Dermatology MCQ 1700

DERMATOLOGY-System
Wise 1700-by Sush and Team. 2016

Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

Dear Plabber,

• This first ever System Wise 1700 document was created thanks to 3 months of daily hard
work by the PLAB Skype group ‘Unity’ which was brought together by Dr Susmita
Chowdhury.
• Please ignore the old versions posted by my new skype member Murtaza as he did so
without permission.

The team members were:

& Susmita (Lead/most ignorant as she is working full time in public health for 13 years)
& Asad (Invaluable in IT and all types of support/the heart of the group)
& Manu (Volunteered to solve more questions/pathologist/amazing genuine person)
& Saima (Most concise clear notes/ photographic memory)
& Zohaib (Great research/a surgeon)
& Savia (Great research/multi-tasker with two little ones)
& Shanu (Very helpful after her March exam for those appearing in June)
& Mona (Great contributor in discussions)
& Manisha (Gyne/great discussion contributor)
& Sitara (Good discussion contributor)
& Samreena (Stayed a shorter time but great)
& Sami (Contributed the most early on but too brilliant for the group/still great friends)
& Komal (Knowledgeable sweet supportive girl)

• The main purpose was to break down the 1700 Q Bank System wise.

• We did our own reliable research for the options (OHCM/Patient info etc.) and concluded
these keys below on skype. This can save you 100s of hours of research. But I suggest you
also do your own.

• 90% of the document consists of Unity research. We also added information from other
circulating documents and they are referenced as Dr Khalid/Dr Rabia (and her Team).

• However, several keys may be ‘incorrect’ and so please use your own judgment as we take
no responsibility. I suggest cross checking with Dr Khalid’s latest keys (a few of which are still
debatable). Finally decide on your own key.

• Sorry if some members failed to make their answers thorough. The highlights are mostly as
per what the team members wanted to highlight. Blank tables to be ignored.

• Note that some 1700 Questions are missing from here (when members did not do their
share). Questions may not be in order due to merging of documents and there is excess
information than required. Read as much as needed.

• This has been circulated by our team as a generous contribution to the Plabbers’ success and
must not be ‘sold’.

Good luck and best wishes: Sush and Team
1
DERMATOLOGY-System Wise 1700-by Sush and Team. 2016
Q: 165 A 20yo man complains of recent onset of itching which followed a viral
infection. There are numerous wheals of all sizes on his skin particularly after
he has scratched it. These can last up to an hour. What is the most probable
dx?
a. Uremia
b. Urticaria
c. Psychogenic itching
d. Atopic eczema
e. Primary biliary cirrhosis

Clincher(s) Sudden onset, last up to an hour, numerous wheals, post viral infection
A
B Wheals and rapid onset lasting an hour ! urticarial .. see below
C
D
E
KEY B
Additional
Information
2
3

Reference http://www.gpnotebook.co.uk/simplepage.cfm?ID=2020278290&linkID=3489
9&cook=yes

OHCS
Dr Khalid/Rabia Ans. The key is B. Urticaria.
4
Urticaria Signs: wheals, rapid onset after taking drug ± association with angio-
oedema /anaphylaxis. It can result from both immunological and non-
immunological mechanisms.
Causes: Drugs:morphine & codeine cause direct mast cell degranulation;
penicillins & cefalosporins trigger IgE responses; NSAIDs; ACEi.
Clinical diagnosis. No investigations required.

Management:
Find the cause and avoid/treat it.

Antihistamines:
• Non-sedating H1 antihistamines are the mainstay of treatment
• In pregnancy chlorphenamine is often the first choice of
antihistamine.

Q: 340 A pt complains of SOB, wheeze, cough and nocturnal waking. He has dry
scaly shin with rashes that are itchy. What is the single most likely dx?
a. Scabies
b. Eczema
c. Rheumatism
d. Dermatitis
e. Psoriasis

Clincher(s) SOB, Cough, Wheeze, Dry scaly shin with rashes and are itchy
A
5
B Atopic Eczema -> asthma may develop

C
D
E
KEY B
Additional
Information
6

Reference
Dr Khalid/Rabia Ans. The key is B. Eczema. [Asthma may be associated with atopy].

