DERMA TAS Pastest Derma Part 1b

A ypung 1-it-,rearp|=:t giri presents with rnptzierate aene anel pustules at1e1::t1n~_g the tape pack
and chest.
What is the rnast appropriate treatment?
A Tppipal tretinpin
B Oral tetracycline fer three rnenths
C Ergrthrpnwpin
D Oral tsptretin-pin
E UWB phptptherapy
C Erythrcinwycin
D
D Oral iscitretinciin
E Uy'E?i phcitptherapy Fiiespt
Fiespc
Explanation Resp:
Fiespc
The ansyyer is c-ral tetracycline fer three rnenths. This patient has i"i"if.I3HZIit'_1i'EJ1I1 acne anci is
theretc-re suitaple tcir secpnciline therapy. Firstline therapy fer acne inyplyes the use pt
tppical antihic-tics such as tetracyclines, i<eratc-ilytics pr tppical retinc-icis. Secc-nci-line therapy
inyplyes a 3-4 rncinths cpurse pf |ey~rc:ipse antipietics such as tetracyciines pr erythrprnycin,
Dianette (it there is nc:~ cpntrainciicatipn), pr UVB phcitc-therapy (althpugh this is rarely useci
nciyy). Thirci-line therapy inyciiyes the use cit ciral retinciicis, altheucih these are prescripeci
ciniy lay specialists in ciern'1atc~lc=gy anci carry high risk cif teratc-genicity.
Data H-"|ic .r'-||u:1.::H|-1r'|' -.
A '|i?iyearp|ci cgiirl presenteci in autunin i.-yith -II'i"y"J[i'_iE|'"|"ii_:J|J[IIII'|u|?3 placiues en the chest anci tclrearrn
Which cit the fpllcwying yypuicl help with a ciiagnesis?
A Ar'itihLic|eE:1r antilpciply
Ei i3=IIi|"i';IJ|"|yiiEI1 screen
C Anti-srni::~pti"i-n"|i_isc|e antih-pciies
D Anti-phcisphplipici antippciies
E hlpne pt the apc;=ye
Subrnit
F | "=;= :-: 1: L i t'_;= i :e- st a - ~- | 1 ii} !-<1 i iii ill-Ii i : i ~: :~" 1

B Porphyria screen
C Antisrnoothn"iusc|e antilooclies
D Antlphospholipicl antipoclies U
Flespi:
Ftespc
Explanation
Ftespc
The rnost likely cliagnosis is pityriasis rosea, a postyiral rash cornrnonly seen in chilolren,
F-lespr:
aclolescents or young aclults in the spring ancl auturnn. It rnay (put not always) start with a
solitary recl patch with peripheral scaling ("the heralcl patch) which is followecl within a few
clays loy a wiclespreacl eruption of srnail scaly lesions niost n'iarl<ecl on the trunk. Lesions are
often oyal with the long asis running along clernwatonies, alrnost in the pattern of a
Christmas tree {unlike guttate psoriasis which has niore circular, rnore scaly lesions that are
not clerrnaton"ia|). E5yn"ipton'is are often alosent put a cnilcl itch can lo-e present. The rash
usually resolyes in 4-8 weeks ancl no specific treatnrient is inclicatecl for the conclition.
r":-.4-.-. +-i.-;.- .--|.|.|..--..--l-l.--.- -.
Which one of the following olisor-::lers is MOST commonly associateol with Stevens-Johnson
synclrome?
A llerpes sirnples infection
E5 55l5ir=:itfiiclc:=sis
C Systemic lupus erythernatosus
[ll llerpes soster infection
E Coeliac clisease
Submit
l1lr=__~;'-._.-i-:;":-i._i?_;. I113 iie;'_+stir.j;i|'i ..ll:.iiji Iijli ...e ;1_-".ti=;j.ie'i

is |
B Sarcoiclosis E
c
C Systemic lupus erythematosus E;-,
E
D Herpes zoster infection U
E Coeliac clisease
Flespi:
Explanation RESP
SteyensJohnson synclrome is an immunological reaction in the skin anol mucous memprane HES?"
characterisecl loy erythema multiforme in the skin ancl extensiye pullae formation in the Rggpg
mouth ancl conjunctiyae. The commonest clisease association is with a prececling herpes
simplex or Mycoplasma pneumoriiae infection. Either causes inclucle clrug sensitiyity {e.g.
suiphonamicles. penicillins. loarloiturate. phenytoin ancl possiply the contraceptiye pill).
