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399 Cards in this Set
- Front
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A 52-year-old woman presents with pruritus and lethargy. She has recently put on weight and is complaining about dry skin |
Hypothyroidism |
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A 57-year-old woman presents with pruritus. She states she has been gaining weight despite eating less and complains of constant nausea. On examination she is pale |
Chronic kidney disease Pregnancy is unlikely given her age. |
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A 59-year-old man complains of pruritus and lethargy. On examination he has spoon shaped nails and a smooth tongue |
Iron deficiency anaemia |
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Pruritus differentials most important causes of pruritus (there are other causes) |
Liver disease Iron deficiency anaemia Polycythaemia Chronic kidney disease Lymphoma |
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most important causes of pruritus Liver disease features |
History of alcohol excess Stigmata of chronic liver disease: spider naevi, bruising, palmar erythema, gynaecomastia etc Evidence of decompensation: ascites, jaundice, encephalopathy |
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most important causes of pruritus Iron deficiency anaemia features |
Pallor Other signs: koilonychia, atrophic glossitis, post-cricoid webs, angular stomatitis |
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most important causes of pruritus Polycythaemia features |
Pruritus particularly after warm bath 'Ruddy complexion' Gout Peptic ulcer disease |
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most important causes of pruritus Chronic kidney disease features |
Lethargy & pallor Oedema & weight gain Hypertension |
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most important causes of pruritus Lymphoma features |
Night sweats Lymphadenopathy Splenomegaly, hepatomegaly Fatigue |
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other causes of pruritis |
hyper- and hypothyroidism diabetes pregnancy 'senile' pruritus urticaria skin disorders: eczema, scabies, psoriasis, pityriasis rosea |
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A 23-year-old female presents with red, thickened skin on the soles. On closer inspection a crop of raised lesions are seen. |
Palmoplantar pustulosis |
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A 22-year-old man presents with a 3 cm area of hyperkeratotic skin on the heel of his right foot. A number of pinpoint petechiae are seen in the lesion. |
Mosaic wart |
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A 15-year-old complains of excessively smelly feet. On examination he has white skin over the sole of the forefoot bilaterally. Small holes can be seen on the surface of the affected skin. |
Pitted keratolysis |
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Skin disorders affecting the soles of the feet The table below gives characteristic exam question features for conditions affecting the soles of the feet |
Verrucas Tinea pedis Corn and calluses Keratoderma Pitted keratolysis Palmoplantar pustulosis Juvenile plantar dermatosis |
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Skin disorders affecting the soles of the feet Verrucas |
Secondary to the human papilloma virus Firm, hyperkeratotic lesions Pinpoint petechiae centrally within the lesions May coalesce with surrounding warts to form mosaic warts |
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Skin disorders affecting the soles of the feet Tinea pedis |
More commonly called Athlete's foot Affected skin is moist, flaky and itchy |
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Skin disorders affecting the soles of the feet Corn and calluses |
A corn is small areas of very thick skin secondary to a reactive hyperkeratosis A callus is larger, broader and has a less well defined edge than a corn |
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Skin disorders affecting the soles of the feet Keratoderma |
May be acquired or congenital Describes a thickening of the skin of the palms and soles Acquired causes include reactive arthritis (keratoderma blennorrhagica) |
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Skin disorders affecting the soles of the feet Pitted keratolysis |
Affects people who sweat excessively Patients may complain of damp and excessively smelly feet Usually caused by Corynebacterium Heel and forefoot may become white with clusters of punched-out pits |
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Skin disorders affecting the soles of the feet Palmoplantar pustulosis |
Crops of sterile pustules affecting the palms and soles The skin is thickened, red. Scaly and may crack More common in smokers |
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Skin disorders affecting the soles of the feet Juvenile plantar dermatosis |
Affects children. More common in atopic patients with a history of eczema Soles become shiny and hard. Cracks may develop causing pain Worse during the summer |
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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? |
Pemphigus vulgaris |
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Blisters/bullae |
no mucosal involvement: bullous pemphigoid mucosal involvement: pemphigus vulgaris |
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Pemphigus vulgaris definition |
is an autoimmune disease caused by antibodies directed against desmoglein 3, a cadherin-type epithelial cell adhesion molecule. |
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Pemphigus vulgaris 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 |
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dx |
Pemphigus vulgaris |
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dx |
Pemphigus vulgaris |
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Pemphigus vulgaris management |
steroids immunosuppressants |
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An 84-year-old woman with a history of ischaemic heart disease is reviewed in a nursing home. She has developed tense blistering lesions on her legs. Each lesion is around 1 to 3 cm in diameter and she reports that they are slightly pruritic. Examination of her mouth and vulva is unremarkable. What is the most likely diagnosis? |
Bullous pemphigoid |
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Blisters/bullae |
no mucosal involvement (in exams at least*): bullous pemphigoid mucosal involvement: pemphigus vulgaris |
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Bullous pemphigoid is |
an autoimmune condition causing sub-epidermal blistering of the skin. This is secondary to the development of antibodies against hemidesmosomal proteins BP180 and BP230 |
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Bullous pemphigoid is more common in elderly patients. Features include |
itchy, tense blisters typically around flexures the blisters usually heal without scarring mouth is usually spared* |
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Bullous pemphigoid Skin biopsy |
immunofluorescence shows IgG and C3 at the dermoepidermal junction |
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Bullous pemphigoid management |
referral to dermatologist for biopsy and confirmation of diagnosis oral corticosteroids are the mainstay of treatment topical corticosteroids, immunosuppressants and antibiotics are also used |
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A 50-year-old man presents with shiny, flat-topped papules on the palmar aspect of the wrists. He is mainly bothered by the troublesome and persistent itching. A diagnosis of lichen planus is suspected. What is the most appropriate treatment? |
Topical steroid |
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Lichen planus |
is a skin disorder of unknown aetiology, most probably being immune mediated. |
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Lichen planus features |
itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms rash often polygonal in shape, 'white-lace' pattern on the surface (Wickham's striae) Koebner phenomenon may be seen (new skin lesions appearing at the site of trauma) oral involvement in around 50% of patients nails: thinning of nail plate, longitudinal ridging |
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Lichenoid drug eruptions - causes: |
gold quinine thiazides |
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Lichen planus management |
topical steroids are the mainstay of treatment extensive lichen planus may require oral steroids or immunosuppression |
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dx |
Lichen planus |
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dx |
Lichen planus |
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dx |
Lichen planus |
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These skin lesions have been present for the past year. What is the most likely diagnosis? |
Actinic keratoses |
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Actinic keratoses definition |
Actinic, or solar, keratoses (AK) is a common premalignant skin lesion that develops as a consequence of chronic sun exposure |
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Actinic keratoses features |
small, crusty or scaly, lesions may be pink, red, brown or the same colour as the skin typically on sun-exposed areas e.g. temples of head multiple lesions may be present |
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Actinic keratoses Management options include |
prevention of further risk: e.g. sun avoidance, sun cream fluorouracil cream: typically a 2 to 3 week course. The skin will become red and inflamed - sometimes topical hydrocortisone is given following fluorouracil to help settle the inflammation topical diclofenac: may be used for mild AKs. Moderate efficacy but much fewer side-effects topical imiquimod: trials have shown good efficacy cryotherapy curettage and cautery |
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A 59-year-old man presents with a new skin lesion which has developed over the past few months: You plan to refer the patient to dermatology. What is the most likely diagnosis? |
Bowen's disease |
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Bowen's disease |
Bowen's disease is a type of intraepidermal squamous cell carcinoma. More common in elderly females. There is around a 3% chance of developing invasive skin cancer |
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Bowen's disease features |
red, scaly patches often occur on the lower limbs |
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dx |
Bowen's disease |
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A 30-year-old man who is an immigrant from Albania presents to surgery with a translator. He has been unwell for a number of months and describes losing 8 kgs in weight and having chronic diarrhoea. On examination of his skin the following is seen: Inside his mouth similar lesions can be seen on his hard palate and there is some bleeding around his gums. What is the most appropriate action? |
Order a HIV test |
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HIV: Kaposi's sarcoma |
caused by HHV-8 (human herpes virus 8) presents as purple papules or plaques on the skin or mucosa (e.g. gastrointestinal and respiratory tract) skin lesions may later ulcerate respiratory involvement may cause massive haemoptysis and pleural effusion radiotherapy + resection |
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A 62-year-old female is referred due to a long-standing ulcer above the right medial malleolus. Ankle-brachial pressure index readings are as follows:Right0.95Left0.95To date it has been managed by the District Nurse with standard dressings. What is the most appropriate management to maximize the likelihood of the ulcer healing? |
Compression bandaging |
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Management of venous ulceration - compression bandaging |
true The ankle-brachial pressure index readings indicate a reasonable arterial supply and suggest the ulcers are venous in nature. |
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Venous ulceration is typically seen above the medial malleolus |
true |
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Venous ulceration investigations |
ABPI ankle-brachial pressure index (ABPI) is important in non-healing ulcers to assess for poor arterial flow which could impair healing |
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ABPI |
a 'normal' ABPI may be regarded as between 0.9 - 1.2. Values below 0.9 indicate arterial disease. Interestingly, values above 1.3 may also indicate arterial disease, in the form of false-negative results secondary to arterial calcification (e.g. In diabetics) |
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Venous ulceration management |
compression bandaging, usually four layer (only treatment shown to be of real benefit) oral pentoxifylline, a peripheral vasodilator, improves healing rate small evidence base supporting use of flavinoids little evidence to suggest benefit from hydrocolloid dressings, topical growth factors, ultrasound therapy and intermittent pneumatic compressionNext question |
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What is the most likely diagnosis? |
Keratoacanthoma This patient should be fast-tracked to exclude a squamous cell carcinoma. |
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Keratoacanthoma definition |
is a benign epithelial tumour. They are more frequent in middle age and do not become more common in old age (unlike basal cell and squamous cell carcinoma) |
