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Core Questions
Pityriasis rosea is a rash that can occur at any age, but it occurs most commonly in
people between the ages of 10 and 35 years.
It may be set off by a viral infection but does not appear to be contagious; herpes
viruses 6 and 7 have most often been associated with pityriasis rosea. It is not
caused by a fungus.
The condition often begins as a large single pink patch on the chest or back. This
patch may be scaly and is called a 'herald' or 'mother' patch.
Within a week or two, more pink patches, sometimes hundreds of them, appear on
the body and on the arms and legs. Patches may also occur on the neck, and though
rare, the face.
The oval patches follow the line of the ribs like a fir tree. They have a dry surface and
may have an inner circlet of scaling.
Question 2 of 13
Core Questions
Optic neuritis
Scarring alopecia
New lesions often appear at sites of injury or trauma (Koebner phenomenon), which
typically occurs one to two weeks after the skin has been damaged.
Psoriasis can be associated with an anterior uveitis, but optic neuritis is not a
recognised complication.
Angular stomatitis describes erythema and fissuring of the skin adjacent to the angle
of the mouth. The most common cause is Candida infection, but it is also associated
with allergy, seborrhoeic dermatitis, vitamin B deficiencies, and iron deficiency. It is
not commonly described in association with psoriasis.
The scalp is often involved in psoriasis, especially in children and adolescents. Most
commonly, it causes a telogen effluvium, that is, the hair follicles are forced into the
telogen resting stage.
Whilst the exact cause is unknown, psoriasis has a strong genetic basis. European
populations are commonly affected, and there are two peaks of incidence at 16-22
years and 57-60 years. Males and females are equally affected.
External factors such as infection, stress, and medication may exacerbate psoriasis.
Some of the common medications associated with triggering or worsening psoriasis
include lithium, gold salts, beta blockers, and antimalarials (including chloroquine).
References:
IgA antibodies
Pemphigus is associated with loss of intercellular cohesion in the lower part of the
epidermis, leading to acantholysis (separation of keratinocytes). Pemphigus is
classically associated with flaccid blistering, and often with immunoglobulin (Ig)G
antibodies.
She has no significant past medical history but admits to significant use of tanning
beds and having spent a few years living in California.
Investigations show:
Which of the following features is most associated with a poor prognosis in this
patient?
Her age
Lack of ulceration
Survival is strongly correlated with depth of melanoma at the point of diagnosis, with
lesions over 4 mm thick being associated with a particularly poor outcome.
Other predictors of a poor outcome include increasing age and male sex.
Ulceration of the lesion also implies greater risk of metastases. For lesions over 4
mm thick with ulceration, five year survival is less than 50%.
Question 5 of 13
Core Questions
A 62-year-old woman presents with severe nausea and lethargy a few days after
beginning diclofenac and amoxicillin from her GP for pain and a urinary tract
infection. She has no past history of note apart from hypertension for which she
takes ramipril, and she believes she injured her back lifting a wardrobe.
Investigations show:
Eosinophilia
Urine Protein++
Blood-
White cells-
Churg-Strauss syndrome
Membranous nephropathy
Pyelonephritis
The rapid onset of renal failure, coupled with a rash and eosinophilia is highly
suspicious of a diagnosis of interstitial nephritis as a result of exposure to non-
steroidal or amoxicillin.
40-60% of cases of interstitial nephritis are due to drug hypersensitivity. Those most
commonly involved include penicillins, cephalosporins, vancomycin, NSAIDs,
thiazides and furosemide. Interstitial nephritis usually develops within 2-60 days of
treatment with a beta-lactam, and presents with haematuria, acute kidney injury, and
fever. A maculopapular rash and hepatic involvement can also occur. Interstitial
nephritis associated with NSAIDs is most commonly seen in elderly patients who
have taken non-steroidals intermittently for months to years. Proteinuria is dominant,
and the nephrotic syndrome can develop.
A 48-year-old father and his 20-year-old son presented with multiple itchy red lesions
over their trunks and groins.
The son had initially developed the rash after working out in the local gym. Following
this his father noticed a similar rash afflicting him.