Q:1547 70yo man presents with a punched out ulcer between his toes. He is a heavy
drinker and smoker. Exam: ulcer is yellow and the foot turns red when dangling
off the bed. What is the single most likely dx? (beurger’s ischemia)
a. Arterial ischemia ulcer (punched out)
b. Malignancy
c. Neuropathic ulcer (no pain felt: mostly in dermatic patient)
d. Pressure ulcer
e. Venous stasis ulcer (punched out)

if patient was young: thomboangitis

Clincher(s) Punched out ulcer between toes
A
B If there is malignancy it often has discharge,bleed,may become infected and
cause unpleasant smell
Such ulcer are treated with charcoal dressing because the charcoal used trap
7
the gas molecules which causes unpleasant smell

Metronidazole tablets are given –kills bacteria causing skin ulcers
Perfumed talc
C Pressure ulcer in the diabetic foot. All patients with neuropathic or
neuroischaemic feet are at risk of pressure ulcers, especially of the heel.
Pressure over heel ulcers can be off-loaded by “pressure relief ankle foot
orthoses.
D Pressure ulcers are an injury that breaks down the skin and underlying tissue.
They are caused when an area of skin is placed under pressure.
They are sometimes known as "bedsores" or "pressure sores".
Pressure ulcers can range in severity from patches of discoloured skin to open
wounds that expose the underlying bone or muscle.
Symptoms:
The parts of the body most at risk of developing pressure ulcers are those that
are not covered by a large amount of body fat and are in direct contact with a
supporting surface, such as a bed or a wheelchair.
Treatment includes:
Changing position
Mattresses
Cushions
Hydro colloid dressings and alginate dressing
Creams and ointments
Antibiotic
Nutrition
Debridement -usg,laser,surgical debridement,cleansing and pressure irrigation
Maggot therapy
Surgery
E Venous ulcers (venous insufficiency ulceration, stasis ulcers, stasis dermatitis,
varicose ulcers, or ulcus cruris) are wounds that are thought to occur due to
improper functioning of venous valves, usually of the legs (hence leg ulcers).
it's common in older people
Symptoms:
Venous leg ulcers are open, often painful, sores in the skin that take more than
8
four to six weeks to heal. They most often develop on the inside of the leg, just
above the ankle.
If you have a venous leg ulcer, you may also have:
swollen ankles (oedema)
discolouration and darkening of the skin around the ulcer
hardened skin around the ulcer, which may make your leg feel hard and
resemble the shape of an upside-down champagne bottle
a heavy feeling in your legs
aching or swelling in your legs
red, flaky, scaly and itchy skin on your legs (varicose eczema)
swollen and enlarged veins on your legs (varicose veins)
an unpleasant and foul-smelling discharge from the ulcer
Signs of an infection
A venous leg ulcer can be susceptible to bacterial infection. Symptoms of an
infected leg ulcer can include:
worsening pain
a green or unpleasant discharge coming from the ulcer
redness and swelling of the skin around the ulcer
a high temperature (fever)

Treated with compression bandages
KEY A
Additional These ulcers occur most commonly in areas of poor blood supply - eg,
Information
the tip of the toes or over the tibia)
Arterial leg ulcers: These are often more distal and on the dorsum of the foot
or toes.Initially they have irregular edges, but this may become more clearly
defined. The ulcer base contains grayish, granulation tissue. Handling, such as
debriding these ulcers, produces little or no blood.Nocturnal pain is typical. It
is worse when supine and is relieved by dangling the legs out of bed.There are
often features of chronic ischaemia, such as hairlessness, pale skin, absent
pulses, nail dystrophy and wasting of calf muscles.
9
Risks for arterial ulcers
Coronary heart disease.
History of stroke or transient ischaemic attack.
Diabetes mellitus.
Peripheral arterial disease including intermittent claudication.
Obesity and immobility.
Treatment:
These will usually require referral for assessment and care. It is really the
management of peripheral vascular disease. See separate article Peripheral
Arterial Disease.
Characteristic of venous and arterial ulcer:

Venous ulcer:
Ulcer has uneven edges
R Ruddygranulationtissue
R No dead tissue
R Moderatetonopainatall
R Pain is present is eased byraising the leg
Commonlyhasahistoryof:
R DeepVeinThrombosis(DVT)
R Obesity
R Calf muscle pump function
deficits
R Valvular incompetence insuperficial perforating veins
Arterial ulcer:
Deep pale base
10
R Well defined edges
R Black or necrotic tissue
R Verypainful
R Pain is reduced by lowering theleg to a dependent position
Commonlyahistoryof:
R Aging
R Diabetes
R Arteriosclerosis
R Smoking
R Hypertension
Reference NHS.co.uk
Dr Khalid/Rabia Rabia

Q:1548 A 65yo woman complains of a painful discharging ulcer above her ankle on the
inner side of her left lower leg. Exam: the base of the ulcer is red and covered
by a yellow fibrous tissue. The border is irregular. The skin is tight. What is the
single most likely dx?
a. Arterial ischemia ulcer
b. Malignancy (foul smelling)
c. Neuropathic ulcer
d. Pressure ulcer
e. Venous stasis ulcer

