION:
The diagnosis is a morphoeic basal cell carcinoma. These are
a type of BCC which present with firm/rough/waxy patches
often on the cheeks. They often have poorly defined edges.
Whilst radiotherapy can be used to manage some basal or
squamous cell carcinomas, Mohs surgery is the gold standard
for treating these lesions.

As this lesion is a basal cell carcinoma it should be removed.

Therefore answers 4 and 5 are wrong. An excision biopsy is
not necessary as it is a clinical diagnosis. Mohs surgery will
also confirm this diagnosis as well as treat the lesion by
removing it fully until clear margins are present.

BASAL CELL CARCINOMA

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.

Features
• many types of BCC are described. The most common type
is nodular BCC, which is described here
• 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'

Management options:
• surgical removal
• curettage
• cryotherapy
• topical cream: imiquimod, fluorouracil
• radiotherapy
 Features
• herald patch (usually on trunk)
• followed by erythematous, oval, scaly patches which
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

Management
• self-limiting, usually disappears after 4-12 weeks

Q-64
A man presents with an area of dermatitis on his left wrist.
He thinks he may be allergic to nickel. Which one of the
following is the best test to investigate this possibility?

A. Skin patch test

B. Radioallergosorbent test (RAST)
C. Nickel IgG levels On the left a typical herald patch is seen. After a few days a more generalised 'fir-
D. Skin prick test tree' rash appears
E. Nickel IgM levels

ANSWER:
Skin patch test

EXPLANATION:
Please see Q-19 for Allergy Tests

Q-65
A 26-year-old male presents with a rash. Examination reveals
erythematous oval lesions on his back and upper arms which
have a slight scale just inside the edge. They vary in size from
1 to 5 cm in diameter. What is the most likely diagnosis?

A. Lichen planus
B. Guttate psoriasis
C. Lichen sclerosus
D. Pityriasis rosea
E. Pityriasis versicolor

ANSWER:
Pityriasis rosea

EXPLANATION:
The skin lesions seen in pityriasis rosea are generally larger
than those found in guttate psoriasis and scaling is typically
confined to just inside the edges

PITYRIASIS ROSEA
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.
 Previously it was thought that Stevens-Johnson syndrome
(SJS) was a severe form of erythema multiforme. They are
now however considered as separate entities.

Features
• rash is typically maculopapular with target lesions being
characteristic. May develop into vesicles or bullae
• mucosal involvement
• systemic symptoms: fever, arthralgia

Causes
• penicillin
• sulphonamides
• lamotrigine, carbamazepine, phenytoin
• allopurinol
• NSAIDs
• oral contraceptive pill
Differentiating guttate psoriasis and pityriasis rosea

Guttate psoriasis Pityriasis rosea

Management
Prodrome Classically preceded by a Many patients report recent • hospital admission is required for supportive treatment
streptococcal sore throat respiratory tract infections but this
2-4 weeks is not common in questions Q-67
Appearance 'Tear drop', scaly papules Herald patch followed 1-2 weeks A 22-year-old male is referred to dermatology clinic with a
on the trunk and limbs later by multiple erythematous, longstanding problem of bilateral excessive axillary
slightly raised oval lesions with a sweating. He is otherwise well but the condition is affecting
fine scale confined to the outer his confidence and limiting his social life. What is the most
aspects of the lesions.
appropriate management?
May follow a characteristic
distribution with the longitudinal A. Non-sedating antihistamine
diameters of the oval lesions B. Topical hydrocortisone 1%
running parallel to the line of C. Perform thyroid function tests
Langer. This may produce a 'fir- D. Topical aluminium chloride
tree' appearance E. Trial of desmopressin
Treatment Most cases resolve Self-limiting, resolves after around
/ spontaneously within 2-3 6 weeks
ANSWER:
natural months
history Topical agents as per
Topical aluminium chloride
psoriasis
UVB phototherapy EXPLANATION:
HYPERHIDROSIS
Q-66 Hyperhidrosis describes the excessive production of sweat
Which one of the following antibiotics is most associated
with the development of Stevens-Johnson syndrome? Management options include
• topical aluminium chloride preparations are first-line.
A. Co-trimoxazole Main side effect is skin irritation
B. Ethambutol • iontophoresis: particularly useful for patients with
C. Chloramphenicol palmar, plantar and axillary hyperhidrosis
D. Ciprofloxacin • botulinum toxin: currently licensed for axillary symptoms
E. Gentamicin • surgery: e.g. Endoscopic transthoracic sympathectomy.
Patients should be made aware of the risk of
ANSWER: compensatory sweating
Co-trimoxazole

EXPLANATION: Q-68
STEVENS-JOHNSON SYNDROME A 62-year-old female is referred to dermatology due to a
Stevens-Johnson syndrome is a severe systemic reaction lesion over her shin. It initially started as a small red papule
affecting the skin and mucosa that is almost always caused by which later became a deep, red, necrotic ulcer with a
a drug reaction. violaceous border. What is the likely diagnosis?
A. Necrobiosis lipoidica diabeticorum A. Intravenous immunoglobulin
B. Syphilis B. Cyclophosphamide
C. Erythema nodosum C. Supportive care only
D. Pretibial myxoedema D. Pulsed methylprednisolone
E. Pyoderma gangrenosum E. Plasmapheresis

ANSWER: ANSWER:
Pyoderma gangrenosum Intravenous immunoglobulin

EXPLANATION: EXPLANATION:
This is a classic description of pyoderma gangrenosum TOXIC EPIDERMAL NECROLYSIS
Toxic epidermal necrolysis (TEN) is a potentially life-
Please see Q-22 for Shin Lesions threatening skin disorder that is most commonly seen
secondary to a drug reaction. In this condition the skin
Q-69 develops a scalded appearance over an extensive area. Some
A 81-year-old man is investigated after he develops a authors consider TEN to be the severe end of a spectrum of
number of itchy blisters on his trunk. A skin biopsy suggests skin disorders which includes erythema multiforme and
a diagnosis bullous pemphigoid. This is most likely to be Stevens-Johnson syndrome
caused by antibodies directed against:
Features
A. Adherens • systemically unwell e.g. pyrexia, tachycardic
B. Desmoglein-3 • positive Nikolsky's sign: the epidermis separates with mild
C. Hemidesmosomal BP antigens lateral pressure
D. Occludin-2
E. Desmoglein-1 Drugs known to induce TEN
• phenytoin
ANSWER: • sulphonamides
Hemidesmosomal BP antigens • allopurinol
• penicillins
EXPLANATION: • carbamazepine
Please see Q-58 for Bullous Pemphigoid • NSAIDs