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Keratoacanthoma features |
said to look like a volcano or crater initially a smooth dome-shaped papule rapidly grows to become a crater centrally-filled with keratin |
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Keratoacanthoma |
Spontaneous regression of keratoacanthoma within 3 months is common, often resulting in a scar. Such lesions should however be urgently excised as it is difficult clinically to exclude squamous cell carcinoma. Removal also may prevent scarring. |
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Keratoacanthoma if its is suspected how should it be managed |
Such lesions should however be urgently excised as it is difficult clinically to exclude squamous cell carcinoma |
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A 35-year-old female presents with tender, erythematous nodules over her forearms. Blood tests reveal:Calcium2.78 mmol/lWhat is the most likely diagnosis? |
Erythema nodosum The likely underlying diagnosis is sarcoidosis |
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A 4-year-old boy develops multiple tear-drop papules on his trunk and limbs. He is otherwise well. A diagnosis of guttate psoriasis is suspected. What is the most appropriate management? |
Reassurance + topical treatment if lesions are symptomatic The British Association of Dermatologists state in their psoriasis guidelines that 'evidence does not support a therapeutic benefit from antibiotic therapy'. |
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dx |
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 |
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dx |
Psoriasis: guttate |
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dx |
Psoriasis: guttate |
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Psoriasis: guttate management |
most cases resolve spontaneously within 2-3 months there is no firm evidence to support the use of antibiotics to eradicate streptococcal infection topical agents as per psoriasis UVB phototherapy tonsillectomy may be necessary with recurrent episodes |
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Guttate psoriasis Prodrome |
Classically preceded by a streptococcal sore throat 2-4 weeks |
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Pityriasis rosea Prodrome |
Many patients report recent respiratory tract infections but this is not common in questions |
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Guttate psoriasis Appearance |
'Tear drop', scaly papules on the trunk and limbs |
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Pityriasis rosea Appearance |
Herald patch followed 1-2 weeks later by multiple erythematous, slightly raised oval lesions with a fine scale confined to the outer aspects of the lesions. May follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer. This may produce a 'fir-tree' appearance |
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Guttate psoriasis Treatment / natural history |
Most cases resolve spontaneously within 2-3 months Topical agents as per psoriasis UVB phototherapy |
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Pityriasis rosea Treatment / natural history |
Self-limiting, resolves after around 6 weeks |
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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. |
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A 20-year-old woman who is in the second trimester of her first pregnancy comes for review. Unfortunately her longstanding acne has flared again and she is keen to try something to improve the situation. Which one of the following should be avoided? |
Topical isotretinoin |
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Topical isotretinoin is a type of retinoid and is therefore strongly contraindicated in pregnancy, even in the topical form. |
true |
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This patient complains of a painful 'spot' on his ear: Which one of the following statements regarding this condition is correct? |
Cryotherapy is a treatment option |
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Chondrodermatitis nodularis helicis (CNH) |
is a common and benign condition characterised by the development of a painful nodule on the ear. It is thought to be caused by factors such as persistent pressure on the ear (e.g. secondary to sleep, headsets), trauma or cold. CNH is more common in men and with increasing age. |
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Chondrodermatitis nodularis helicis management |
reducing pressure on the ear: foam 'ear protectors' may be used during sleep other treatment options include cryotherapy, steroid injection, collagen injection surgical treatment may be used but there is a high recurrence rate |
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dx |
Chondrodermatitis nodularis helicis |
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dx |
Chondrodermatitis nodularis helicis |
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Please look at this skin lesion below a patient's sye: Which one of the following medications is most associated with the development of these lesions? |
Combined oral contraceptive pill |
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Spider naevi (also called spider angiomas) describe a |
central red papule with surrounding capillaries. The lesions blanch upon pressure. Spider naevi are almost always found on the upper part of the body. |
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Around 10-15% of people will have one or more spider naevi and they are more common in childhood. Other associations |
liver disease pregnancy combined oral contraceptive pill |
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A 34-year-old who has recently returned from a business trip to New York presents with a one-day history of a painful rash on his neck: What is the most appropriate management? |
Oral aciclovir One of the main clues in the question is the combination of a rash with pain. Other than shingles, there are not many conditions which cause both. Whilst there is some evidence that systemic steroids speed up the healing of shingles, consensus guidelines do not advocate their use as adverse effects probably outweigh potential benefits |
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Herpes zoster shingles |
Shingles is an acute, unilateral, painful blistering rash caused by reactivation of the Varicella Zoster Virus (VZV). |
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The 'shingles vaccine' In 2013 the NHS introduced a vaccine to boost the immunity of elderly people against herpes zoster. Some important points about the vaccine: |
will be offered to patients at the age of 70 years (a catch-up programme will also be launched initially) is live-attenuated and given sub-cutaneously As it is a live-attenuated vaccine the main contraindications are immunosuppression. |
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The 'shingles vaccine' side effects |
injection site reactions less than 1 in 10,000 individuals will develop chickenpox |
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Management of shingles |
Oral aciclovir is first-line One of the main benefits of treatment is a reduction in the incidence of post-herpetic neuralgia. |
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A 34-year-old female presents due to a skin rash under her new wrist watch. An allergy to nickel is suspected. What is the best investigation? |
Skin patch test |
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Nickel dermatitis |
Nickel is a common cause allergic contact dermatitis and is an example of a type IV hypersensitivity reaction. It is often caused by jewellery such as watches |
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Nickel dermatitis how is it diagnosed |
It is diagnosed by a skin patch test |
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A 41-year-old woman shows you a rash on her legs: What is the most likely cause of such a rash? |
Infrared radiation This patient has erythema ab igne, a skin reaction caused by excessive infrared radiation. |
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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. If the cause is not treated then patients may go on to develop squamous cell skin cancer. |
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A patient presents to his GP following the development of an urticarial skin rash following the introduction of a new drug. Which one of the following is most likely to be responsible? |
Aspirin |
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Aspirin is a common cause of urticaria |
true Although all medications can potentially cause urticaria it is commonly seen secondary to aspirin |
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Drug causes of urticaria The following drugs commonly cause urticaria: |
aspirin penicillins NSAIDs opiates |
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Please look at the skin lesion shown below: What is the most likely diagnosis? |
BCC |
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DX |
BCC |
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DX |
BCC |
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dx |
bcc |
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DX |
BCC |
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A 41-year-old man presents with an itchy rash over his arms and abdomen. It has got gradually worse over the past three days. DX |
The linear burrows of the scabies mite are clearly seen on this image. |
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Scabies is caused by |
the mite Sarcoptes scabiei and is spread by prolonged skin contact. It typically affects children and young adults. |
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Scabies 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 |
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Patient guidance on treatment (from Clinical Knowledge Summaries) scabies |
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. |
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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 instructions: |
apply the insecticide cream or liquid to cool, dry skin pay close attention to areas between fingers and toes, under nails, armpit area, creases of the skin such as at the wrist and elbow allow to dry and leave on the skin for 8-12 hours for permethrin, or for 24 hours for malathion, before washing off reapply if insecticide is removed during the treatment period, e.g. If wash hands, change nappy, etc repeat treatment 7 days later |
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A 72 year-old woman presents to the GP with a large itchy, sore white plaque on her vulva. Upon examination, a diagnosis of lichen sclerosus is made. What is the first line management plan? |
Topical clobetasol propionate |
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Lichen sclerosis is a dermatological condition that affects the vulva. The first line treatment is a |
strong topical steroid thus the answer is topical clobetasol propionate In around 4-10% of women with lichen sclerosus, the disease will be resistant to steroids and in this case topical tacrolimus is the next line of treatment however this is only initiated in specialist clinics. Surgical excision with access to reconstruction is the first line treatment in vulval intraepithelial neoplasia but is not appropriate in treatment of lichen sclerosus. Topical imiquimod cream, a treatment for genital warts, has been described as inducing florid lichen sclerosus and as such is not a correct answer. Analgesia would not be sufficient treatment in this patient. |
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Lichen sclerosus definition |
Lichen sclerosus was previously termed lichen sclerosus et atrophicus. It is an inflammatory condition which usually affects the genitalia and is more common in elderly females. Lichen sclerosus leads to atrophy of the epidermis with white plaques forming |
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Lichen sclerosus features |
itch is prominent |
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Lichen sclerosus dx |
The diagnosis is usually made on clinical grounds but a biopsy may be performed if atypical features are present* |
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Lichen sclerosus management |
topical steroids and emollients |
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Lichen sclerosus follow up |
increased risk of vulval cancer the RCOG advise the following Skin biopsy is not necessary when a diagnosis can be made on clinical examination. Biopsy is required if the woman fails to respond to treatment or there is clinical suspicion of VIN or cancer.and the British Association of Dermatologists state the following: A confirmatory biopsy, although ideal, is not always practical, particularly in children. It is not always essential when the clinical features are typical. However, histological examination is advisable if there are atypical features or diagnostic uncertainty and is mandatory if there is any suspicion of neoplastic change. Patients under routine follow-up will need a biopsy if: (i) there is a suspicion of neoplastic change, i.e. a persistent area of hyperkeratosis, erosion or erythema, or new warty or papular lesions;(ii) the disease fails to respond to adequate treatment;(iii) there is extragenital LS, with features suggesting an overlap with morphoea;(iv) there are pigmented areas, in order to exclude an abnormal melanocytic proliferation;and (v) second-line therapy is to be used. |
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A woman who is 30 weeks pregnant asks you about an itchy rash on her abdomen: What is the most likely diagnosis? |