A sixmonth-olcl ltzialoy appears to haye experiencecl a fit. The parents noticecl Jerking of one
arm followecl loy generalisecl sl"'iai~tirig. A flat erythematous lesion uncler the right lower eyelicl
which has not changecl in size or appearance, has loeen present since loirth.
What is the most likely oiagnosis?
A 5turgeWeloer synclrome
El Tuperous sclerosis
C Strawiaerry naeyus
[J Flyogenic granuloma
E Type l neuroficiromatosis
Submit
El Tuloerous sclerosis
D 1
C Strawberry naeyus
Resp:
D Ryogenic granulorna
Resp:
Resp:
E Type 1 neurofipromatosis
Resp:
Explanation
A feature of the SturgeWel::er syn::lrome is the presence of a port-wine stain (capillary
angioma) a loenign proliferation of yascular ancl connectiye tissue that may loe associatecl
with a cleyelopmental clefect of mature clermal capillaries. llistologically. networks of ectatic
yessels in the outer clermis are eyiclent. The lesion is present at hirth, is generally unilateral
affecting the face. trunk or limlos ancl is yarialole in size. Usually. there is a sharp miclline
loorer on the more common unilateral lesions. If areas suppliecl loy the maxillary ancl
ophthalmic cliyisions of the trigeminal nerye are inyolyecl there may loe associatecl angiomas
of the unclerlying meninges. proclucing neurological manifestations comprising the Sturge-
Weloer synclrome. t arises sporaclically. Jacksonian epilepsy, hemisensory clisturloance.
hemiplegia. contra ateral hemianopia ancl cleyelopmental clelay haye all peen clescripeol.
hemiplegia. contralateral hemianopia ancl cleyelopmental clelay haye all heen ClE.*SCl'liI1E!Cl.
Choroiclal angioma, glaucoma. louphthalmos (large eye) are ocular manifestations. Skull
racliography may clemonstrate intracranial 'tramline calcification.
llistologicaily_. a strawperry naeyus is causecl loy a laenlgn proliferation of enclothelial cells.
followecl py inyolution ancl cleyelopment of filorous tissue in the yascular spaces. It occurs in
ills of chilclren ancl although it sometimes presents at l::-irth. it usually appears shortly
afterwarcls. Clinically. it presents as one or more rapiclly growing. olome-shapeci, loright-recl
lumps. most commonly on the heacl or neck. The lesions grow for the first l2lS months of
life then graclually ancl spontaneously resolye, in most cases olisappearing lay the age of
seyen years. The surface of a lesion may become erocieci. crustecl or hleecl: infection can
occur. Large facial lesions may he associatecl with coarctation of the aorta. ancl posterior
fossa alanormalities can sometimes occur. Laser therapy may loe useful for haemangiomas.
Tulaerous sclerosis is an autosomalclominant clisorcler characterisecl loy hamartomas locateci
throughout the loooly. often prominently inyolying the central neryous system ancl skin. Two
loci on chromosomes 9 ancl 16 haye been iclentifie-ol. The conclition has a yarialole expression
ancl penetrance ancl is further characterisecl by angiofipromas. seizures ancl cleyelopmental
olelay. Skin features comprise periungual filaromas. cutaneous angiofiloromas (aclenoma
selaaceum) proclucing small anol oliscrete pink papules mainly affecting the centre of the
face, Shagreen patches (flesh-coloureol leathery thickenings of the skin) ancl ElSl'l|i-EHZHT-S"lEllIIllE'CIl
areas of clepigrnentation that pecome more yisilole uncler a Woocfs light lamp. The on y
treatment is symptomatic, i.e. anticonyulsants.