Q-70 Management
A 26-year-old man who is HIV positive is noted to have • stop precipitating factor
developed seborrhoeic dermatitis. Which of the following
• supportive care, often in intensive care unit
two complications are most associated with this condition?
• intravenous immunoglobulin has been shown to be
effective and is now commonly used first-line
A. Alopecia and otitis externa
• other treatment options include: immunosuppressive
B. Blepharitis and otitis externa
agents (ciclosporin and cyclophosphamide),
C. Photosensitivity and alopecia
plasmapheresis
D. Photosensitivity and blepharitis
E. Blepharitis and alopecia
Q-72
Which one of the following conditions is least associated
ANSWER:
with pruritus?
Blepharitis and otitis externa
A. Pemphigus vulgaris
EXPLANATION:
B. Iron-deficiency anaemia
Alopecia is not commonly seen in seborrhoeic dermatitis, but
C. Polycythaemia
may develop if a severe secondary infection develops
D. Chronic renal failure
E. Scabies
Please see Q-33 for Seborrhoeic Dermatitis in Adults
ANSWER:
Q-71 Pemphigus vulgaris
A 45-year-old man develops toxic epidermal necrolysis
following a change in his epilepsy medication. He is EXPLANATION:
systemically unwell and is admitted to ITU for supportive Pemphigus vulgaris is an autoimmune bullous disease of the
care. What is the most appropriate treatment? skin. It is not commonly associated with pruritus
PRURITUS Please see Q-1 for Acne Rosacea
The table below lists the main characteristics of the most
important causes of pruritus Q-74
A 48-year-old presents with diarrhoea and confusion. He is
Condition Notes known to be alcohol dependent, having previously had
Liver disease History of alcohol excess several admission with alcohol toxicity. He consumes 45
Stigmata of chronic liver disease: spider naevi, units of alcohol per week, and has had previous admissions
bruising, palmar erythema, gynaecomastia etc for aspiration pneumonia. He denies head trauma. On
Evidence of decompensation: ascites, jaundice, examination he appears confused and anxious, and there is a
encephalopathy rash around his neck which appears to be in sun exposed
Iron deficiency Pallor areas. It appears pigmented. A CT scan of the head is normal.
anaemia Other signs: koilonychia, atrophic glossitis, post-
What deficiency would most likely explain his presentation?
cricoid webs, angular stomatitis
Polycythaemia Pruritus particularly after warm bath
'Ruddy complexion'
A. Thiamine
Gout B. Vitamin A
Peptic ulcer disease C. Vitamin C
Chronic kidney Lethargy & pallor D. Niacin
disease Oedema & weight gain E. Riboflavin
Hypertension
Lymphoma Night sweats ANSWER:
Lymphadenopathy Niacin
Splenomegaly, hepatomegaly
Fatigue
EXPLANATION:
The correct answer is niacin. Niacin deficiency, or pellagra,
Other causes:
typically presents as the triple combination of dementia,
• hyper- and hypothyroidism diarrhoea and dermatitis. The dermatitis is a photosensitive
• diabetes pigmented dermatitis. The significant alcohol history makes
• pregnancy niacin deficiency very likely. Thiamine deficiency causes
• 'senile' pruritus beriberi and Wernicke-Korsakoff syndrome, neither which
• urticaria would explain his rash. Vitamin C deficiency causes scurvy
• skin disorders: eczema, scabies, psoriasis, pityriasis rosea which is associated with bleeding and gum ulceration.

Q-73 Please see Q-4 for Pellagra

A 54-year-old lady attends with a rash. She describes a facial
rash present for several weeks associated with flushing. On Q-75
examination, there is erythematous papulopustular rash A 49-year-old man is reviewed in the dermatology clinic
with telangiectasia across both cheeks and nose. Given the complaining of losing hair. Examination reveals generalised
likely diagnosis, which associated complication may she also scalp hair loss that does not follow the typical male-pattern
have? distribution. Which one of the following medications is least
likely to be responsible?
A. Blepharitis
B. Parotitis
A. Colchicine
C. Vulvovaginitis
B. Cyclophosphamide
D. Pancreatitis
C. Heparin
E. Pericarditis
D. Carbimazole
ANSWER: E. Phenytoin
Blepharitis
ANSWER:
EXPLANATION: Phenytoin
Acne rosacea
• chronic skin condition which causes persistent facial EXPLANATION:
flushing, erythema, telangiectasia, pustules, papules and Phenytoin is a recognised cause of hirsutism, rather than
rhinophyma alopecia
• It can also affect the eyes causing blepharitis, keratitis,
conjunctivitis Please see Q-10 for Alopecia
• It is treated with topical antibiotics e.g. metronidazole
gel or oral tetracycline (especially if ocular symptoms).
Q-76 Q-77
A 54-year-old man presents with a brown velvety rash on the A patient who is suspected of having dermatitis
back of his neck around his axilla. A clinical diagnosis of herpetiformis undergoes a skin biopsy. Which one of the
acanthosis nigricans is made. Which one of the following following antibodies is most likely to be found in the dermis?
conditions is most associated with this kind of rash?
A. IgM
A. Hypothyroidism B. IgA
B. Psoriasis C. IgD
C. Tuberculosis D. IgE
D. Ulcerative colitis E. IgG
E. Acute pancreatitis
ANSWER: ANSWER:
Hypothyroidism IgA

EXPLANATION: EXPLANATION:
ACANTHOSIS NIGRICANS Dermatitis herpetiformis - caused by IgA deposition in the
Describes symmetrical, brown, velvety plaques that are often dermis
found on the neck, axilla and groin
Please see Q-50 for Dermatitis Herpetiformis
Causes
• gastrointestinal cancer Q-78
• diabetes mellitus A 19-year-old man is started on isotretinoin for severe
• obesity nodulo-cystic acne. Which one of the following side-effects is
• polycystic ovarian syndrome most likely to occur?
• acromegaly
• Cushing's disease A. Low mood
• hypothyroidism B. Thrombocytopaenia
• familial C. Raised plasma triglycerides
• Prader-Willi syndrome D. Reversible alopecia
• drugs: oral contraceptive pill, nicotinic acid E. Dry skin

ANSWER:
Dry skin

EXPLANATION:
Dry skin is the most common side-effect of isotretinoin

Please see Q-60 for Isotretinoin

Q-79
A 23-year-old student is investigated following an
anaphylactic reaction suspected to be secondary to a wasp
sting. Which one of the following is the most appropriate
first-line test to investigate the cause of the reaction?

A. Hair analysis
B. Radioallergosorbent test (RAST)
C. Desensitization therapy
D. Skin patch test
E. Skin prick test

ANSWER:
30%

EXPLANATION:
Given the history of anaphylaxis it would not be appropriate
to perform a skin prick test

Please see Q-19 for Allergy Tests

Q-80 EXPLANATION:
A 72-year-old woman is diagnosed with a number of Acne rosacea treatment:
erythematous, rough lesions on the back of her hands. A • mild/moderate: topical metronidazole
diagnosis of actinic keratoses is made. What is the most • severe/resistant: oral tetracycline
appropriate management? Given that this woman has mild symptoms, topical
metronidazole should be used first line
A. Reassurance
B. Urgent referral to a dermatologist Please see Q-1 for Acne Rosacea
C. Topical fluorouracil cream
D. Review in 3 months Q-82
E. Topical betnovate A 45-year-old woman presents for review. She has noticed a
number of patches of 'pale skin' on her hands over the past
ANSWER: few weeks. The patient has tried using an emollient and
Topical fluorauracil cream topical hydrocortisone with no result. On examination, you
note a number of depigmented patches on the dorsum of
EXPLANATION: both hands. Her past medical history includes thyrotoxicosis
ACTINIC KERATOSES for which she takes carbimazole and thyroxine.
Actinic, or solar, keratoses (AK) is a common premalignant
skin lesion that develops as a consequence of chronic sun What is the most likely cause of her symptoms?
exposure
A. Vitiligo
Features B. Carbimazole-induced hypopigmentation
• small, crusty or scaly, lesions C. Leukopaenia-induced fungal infection
• may be pink, red, brown or the same colour as the skin D. Idiopathic guttate hypomelanosis
• typically on sun-exposed areas e.g. temples of head E. Addison disease
• multiple lesions may be present
ANSWER:
Management options include Vitiligo
• prevention of further risk: e.g. sun avoidance, sun cream
• fluorouracil cream: typically a 2 to 3 week course. The EXPLANATION:
skin will become red and inflamed - sometimes topical Vitiligo is more common in patients with known autoimmune
hydrocortisone is given following fluorouracil to help conditions such as thyrotoxicosis. There is nothing else in the
settle the inflammation history to suggest Addison's disease.
• topical diclofenac: may be used for mild AKs. Moderate
efficacy but much fewer side-effects VITILIGO
• topical imiquimod: trials have shown good efficacy Vitiligo is an autoimmune condition which results in the loss of
• cryotherapy melanocytes and consequent depigmentation of the skin. It is
• curettage and cautery thought to affect around 1% of the population and symptoms
typically develop by the age of 20-30 years.
Q-81
Features
A 58-year-old woman presents with a persistent
• well demarcated patches of depigmented skin
erythematous rash on her cheeks and a 'red nose'. She
• the peripheries tend to be most affected
describes occasional episodes of facial flushing. On
• trauma may precipitate new lesions (Koebner
examination erythematous skin is noted on the nose and
phenomenon)
cheeks associated with occasional telangiectasia. What is the
most appropriate management? Associated conditions
• type 1 diabetes mellitus
A. Topical metronidazole
• Addison's disease
B. Topical isotretinoin
• autoimmune thyroid disorders
C. Benzyl peroxide
• pernicious anaemia
D. Daktacort
E. Topical hydrocortisone • alopecia areata