Clincher(s) Above ankle ,irregular border and is painful
A
B
C
D
E
KEY E
Additional Venous ulceration is typically seen just above the medial malleolus.)
Information
Exclusion of options
A; Arterial ulcer - look for reduced pulses in the foot, ankle and possibly
femoral artery. These ulcers occur most commonly in areas of poor blood
supply - eg, the tip of the toes or over the tibia - and are typically painful and
11
deep. Other evidence of poor blood supply may include peripheral cyanosis
and claudication. An arterial ulcer tends to occur on lateral side of distal leg
and leg is pulseless and cool.
B: Malignancy - malignant ulcers in this area are rare but the possibility
should not be overlooked. Watch out for an ulcer with a rolled everted edge.
If ulceration occurs in the area of scar tissue, Marjolin's ulcer should be
considered. Chronic venous ulcers can develop into malignant ones, so any
non-healing ulcer should be referred for biopsy.
C: Neuropathic ulcer - this is painless, deep, often with overlying

hyperkeratosis and occur at sites of loss of nerve supply and recurrent
trauma, ie the heel, metatarsal heads.
D: are localized injuries to the skin and/or underlying tissue that usually
occur over a bony prominence as a result of pressure, friction or rub. Venous
ulcers are caused by incompetent valves in the veins of the lower leg,
especially in the perforators. These incompetent valves cause blood to be
squeezed out into the superficial veins, when the calf muscles are
contracted, instead of upwards towards the heart. Dilation of superficial
veins occurs (varicosities) and the subsequent raised venous pressure results
in oedema, venous eczema and ulceration. Valves may also become
damaged following the venous hypertension that occurs in pregnant women
and there may be congenital absence of valves. 80% of all leg ulcers are
venous ulcers and a large shallow relatively painless ulcer with an irregular
granulating base in the 'gaiter' region of the leg (between the knee and
ankle) is likely to be venous in origin.
Investigations:
Measurement of ankle brachial pressure index (ABPI) using Doppler
Swabs for microbiology
Patch testing
Biopsy
Treatment:
Compression bandage
Debridement and cleaning
Dressing
12
Antibiotics
Pentoxifylline
Topical steroids
Aspirin

Reference
Dr Khalid/Rabia Rabia

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Q:1064 1064. A 62yo farmer presents with a persistent firm irregular lesion on upper
part of pinna which grew over the last few months. What is the most
appropriate dx?
a. Basal cell
b. Squamous cell
c. Keratocanthoma
Anything above head is basal cell Ca until proven otherwise
Clincher(s)
A Basal cell carcinoma (aka rodent ulcer) Nodular: Typically a pearly nodule with
rolled telangiectatic edge, on the face or a sun-exposed site. May have a
central
ulcer. Metastases are very rare. It slowly causes local destruction if left
untreated. Superfi cial: Lesions appear as red scaly plaques with a raised
smooth
edge, often on the trunk or shoulders. Cause: (most frequently) UV exposure.
: Excision;
cryotherapy; for superfi cial BCCS topical fl urouracil or imiquimod (
B Squamous cell cancer Usually presents as an ulcerated lesion, with hard, raised
edges, in sun-exposed sites. May begin in solar keratoses (below), or be found
on the
lips of smokers or in long-standing ulcers (=Marjolin’s ulcer). Metastasis to
15
lymph
nodes is rare, local destruction may be extensive. : Excision + radiotherapy
to treat
recurrence/aff ected nodes. See fi g 2. NB: the condition may be confused with
a keratoacanthoma—
a fast-growing, benign, self-limiting papule plugged with keratin
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia Dx is basal cell
Basal cell is most common.
Squamous and keratocanthoma are less common and similar in presentation.
GOLJAN PATHOLOGY it says that such lesions above the upper lip is basal cell.
And below that is SCC- if on face.

Q:1092 1092. A 9yo child presented with a rash on his skin which did’nt respond to
antibacterial ointment? What med should be added next?
a. Corticosteroid
b. Antifungal
c. Emollient
d. Permethrin
e. Coal tar
Emollient> steroid>antifungal
Clincher(s)
A
B
C
D
E
KEY A
Additional
Information
Reference
Dr Khalid/Rabia

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Q: 567 A 78yo nursing home resident is revived due to the development of an
intensely itchy rash.
Exam: white linear lesions are seen on the wrists and elbows and red papules
are present on the penis. What is the most appropriate management?
a. Topical permethrin
b. Referral to GUM clinic (norweigian scabies, STI)
c. Topical betnovate (eczema, irritant contact dermatis, s dermatitis, seb
dermatic)
d. Topical ketoconazole (seborhic dermatis – more common in parkinsons
e. Topical selenium sulfide hyoscine (tinea versicolour, dandruff, seboroohea)

1st permethrin, and then melathione
Clincher(s) 78 year old nursing home resident. White linear lesions on wrists etc
A For scabies
B
C
D
E
KEY A. Topical permethrin
Additional The two most widely used treatments for scabies are permethrin cream
Information and malathion lotion (brand name Derbac M). Both medications contain
insecticides that kill the scabies mite.
Permethrin 5% cream is usually recommended as the first treatment.
Malathion 0.5% lotion is used if permethrin is ineffective.