Polymorphic eruption of pregnancy |
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A 64-year-old female is referred to dermatology due to a non-healing skin ulcer on her lower leg. This has been present for around 6 weeks and the appearance didn't improve following a course of oral flucloxacillin. What is the most important investigation to perform first? |
Ankle-brachial pressure index dx Venous ulceration |
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A 27-year-old female presents with spots around her left eye: What is the most likely diagnosis? |
Milia |
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Milia |
Milia are small, benign, keratin-filled cysts that typically appear around the face. They may appear at any age but are more common in newborns. |
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A 30-year-old woman presents with a painful 'rash' on her shins: These have been present for the past 2 weeks. There is no past medical history of note and she takes no regular medications. What is the most useful next investigation? |
Chest x-ray 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 |
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A 58 year old female presents to GP complaining of tiredness, aches and pains. On further questioning the patient has been feeling increasingly fatigued over the past few months and has been having joint and muscle pains. Past medical history reveals chronic heart failure treated with isosorbide dinitrate and hydralazine. Hydralazine can cause drug-induced lupus. What is the most useful investigation to confirm this diagnosis? |
Anti-histone antibodies Drug induced lupus can present with fatigue, arthritis, myalgia, pericarditis and pleuritis. Option 1 is the correct answer - anti-histone antibodies are present in 95% of patients with drug-induced lupus. |
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dx |
Drug-induced lupus |
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In drug-induced lupus |
not all the typical features of systemic lupus erythematosus are seen, with renal and nervous system involvement being unusual. It usually resolves on stopping the drug. |
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Drug-induced lupus features |
arthralgia myalgia skin (e.g. malar rash) and pulmonary involvement (e.g. pleurisy) are common ANA positive in 100%, dsDNA negative anti-histone antibodies are found in 80-90% anti-Ro, anti-Smith positive in around 5% |
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Drug-induced lupus Most common causes |
procainamide hydralazine |
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Drug-induced lupus Less common causes |
isoniazid minocycline phenytoin |
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A 72-year-old woman is diagnosed with a number of erythematous, rough lesions on the back of her hands. A diagnosis of actinic keratoses is made. What is the most appropriate management? |
Topical fluorouracil cream |
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A 22-year-old male presents due to a longstanding problem of bilateral excessive axillary sweating. He is otherwise well but the condition is affecting his confidence and limiting his social life. What is the most appropriate management? |
Topical aluminium chloride |
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Hyperhidrosis describes |
the excessive production of sweat |
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Hyperhidrosis Management options include |
topical aluminium chloride preparations are first-line. Main side effect is skin irritation iontophoresis: particularly useful for patients with palmar, plantar and axillary hyperhidrosis botulinum toxin: currently licensed for axillary symptoms surgery: e.g. Endoscopic transthoracic sympathectomy. Patients should be made aware of the risk of compensatory sweating |
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A 29-year-old man presents due to the development of 'hard 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? |
Psoriasis As the skin scraping is negative for fungi the most likely diagnosis is psoriasis. Scalp psoriasis may occur in isolation in 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. |
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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. |
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Psoriasis Pathophysiology |
multifactorial and not yet fully understood genetic: associated HLA-B13, -B17, and -Cw6. Strong concordance (70%) in identical twins immunological: abnormal T cell activity stimulates keratinocyte proliferation. There is increasing evidence this may be mediated by a novel group of T helper cells producing IL-17, designated Th17. These cells seem to be a third T-effector cell subset in addition to Th1 and Th2 environmental: it is recognised that psoriasis may be worsened (e.g. Skin trauma, stress), triggered (e.g. Streptococcal infection) or improved (e.g. Sunlight) by environmental factors |
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Recognised subtypes of psoriasis |
plaque psoriasis: the most common sub-type resulting in the typical well demarcated red, scaly patches affecting the extensor surfaces, sacrum and scalp flexural psoriasis: in contrast to plaque psoriasis the skin is smooth guttate psoriasis: transient psoriatic rash frequently triggered by a streptococcal infection. Multiple red, teardrop lesions appear on the body pustular psoriasis: commonly occurs on the palms and soles |
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Psoriasis Other features |
nail signs: pitting, onycholysis arthritis |
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Recognised subtypes of psoriasis |
plaque psoriasis flexural psoriasis guttate psoriasis pustular psoriasis |
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dx |
psoriasis |
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dx |
psoriasis |
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psoriasis Complications |
psoriatic arthropathy (around 10%) increased incidence of metabolic syndrome increased incidence of cardiovascular disease increased incidence of venous thromboembolism psychological distress |
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A 62-year-old woman presents with a 'volcano' like spot on her left arm, which has appeared over the past 3 months. She initially thought it may be a simple spot but it has not gone away. On examination she has a 5 mm red, raised lesion with a central keratin filled crater. A clinical diagnosis of probable keratoacanthoma is made. What is the most suitable management? |
Urgent referral to dermatology |
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A father attends your surgery regarding his 4-month old baby sons birthmark. There is a small vascular plaque on the scalp which doesn't seem to be bothering the baby. You diagnose a strawberry naevus. What is the most appropriate first-line management? |
Watch and wait |
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Strawberry naevus |
Strawberry naevi (capillary haemangioma) are usually not present at birth but may develop rapidly in the first month of life. They appear as erythematous, raised and multilobed tumours.Typically they increase in size until around 6-9 months before regressing over the next few years (around 95% resolve before 10 years of age).Common sites include the face, scalp and back. Rarely they may be present in the upper respiratory tract leading to potential airway obstructionCapillary haemangiomas are present in around 10% of white infants. Female infants, premature infants and those of mothers who have undergone chorionic villous sampling are more likely to be affectedPotential complicationsmechanical e.g. Obstructing visual fields or airwaybleedingulcerationthrombocytopaeniaIf treatment is required (e.g. Visual field obstruction) then propranolol is increasingly replacing systemic steroids as the treatment of choice.Cavernous haemangioma is a deep capillary haemangiomaNext question |
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dx |
SCC Don't be fooled into thinking this is a basal cell carcinoma (BCC) by the presence of telangiectasia near the lesion. With BCC's these are generally found on the rolled edges of the lesion rather than being scattered around the periphery. |
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dx |
SCC |
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DX |
SCC |
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DX |
SCC |
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DX |
SCC |
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DX |
SCC |
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A 58-year-old woman presents with a persistent erythematous rash on her cheeks and a 'red nose'. She describes occasional episodes of facial flushing. On examination erythematous skin is noted on the nose and cheeks associated with occasional papules. What is the most appropriate management? |
Topical metronidazole Given that this woman has mild symptoms, topical metronidazole should be used first line |
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Acne rosacea treatment: |
mild/moderate: topical metronidazole severe/resistant: oral tetracycline |
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Acne rosacea is a chronic skin disease of unknown aetiology |
true |
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Acne rosacea features |
typically affects nose, cheeks and forehead flushing is often first symptom telangiectasia are common later develops into persistent erythema with papules and pustules rhinophyma ocular involvement: blepharitis |
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acne rosacea management |
topical metronidazole may be used for mild symptoms (i.e. Limited number of papules and pustules, no plaques) 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 |
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The lesion below started as a small red papule which grew in size before starting to ulcerate: Which one of the following conditions is most associated with this skin condition? |
rheumatoid arthritis |
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Pyoderma gangrenosum features |
typically on the lower limbs initially small red papule later deep, red, necrotic ulcers with a violaceous border may be accompanied systemic symptoms e.g. Fever, myalgia |
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what are the causes of pyoderma gangrenosum |
idiopathic in 50% inflammatory bowel disease: ulcerative colitis, Crohn's rheumatoid arthritis, SLE myeloproliferative disorders lymphoma, myeloid leukaemias monoclonal gammopathy (IgA) primary biliary cirrhosis |
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management of pyoderma gangrenosum |
the potential for rapid progression is high in most patients and most doctors advocate oral steroids as first-line treatment other immunosuppressive therapy, for example ciclosporin and infliximab, have a role in difficult cases |
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dx |
pyoderma gangrenosum note whilst pyoderma gangrenosum can occur in diabetes mellitus it is rare and is generally not included in a differential of potential causes |
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dx |
pyoderma gangrenosum |
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dx |
pyoderma gangrenosum |
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A 59 year old patient presents to dermatology outpatients clinic with a three month history of discolouration of the skin on his back. On examination there is patchy areas of mild hypo-pigmentation covering large areas of the back. You suspect a diagnosis of pityriasis versicolor. What is the likely causative organism? |
Malassezia |
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Pityriasis versicolour is caused by infection with |
Malassezia fungus. Initial treatment is with topical anti-fungals such as ketoconazole shampoo. |
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notes |
Microsporum, Trichophyton and Epidermophyton are dermatophytes and cause fungal nail infections and ringworm. Histoplasma is a fungi that can cause pneumonia in immuno-compromised patients. |
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Pityriasis versicolor |
Pityriasis versicolor, also called tinea versicolor, is a superficial cutaneous fungal infection caused by Malassezia furfur (formerly termed Pityrosporum ovale) |
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Pityriasis versicolor features |
most commonly affects trunk patches may be hypopigmented, pink or brown (hence versicolor) scale is commonmild pruritus |
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Pityriasis versicolor Predisposing factors |
occurs in healthy individuals immunosuppression malnutrition Cushing's |
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Pityriasis versicolor |
topical antifungal. = ketoconazole shampoo as this is more cost effective for large areas if extensive disease or failure to respond to topical treatment then consider oral itraconazole |
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A 54-year-old man with a history of type 2 diabetes mellitus and benign prostatic hyperplasia is referred to dermatology due to a number of lesions over his shin. On examination symmetrical, erythematous, tender, nodules are found. The lesions have started to heal without scarring. What is the most likely diagnosis? |
Erythema nodosum The diagnosis in this question needs to be made on the description of the lesions as the past medical history is not relevant. |