Management
ANSWER:
• sun block for affected areas of skin
Topical metronidazole
• camouflage make-up
• topical corticosteroids may reverse the changes if applied Q-83
early A 17-year-old female originally from Nigeria presents due to
• there may also be a role for topical tacrolimus and a swelling around her earlobe. She had her ears pierced
phototherapy, although caution needs to be exercised around three months ago and has noticed the gradual
with light-skinned patients development of an erythematous swelling since. On
examination a keloid scar is seen. What is the most
appropriate management?

A. Intralesional diclofenac
B. Advise no treatment is available
C. Intralesional triamcinolone
D. Advise will spontaneously regress within 4-6 months
E. Intralesional sclerotherapy

ANSWER:
Intralesional triamcinolone

EXPLANATION:
Please see Q-12 for Keloid Scars

Q-84
A woman presents with painful erythematous lesions on her
shins. Which one of the following is least associated with this
presentation?

A. Pregnancy
B. Behcet's syndrome
C. Streptococcal infection
D. Penicillin
E. Amyloidosis

ANSWER:
Amyloidosis

EXPLANATION:
Please see Q-13 for Erythema Nodosum

Q-85
A 30-year-old man presents with painful, purple coloured
lesions on his shins. Some of these lesions have started to
heal and no evidence of scarring is seen. These have been
present for the past 2 weeks. There is no past medical
history of note and he takes no regular medications. What is
the most useful next investigation?

A. Liver function tests

B. Anti-nuclear antibody
C. ECG
D. HIV test
E. Chest x-ray

ANSWER:
Chest x-ray

EXPLANATION:
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
Please see Q-13 for Erythema Nodosum
Q-86 ANSWER:
A 25-year-old male presents with extensive patches of Loratadine
altered pigmentation on his front, back, face and thighs.
There is mild pruritus. A diagnosis of extensive pityriasis EXPLANATION:
versicolor is made. What is the most appropriate The obvious concern in a lorry driver is drowsiness. Of the
management? non-sedating antihistamines there is some evidence that
cetirizine causes more drowsiness than loratadine
A. Oral metronidazole
B. Topical terbinafine ANTIHISTAMINES
C. Oral itraconazole Antihistamines (H1 inhibitors) are of value in the treatment of
D. Topical selenium sulphide allergic rhinitis and urticaria.
E. Oral terbinafine
Examples of sedating antihistamines
ANSWER: • chlorpheniramine
Oral itraconazole
As well as being sedating these antihistamines have some
EXPLANATION: antimuscarinic properties (e.g. urinary retention, dry mouth).
Given the extensive nature of the lesions systemic therapy is
indicated in this case Examples of non-sedating antihistamines
• loratidine
PITYRIASIS VERSICOLOR • cetirizine
Pityriasis versicolor, also called tinea versicolor, is a superficial
cutaneous fungal infection caused by Malassezia furfur Of the non-sedating antihistamines there is some evidence
(formerly termed Pityrosporum ovale) that cetirizine may cause more drowsiness than other drugs in
the class.
Features
• most commonly affects trunk Q-88
• patches may be hypopigmented, pink or brown (hence A 29-year-old man consults you regarding a rash he has
versicolor). May be more noticeable following a suntan noticed around his groin. It has been present for the past 3
• scale is common months and is asymptomatic. On examination, a
• mild pruritus symmetrical rash around the groin is noted consisting of
well-defined pink/brown patches with fine scaling and
Predisposing factors superficial fissures.
• occurs in healthy individuals
• immunosuppression What is the most likely diagnosis?
• malnutrition
• Cushing's A. Erythrasma
B. Pityriasis versicolor
Management C. Secondary syphilis
• topical antifungal. NICE Clinical Knowledge Summaries D. Acanthosis nigricans
advise ketoconazole shampoo as this is more cost E. Candida intertrigo
effective for large areas
• if extensive disease or failure to respond to topical ANSWER:
treatment then consider oral itraconazole Erythrasma

Q-87 EXPLANATION:
A 47-year-old lorry driver presents following the ERYTHRASMA
development of a widespread urticarial rash. This is Erythrasma is a generally asymptomatic, flat, slightly scaly,
associated with pruritus. What is the most appropriate pink or brown rash usually found in the groin or axillae. It is
medication to help relieve the itch? caused by an overgrowth of the diphtheroid Corynebacterium
minutissimum
A. Cetirizine
B. Loratadine Examination with Wood's light reveals a coral-red
C. Chlorphenamine fluorescence.
D. Ranitidine Topical miconazole or antibacterial are usually effective. Oral
E. Alimemazine erythromycin may be used for more extensive infection
Q-89
A 35-year-old female presents tender, erythematous nodules
over her forearms. Blood tests reveal:

Calcium 2.78 mmol/l

What is the most likely diagnosis?

A. Granuloma annulare
B. Erythema nodosum
C. Lupus pernio
D. Erythema multiforme
E. Necrobiosis lipoidica

ANSWER:
Erythema nodosum

EXPLANATION:
The likely underlying diagnosis is sarcoidosis

Please see Q-13 for Erythema Nodosum

Q-90
A 33-year-old lady presents complaining of facial
discolouration. She is 26 weeks pregnant. So far it has been
an uncomplicated pregnancy. She has a background of
rheumatoid arthritis but has been off treatment for 2 years.

On examination she has a large, flat, symmetrical, brown-

pigmented patch across her cheeks, forehead, nose and
upper lip.

What is the most likely diagnosis?

A. Systemic Lupus Erythematosus (SLE)

B. Melasma
C. Polymorphic eruption of pregnancy
D. Rosacea
E. Vitiligo

ANSWER:
Melasma

EXPLANATION:
Melasma is a benign but relatively common skin condition
which can appear in pregnancy. In this situation it may
resolve a few months after delivery. Pemphigoid gestationis
• pruritic blistering lesions
SKIN DISORDERS ASSOCIATED WITH PREGNANCY • often develop in peri-umbilical region, later spreading to
the trunk, back, buttocks and arms
Polymorphic eruption of pregnancy • usually presents 2nd or 3rd trimester and is rarely seen in
• pruritic condition associated with last trimester the first pregnancy
• lesions often first appear in abdominal striae • oral corticosteroids are usually required
• management depends on severity: emollients, mild
potency topical steroids and oral steroids may be used
 ANSWER:
Intravenous aciclovir

EXPLANATION:
ECZEMA HERPETICUM
Eczema herpeticum describes a severe primary infection of
the skin by herpes simplex virus 1 or 2. It is more commonly
seen in children with atopic eczema. As it is potentially life
threatening children should be admitted for IV aciclovir

Q-93
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 investigation would be most useful in determining

further management?