Reference nhs
Dr Khalid/Rabia Red papule on penis typical with wrist and elbow lesion goes with Scabies,
topical permethrin once wk and repeat if symptoms remain.
white linear lesions

Features
• widespread pruritus
• linear burrows on the side of fingers, interdigital webs and flexor
aspects of the wrist
• Nodules may develop. These occur particularly at the elbows, anterior
axillary folds, penis, and scrotum.
19
• in infants the face and scalp may also be affected

• secondary features are seen due to scratching: excoriation, infection

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

Q: 622 A 70yo woman lives in a nursing home following a stroke has developed
reddish scaly rash on her trunk. She has many scratch marks on her limbs and
trunk with scaling lesions on her hands and feet. What is the single most
appropriate initial tx?
a. Aqueous cream
b. Chlorphenaramine
c. Coal tar
d. 1% hydrocortisone ointment
e. Permethrin

Clincher(s) Nursing home, multiple scratch marks: scabies

A
B
C
D
E
KEY e. Permethrin

Additional
Information
Reference
Dr Khalid/Rabia Features
• widespread pruritus
• linear burrows on the side of fingers, interdigital webs and flexor
aspects of the wrist
• Nodules may develop. These occur particularly at the elbows, anterior
axillary folds, penis, and scrotum.
• in infants the face and scalp may also be affected
• secondary features are seen due to scratching: excoriation, infection

Management
20
• 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

Q:

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Q:314 A child presents with eczema. She was given two creams by the GP – emollient
and steroid. What advice would you give her regarding application of the
cream?
a. Sparingly use both the cream
b. First use emollient, then steroid
c. Apply steroid then emollient
d. Mix emollient & steroid before use
e. Emollient at night with steroid

Emollient first to be absorbed for moisture, then steroid…
Clincher(s) Advice for application of eczema creams.
A
B
C
D
E
KEY B
Additional
Information
Reference
Dr Khalid/Rabia emmolient 30 minutes before steroid].

23
Q:499 A pt presents with purple papular lesions on his face and upper trunk
measuring 1-2 cm across. They aren't painful or itchy. . What is the single most
likely diagnosis?
a. Kaposi sarcoma
b. Hairy leukoplakia
c. Cryptosporidium
d. CMV infection
e. Cryptococcal infection

Clincher(s) Non tender Purple popular lesion on face and upper trunk. Not itchy either.
A
B It's a white patchy lesion associated with EBV and HIV infection.
C
D
E
KEY A
Additional Kaposi's sarcoma is a rare type of cancer caused by a virus(HHV 8) It can
Information affect the skin and internal organs.
It's mainly seen in people with a poorly controlled or severe HIV infection. It
can also affect some people who have a weakened immune system for
another reason, as well as people who have a genetic vulnerability to the
virus.
The most common initial symptom is the appearance of small, painless, flat
and discoloured patches on the skin or inside the mouth. They're usually red or
purple and look similar to bruises.

Tx:
AIDS-associated KS (epidemic KS) - starting HAART will usually lead to a
reduction of lesions in almost 40% of patients, although there are a few in
whom the KS will continue to grow despite antiretrovirals.
If there are only a few lesions then the following can be considered:
Radiotherapy.
Cryotherapy/cryosurgery.
Surgery - this carries the risk of KS appearing in wound edges and is probably
only appropriate for small surface lesions. Electrodessication with curettage
can also be used (tumour cut and edges burnt).

Reference
Dr Khalid/Rabia Kaposi’s sarcoma is a spindle-cell tumour derived from capillary endothelial
24
cells or from fibrous tissue, caused by human herpes virus. It presents as non
painful purple papules (½ to 1 cm) or plaques on skin and mucosa (any
organ). It is not itchy, and it metastasizes to nodes. Associated with AIDS
infection. OHCM 9th edition, page 716.