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The differential diagnosis of shin lesions includes the following conditions: |
erythema nodosum pretibial myxoedema pyoderma gangrenosum necrobiosis lipoidica diabeticorum |
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Erythema nodosum features |
symmetrical, erythematous, tender, nodules which heal without scarring most common causes are streptococcal infections, sarcoidosis, inflammatory bowel disease and drugs (penicillins, sulphonamides, oral contraceptive pill) |
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Pretibial myxoedema features |
symmetrical, erythematous lesions seen in Graves' disease shiny, orange peel skin |
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Pyoderma gangrenosum features |
initially small red papule later deep, red, necrotic ulcers with a violaceous border idiopathic in 50%, may also be seen in inflammatory bowel disease, connective tissue disorders and myeloproliferative disorders |
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Necrobiosis lipoidica diabeticorum features |
shiny, painless areas of yellow/red skin typically on the shin of diabetics often associated with telangiectasia |
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A 45-year-old woman is presents with itchy, violaceous papules on the flexor aspects of her wrists. She is normally fit and well and has not had a similar rash previously. Given the likely diagnosis, what other feature is she most likely to have? |
Mucous membrane involvement |
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Lichen |
planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham's striae over surface. Oral involvement common sclerosus: itchy white spots typically seen on the vulva of elderly women |
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You see a 42 year-old gentleman who presents feeling tired all the time. You ask if he has been on holiday because he appears tanned, but he says he has not been in the sun. On examination the palmar creases and buccal mucosa show pigmentation. What underlying condition might cause this presentation? |
Addison's disease |
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Addison's disease is |
primary adrenocorticoid deficiency. It often presents insidiously with vague symptoms such as tiredness. Hyperpigmentation, characteristically involving the skin creases, buccal mucosa and scars is a common feature. This occurs because adrenocorticotropic hormone (ACTH), the hormone produced by the pituitary to stimulate the adrenals to produce steroid hormones, has the same precursor molecule as melanocyte-stimulating hormone (MSH), so increased production of ACTH has the side effect of raising MSH levels. |
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Addison's disease |
Autoimmune destruction of the adrenal glands is the commonest cause of hypoadrenalism in the UK, accounting for 80% of cases |
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Addison's disease features |
lethargy, weakness, anorexia, nausea & vomiting, weight loss, 'salt-craving' hyperpigmentation (especially palmar creases), vitiligo, loss of pubic hair in women, hypotension crisis: collapse, shock, pyrexia |
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Other causes of hypoadrenalism Primary causes |
tuberculosis metastases (e.g. bronchial carcinoma) meningococcal septicaemia (Waterhouse-Friderichsen syndrome) HIV antiphospholipid syndrome |
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Addison's disease Secondary causes |
pituitary disorders (e.g. tumours, irradiation, infiltration) |
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A 19-year-old man is started on isotretinoin for severe nodulo-cystic acne. Which one of the following side-effects is most likely to occur? |
Dry skin |
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Dry skin is the most common side-effect of isotretinoin |
true |
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Isotretinoin |
Isotretinoin is an oral retinoid used in the treatment of severe acne. Two-thirds of patients have a long term remission or cure following a course of oral isotretinoin |
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Isotretinoin adverse effects |
teratogenicity: females should ideally be using two forms of contraception (e.g. Combined oral contraceptive pill and condoms) dry skin, eyes and lips: the most common side-effect of isotretinoin low mood raised triglycerides hair thinning nose bleeds (caused by dryness of the nasal mucosa) benign intracranial hypertension: isotretinoin treatment should not be combined with tetracyclines for this reason photosensitivity |
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What is the most appropriate management? |
Baby shampoo and baby oil dx Seborrhoeic dermatitis in children |
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Seborrhoeic dermatitis in children is a relatively common skin disorder seen in children. It typically affects the |
scalp ('Cradle cap'), nappy area, face and limb flexures. |
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Seborrhoeic dermatitis in children |
Cradle cap is an early sign which may develop in the first few weeks of life. It is characterised by an erythematous rash with coarse yellow scales. |
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Seborrhoeic dermatitis in children Management depends on severity |
mild-moderate: baby shampoo and baby oils severe: mild topical steroids e.g. 1% hydrocortisone |
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Seborrhoeic dermatitis in children tends to resolve spontaneously by around 8 months of age |
true |
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A 55 year old gentleman presents with a new skin lesion to the forehead. On examination there is a 6mm diameter scaly patch which does not appear indurated or ulcerated. He works as a gardener. He has a past medical history of type 1 diabetes and renal transplant, and his medications include insulin, aspirin, simvastatin, and tacrolimus. What is the most appropriate course of action? |
Urgent referral to dermatologist Although this lesion may turn out to be a simple actinic keratosis, squamous cell carcinomas are more common in patients who are immunosuppressed, and may present atypically and grow rapidly. |
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Each one of the following is associated with hirsutism, except: |
Porphyria cutanea tarda |
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Porphyria cutanea tarda is a cause of hypertrichosis rather than hirsutism. |
true |
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hirsutism is often used to describe |
androgen-dependent hair growth in women |
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|
hypertrichosis being used to describe |
androgen-independent hair growth |
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Polycystic ovarian syndrome is the most common causes of hirsutism. Other causes include: |
Cushing's syndrome congenital adrenal hyperplasia androgen therapy obesity: due to peripheral conversion oestrogens to androgens adrenal tumour androgen secreting ovarian tumour drugs: phenytoin |
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Assessment of hirsutism |
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 |
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Management of hirsutism |
advise weight loss if overweightcosmetic techniques such as waxing/bleaching - not available on the NHS consider using combined oral contraceptive pills such as co-cyprindiol (Dianette) or ethinylestradiol and drospirenone (Yasmin). Co-cyprindiol should not be used long-term due to the increased risk of venous thromboembolism facial hirsutism: topical eflornithine - contraindicated in pregnancy and breast-feeding |
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Causes of hypertrichosis |
drugs: minoxidil, ciclosporin, diazoxide congenital hypertrichosis lanuginosa, congenital hypertrichosis terminalis porphyria cutanea tarda anorexia nervosa |
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A neonate is brought to your surgery because his mother has noticed some skin lesions on his face. On examination there are multiple tiny white papules on the nose. What is the most likely diagnosis? |
Milia Milia are a common and normal finding on examination of the newborn, seen in up to half of babies, typically on the face. They will resolve spontaneously over the course of a few weeks. |
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Milia features |
Milia are small, benign, keratin-filled cysts that typically appear around the face. They may appear at any age but are more common in newborns. |
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Which one of the following is LEAST likely to have a role in the management of this patient? |
Topical ketoconazole dx vitiligo |
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Vitiligo management |
sun block for affected areas of skin camouflage make-up topical corticosteroids may reverse the changes if applied early there may also be a role for topical tacrolimus and phototherapy, although caution needs to be exercised with light-skinned patients |
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What is the most likely diagnosis? |
Melasma |
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Melasma definition |
is a condition associated with the development of hyperpigmented macules in sun-exposed areas, particularly the face. The term chloasma is sometimes used interchangeably but more specifically describes the appearance of melasma during pregnancy. |
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melasma epidemiology |
more common in women more common in people with darker skin |
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melasma causes |
pregnancy combined oral contraceptive pill, hormone replacement therapy |
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A patient develops an eczematous, weeping rash on his wrist following the purchase of a new watch. In the Gell and Coombs classification of hypersensitivity reactions this is an example of a: |
Type IV reaction This patient has allergic contact dermatitis, which is commonly precipitated by nickel |
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Hypersensitivity
The Gell and Coombs classification divides hypersensitivity traditionally divides reactions into 4 types: |
Type I - Anaphylactic: Antigen reacts with IgE bound to mast cells (blood test: tryptase)
Type II - Cell bound:
IgG or IgM binds to antigen on cell surface
Type III - Immune complex:
Free antigen and antibody (IgG, IgA) combine
Type IV - Delayed hypersensitivity:
T-cell mediated
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Type I - Anaphylactic |
Antigen reacts with IgE bound to mast cells Examples: • Anaphylaxis • Atopy (e.g. asthma, eczema and hayfever) |
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Type II - Cell bound |
IgG or IgM binds to antigen on cell surface Examples: • Autoimmune haemolytic anaemia • ITP • Goodpasture's syndrome • Pernicious anaemia • Acute haemolytic transfusion reactions • Rheumatic fever • Pemphigus vulgaris / bullous pemphigoid |
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Type III - Immune complex |
Free antigen and antibody (IgG, IgA) combine Examples: • Serum sickness • Systemic lupus erythematosus • Post-streptococcal glomerulonephritis • Extrinsic allergic alveolitis (especially acute phase) |
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Type IV - Delayed hypersensitivity |
T-cell mediated Examples • Tuberculosis / tuberculin skin reaction • Graft versus host disease • Allergic contact dermatitis • Scabies • Extrinsic allergic alveolitis (especially chronic phase) • Multiple sclerosis • Guillain-Barre syndrome |
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In recent times a further category has been added: Type V |
Antibodies that recognise and bind to the cell surface receptors. This either stimulating them or blocking ligand binding Examples • Graves' disease • Myasthenia gravis |
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A 78-year-old man asks you to look at a lesion on the right side of nose which has been getting slowly bigger over the past 2-3 months. On examination you observe a round, raised, flesh coloured lesion which is 3mm in diameter and has a central depression. The edges of the lesion appear rolled and contain some telangiectasia. What is the single most likely diagnosis? |
Basal cell carcinoma |
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A 39-year-old man asks you to look at a skin lesion on the dorsum of his hand. It has been present for the past two years and has not changed recently. What is the most likely diagnosis? |
Granuloma annulare |
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Granuloma annulare features |
papular lesions that are often slightly hyperpigmented and depressed centrally typically occur on the dorsal surfaces of the hands and feet, and on the extensor aspects of the arms and legs nb A number of associations have been proposed to conditions such as diabetes mellitus but there is only weak evidence for this |
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A 33-year-old woman presents with patchy, well demarcated hair loss on the scalp. This is affecting around 20% of her total scalp, and causing significant psychological distress. A diagnosis of alopecia areata is suspected. Which one of the following is an appropriate management plan? |
Topical corticosteroid + referral to dermatologist |