A. Serum calcium
B. Ankle-brachial pressure index
C. CT venogram
Q-91 D. C-reactive protein
Which one of the following complications is most associated E. Lower limb doppler
with psoralen + ultraviolet A light (PUVA) therapy?
ANSWER:
A. Squamous cell cancer Ankle-brachial pressure index
B. Osteoporosis
C. Basal cell cancer EXPLANATION:
D. Dermoid cysts This patient has the classic appearances of a venous ulcer.
E. Malignant melanoma She is systemically well with no evidence to suggest
infection. The most appropriate management of venous
ANSWER: ulcers is with compression dressings, however it is important
Squamous cell cancer to make sure the patient's arterial supply is good enough to
allow some compression.
EXPLANATION:
The most significant complication of PUVA therapy for VENOUS ULCERATION
psoriasis is squamous cell skin cancer. Venous ulceration is typically seen above the medial malleolus

Please see Q-20 for Psoriasis: Management Investigations

• ankle-brachial pressure index (ABPI) is important in non-
Q-92 healing ulcers to assess for poor arterial flow which could
A 9-year-old child with a history of atopic eczema presents impair healing
with a sudden worsening of her skin. Her eczema is usually • a 'normal' ABPI may be regarded as between 0.9 - 1.2.
well controlled with emollients but her parents are Values below 0.9 indicate arterial disease. Interestingly,
concerned as the facial eczema has got significantly worse values above 1.3 may also indicate arterial disease, in the
overnight. She now has painful clustered blisters on both form of false-negative results secondary to arterial
cheeks, around her mouth on her neck. Her temperature is calcification (e.g. In diabetics)
37.9ºC. What is the most appropriate management?
Management
A. Advise paracetamol + emollients and reassure
• compression bandaging, usually four layer (only
B. Intravenous aciclovir
treatment shown to be of real benefit)
C. Potent topical steroid
• oral pentoxifylline, a peripheral vasodilator, improves
D. Intravenous flucloxacillin
healing rate
E. Oral fluconazole
• small evidence base supporting use of flavinoids
• little evidence to suggest benefit from hydrocolloid EXPLANATION:
dressings, topical growth factors, ultrasound therapy and Please see Q-38 for Lichen Planus
intermittent pneumatic compression
Q-97
Q-94 An elderly, frail woman is admitted to the ward following a
A 38-year-old woman with a history of rheumatoid arthritis fall at home. What is the most appropriate way to assess her
and epilepsy presents with generalised increased hair risk of developing a pressure sore?
growth over her trunk and arms. Which one of the following
drugs is associated with hypertrichosis? A. PSST-6 score
B. PAST score
A. Sodium valproate C. MUST score
B. Prednisolone D. Waterlow score
C. Phenytoin E. Honeywell score
D. Ciclosporin
E. Methotrexate ANSWER:
Waterlow score
ANSWER:
Ciclosporin EXPLANATION:
Waterlow score - used to identify patients at risk of pressure
EXPLANATION: sores
Please see Q-61 for Hirsutism and Hypertrichosis
PRESSURE ULCERS
Q-95 The following is based on a 2009 NHS Best Practice Statement.
A 26-year-old man with a history of hereditary haemorrhagic Please see the link for further details. Some selected points
telangiectasia is planning to start a family. What is the mode are listed below. NICE also published guidelines in 2014.
of inheritance?
Pressure ulcers develop in patients who are unable to move
A. Autosomal dominant with incomplete penetrance parts of their body due to illness, paralysis or advancing age.
B. Autosomal codominant They typically develop over bony prominences such as the
C. Autosomal recessive with incomplete penetrance sacrum or heel. The following factors predispose to the
D. Autosomal dominant development of pressure ulcers:
E. Autosomal recessive • malnourishment
• incontinence
ANSWER: • lack of mobility
Autosomal dominant • pain (leads to a reduction in mobility)

EXPLANATION: The Waterlow score is widely used to screen for patients who
Hereditary haemorrhagic telangiectasia - autosomal are at risk of developing pressure areas. It includes a number
dominant of factors including body mass index, nutritional status, skin
type, mobility and continence.
Please see Q-23 for Hereditary Haemorrhagic Telangiectasia
Grading of pressure ulcers - the following is taken from the
Q-96 European Pressure Ulcer Advisory Panel classification system.
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 Grade Findings
the likely diagnosis, what other feature is she most likely to Grade Non-blanchable erythema of intact skin. Discolouration of the skin,
have? 1 warmth, oedema, induration or hardness may also be used as
indicators, particularly on individuals with darker skin
A. Onycholysis Grade Partial thickness skin loss involving epidermis or dermis, or both. The
B. Raised ESR 2 ulcer is superficial and presents clinically as an abrasion or blister
C. Mucous membrane involvement Grade Full thickness skin loss involving damage to or necrosis of
D. Pain in small joints 3 subcutaneous tissue that may extend down to, but not through,
E. Microscopic haematuria underlying fascia.
Grade Extensive destruction, tissue necrosis, or damage to muscle, bone or
4 supporting structures with or without full thickness skin loss
ANSWER:
Mucous membrane involvement
Management patches which follow a characteristic distribution with the
• a moist wound environment encourages ulcer healing. longitudinal diameters of the oval lesions running parallel to
Hydrocolloid dressings and hydrogels may help facilitate the line of Langer. This may produce a 'fir-tree' appearance.
this. The use of soap should be discouraged to avoid
drying the wound Please see Q-33 for Seborrhoeic Dermatitis in Adults
• wound swabs should not be done routinely as the vast
majority of pressure ulcers are colonised with bacteria. Q-100
The decision to use systemic antibiotics should be taken A 41-year-old man presents with a persistent itch rash that
on a clinical basis (e.g. Evidence of surrounding cellulitis) has been present for the past few weeks. On examination he
• consider referral to the tissue viability nurse has erythematous, scaly lesions underneath the eyebrows,
• surgical debridement may be beneficial for selected around the nose and at the top of his chest. He also has a
wounds history of dandruff which is well controlled with over the
counter shampoos. What is the most appropriate treatment
Q-98 for his face and trunk lesions?
A 55-year-old female is referred to dermatology due to a
lesions over both shins. On examination symmetrical A. Topical metronidazole
erythematous lesions are found with an orange peel texture. B. Oral oxytetracycline
What is the likely diagnosis? C. Oral isotretinoin
D. Topical ketoconazole
A. Pretibial myxoedema E. Topical hydrocortisone
B. Pyoderma gangrenosum
C. Necrobiosis lipoidica diabeticorum ANSWER:
D. Erythema nodosum Topical ketoconazole
E. Syphilis
EXPLANATION:
ANSWER: Seborrhoeic dermatitis - first-line treatment is topical
Pretibial myxoedema ketoconazole
The combination of a peri-orbital and nasolabial scaly rash
EXPLANATION: associated dandruff is a classical history for seborrhoeic
Please see Q-22 for Shin Lesions dermatitis.