Q:

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26
Information
Reference
Dr Khalid/Rabia

Q: 838 A 12yo boy presented with itching in his hands. Exam: skin is dry and red. His
mother is asthmatic and older brother has hay fever. What is the single most
likely causative factor?
a. Dermatitis herpitiformis
b. Scabies
c. Eczema
d. Uremia
e. Drug induced

Clincher(s) Itching in hands, skin is dry and red, h/o of asthma and hay fever
A Dermatitis herpetiformis is an intensely itching subepidermal blistering
condition (vesicular rash chiefly affecting the extensor surfaces of shoulders,
buttocks, knees, forehead and scalp, sparing the mucosae) that usually
develops in the 3rd or 4th decade. Men are affected more frequently than
women. 90% of patients with dermatitis herpetiformis will have a gluten
enteropathy
B Scabies presents as very itchy papules, vesicles, pustules, and nodules affecting
finger-webs (esp. first), wrist flexures, axillae, abdomen (esp. around umbilicus
and waistband area), buttocks, and groins (itchy red penile or scrotal papules
are virtually diagnostic). In young infants, palms and soles are characteristically
involved. The eruption is usually excoriated and becomes eczematized.
C
D Pruritus, "half-and-half" nails [the proximal portion on the nail bed is white
(due to oedema of the nail bed and the capillary network) and the distal
portion is pink or reddish brown with a sharp line of demarcation. Nail plate
involvement is not seen]
E Erythema multiform
KEY: C Eczema.
Itchy lesion and family history of asthma and hay fever in 1st degree relatives
favours the diagnosis of eczema.

OHCM >> A family history of atopy is common (70%)

Additional
Information
27
Reference
Dr Khalid/Rabia Eczema
Diagnostic criteria
Must have an itchy skin condition (or report of scratching or rubbing in a child)
plus three or more of the following:
• History of itchiness in skin creases such as folds of the elbows, behind the
knees, fronts of ankles, or around the neck (or the cheeks in children aged 18
months or under).
• History of asthma or hay fever (or history of atopic disease in a first-degree
relative in children aged under 4 years).
• General dry skin in the preceding year.
• Visible flexural eczema (or eczema affecting the cheeks or forehead and
outer limbs in children aged under 4 years).
• Onset in the first two years of life (not always diagnostic in children aged
under 4 years).
• If it does not itch it is very unlikely to be eczema.
management :
emolient + topical steroids

Q: 1046 A 75yo woman has weakness of the left side of her face. She has had a painful
ear for 48h. There are pustules in the left ear canal and on the eardrum. What
is the single most likely dx?
a. Chronic serous OM
b. Herpes zoster infection
c. Impacted earwax
d. Perforation of eardrum
e. Presbycusis (old age- bilat sensory hearing loss- Hz lost at after 40 DB) They
hear between 40-80DB; don’t hear both low and high pitched sounds

Clincher(s) 75yo, weakness on one side of her face, painful ear, pustules in the ear canal
and eardrum
A
B
C
D
E Decreased peripheral auditory sensitivity, bilateral
KEY: B Herpes zoster infection.
given symptoms particularly pustules point towards herpes infection. when
the varicella zoster virus (chickenpox) becomes reactivated in the geniculate
ganglion of the VIIth cranial nerve (facial nerve), it is called ramsay hunt
syndrome.
28
Additional
Information
Reference
Dr Khalid/Rabia given symptoms particularly pustules point towards herpes infection. when
the varicella zoster virus (chickenpox) becomes reactivated in the geniculate
ganglion of the VIIth cranial nerve (facial nerve), it is called ramsay hunt
syndrome.
ramsay Hunt syndrome:
presenting features:
* Vertigo and ipsilateral hearing loss.
* Tinnitus.
* Facial weakness or face drop.
* The patient also complains of rash or blisters which may be on the skin of the
ear canal, auricle or both, and may become infected secondarily, causing
cellulitis
Signs
* There is a rash or herpetic blisters in the distribution of the nervus
intermedius.
* The distribution of the rash varies, as does the area innervated by the nervus
intermedius. It may include the following:
o The anterior two thirds of the tongue.
o The soft palate.
o The external auditory canal.
o The pinna.
* An ipsilateral face drop or weakness may be obvious or it may be elicited on
testing.
* There may be hyperacusis on that side due to paralysis of the stapedius and
tensor tympani.
* The patient may have associated ipsilateral hearing loss and balance
problems.
· The unilateral facial weakness is very similar to Bell's palsy but the rash is the
characteristic diagnostic feature to differentiate the two.
· There is not always a rash, especially in younger patients. In children aged 5
to 15, acute facial palsy, like a Bell's palsy and without a rash, may be produced
by the varicella-zoster virus.[6]
· Trigeminal neuralgia is paroxysmal and tends to be precipitated by a stimulus
such as a cold wind or washing the face.
· Other conditions in the differential diagnosis include postherpetic neuralgia,
persistent idiopathic facial pain and temporomandibular disorders.[7]
· You may also consider otitis (external, media),[8] referred pain (eg dental
abscess) and carcinoma of the nasopharynx
Diagnosis: usually clinical. Occasionally audiometry and NCV for facial nerve
damage.