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A 47-year-old man who is known to have dermatomyositis secondary to small cell lung cancer is noted to have roughened red papules over the extensor surfaces of the fingers. What are these lesions called? |
Gottron's papules Gottron's papules are roughened red papules over the extensor surfaces and are seen in dermatomyositis |
|
Dermatomyositis overview |
inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions may be idiopathic or associated with connective tissue disorders or underlying malignancy (typically lung cancer, found in 20-25% - more if patient older) polymyositis is a variant of the disease where skin manifestations are not prominent |
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Dermatomyositis Skin features |
photosensitive macular rash over back and shoulder heliotrope rash in the periorbital region Gottron's papules - roughened red papules over extensor surfaces of fingersnail fold capillary dilatation |
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Dermatomyositis other features |
proximal muscle weakness +/- tenderness Raynaud's respiratory muscle weakness interstitial lung disease: e.g. Fibrosing alveolitis or organising pneumonia dysphagia, dysphonia |
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A 14-year-old male is reviewed by his GP 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? |
Trichophyton tonsurans |
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|
Tinea is a term given to |
dermatophyte fungal infections |
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|
Three main types of tinea infection are described depending on what part of the body is infected |
tinea capitis - scalp tinea corporis - trunk, legs or arms tinea pedis - feet |
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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 |
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dx |
Tinea capitis (scalp ringworm) |
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Tinea corporis (ringworm) |
causes include Trichophyton rubrum and Trichophyton verrucosum (e.g. From contact with cattle) well-defined annular, erythematous lesions with pustules and papules may be treated with oral fluconazole |
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Tinea pedis (athlete's foot) |
characterised by itchy, peeling skin between the toes common in adolescence |
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dx |
Tinea corporis (ringworm) |
|
dx |
Tinea corporis (ringworm) |
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A 34-year-old man presents with a three week history of an intensely itchy rash just below his knees. On examination he has a symmetrical vesicular rash as shown below and also some early lesions on the back of his arms. Which one of the following antibodies is most likely to be positive? |
Anti-gliadin antibody dx Dermatitis herpetiformis |
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An 18-year-old girl presents with mild acne. She finds it very distressing, and mentions find it affects her self esteem, even with her regular partner. Currently she does not use the pill, but her partner uses condoms. What would you prescribe? |
Combined oral contraceptive pill |
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ACNE management Prescribe a single topical treatment: |
Prescribe a topical retinoid (tretinoin, isotretinoin, or adapalene) or benzoyl peroxide (especially if papules and pustules are present) as first-line treatment. Note that retinoids should be avoided where possible in fertile females, given there known teratogenicity. Prescribe azelaic acid if both topical retinoids and benzoyl peroxide are poorly tolerated. Combined treatment is rarely necessary for mild acne. Consider prescribing a standard combined oral contraceptive in women who require contraception, particularly if the acne is having a negative psychosocial impact. Arrange follow up after about 6-8 weeks to review the effectiveness and tolerability of treatment,and the person's compliance with the treatment. |
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What is the most likely underlying diagnosis? |
Hypercholesterolaemia |
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Hyperlipidaemia: xanthomata Characteristic xanthomata seen in hyperlipidaemia: |
Palmar xanthoma remnant hyperlipidaemiamay less commonly be seen in familial hypercholesterolaemia |
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Eruptive xanthoma are due to high triglyceride levels and present as multiple red/yellow vesicles on the extensor surfaces (e.g. elbows, knees) |
true |
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Causes of eruptive xanthoma |
familial hypertriglyceridaemia lipoprotein lipase deficiency |
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|
Tendon xanthoma, tuberous xanthoma, xanthelasma |
familial hypercholesterolaemia remnant hyperlipidaemia |
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Xanthelasma are also seen without lipid abnormalities |
true |
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Management of xanthelasma, options include: |
surgical excision topical trichloroacetic acid laser therapy electrodesiccation |
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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? |
Erythema ab igne |
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A 65-year-old woman presents with bullae on her forearms following a recent holiday in Spain. She also notes that the skin on her hands is extremely fragile and tears easily. In the past the patient has been referred to dermatology due to troublesome hypertrichosis. What is the most likely diagnosis? |
Porphyria cutanea tarda |
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Porphyria cutanea tarda classic features |
blistering photosensitive rash hypertrichosis hyperpigmentation |
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|
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 |
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Porphyria cutanea tarda investigations |
urine: elevated uroporphyrinogen and pink fluorescence of urine under Wood's lamp |
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Management of Porphyria cutanea tarda |
chloroquine venesection |
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A 32 year-old builder presents with sore and itchy skin on his hands and wrists. He has noticed it gets better when he is not in work and wonders if it is something he is coming into contact with at work causing the irritation. Which of the following tests could best further investigate this theory? |
Patch testing Contact dermatitis may be irritant or allergic in nature. Patch testing is the investigation of choice for suspected allergic contact dermatitis. Various allergens are applied to the patient's back, and the skin assessed at 48 hours and 7 days for any reaction. Standard batteries of allergens are used, in addition to samples of any substances the patient suspects. |
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A 31-year-old woman develops painful, purple lesions on her shins. Which one of the following medications is most likely to be responsible? its Erythema nodosum |
Combined oral contraceptive pill |
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A 49-year-old woman complains of 'spots' on her cheeks. She has tried using her daughter's 'Clearasil' but this has had no effect. What is the most likely diagnosis? |
Acne rosacea |
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This 17-year-old man has a history of asthma and eczema but is normally fit and well. Yesterday he developed a rash on face with extends down to his torso. He feels generally unwell with flu-like symptoms. What is the most likely diagnosis? |
Eczema herpeticum |
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|
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 |
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A 23-year-old woman who is 10 weeks pregnant presents with a rapidly growing lesion on her finger. This has grown from the size of a 'pin-prick' when it first appeared 4 weeks ago. dx |
Pyogenic granuloma |
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Pyogenic granuloma dx |
Pyogenic granuloma is a relatively common benign skin lesion. The name is confusing as they are neither true granulomas nor pyogenic in nature. There are multiple alternative names but perhaps 'eruptive haemangioma' is the most useful. |
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|
Pyogenic granuloma The cause of pyogenic granuloma is not known but a number of factors are linked: |
trauma pregnancy more common in women and young adults |
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Pyogenic granuloma features |
most common sites are head/neck, upper trunk and hands. Lesions in the oral mucosa are common in pregnancy initially small red/brown spot rapidly progress within days to weeks forming raised, red/brown lesions which are often spherical in shape the lesions may bleed profusely or ulcerate |
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Pyogenic granuloma management |
lesions associated with pregnancy often resolve spontaneously post-partum other lesions usually persist. Removal methods include curettage and cauterisation, cryotherapy, excision |
|
dx |
Pyogenic granuloma |
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A 24-year-old student presents with due to some lesions on his lower abdomen. These have been present for the past six weeks. Initially there was one lesion but since that time more lesions have appeared. On examination around 10 lesions are seen; they are raised, around 1-2mm in diameter and have an umbilicated appearance. What is the most likely diagnosis? |
Molluscum contagiosum |
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A middle aged man develops a non-pruritic rash after starting allopurinol therapy for gout. The rash develop within 24 hours and started on the back of his hands.What is the most likely diagnosis? |
Erythema multiforme |
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An elderly man develops a generalised pruritic rash: Which one of the following is the mainstay of treatment? |
Oral corticosteroids |
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Please look at the multiple red lesions in the image below: Which one of the following statements regarding these lesions is correct? |
They affect men and women equally Cherry haemangioma |
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You refer a 60-year-old man to secondary care due to the persistent white patches on the inside of his mouth. He has a 40-pack-year history of smoking and has had the lesions for around two years. Biopsies are taken which exclude lichen planus and squamous cell carcinoma. Which one of the following statements regarding the likely diagnosis is correct? |
It is a diagnosis of exclusion |
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A 4-year-old boy is brought in to your GP practice by his mother as he has had a 2 day history of erythematous sores across, but limited to, his face. Over the last 24 hours these have started to weep and progress to what appear to be honey crusted lesions. He is systemically well. What is the first line treatment option? |
Topical fusidic acid impetigo, caused predominantly by Staphylococcus aureus |
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A 35-year-old man presents with an itchy, scaly rash that has gradually developed over the past few months. He is normally fit and well and the only past medical history of note is generalised anxiety disorder. On examination he has a number of ill-defined, pink coloured patches with a yellow/brown scale.The main affected areas are the sternum, eyebrows and the nasal bridge. What is the most likely diagnosis? |
Seborrhoeic dermatitis |
|
|
Seborrhoeic dermatitis in adults |
Seborrhoeic dermatitis in adults is a chronic dermatitis thought to be caused by an inflammatory reaction related to a proliferation of a normal skin inhabitant, a fungus called Malassezia furfur (formerly known as Pityrosporum ovale). It is common, affecting around 2% of the general population |
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Seborrhoeic dermatitis in adults features |
eczematous lesions on the sebum-rich areas: scalp (may cause dandruff), periorbital, auricular and nasolabial folds otitis externa and blepharitis may develop |
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|
Seborrhoeic dermatitis in adults Associated conditions include |
HIV Parkinson's disease |
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Seborrhoeic dermatitis in adults Scalp disease management |
over the counter preparations containing zinc pyrithione ('Head & Shoulders') and tar ('Neutrogena T/Gel') are first-line the preferred second-line agent is ketoconazole selenium sulphide and topical corticosteroid may also be useful |
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Seborrhoeic dermatitis in adults Face and body management |
topical antifungals: e.g. Ketoconazole topical steroids: best used for short periods difficult to treat - recurrences are common |
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An elderly, frail woman is admitted to the ward following a fall at home. What is the most appropriate way to assess her risk of developing a pressure sore? |
Waterlow score |
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|
Waterlow score - used to identify patients at risk of pressure sores |
true |
|
You review an 82-year-old woman who has developed 'sores' on her legs. For the past two years she has had dry, itchy skin around her ankles but over the past few weeks the skin has started to break down. What is the most likely diagnosis?