Q-99 Please see Q-33 for Seborrhoeic Dermatitis in Adults

A 35-year-old man presents with an itchy, scaly rash that has
gradually developed over the past few months. He is Q-101
normally fit and well and the only past medical history of A 78-year-old man is admitted from a nursing home with
note is generalised anxiety disorder. On examination he has multi-infarct dementia, chronic obstructive pulmonary
a number of ill-defined, pink coloured patches with a disease and biventricular failure. You are asked to assess his
yellow/brown scale.The main affected areas are the risk of pressure sores and need for referral to the tissue
sternum, eyebrows and the nasal bridge. What is the most viability team during his inpatient stay.
likely diagnosis?
Which of the following is most useful in determining the risk
A. Acne rosacea of pressure sores?
B. Atopic dermatitis
C. Seborrhoeic dermatitis A. Glasgow criteria
D. Pityriasis rosea B. Rankin scale
E. Psoriasis C. Ransom criteria
D. Waterlow scale
ANSWER: E. Townsend scale
Seborrhoeic dermatitis
ANSWER:
EXPLANATION: Waterlow scale
The distribution is very typical for seborrhoeic dermatitis.
Atopic dermatitis presents more commonly in the flexural EXPLANATION:
areas and does not have the same characteristic scale. The Waterlow scale was developed in 1985 to assess the risk
of pressure sore development, helping to drive level of
Pityriasis rosea typically presents with a herald patch nursing intervention and use of special mattresses to reduce
(usually on trunk) followed by erythematous, oval, scaly risk. Potential scores range from 1-64. A score greater than
10 indicates an increased risk of pressure sore development, EXPLANATION:
with scores >15 indicating high risk and >20 indicating very Topical therapy does have a role in pyoderma gangrenosum
high risk. A number of factors are taken into account when and it may seem intuitive to try this first before moving on to
assessing patients using the scale including body habitus, systemic treatment. However, pyoderma gangrenosum has
continence status, malnutrition, mobility, neurological status the potential to evolve rapidly and for this reason oral
and presence of major trauma. prednisolone is usually given as initial treatment.

The Glasgow and Ransom criteria were drawn up to stratify Please see Q-2 for Pyoderma Gangrenosum
risk in patients presenting with acute pancreatitis, with
respect to identifying those at increased risk of mortality, Q-104
and those who need to be treated in a high dependency A 69-year-old woman with a history of learning difficulties is
area. reviewed in clinic. She is known to have erythema ab igne on
her legs but according to her carer still spends long hours in
The Rankin scale relates to the degree of disability in front of her electric fire. Which one of the following skin
patients post stroke, and the Townsend scale is an indicator lesions is she at risk of developing?
of deprivation.
A. Squamous cell carcinoma
Please see Q-97 for Pressure Ulcers B. Cutaneous T-cell lymphoma of the skin
C. Dermatofibrosarcoma protuberans
Q-102 D. Basal cell carcinoma
A 34-year-old female is reviewed in the dermatology clinic E. Malignant melanoma
with a skin rash under her new wrist watch. An allergy to
nickel is suspected. What is the best investigation? ANSWER:
Squamous cell carcinoma
A. Skin prick test
B. Skin patch test EXPLANATION:
C. Skin biopsy Please see Q-25 for Erythema Ab Igne
D. Serum IgE
E. Serum nickel antibodies Q-105
A 34-year-old man presents with a three week history of an
ANSWER: intensely itchy rash on the back of his elbows. On
Skin patch test examination he has a symmetrical vesicular rash on the
extensor aspects of his arms. Which one of the following
EXPLANATION: antibodies is most likely to be positive?
NICKEL DERMATITIS
Nickel is a common cause allergic contact dermatitis and is an A. Anti-mitochondrial antibody
example of a type IV hypersensitivity reaction. It is often B. Anti-gliadin antibody
caused by jewellery such as watches C. Anti-nuclear antibody
D. Anti-neutrophil cytoplasmic antibody
It is diagnosed by a skin patch test E. Anti-Jo-1 antibody

Q-103 ANSWER:
A 36-year-old female with a history of ulcerative colitis is Anti-gliadin antibody
diagnosed as having pyoderma gangrenosum. She presented
4 days ago with a 1 cm lesion on her right shin which rapidly EXPLANATION:
ulcerated and is now painful. What is the most appropriate Please see Q-50 for Dermatitis Herpetiformis
management?
Q-106
A. Topical hydrocortisone A 34-year-old man presents to dermatology clinic with an
B. Oral prednisolone itchy rash on his palms. He has also noticed the rash around
C. Surgical debridement the site of a recent scar on his forearm. Examination reveals
D. Topical tacrolimus papules with a white-lace pattern on the surface. Some
E. Infliximab isolated white streaks are also noted on the mucous
membranes of the mouth. What is the diagnosis?
ANSWER:
Oral prednisolone
A. Lichen planus A. Pityriasis versicolor
B. Scabies B. Seborrhoeic keratosis
C. Lichen sclerosus C. Polymorphous light eruption
D. Morphea D. Actinic keratoses
E. Pityriasis rosea E. Malignant melanoma

ANSWER: ANSWER:
Lichen planus Actinic keratoses

EXPLANATION: EXPLANATION:
Please see Q-38 for Lichen Planus Please see Q-80 for Actinic Keratoses

Q-107 Q-110
A 65-year-old woman with blistering lesions on her leg is A 25-year-old female patient presents to the dermatology
diagnosed as having bullous pemphigoid. What is the most clinic complaining of distressing symptoms of excessive facial
appropriate initial management? hair growth. She has a history of the polycystic ovarian
syndrome and has been on Yasmin. She has not found it to
A. Reassurance have significant benefit in her facial hair growth. This has
B. Topical corticosteroids caused her to lose her self-esteem greatly.
C. Oral itraconazole
D. Screen for solid-tumour malignancies What medication would you recommend?
E. Oral corticosteroids
A. Topical minoxidil
ANSWER: B. Oral metformin
Oral corticosteroids C. Topical eflornithine
D. Topical spironolactone
EXPLANATION: E. Topical psoralen
Please see Q-58 for Bullous Pemphigoid
ANSWER:
Q-108 Topical eflornithine
A 26-year-old newly qualified nurse presents as she has
developed a bilateral erythematous rash on both hands. She EXPLANATION:
has recently emigrated from the Philippines and has no past Topical eflornithine is the treatment of choice for facial
medical history of note. A diagnosis of contact dermatitis is hirsutism
suspected. What is the most suitable to test to identify the Topical eflornithine is the treatment of choice for facial
underlying cause? hirsutism.

A. Radioallergosorbent test (RAST) Minoxidil causes hypertrichosis.

B. Latex IgM levels
C. Skin prick test Oral metformin does not affect hirsutism.
D. Urinary porphyrins
E. Skin patch test Spironolactone can be used to treat hirsutism but usually in
oral form.
ANSWER:
Skin patch test Psoralen is not used to treat hirsutism.
EXPLANATION:
The skin patch test is useful in this situation as it may also Please see Q-61 for Hirsutism and Hypertrichosis
identify for irritants, not just allergens
Q-111
Please see Q-19 for Allergy Tests Which one of the following features is least likely to be seen
in a patient with pellagra?
Q-109
A 67-year-old man who is a retired builder presents A. Diarrhoea
following the development of a number of red, scaly lesions B. Depression
on his left temple. These were initially small and flat but are C. Dysphagia
now erythematous and rough to touch. What is the most D. Dermatitis
likely diagnosis? E. Dementia
ANSWER: EXPLANATION:
Dysphagia Please see Q-13 for Erythema Nodosum