Dr. Khalid >> A case of Ramsay Hunt syndrome defined as an acute peripheral
facial neuropathy associated with erythematous vesicular rash of the skin of
the ear canal, auricle (also termed herpes zoster oticus), and/or mucous
29
membrane of the oropharynx caused by Herpes zoster infection

Q:628 . A lady who works at a nursing home presents with itching. Exam: linear tracks
on the wrist. She says that 2d ago she had come in contact with a nursing
home inmate with similar symptoms.What is the mechanism of itching?
a. Infection
b. Destruction of keratinocytes (occurs in steven Johnson – erythema
multimormis-and toxic derma necro lysis)
c. Allergic reaction
d. Immunosuppression
e. None
.

Clincher(s)
A
B
C
D
E
KEY c. Allergic reaction
Scabies. pruritis due to allergic reaction to toxin from mite- sarcoptis scabii
Additional
Information
Reference
Dr Khalid/Rabia

Q:823 A 34yo man was walking along the countryside when an insect bit
him. After which he started to complain of an annular rash spreading
upwards.

a. Penicillin PO
b. Doxycycline PO
c. Flucloxacillin PO
d. Gentamicin PO
e. Ciprofloxacin PO
f. Antihistamine PO
g. Antihistamine IV
h. Corticosteroid IV
i. Corticosteroid IM
j. Adrenaline IM
k. Adrenaline IV
l. Atropine IV
m. Reassurance

30
Clincher(s) Annular rash f/b bite of insect

A
B
C
D
E
KEY Answer: B
Additional
Information Lyme disease can be contracted from a deer tick (Ixodes) bite
containing Borrelia species of bacteria. Erythema migrans is the
pathognomonic skin finding associated with Lyme disease and is
often described as a bull's-eye or target rash. It typically is an
annular, erythematous plaque with central clearing. Lyme disease
can be associated with myalgias and arthralgias, fever, anorexia and
nausea, fatigue, and regional lymphadenopathy, but the rash may be
the only finding at presentation.
Lesions are usually 5 to 68 cm, although they can vary in size.1

They appear three to 30 days after the tick bite, but most commonly
within seven to 14 days. The classic lesion occurs in approximately
80% of cases.2 Lyme disease has been reported in all 50 states but is
endemic in the Northeast and in parts of Minnesota, Wisconsin, and
northern California.3 Most cases occur from May to September
when the Ixodes tick is in the nymph stage.
There are three distinct clinical stages of Lyme disease. The early
localized stage (three to 30 days after tick exposure) includes the
influenza-like symptoms of fever, fatigue, arthralgias, and myalgias.
The early disseminated stage (days to weeks after tick exposure)
includes multiple lesions, neurologic symptoms (palsies,
radiculopathy, or peripheral neuropathy), or cardiac symptoms
(myocarditis and varying degrees of atrioventricular block). The late
stage (months to years after tick exposure) includes arthritis,
primarily affecting the knee, and possible cognitive disturbances.
Treatment should be initiated promptly to avoid progression to late
stages of the disease.
Erythema multiforme is a hypersensitivity reaction to medication

use or an infection, such as herpes simplex virus infection.4,5 It
typically manifests as papules or plaques with erythematous borders.
The target or iris lesions typically appear on the palms, soles,
elbows, or knees.
31
Granuloma annulare is a benign, self-limited, annular eruption that

does not require treatment. It presents as skin-colored plaques or
papules on distal portions of the extremities, specifically the hands,
wrists, and feet. It is idiopathic and occurs in adults and children,
although it is most common between 40 and 50 years of age. It is
more common in women than in men.6
Nummular eczema is an idiopathic papulovesicular dermatitis

commonly associated with asthma and atopic dermatitis. It typically
manifests as coin-shaped lesions and is most prominent in cold or
dry months.
Rheumatic fever is an inflammatory disease that can develop after

group A streptococcal infection and is associated with erythema
marginatum. This annular rash is typically slightly elevated, mildly
erythematous, and nonpruritic, and is primarily found on extensor
surfaces of extremities, sparing the face.
Antibiotics for lyme disease
Lyme disease is curable with several types of antiboitics including

common antibiotics like doxycycline, amoxicillin and azitromycin,
which can be taken orally. Sometimes the antibiotic is administered
intravenous (IV), particularly when the drug of choice is ceftriaxone
(Rocephin), which cannot be taken orally.
Other antibiotics used include: minocycline, tetracycline,

cefuroxime 14 days, claritromycin. Some doctors also experiment
with other types of antibiotics or combinations of antibiotics. Many
of those treatment have not been studied, though.

Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
32
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q: 555 A 14yo girl has developed an itchy, scaly patch on her scalp. She had a similar
patch that cleared spontaneously 2yrs ago. Her aunt has a similar undiagnosed
rash on the extensor aspects of her elbows and knees. What is the single most
likely dx?
a. Eczema (baby-
b. Fungal infection
c. Impetigo
d. Lichen planus
e. Psoriasis
33

Clincher(s)
A
Eczema on flexors. onset below age 2 years, flexural involvement, generally
dry skin, other atopic disease

B Fungal infection of the scalp or Tinea Capati is often due to Microsporum Canis
often acquired from cats and occurs in pre pubertal chidren (commoner in
black children). M Canis is predominant in Europe.