|
Venous ulcers |
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The dry, skin represents varicose eczema |
true |
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Arterial ulcers tend to have a more 'punched-out' appearance. |
true |
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You notice an abnormality on the neck of a 40-year-old woman: Which one of the following is most associated with this appearance? |
Polycystic ovarian syndrome This patient has acanthosis nigricans which is associated with a number of hyperinsulinaemia states such as polycystic ovarian syndrome. |
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|
acanthosis nigricans is associated with |
hyperinsulinaemia states such as polycystic ovarian syndrome. |
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|
Acanthosis nigricans |
Describes symmetrical, brown, velvety plaques that are often found on the neck, axilla and groin |
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Acanthosis nigricans causes |
gastrointestinal cancer diabetes mellitus obesity polycystic ovarian syndrome acromegaly Cushing's disease hypothyroidism familial Prader-Willi syndrome drugs: oral contraceptive pill, nicotinic acid |
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A 55-year-old female is referred to dermatology by her GP due to a lesions over both shins. On examination symmetrical erythematous lesions are found with an orange peel texture. What is the likely diagnosis? |
Pretibial myxoedema |
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A 75 year-old male patient presents with a feeling of weakness of the legs. On examination there are also some skin changes present, with purple plaques on the dorsum of the hands. You suspect a diagnosis of dermatomyositis. Which of the following underlying conditions is associated with dermatomyositis and should be considered? |
Internal malignancy |
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Dermatomyositis is usually an autoimmune condition, being most common in women aged 50-70. However, it can also be a |
paraneoplastic disease, with gastric and ovarian tumours being the most common underlying cancers. The possibility of underlying malignancy should be considered, especially in older patients. |
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Café-au-lait spots are seen in each of the following, except:
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Friedreich's ataxia |
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Café-au-lait spots definition |
Hyperpigmented lesions that vary in colour from light brown to dark brown, with borders that may be smooth or irregular |
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what are the causes of cafe au lait spots |
neurofibromatosis type I & II tuberous sclerosis Fanconi anaemia McCune-Albright syndrome |
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A 36-year-old female with a history of ulcerative colitis is diagnosed as having pyoderma gangrenosum. She presented 4 days ago with a 3 cm lesion on her right shin which rapidly ulcerated and is now painful: What is the most appropriate management? |
Oral prednisolone |
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Topical therapy does have a role in pyoderma gangrenosum and it may seem intuitive to try this first before moving on to systemic treatment. However, pyoderma gangrenosum has the potential to evolve rapidly and for this reason oral prednisolone is usually given as initial treatment. |
true |
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A 4-year-old boy who is being investigated for development delay is noted to have a number of skin lesions similar to the one below: What is the most likely diagnosis? |
Tuberous sclerosis |
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A 55-year-old man who has a 30 year history of chronic plaque psoriasis is reviewed in clinic. His psoriasis has been severe at times but is currently well controlled with topical therapy alone. Which one of the following conditions is he NOT at an increased risk of given his history of psoriasis? |
Melanoma |
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Psoriasis increases the risk of non-melanoma skin cancer |
true |
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Psoriasis: system complications |
It's sometimes tempting to jump straight to topical treatments when managing a patient with psoriasis as we are keen to give them something which may potentially help. We should however remember that psoriasis has a number of physical and psychological complications, not just psoriatic arthritis. |
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Psoriasis: system complications Patients with psoriasis are at an increased risk of: |
cardiovascular disease hypertension venous thromboembolism depression ulcerative colitis and Crohn's disease non-melanoma skin cancer other cancers including liver, lung and upper gastrointestinal tract cancers |
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A 47-year-old woman complains of an itchy neck and scalp: This skin condition is though to occur as a result of a reaction to: |
Malassezia furfur |
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The patient below has psoriasis: Which treatment is he most likely to be using? |
Dithranol This image shows the typical brown staining that can result from dithranol treatment. The staining of the skin is temporary but patients should be warned it can permanently stain their clothes. |
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Management of chronic plaque psoriasis |
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 |
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Management of chronic plaque psoriasis |
emollients first line: topical corticosteroid + vitamin D analogue second line: increase vit D 2x daily third line: up topical steroid or coal tar preparation +/- dithranol |
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Psoriasis: management 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 |
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Psoriasis: management 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 but not the erythema they should be avoided in pregnancy the maximum weekly amount for adults is 100g |
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Psoriasis: management Steroids in psoriasis |
topical steroids are commonly used in flexural psoriasis and there is also a role for mild steroids in facial psoriasis. If steroids are ineffective for these conditions vitamin D analogues or tacrolimus ointment should be used second line patients should have 4 week breaks between course of topical steroids very potent steroids should not be used for longer than 4 weeks at a time. Potent steroids can be used for up to 8 weeks at a time the scalp, face and flexures are particularly prone to steroid atrophy so topical steroids should not be used for more than 1-2 weeks/month |
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Psoriasis: management Scalp psoriasis |
NICE recommend the use of potent topical corticosteroids used once daily for 4 weeks if no improvement after 4 weeks then either use a different formulation of the potent corticosteroid (for example, a shampoo or mousse) and/or a topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid |
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Psoriasis: management 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 |
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Psoriasis: management Secondary care management |
Phototherapy Systemic therapy |
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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) |
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Secondary care management 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 |
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Psoriasis: management 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, stainingNext question |
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dx |
psoriasis |
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dx |
psoriasis |
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dx |
psoriasis |
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dx |
psoriasis |
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A 16-year-old boy comes to see his GP with his mother after complaining of a rash and tiredness. He has felt generally unwell for about 1 week now since returning from an adventure holiday in the USA. On examination he has a circular rash which is worse in the centre and the edges. This rash is warm and red but painless.Which of the following illness should be considered in this patient?
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Lyme disease |
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Please look at the image below, showing a subungual fibromata: Which condition are these most commonly associated with? |
Tuberous sclerosis |
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Which one of the following causes of pneumonia is most associated with the development of Stevens-Johnson syndrome? |
Mycoplasma Stevens-Johnson syndrome |
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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? |
Ankle-brachial pressure index This patient has the classic appearances of a venous ulcer |
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A mother consults you about her newborn baby who has a skin rash. He was born at term, is of normal birthweight and is well in himself. There is a family history of atopy. On examination there is a widespread rash of small papules and pustules, with erythematous patches. What is the most likely diagnosis? |
Erythema toxicum neonatorum |
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Erythema toxicum neonatorum |
Erythema toxicum neonatorum (toxic erythema of the newborn) is a misnomer as it causes no harm to the baby even though it can appear quite alarming when florid. It is extremely common, seen in around half of term newborns (less common in premature infants); the cause is unknown. It is transient, lasting only a few days, and requires no treatment. |
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Which one of the following drugs is associated with hypertrichosis?