EXPLANATION: Q-114
Depression is quite a common early finding in patients with A 43-year-old woman is referred to psychiatry following
pellagra repeated episodes of hypomaniac behaviour interspersed
with periods of depression. Her past medical history includes
Please see Q-4 for Pellagra psoriasis and a deep vein thrombosis 11 years ago. Which
one of the following medications is most likely to worsen her
Q-112 psoriasis?
A 39-year-old female has a pigmented mole removed from
her leg which histology shows to be a malignant melanoma. A. Sodium valproate
What is the single most important prognostic marker? B. Quetiapine
C. Lithium
A. Number of episodes of sunburn before the age of 18 D. Valproaic acid
years E. Fluoxetine
B. Age of patient
C. Diameter of melanoma ANSWER:
D. Depth of melanoma Lithium
E. Mutation in the MC1R gene
EXPLANATION:
ANSWER: Psoriasis: common triggers are beta-blockers and lithium
Depth of melanoma
PSORIASIS: EXACERBATING FACTORS
EXPLANATION: The following factors may exacerbate psoriasis:
Melanoma: the invasion depth of the tumour is the single • trauma
most important prognostic factor • alcohol
• drugs: beta blockers, lithium, antimalarials (chloroquine
MALIGNANT MELANOMA: PROGNOSTIC FACTORS and hydroxychloroquine), NSAIDs and ACE inhibitors,
The invasion depth of a tumour (Breslow depth) is the single infliximab
most important factor in determining prognosis of patients • withdrawal of systemic steroids
with malignant melanoma
Streptococcal infection may trigger guttate psoriasis.
Breslow Thickness Approximate 5 year survival
< 1 mm 95-100% Q-115
1 - 2 mm 80-96% A 50-year-old chronic alcoholic presents with a persistent
2.1 - 4 mm 60-75% skin rash on his hands, arms, neck and face. The rash is red-
> 4 mm 50% brown in colour, symmetrical and scaly. He also complains of
a poor appetite, nausea and diarrhoea. Which vitamin
Q-113 deficiency is most likely to have caused his symptoms?
A 34-year-old man comes for review. Over the past two
weeks he has developed a number of painful, erythematous A. Niacin
lesions on his shins. He has no dermatological history of note B. Folic acid
and is usually fit and well. On examination the lesions are C. Thiamine
consistent with erythema nodosum. You arrange some D. Vitamin B6
baseline investigations. He asks what is likely to happen. E. Zinc
What is the most appropriate response?
ANSWER:
A. Heal without scarring if steroids are given within 2 Niacin
weeks
B. Heal without scarring within 6-12 months EXPLANATION:
C. Heal without scarring within 1-2 months Please see Q-4 for Pellagra
D. Heal with scarring within 1-2 months
E. Heal with scarring within 6-12 months Q-116
Which of the following skin conditions is not associated with
ANSWER:
diabetes mellitus?
Heal without scarring within 1-2 months
A. Necrobiosis lipoidica ANSWER:
B. Sweet's syndrome Nodular
C. Granuloma annulare
D. Vitiligo EXPLANATION:
E. Lipoatrophy Nodular melanoma: Invade aggressively and metastasise
early
ANSWER: The presentation of this lesion is most consistent with
Sweet's syndrome nodular melanoma. Nodular melanoma is the most
aggressive form of melanoma. This is because it tends to
EXPLANATION: grow rapidly, downwards into the deeper layers of skin,
Sweet's syndrome is also known as acute febrile neutrophilic increasing in thickness faster than in diameter.
dermatosis has a strong association with acute myeloid
leukaemia. It is not associated with diabetes mellitus The other forms of melanoma typically take longer to grow
and metastasise. These are described in further detail in the
SKIN DISORDERS ASSOCIATED WITH DIABETES notes below. Actinic keratosis is not a form of melanoma,
Note whilst pyoderma gangrenosum can occur in diabetes but rather a pre-cancerous lesion.
mellitus it is rare and is often not included in a differential of
potential causes (DermNet NZ)

Necrobiosis lipoidica Please see Q-29 for Malignant Melanoma

• shiny, painless areas of yellow/red/brown skin typically
on the shin Q-118
• often associated with surrounding telangiectasia A 26-year-old female, of Han Chinese origin, with newly
diagnosed partial epilepsy is commenced on carbamazepine
Infection and has an HLA B*1502. Two weeks later, she develops a
• candidiasis maculopapular rash, purpuric macules and targetoid lesions;
• staphylococcal full-thickness epidermal necrosis, and mucous membrane
involvement.. What is the predominant cell type involved in
Neuropathic ulcers this reaction?
Vitiligo A. T cells
B. IgG
Lipoatrophy C. Complement
D. IgE
Granuloma annulare* E. B cells
• papular lesions that are often slightly hyperpigmented
ANSWER:
and depressed centrally
T cells
*it is not clear from recent studies if there is actually a
EXPLANATION:
significant association between diabetes mellitus and
HLA allele B*1502 as a marker for carbamazepine-induced
granuloma annulare, but it is often listed in major textbooks
Stevens-Johnson syndrome and toxic epidermal necrolysis in
Q-117 Han Chinese. Stevens-Johnson syndrome and toxic epidermal
A 63-year-old gentleman presents to his general practitioner. necrolysis is a delayed-hypersensitivity reaction, thus
He has recently been diagnosed with melanoma after being involving T-cells.
referred to the dermatologist with a suspicious red lump on Please see Q-66 for Stevens-Johnson Syndrome
his face. He is awaiting further imaging to see if the
melanoma has metastasised. After being told his subtype of Q-119
melanoma, he researched further online. He is now very Which one of the following statements regarding acne
concerned as he has read that his subtype is the most vulgaris is incorrect?
aggressive subtype and that it metastasises early. Which
subtype of melanoma is he likely to have? A. Follicular epidermal hyperproliferation results in
obstruction of the pilosebaceous follicle
A. Actinic keratosis B. Acne vulgaris affects at least 80% of teenagers
B. Lentigo maligna C. Propionibacterium acnes is an anaerobic bacterium
C. Acral lentiginous D. Typical lesions include comedones and pustules
D. Nodular E. Beyond the age of 25 years acne vulgaris is more
E. Superficial spreading common in males
ANSWER: A. Ciprofloxacin
Beyond the age of 25 years acne vulgaris is more common in B. Isotretinoin
males C. Oxytetracycline
D. Hydroxychloroquine
EXPLANATION: E. Prednisolone
Acne is actually more common in females after the age of 25
years ANSWER:
Oxytetracycline
ACNE VULGARIS
Acne vulgaris is a common skin disorder which usually occurs EXPLANATION:
in adolescence. It typically affects the face, neck and upper Acne rosacea treatment:
trunk and is characterised by the obstruction of the • mild/moderate: topical metronidazole
pilosebaceous follicle with keratin plugs which results in • severe/resistant: oral tetracycline
comedones, inflammation and pustules. As there is extensive involvement oral oxytetracycline should
probably be used rather than topical metronidazole
Epidemiology
• affects around 80-90% of teenagers, 60% of whom seek Please see Q-1 for Acne Rosacea
medical advice
• acne may also persist beyond adolescence, with 10-15% Q-122
of females and 5% of males over 25 years old being A 78-year-old nursing home resident is reviewed due to the
affected development of an intensely itchy rash. On examination red
linear lesions are seen on the wrists and elbows, and red
Pathophysiology is multifactorial papules are present on the penis. What is the most
• follicular epidermal hyperproliferation resulting in the appropriate management?
formation of a keratin plug. This in turn causes
obstruction of the pilosebaceous follicle. Activity of A. Topical permethrin
sebaceous glands may be controlled by androgen, B. Referral to GUM clinic
although levels are often normal in patients with acne C. Topical betnovate
• colonisation by the anaerobic bacterium D. Topical ketoconazole
Propionibacterium acnes E. Topical selenium sulphide
• inflammation
ANSWER:
Q-120 Topical permethrin
Which one of the following features is least associated with
zinc deficiency? EXPLANATION:
Lichen planus may give a similar picture but the intense
A. Acrodermatitis itching is more characteristic of scabies. It is also less
B. Alopecia common for lichen planus to present in the elderly - it typical
C. Short stature affects patients aged 30-60 years.
D. Perioral dermatitis
E. Gingivitis Please see Q-14 for Scabies

ANSWER: Q-123
Gingivitis A 55-year-old man presents with multiple erythematous
target lesions two days after starting a new medication.
EXPLANATION: Which one of the following drugs is most likely to have been
Gingivitis is more commonly seen in vitamin C deficiency started?