Presentation will be with scaly patches, associated with hair loss. Small broken
off infected hairs are often present.

Some vaierty can lead to scarring alopecia.

Investigated by scalp scrapings. Rx patient and prevent spread. Best : oral
griseofulvin (avoid in preg). Rx family members with ketoconazol shampoo

C Impetigo 'golden', crusted skin lesions typically found around the mouth, very
contagious

D Lichen planus itchy, papular rash most common on the palms, soles, genitalia
and flexor surfaces of arms, 'white-lace' pattern on the surface (Wickham's
striae)
E Strong genetic predisposition
: other family members with the same problem. Psoriasis is a skin condition
that tends to flare up from time to time
Psoriasis. Rash Always on extensors.

KEY e. Psoriasis
Additional Psoriasis
Information Presents with red, scaly patches on the skin – particularly scalp, sacral area,
extensors of knees and elbows

Major manifestation is chronic skin disease.

Surface silvery scale which can be easily removed leading to pin point capillary
34
bleeding- Auspitz sign.

Strong genetic predisposition

it is now recognised that patients with psoriasis are at increased risk of arthritis
and cardiovascular disease.

[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
(after step infection)

pustular psoriasis: commonly occurs on the palms and soles- common in
children ]

Management of chronic plaque psoriasis (Rabia)
· 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

UVB treatment
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
35
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
36
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
37
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q: 1655 A 37yo female working as a healthcare assistant in a nursing home comes to
the ED with complaints of severe itching all over her body. On asking she
replies that she had applied cream on the body of a resident in the nursing
home who had similar itches. What is the mechanism of itching?
a. Allergic reaction
b. Inflammation of keratinocytes (steven Johnson, toxic epidermal necrolysis-

all urtercaria…of epidermis inflammation)
c. Allergic reaction developed due to use of topical steroid creams
d. Subcutaneous bleeding (bac endocarditis…osler’s nodes, purpura petechie,

HUS, HTP, ITP- all for purpura)
e. None

Clincher(s) Healthcare assistant, severe itching all over body, and resident of nursing has
similar condition.
A This is a typical case of scabies which is contingious disease. It occurs due to
allergic reaction to the secretions of causative organism.
B
C
D
E
KEY A- Allergic reaction
38
Additional
Information

Reference
Dr Khalid/Rabia

Q: 1667 A 58yo man complains of nose disfigurement. He has a hx of facial erythema
particularly of the cheeks and nose. Papules and pustules have been erupting
at intervals over the last 10yrs. He admits to a moderate regular consumption
of alcohol (immunocompromised). Exam: noted to have rhinophyma (inf of
sebaceous gland). The most likely dx is?
a. Eczema
b. Herpes simplex
39
c. Epidermolysis bullosa
d. Dermatomyositis
e. Tinea versicolor
f. Pemphigus vulgaris
g. Acne rosacea
h. Malignant melanoma-sun exposed area- M- trunk, F- legs/shin, difference in

colour of same lesions, irregular, talengectsia, classification: Burlow depth- will
predict prognosis- > 6mm to make diagnosis , occur in mole> changes to
melanoma..Rx- excisional biopsy,
also in mucus membrane…
i. Psoriasis
j. Atopic dermatitis – hx of atopy, > flexor surfaces, contact history, acute

rather than chronic in eczema…

Clincher(s) Middle aged man, nose disfigurement, eczema of cheeks and nose, h/o 10
years.
A
B
C
D
E
KEY G- Acne rosacea.
40
Additional
Information

Reference
Dr Khalid/Rabia

Q: 1681 A 50yo farmer complains of pain in his left arm. Exam: he appears to have a
neuropathy affecting isolated nerves in multiple, random areas of his left arm.
He also has a palpable purpura and tender nodules on both of his upper and
lower limbs. A likely diagnosis is?
a. Carpal tunnel syndrome (esp at night, mx with splinting, release of median

nerve, flexor reticulum)
b. Polyarteritis nodosa (type of vascultiies of medium vessles, tender as
c. Angina Pectoris
d. Gout
e. Cellulitis (fluclox and penicillin)
f. Rheumatoid arthritis
g. Erysipelas (sup cellutiits- streph+ staph> vancomycin or fluclox; more

localized, more superficial only epidermis,…)
h. Fascitis (advanced state of cellulitis of muscle layers with compartment

syndrome)
i. Reiter's Syndrome (young male- conjunctivitis, arthralgia, urethral dischargis,