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Ciclosporin |
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A woman presents with painful erythematous lesions on her shins. Which one of the following is least associated with this presentation?
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Amyloidosis |
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A 19 year-old woman presents to dermatology with what she describes as a persistent unsightly rash on his lips. She has a history of recurrent nose bleeds but is otherwise well. She is unsure of any family history as her father died when she was young, but she thinks it was a brain haemorrhage. Her mother is fit and well and her grandparents on this side are alive and well. On examination you note irregular areas of erythema on the lips, which look like small blood vessels. What are the chances of her next child developing similar problems? |
50% This patient has hereditary haemorrhagic telangiectasia. This is inherited in an autosomal dominant manner. |
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Which of the following conditions is most associated with onycholysis? |
Raynaud's disease |
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Raynaud's disease causes onycholysis, as can any cause of impaired circulation |
true |
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Onycholysis features |
Onycholysis describes the separation of the nail plate from the nail bed |
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Onycholysis 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 |
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Which one of the following is not a management option for patients with hyperhidrosis?
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Topical atropine |
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Hyperhidrosis
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Hyperhidrosis describes the excessive production of sweat |
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Hyperhidrosis management |
topical aluminium chloride preparations are first-line. Main side effect is skin irritation iontophoresis: particularly useful for patients with palmar, plantar and axillary hyperhidrosis botulinum toxin: currently licensed for axillary symptoms surgery: e.g. Endoscopic transthoracic sympathectomy. Patients should be made aware of the risk of compensatory sweating |
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Hyperhidrosis management first line tx |
topical aluminium chloride |
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A 20-year-old man presents with acute gingivitis associated with oral ulceration. A diagnosis of primary herpes simplex infection is suspected. Which one of the following types of rash is he most likely to go an develop? |
Erythema multiforme |
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A 45-year-old Afro-Caribbean lady presents to the dermatology department with several painful raised lesions on her shins. The only past medical history of note is asthma. She uses a salbutamol inhaler as required and takes the oral contraceptive pill. A set of baseline investigations were performed:Hb132 g/lPlatelets374 * 109/lWBC7.8 * 109/lNa+142 mmol/lK+3.9 mmol/lUrea5.5 mmol/lCreatinine67 µmol/lCalcium2.8 mmol/lPhosphate1.2 mmol/lTSH3.0 mlU/lFree T412.6 pmol/lA chest x-ray is reported as normal.What is the most likely underlying diagnosis? |
Sarcoidosis |
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Sarcoidosis |
Sarcoidosis is a multisystem disorder of unknown aetiology characterised by non-caseating granulomas. It is more common in young adults and in people of African descent |
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Sarcoidosis features |
acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia insidious: dyspnoea, non-productive cough, malaise, weight loss skin: lupus pernio hypercalcaemia: macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol) |
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Syndromes associated with sarcoidosis |
Lofgren's syndrome is an acute form of the disease characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis In Mikulicz syndrome* there is enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma Heerfordt's syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis nb *this term is now considered outdated and unhelpful by many as there is a confusing overlap with Sjogren's syndrome |
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A 20-year-old woman presents after developing a white patch on her left foot: Which one of the following statements regarding the diagnosis is correct? |
Skin trauma may precipitate new skin lesions This is known as the Koebner phenomenon dx = vitiligo |
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A 39-year-old female has a pigmented mole removed from her leg, which histology shows to be a malignant melanoma. What is the single most important prognostic marker? |
Depth of melanoma |
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Melanoma: the invasion depth of the tumour is the single most important prognostic factor |
breslow depth |
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Malignant melanoma: prognostic factors |
The invasion depth of a tumour (Breslow depth) is the single most important factor in determining prognosis of patients with malignant melanoma |
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Malignant melanoma: prognostic factors |
Breslow Thickness = Approximate 5 year survival < 1 mm = 95-100% 1 - 2 mm = 80-96% 2.1 - 4 mm = 60-75% > 4 mm = 50% |
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Which one of the following drugs is most likely to result in a photosensitive rash? |
Tetracycline |
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Drugs causing photosensitivity |
thiazideste tracyclines, sulphonamides, ciprofloxacin amiodarone NSAIDs e.g. piroxicam psoralens sulphonylureas |
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A 27-year-old man who has recently moved to the UK from Uganda presents complaining of fatigue and purple skin lesions all over his body. On examination he has multiple raised purple lesions on his trunk and arms. You also notice some smaller purple lesions in his mouth. He has recently started taking acyclovir for herpes zoster infection. What is the most likely diagnosis? |
Kaposi's sarcoma |
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A 69-year-old woman asks you to have a look at her feet. She lives out in Spain most of the year but comes back to the UK periodically to see her family. She has similar changes on her forehead. The skin is not pruritc. What is the most likely diagnosis? |
Actinic keratoses Actinic keratoses may develop on any sun-exposed area, not just the forehead and temple. Bowen's disease tends to be isolated and well demarcated. |
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Which one of the following is least recognised as a cause of erythroderma in the UK? |
Lichen planus |
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Erythroderma |
Erythroderma is a term used when more than 95% of the skin is involved in a rash of any kind |
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Causes of erythroderma |
eczema psoriasis drugs e.g. gold lymphoma, leukaemia idiopathic |
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Erythrodermic psoriasis |
may result from progression of chronic disease to an exfoliative phase with plaques covering most of the body. Associated with mild systemic upset more serious form is an acute deterioration. This may be triggered by a variety of factors such as withdrawal of systemic steroids. Patients need to be admitted to hospital for management |
|
dx |
This image shows the generalised erythematous rash seen in patients with erythroderma, sometimes referred to as 'red man syndrome' |
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A 43-year-old man is admitted to the Emergency Department with a rash and feeling generally unwell. He is known to have epilepsy and his medication was recently changed to phenytoin three weeks ago. Around one week ago he started to develop mouth ulcers associated with malaise and a cough. Two days ago he started to develop a widespread red rash which has now coalesced to form large fluid-filled blisters, covering around 30% of his body area. The lesions separate when slight pressure is applied. On examination his temperature is 38.3ºC and pulse 126 / min. Blood results show:Na+144 mmol/lK+4.2 mmol/lBicarbonate19 mmol/lUrea13.4 mmol/lCreatinine121 µmol/lWhat is the most likely diagnosis? |
Toxic epidermal necrolysis |
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Toxic epidermal necrolysis |
Toxic epidermal necrolysis (TEN) is a potentially life-threatening skin disorder that is most commonly seen secondary to a drug reaction. In this condition the skin develops a scalded appearance over an extensive area. Some authors consider TEN to be the severe end of a spectrum of skin disorders which includes erythema multiforme and Stevens-Johnson syndrome |
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Toxic epidermal necrolysis features |
systemically unwell e.g. pyrexia, tachycardic positive Nikolsky's sign: the epidermis separates with mild lateral pressure |
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Drugs known to induce TEN |
phenytoin sulphonamides allopurinol penicillins carbamazepine NSAIDs |
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Toxic epidermal necrolysis Management |
stop precipitating factor supportive care, often in intensive care unit intravenous immunoglobulin has been shown to be effective and is now commonly used first-line other treatment options include: immunosuppressive agents (ciclosporin and cyclophosphamide), plasmapheresis |
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A 54 year old lady attends with a rash. She describes a facial rash present for several weeks associated with flushing. On examination there is erythematous papulopustular rash with telangiectasia across both cheeks and nose. Given the likely diagnosis, which associated complication may she also have? |
Blepharitis |
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A 24 year old man who is normally well presents with a new skin rash. He has no personal or family history of skin conditions but reports he had a viral illness shortly before noticing the first lesion. It started a couple of weeks ago with a lesion he noted on the hip, which is a patch approximately 4cm in diameter, mildly erythematous, with some mild scaling around the edge. He awoke this morning to find multiple smaller similar lesions, mainly on his back. The lesions are asymptomatic. How should this condition be managed? |
No treatment required dx Pityriasis rosea |
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What is the most likely diagnosis? |
Granuloma annulare |
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A 24-year-old female with a history of anorexia nervosa presents with red crusted lesions around the corner of her mouth and below her lower lip. What is she most likely to be deficient in?Zinc |
Zinc |
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Vitamin B2 (riboflavin) deficiency may also cause angular cheilosis. |
true |
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Zinc deficiency Features
|
perioral dermatitis: red, crusted lesions acrodermatitis alopecia short stature hypogonadism hepatosplenomegaly geophagia (ingesting clay/soil) cognitive impairment |
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During a routine medication review, you notice your patient, a 55 year-old female, has some skin changes. There are purplish plaques on the knuckles of both hands, and the patient's eyelids also appear purple. She has never suffered from skin problems in the past. What is the likely diagnosis? |
Dermatomyositis This is a description of the typical skin changes seen in dermatomyositis, a connective tissue disease. In addition to the plaques on the knuckles (Gottron's papules) and eyelids (heliotrope rash) there may be scaling of the scalp and changes to the nail beds and cuticles. There is inflammation of the proximal muscles causing weakness, but the skin changes often are the first presenting feature. Dermatomyositis is usually an autoimmune condition, in which case it is controlled with immunosuppressants, but may also be a paraneoplastic syndrome. |