Please see Q-30 for Zinc Deficiency A. Levetiracetam

B. Olanzapine
Q-121 C. Carbamazepine
A 54-year-old man is referred to the dermatology outpatient D. Fluoxetine
department due to a facial rash which has persisted for the E. Diazepam
past 12 months. On examination there is a symmetrical rash
consisting of extensive pustules and papules which affects ANSWER:
his nose, cheeks and forehead. What is the most appropriate Carbamazepine
treatment?
EXPLANATION: A. Epidermophyton
This patient appears to have erythema multiforme which is a B. Histoplasma capsulatum
known complication of carbamazepine use C. Micosporum
D. Trichophyton
Please see Q-48 for Erythema Multiforme E. Malassezia

Q-124 ANSWER:
A 15-year-old male returns to the dermatology clinic for Malassezia
review. He has a past history of acne and is currently treated
with oral lymecycline. There has been no response to EXPLANATION:
treatment and examination reveals evidence of scarring on Pityriasis versicolour is caused by infection with Malassezia
his face. What is the most suitable treatment? fungus. Initial treatment is with topical anti-fungals such as
ketoconazole shampoo.
A. Oral doxycycline
B. Oral cyproterone acetate Microsporum, Trichophyton and Epidermophyton are
C. Oral isotretinoin dermatophytes and cause fungal nail infections and
D. IV retinoin ringworm. Histoplasma is a fungi that can cause pneumonia
E. Topical retinoids in immuno-compromised patients.

ANSWER: Please see Q-86 for Pityriasis Versicolor

Oral isotretinoin
Q-127
EXPLANATION: A 78-year-old man asks you to look at a lesion on the right
Please see Q-9 for Acne Vulgaris: Management side of nose which has been getting slowly bigger over the
past 2-3 months. On examination you observe a round,
Q-125 raised, flesh coloured lesion which is 3mm in diameter and
A 24-year-old student presents due to some lesions on his has a central depression. The edges of the lesion appear
lower abdomen. These have been present for the past six rolled and contain some telangiectasia.
weeks. Initially, there was one lesion but since that time
more lesions have appeared. On examination around 10 What is the single most likely diagnosis?
lesions are seen; they are raised, around 1-2mm in diameter
and have an umbilicated appearance. What is the most likely A. Molluscum contagiosum
diagnosis? B. Actinic keratosis
C. Squamous cell carcinoma
A. Genital warts D. Malignant melanoma
B. Lichen planus E. Basal cell carcinoma
C. Keratosis pilaris
D. Molluscum contagiosum ANSWER:
E. Folliculitis Basal cell carcinoma

ANSWER: EXPLANATION:
Molluscum contagiosum This is a classic description of a basal cell carcinoma.

EXPLANATION: Please see Q-63 for Basal Cell Carcinoma

This is a classical description of molluscum contagiosum,
although it is most commonly seen in children. Q-128
A 62-year-old female is referred due to a long-standing ulcer
Please see Q-7 for Molluscum Contagiosum above the right medial malleolus. Ankle-brachial pressure
index readings are as follows:
Q-126
A 59-year-old patient presents to dermatology outpatients Right 0.95
clinic with a three-month history of discolouration of the Left 0.95
skin on his back. On examination, there are patchy areas of
mild hypopigmentation covering large areas of the back. You To date it has been managed by the District Nurse with
suspect a diagnosis of pityriasis versicolor. What is the likely standard dressings. What is the most appropriate
causative organism? management to maximize the likelihood of the ulcer
healing?
 A. Phenytoin-induced neutropaenia
A. Compression bandaging B. Drug-induced lupus
B. Intermittent pneumatic compression C. Kawasaki disease
C. Hydrocolloid dressings D. Toxic epidermal necrolysis
D. Refer to vascular surgeon E. Staphylococcal Scalded Skin syndrome
E. Topical flucloxacillin
ANSWER:
ANSWER: Toxic epidermal necrolysis
Compression bandaging
EXPLANATION:
EXPLANATION: Please see Q-71 for Toxic Epidermal Necrolysis
Management of venous ulceration - compression bandaging
The ankle-brachial pressure index readings indicate a Q-131
reasonable arterial supply and suggest the ulcers are venous A 22-year-old woman presents due to hypopigmented skin
in nature. lesions on her chest and back. She has recently returned
from the south of France and has tanned skin. On
Please see Q-93 for Venous Ulceration examination the lesions are slightly scaly. What is the most
likely diagnosis?
Q-129
A 62-year-old male is referred to dermatology with a lesion A. Tinea corporis
over his shin. On examination shiny, painless areas of yellow B. Pityriasis versicolor
skin over the shin are found with abundant telangiectasia. C. Porphyria cutanea tarda
What is the most likely diagnosis? D. Lyme disease
E. Psoriasis
A. Pretibial myxoedema
B. Necrobiosis lipoidica diabeticorum ANSWER:
C. Erythema nodosum Pityriasis versicolor
D. Pyoderma gangrenosum EXPLANATION:
E. Syphilis Please see Q-86 for Pityriasis Versicolor