HLVA 27-)
41
j. Polymyalgia Rheumatica (no purpura or tender bodules: gradual proximal

muscle weakness; c. kinase normal )

Clincher(s) H/o farmer, multiple dermatomal involvement with tender nodules,
palpable purpura.
A
B
C
D
E
KEY A- Poly arteritis nodosa.
Additional PAN is necrotising arteritis of medium or small arteries without
Information glomerulonephritis or vasculitis in arterioles, capillaries, or venules, and not
associated with antineutrophil cytoplasmic antibodies (ANCAs).It can affect
any organ but, for unknown reasons, it spares the pulmonary and glomerular
arteries.
Presentation:Peripheral nerves and skin are the most frequently affected

tissues. PURPURA,LIVEDOID,SUBCUTANEOUS NODULES and NECROTIC
ULCERS. Neurologically, MONONEURITIS MULTIPLEX>...involvemnet of
CNS,Git,kidneys and heart means higher mortality.RENAL
INVOLVEMENT:hypertension,AKI, GIT:necrosis,perforation.Myalgia
Investigations: Hepatitis B surface antigen is positive in 30%.
The p-ANCA test is usually negative in PAN.
There is a prominent acute phase response but this is nonspecific.
FBC shows leukocytosis with raised neutrophils.
Hypergammaglobulinemia occurs in 30%.
Biopsy
Arteriography shows aneurysms

TREATMENT: Corticosteroids. RELAPSE add Cyclophosphamide.=>

Azathioprine useful in maintenance therapy.
42
(IV-Ig) and aspirin are effective in childhood PA

Reference Farmers exposed to Organophosphorous compunds may get this
Dr Khalid/Rabia Dd: rheumatoid arthritis but not tender

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
43
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
44
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

45

Dermatology MCQ 1700

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DERMATOLOGY-System

Wise 1700-by Sush and Team. 2016

B Atopic Eczema -> asthma may develop

the gas molecules which causes unpleasant smell

a high temperature (fever)

Risks for arterial ulcers

Coronary heart disease.

History of stroke or transient ischaemic attack.

Peripheral arterial disease including intermittent claudication.

Obesity and immobility.

Characteristic of venous and arterial ulcer:

Ulcer has uneven edges

R Pain is present is eased byraising the leg

R Calf muscle pump function

R Valvular incompetence insuperficial perforating veins

Deep pale base

R Well defined edges

R Black or necrotic tissue

R Pain is reduced by lowering theleg to a dependent position

C: Neuropathic ulcer - this is painless, deep, often with overlying

Measurement of ankle brachial pressure index (ABPI) using Doppler

Swabs for microbiology

Debridement and cleaning

• in infants the face and scalp may also be affected

membrane of the oropharynx caused by Herpes zoster infection

Clincher(s) Annular rash f/b bite of insect

Lesions are usually 5 to 68 cm, although they can vary in size.1

Erythema multiforme is a hypersensitivity reaction to medication

Granuloma annulare is a benign, self-limited, annular eruption that

Nummular eczema is an idiopathic papulovesicular dermatitis

Rheumatic fever is an inflammatory disease that can develop after

Antibiotics for lyme disease

Lyme disease is curable with several types of antiboitics including

Other antibiotics used include: minocycline, tetracycline,

bleeding- Auspitz sign.

b. Inflammation of keratinocytes (steven Johnson, toxic epidermal necrolysis-

c. Allergic reaction developed due to use of topical steroid creams

d. Subcutaneous bleeding (bac endocarditis…osler’s nodes, purpura petechie,

h. Malignant melanoma-sun exposed area- M- trunk, F- legs/shin, difference in

also in mucus membrane…

j. Atopic dermatitis – hx of atopy, > flexor surfaces, contact history, acute

a. Carpal tunnel syndrome (esp at night, mx with splinting, release of median

b. Polyarteritis nodosa (type of vascultiies of medium vessles, tender as

e. Cellulitis (fluclox and penicillin)

g. Erysipelas (sup cellutiits- streph+ staph> vancomycin or fluclox; more

h. Fascitis (advanced state of cellulitis of muscle layers with compartment

i. Reiter's Syndrome (young male- conjunctivitis, arthralgia, urethral dischargis,

j. Polymyalgia Rheumatica (no purpura or tender bodules: gradual proximal

Presentation:Peripheral nerves and skin are the most frequently affected

Investigations: Hepatitis B surface antigen is positive in 30%.

The p-ANCA test is usually negative in PAN.

There is a prominent acute phase response but this is nonspecific.

FBC shows leukocytosis with raised neutrophils.

Hypergammaglobulinemia occurs in 30%.

Arteriography shows aneurysms

(IV-Ig) and aspirin are effective in childhood PA

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