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This patient is known to suffer from Raynaud's phenomenon: What does the lesion on her thumb most likely represent? |
Calcium deposit This lesion represents calcinosis. |
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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 he has expressed a dislike of messy or cumbersome creams. What is the most appropriate treatment? |
Topical steroid |
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Flexural psoriasis - topical steroid
|
true This patient has flexural psoriasis which responds well to topical steroids |
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Which one of the following conditions is most strongly associated with erythema multiforme? |
Herpes simplex virus This is difficult as both herpes simplex and streptococcal infections are known causes of erythema multiforme (EM). However, studies suggest that HSV is the trigger in over 50% of cases. Sarcoidosis is more strongly associated with erythema nodosum |
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Which one of the following features is least associated with acne rosacea? |
Pruritus |
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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? |
Skin patch test |
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Allergy tests |
Skin prick test Radioallergosorbent test (RAST) Skin patch testing |
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Skin prick test |
Most commonly used test as easy to perform and inexpensive. Drops of diluted allergen are placed on the skin after which the skin is pierced using a needle. A large number of allergens can be tested in one session. Normally includes a histamine (positive) and sterile water (negative) control. A wheal will typically develop if a patient has an allergy. Can be interpreted after 15 minutes Useful for food allergies and also pollen |
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Radioallergosorbent test (RAST) |
Determines the amount of IgE that reacts specifically with suspected or known allergens, for example IgE to egg protein. Results are given in grades from 0 (negative) to 6 (strongly positive)Useful for food allergies, inhaled allergens (e.g. Pollen) and wasp/bee venomBlood tests may be used when skin prick tests are not suitable, for example if there is extensive eczema or if the patient is taking antihistamines |
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Skin patch testing |
Useful for contact dermatitis. Around 30-40 allergens are placed on the back. Irritants may also be tested for. The patches are removed 48 hours later with the results being read by a dermatologist after a further 48 hoursNext question |
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A 61-year-old man presents with pruritus. He has had recurrent episodes of painful swelling in the MTP joints and a history of peptic ulcer disease. On examination he has a 'ruddy' complexion |
Polycythaemia |
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A 41-year-old woman requests a repeat prescription for citalopram. She also mentions she is constantly itchy and bruises easily. On examination she has reddened palms and a distended abdomen |
Liver disease |
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A 27-year-old woman presents with itch and lethargy. She is having difficulty sleeping due to night sweats and is wondering if she may be 'going through the change'. A chest x-ray is normal. |
Lymphoma She is quite young to be going through the menopause. Whilst some menopausal women report itch it is not common |
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What is the most likely underlying diagnosis? |
sarcoidosis Lupus pernio is an uncommon but pathognomic sign of sarcoidosis. |
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A 26 year-old lady presents complaining of persistent itching. She has a history of eczema and uses emollients daily but this has not helped. She is currently 30 weeks pregnant. On examination there is evidence of excoriation on the hands but no obviously visible dermatitis. Which of the following tests is the most important investigation to request?
|
Liver function tests Pruritus is extremely common in pregnancy, affecting as many as a quarter of women. Causes include exacerbations of eczema, polymorphic eruption of pregnancy, or simply just as the result of skin stretching and changes in circulation. Pruritus in the absence of a rash should raise the possibility of obstetric cholestasis. This potentially serious condition increases the risk of complications such as prematurity, passage of meconium, post partum haemorrhage, and possibly stillbirth. Liver function tests and bile acids are therefore the most important tests to check. Iron deficiency anaemia can also cause pruritus so full blood count would also be relevant. |
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Pregnancy: jaundice causes |
Intrahepatic cholestasis of pregnancy Acute fatty liver of pregnancy Gilbert's, Dubin-Johnson syndrome, may be exacerbated during pregnancy HELLP |
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Intrahepatic cholestasis of pregnancy |
Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) occurs in around 1% of pregnancies and is generally seen in the third trimester. It is the most common liver disease of pregnancy. |
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Intrahepatic cholestasis of pregnancy features |
pruritus, often in the palms and soles no rash (although skin changes may be seen due to scratching) raised bilirubin |
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Intrahepatic cholestasis of pregnancy management |
ursodeoxycholic acid is used for symptomatic relief women are typically induced at 37 weeks |
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Intrahepatic cholestasis of pregnancy complications |
Complications include an increased rate of stillbirth. It is not generally associated with increased maternal morbidity |
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Acute fatty liver of pregnancy |
Acute fatty liver of pregnancy is rare complication which may occur in the third trimester or the period immediately following delivery. |
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Acute fatty liver of pregnancy features |
abdominal pain nausea & vomiting headache jaundice hypoglycaemia severe disease may result in pre-eclampsia |
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Acute fatty liver of pregnancy investigations |
ALT is typically elevated e.g. 500 u/l |
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Acute fatty liver of pregnancy management |
support care once stabilised delivery is the definitive management |
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A 26 year-old lady presents with a new skin lesion. She is generally well but is currently 20 weeks in to her first pregnancy. She tells you the lesion appeared three weeks ago and has rapidly grown. On examination the lesion is bright red and nodular, measuring 13mm in diameter, and there is evidence of recent bleeding. What is the likely diagnosis?
|
Pyogenic granuloma Pyogenic granulomas are rapidly growing vascular skin lesions. They are friable, bleeding easily. They can occur at any age, but are particularly common in pregnancy due to hormonal influences. They often appear at the site of minor trauma. Pyogenic granuloma caused by pregnancy will often resolve spontaneously after delivery, but otherwise they can be treated with minor surgery. A key differential diagnosis is amelanotic melanoma |
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A 41-year-old man presents with a persistent itch rash that has been present for the past few weeks. On examination he has erythematous, scaly lesions underneath the eyebrows, around the nose and at the top of his chest. He also has a history of dandruff which is well controlled with over the counter shampoos. What is the most appropriate treatment for his face and trunk lesions? |
Topical ketoconazole |
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|
Seborrhoeic dermatitis - first-line treatment is topical ketoconazole |
true |
|
|
The combination of a peri-orbital and nasolabial scaly rash associated dandruff is a classical history for seborrhoeic dermatitis. |
true |
|
A 25-year-old woman asks you to look at her tongue. It has had this appearance for 'a few months' and she is asymptomatic. What is the most likely diagnosis? |
Geographic tongue |
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A 17-year-old male is reviewed six weeks after starting an oral antibiotic for acne vulgaris. He stopped taking the drug two weeks ago due to perceived alteration in his skin colour, and denies been exposed to strong sunlight for the past six months. On examination he has generalised increased skin pigmentation, including around the buttocks. Which one of the following antibiotics was he likely to be taking? |
Minocycline Minocycline can cause irreversible skin pigmentation and is now considered a second line drug in acne. Photosensitivity secondary to tetracycline/doxycycline is less likely given the generalised distribution of the pigmentation and the failure to improve following drug withdrawal |
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A 67-year-old man presents with a rough, scaly lesion on his nose: A diagnosis of actinic keratosis is suspected. Which one of the following is NOT a treatment option for the management of this condition? |
Topical betnovate |
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Each one of the following is associated with hypertrichosis, except: |
psoriasis
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You are investigating a 68-year old patient with acanthosis nigricans. You recommend testing for diabetes. As the skin changes are extensive in this patient, including some changes in the mouth, what other underlying condition should be considered? |
Internal malignancy Acanthosis nigicans can occur in isolation (generally in dark skin types) but is usually an indicator of insulin resistance and related conditions (type 2 diabetes, polycystic ovarian syndrome, Cushings syndrome, hypothyroidism). It can also be caused by medications including corticosteroids, insulin and hormone medications. If acanthosis nigricans develops rapidly and in atypical locations such as in the oral cavity, internal malignancy should be suspected, particularly gastric cancer. |
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A 26-year-old male presents with a rash that has developed over the past three days. 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? |
Pityriasis rosea |
|
|
Which one of the following skin disorders is not commonly seen with systemic lupus erythematous?
|
Keratoderma blenorrhagica |
|
|
Skin disorders associated with SLE Skin manifestations of systemic lupus erythematosus |
photosensitive 'butterfly' rash discoid lupus alopecia livedo reticularis: net-like rash |
|
dx |
SLE |
|
|
A 67-year-old man is diagnosed with actinic keratoses on his right temple and prescribed fluorouracil cream. One week later he presents as the skin where he is applying treatment has become red and sore. On examination there is no sign of weeping or blistering. What is the most appropriate action? |
Continue fluorouracil cream + review in 1 week This is a normal reaction to treatment. Fluorouracil should be continued for at least another week before starting topical steroids. |
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|
Which one of the following types of rash is most often seen in early Lyme disease? |
Erythema chronicum migrans Other skin rashes associated with Lyme disease include acrodermatitis chronica atrophicans and Borrelia lymphocytosis. Erythema marginatum is seen in rheumatic fever whilst erythema ab igne refers to skin that is reddened secondary to long-term exposure to infrared radiation |
|
A 67-year-old woman presents with a rash. For the past two weeks she has felt tired and 'achey'. She also has a dry cough and some pleuritic chest pain. She is most concerned however with a new rash on her face: Which drug is most likely to cause this presentation? |
Procainamide |
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|
what is easy way to remember how to assess the depth of a burn |
full thickness (third degree) burn is not painful and no blisters superficial epidermal and partial thickness are painful partial thickness (superficial dermal) burn has blisters |