ANSWER: Q-132
Necrobiosis lipoidica diabeticorum You review a 50-year-old man who has a history of ischaemic
heart disease and psoriasis. Over the past two weeks he has
EXPLANATION: experienced a significant worsening of the plaque psoriasis
Please see Q-22 for Shin Lesions affecting his elbows and knees. His medications have
recently been altered at the cardiology clinic. Which one of
Q-130 the following medications is most likely to have exacerbated
A 43-year-old man is admitted to the Emergency Department his psoriasis?
with a rash and feeling generally unwell. He is known to A. Nicorandil
have epilepsy and his medication was recently changed to B. Simvastatin
phenytoin three weeks ago. Around one week ago he started C. Verapamil
to develop mouth ulcers associated with malaise and a D. Atenolol
cough. Two days ago he started to develop a widespread red E. Isosorbide mononitrate
rash which has now coalesced to form large fluid-filled
blisters, covering around 30% of his body area. The lesions ANSWER:
separate when slight pressure is applied. On examination his Atenolol
temperature is 38.3ºC and pulse 126 / min. Blood results
EXPLANATION:
show:
Psoriasis: common triggers are beta-blockers and lithium
Na+ 144 mmol/l Please see Q-114 for Psoriasis: Exacerbating Factors
K+ 4.2 mmol/l
Bicarbonate 19 mmol/l Q-133
Urea 13.4 mmol/l A 64-year-old female is referred to dermatology due to a
Creatinine 121 µmol/l non-healing skin ulcer on her lower leg. This has been
present for around 6 weeks and the appearance didn't
What is the most likely diagnosis? improve following a course of oral flucloxacillin. What is the
most important investigation to perform first?
A. MRI A. From neck down + leave for 12 hours
B. Rheumatoid factor titres B. All skin including scalp + leave for 12 hours + retreat in 2
C. Ankle-brachial pressure index days
D. Swab of ulcer for culture and sensitivity C. All skin including scalp + leave for 12 hours + retreat in 7
E. X-ray days
D. From neck down + leave for 4 hours
ANSWER: E. From neck down + leave for 12 hours + retreat in 7 days
Ankle-brachial pressure index
ANSWER:
EXPLANATION: All skin including scalp + leave for 12 hours + retreat in 7 days
An ankle-brachial pressure index measurement would help
exclude arterial insufficiency as a contributing factor. If this EXPLANATION:
was abnormal then a referral to the vascular surgeons Scabies - permethrin treatment: all skin including scalp +
should be considered. leave for 12 hours + retreat in 7 days
The BNF advises to apply the insecticide to all areas,
If the ulcer fails to heal with active management (e.g. including the face and scalp, contrary to the manufacturer's
Compression bandaging) then referral for consideration of recommendation (and common practice).
biopsy to exclude a malignancy should be made.
Please see Q-14 for Scabies
Ongoing infection is not a common cause of non-healing leg
ulcers. Q-136
A 35-year-old man presents with anaemia. On further
Please see Q-93 for Venous Ulceration questioning, you find that he has a lifelong history of
recurrent, severe nosebleeds and characteristic
Q-134 erythematous spots around his lips, which blanch when
A 65-year-old woman presents with bullae on her forearms pressed. What is the most likely diagnosis?
following a recent holiday in Spain. She also notes that the
skin on her hands is extremely fragile and tears easily. In the A. von Hippel-Lindau
past the patient has been referred to dermatology due to B. Peutz-Jeghers syndrome
troublesome hypertrichosis. What is the most likely C. Neurofibromatosis type 1
diagnosis? D. Hereditary haemorrhagic telangiectasia
E. Granulomatosis with polyangiitis
A. Pellagra
B. Pemphigus vulgaris ANSWER:
C. Epidermolysis bullosa Hereditary haemorrhagic telangiectasia
D. Bullous pemphigoid
E. Porphyria cutanea tarda EXPLANATION:
The key is in the recognition of the telangiectasias, which are
ANSWER: often found on the skin of the lips, nose and fingers. With
Porphyria cutanea tarda this and the epistaxis, two of the three criteria to diagnose
Hereditary Haemorrhagic Telangiectasia (HHT) are met.
EXPLANATION: Anaemia is a common complaint in those with HHT. It is due
Porphyria cutanea tarda to epistaxis or otherwise asymptomatic GI tract bleeding.
• blistering photosensitive rash Another finding could be hypoxia due to pulmonary
• hypertrichosis arteriovenous malformations. The exact features vary,
• hyperpigmentation depending on where the arteriovenous malformations are
located.
Please see Q-39 for Porphyria Cutanea Tarda
Von Hippel-Lindau disease is caused by a faulty tumour
Q-135 suppressor gene resulting in the development of multiple
A 45-year-old man who presented with itchy lesions on his unusual tumours including haemangioblastoma,
hands is diagnosed with scabies. It is decided to treat him phaeochromocytoma or renal cell carcinoma. At least two
with permethrin 5%. You have explained the need to treat all tumours must be present to make the diagnosis in someone
members of the household and hot wash all bedding and without a family history (compared to just one when a family
clothes. What advice should be given about applying the history is present).
cream?
Peutz Jeghers syndrome is a disorder causing large numbers ANSWER:
of polyps in the intestine which become cancerous in a Pemphigoid gestationis
majority of patients. They have pigmented lesions around
the lips which are not telangiectasia. There is no history of EXPLANATION:
epistaxis. Polymorphic eruption of pregnancy is not associated with
blistering
Neurofibromatosis Type 1 is benign tumour disorder. Despite Pemphigoid gestationis is the correct answer. Polymorphic
the non-malignant nature of the tumours, they can have eruption of pregnancy is not associated with blistering
severe consequences depending on the location. Optic
gliomas can lead to blindness, neurofibromas (found in the Please see Q-90 for Skin Disorders Associated with Pregnancy
peripheral nervous system) can lead to learning disabilities
and epilepsy. Other characteristic findings include caf-au-lait Q-139
spots (flat, hyperpigmented, brown cutaneous lesions), A 62-year-old woman mentions in diabetes clinic that she
axillary freckling, Lisch nodules (on the iris) and dermal has a 'volcano' like spot on her left cheek, which has
neurofibromas (small, rubbery, cutaneous lumps). appeared over the past 3 months. She initially thought it
may be a simple spot but it has not gone away. On
Granulomatosis with polyangiitis is a small- and medium- examination she has a 5 mm red, raised lesion with a central
vessel vasculitis which primarily affects the sinuses, kidneys keratin filled crater. A clinical diagnosis of probable
and lungs. Sinus dysfunction is the most common initial keratoacanthoma is made. What is the most suitable
symptom causing nasal congestion or epistaxis. If a rash is management?
present, it is usually made up of palpable purpura from small
vessel inflammation. A. Reassure will spontaneously involute within 3 months
B. Urgent referral to dermatology
Please see Q-23 for Hereditary Haemorrhagic Telangiectasia C. Topical 5-FU
D. Non-urgent referral to dermatology
Q-137 E. Oral prednisolone
Which one of the following statements regarding vitiligo is
true? ANSWER:
Urgent referral to dermatology
A. It is seen in around 0.1% of patients
B. The average age of onset is 40-50 years EXPLANATION:
C. Skin trauma may precipitate new skin lesions Whilst keratoacanthoma is a benign lesion it is difficult
D. It is rare in Caucasian people clinically to exclude squamous cell carcinoma so urgent
E. The torso tends to be affected first excision is advised

ANSWER: Please see Q-27 for Keratocanthoma

Skin trauma may precipitate new skin lesions
Q-140
EXPLANATION: Which one of the following is least recognised as a cause of
This is known as the Koebner phenomenon erythroderma in the UK?

Please see Q-82 for Vitiligo A. Lymphoma

B. Drug eruption
Q-138 C. Lichen planus
A 30-year-old female in her third trimester of pregnancy D. Psoriasis
mentions during an antenatal appointment that she has E. Eczema
noticed an itchy rash around her umbilicus. This is her
second pregnancy and she had no similar problems in her ANSWER:
first pregnancy. Examination reveals blistering lesions in the Lichen planus
peri-umbilical region and on her arms. What is the likely
diagnosis? EXPLANATION:
ERYTHRODERMA
A. Seborrhoeic dermatitis Erythroderma is a term used when more than 95% of the skin
B. Pompholyx is involved in a rash of any kind.
C. Polymorphic eruption of pregnancy
D. Lichen planus Causes of erythroderma
E. Pemphigoid gestationis • eczema
• psoriasis Q-141
• drugs e.g. gold A 45-year-old man with a history of seborrhoeic dermatitis
• lymphomas, leukaemias presents in late winter due a flare in his symptoms, affecting
• idiopathic both his face and scalp. Which one of the following agents is
least likely to be beneficial?
Erythrodermic psoriasis
• may result from progression of chronic disease to an A. Topical ketoconazole
exfoliative phase with plaques covering most of the body. B. Selenium sulphide shampoo
Associated with mild systemic upset C. Topical hydrocortisone
• more serious form is an acute deterioration. This may be D. Tar shampoo
triggered by a variety of factors such as withdrawal of E. Aqueous cream
systemic steroids. Patients need to be admitted to
hospital for management NSWER:
Aqueous cream

EXPLANATION:
There is less of a role for emollients in the management of
seborrhoeic dermatitis than in other chronic skin disorders

Please see Q-33 for Seborrhoeic Dermatitis in Adults

Q-142
A 74-year-old woman develops tense, itchy blisters on her
inner thighs and upper arms. Given the likely diagnosis, what
will immunofluorescence of the skin biopsy demonstrate?

A. Loss of fibrinogen at the basement membrane

B. Granular IgG along the basement membrane
C. IgM crystallization at the dermal junctions
D. Linear IgA deposits at the dermoepidermal junction
This image shows the generalised erythematous rash seen in patients with
E. IgG and C3 at the dermoepidermal junction
erythroderma, sometimes referred to as 'red man syndrome'
ANSWER:
IgG and C3 at the dermoepidermal junction

EXPLANATION:
Please see Q-58 for Bullous Pemphigoid

Note the extensive exfoliation seen in this patient