Psoriasis
Sarcoidosis
Allergic contact dermatitis will present with itchy papulovesicular eruption at the site
of contact of the allergen.
Sarcoidosis may present with scaly plaques, however, features of peripheral activity
and central clearing are usually not seen and itching is not a feature.
Question 7 of 13
Core Questions
A 35-year-old man presents to the dermatology clinic with a strange rash which
affects the dorsum of his hands and feet and the extensor surface of his arms. He
has no past medical history of note.
Investigations show:
Lichen planus
The clinical scenario described is not typical of any of the other options given:
Besides starting on a gluten-free diet, his dermatologist has decided to start him on
oral dapsone.
Which laboratory test needs to be within the normal range before commencing
therapy?
Fasting lipids
Abnormal HbA1C, fasting lipids and fasting glucose levels are not considered
contraindications to treatment with dapsone.
A 52-year-old woman comes to the dermatology clinic for review. She has suffered
from blisters and ulcers which have progressed over a number of months to include
extensive areas of her upper body, arms and legs. The blisters are painful, but
pruritis is minimal. She has a past medical history of hypertension for which she
takes lisinopril and indapamide. She also suffers from epilepsy for which she takes
carbamazepine.
T cell infiltration within the dermis and the dermo-epidermal junction Incorrect answer selected
Topical diclofenac
Reassurance that this condition will resolve is the most appropriate action here. The
most likely cause for erythema nodosum (EN) in this case is the tuberculosis. Given
that he is committing to quadruple antibiotic therapy, you would expect the EN to
resolve as the infection subsides and therefore no specific treatment for the EN is
warranted.
Topical diclofenac and antibiotics are not effective in this situation. The underlying
panniculitis which is responsible for EN is not infective in nature, and responds best,
if required to topical potassium iodide. Oral corticosteroids may blunt his immune
response to TB and should therefore be avoided. In summary, topical potassium
iodide can be considered in patients with very troublesome EN, but other treatment
isn't indicated in this situation.
Question 11 of 13
Core Questions
Flucloxacillin
Oral corticosteroids
The answer is Aciclovir. This patient's vesicular rash is most likely due to herpes
simplex infection, superadded over the eczema rash: a condition known as eczema
herpeticum. Patients with poorly controlled eczema are at increased risk of
developing disseminated infection. It is a dermatological emergency, and oral
aciclovir should be initiated immediately. Parenteral treatment is usually only
required if a patient is unable to take tablets, or their condition is deteriorating
despite oral medication.
The superficial infection isn't bacterial, flucloxacillin is therefore not of value. VZIG is
not of value because the rash is related to herpes simplex infection, and further use
of corticosteroids risk spreading the vesicles further (although topical steroids can
sometimes be used if the atopic rash is severe).
Further reading:
Which of the following is the most useful intervention for her rash?
Topical clotrimoxazole
Topical hydrocortisone
Topical terbinafine
The answer is oral fluconazole. The presentation here is consistent with candida
related intertrigo, as a result of this patient's diabetes and obesity, which leads to
skin folds being warm and moist, increasing the chances of fungal infection. The
debate is between topical and oral therapy, but given this patient has very extensive
infection and a history of diabetes (known to result in relative immunosuppression),
oral intervention is preferred to the topical option. In total oral fluconazole can be
given for a period of 2-4 weeks.
Intensified glycaemic control will be useful in reducing the risk of future infection, but
it is highly unlikely to eradicate the current problem, and as such anti-fungal
intervention is preferred. Both topical clotrimoxazole and terbinafine are options in
patients with more limited infection, and hydrocortisone may be added where there is
marked inflammation but is not used as monotherapy.
Question 13 of 13
Core Questions
Pityriasis lichenoides
Pityriasis rosea
A drug eruption is unlikely two weeks after completion of the course of antibiotics,
and pityriasis rosea normally begins with a herald patch on the chest.
Pityriasis lichenoides is a possible differential, although acute disease normally
occurs as a papular rash rather than the psoriatic plaques seen here. Similar to
pityriasis rosea, lichen planus usually affects a limited area of skin at onset.