Neurofitiromatosis is another example of a neurocutaneous synclrome (phacociermatoses).
This is an autosomalciominant clisorcler characterisecl loy neurofilaromas affecting the
neryous system ancl skin. The gene responsilole is locatecl on chromosome l? ancl encocies
|"'I ' I' I I I I II: I" I' I'll |""I|"I I ' I '
Tulaerous sclerosis is an autosomalclominant clisorcler characterisecl loy hamartomas locateci
throughout the pocly. often prominently inyolying the central neryous system ancl skin. Two
loci on chromosomes SI ancl lF5 haye loeen icientifieol. The conclition has a yariaple expression
ancl penetrance ancl is further characterisecl loy angiofipromas. seizures ancl cleyelopmental
clelay. Skin features comprise periungual fibromas. cutaneous angiofilorornas ijaolenonna
seloaceum) proclucing small ancl cllsc-rete pink papules mainly affecting the centre of IIlE'
face. Shagreen patches (fleshcolourecl leathery thickenings of the skin) ancl ashleafs"iapecl
areas of ciepigmentation that loecome more yisilole under a Woo-cls light lamp. The on y
treatment is symptomatic, i.e. anticonyulsants.
l\leurofil::romatosis is another example of a neurocutaneous synclrome (phacoclermatoses).
This is an autosomal-ciominant clisorcler characterise-ol loy neurofipromas affecting the
neryous system ancl skin. The gene responsilole is locateci on chromosome lT" ancl encocies
neurofihromin, which clownregulates the function of the p2l ras oncoprotein. Lesions
inclucle acoustic neuroma. schwannoma, cafeau-lait spots (hyperpigmenteci macules),
axillary freckling ancl cutaneous neurofiloromas. Systemic manifestations inclucle
kyphoscoliosis. pone cysts. phaeochromocytoma. acromegaly. cleyelopmental -olelay ancl
epilepsy. Type 2 neurofiloromatosis is a olifferent entity: there is a propensity in this clisease
for the cieyelopment of ylllth nerye schwannomas (acoustic neuromas) or meningiomas.
Ryogenic granuloma is a primarily oral olisease which appears in the mouth as an oyergrowth
of tissue. it is often founcl to inyolye the skin ancl nasal septum although has also loeen founcl
in the limlos.
Rate this ciuestion:

A lS-year-olci scroollaoy presents for reyiew. lle has just returnelil to school for the start of
the Spring term. le giyes a history of a recl patch of skin on his chest. surrouncleci la-y an area
of skin scaling. w-"iich was followe::i al:a:aut S clays later lay the iiieyelopment of oyal macules
oyer the rest of his trunk_. arms anol thighs. lie is otherwise well.
What cliagnosis fits best with this clinical picture?
A Rityriasis rupra pilaris
El Rityriasis yesicular
C Rityriasis rosea
D E?-'arier's clisease
E Likely clrug reaction
Submit
D Dariers ::lisease Resp:
Resp:
E Likely clrug reaction
Resp:
Resp:
Explanation
The first clinical lesion to appear in pityriasis rosea is the socallecl 'heralcl patch. an isoiatecl
erythematous patch, appearing on the trunk. surrouncleci lay a ring of scaling skin. A numlaer
of oyal macules appear on the upper arms, remain::ler of the trunk ancl upper thighs some 2-
4 olays later. These can run along olermatomes. almost in the pattern of a Christmas tree
(unlike guttate psoriasis which has more circular. more scaly lesions that are not
clermatomal). lnyolyement of the hancls. feet or scalp is rare. Seyere itching is uncommon.
but a milcl itching can occur. Rityriasis rosea normally remits within A-8 weeks. Cases occur
with increasing freciuency in spring ancl autumn. suggesting a possible yiral aetiology.
Treatment is not usually neeclecl. but systemic antihistamines or calamine lotion may be
useful to relieye itching. Topical steroiols clo not shorten the cluration of the clisease, ancl
systemic steroicls haye no yalue in clisease moclification.
An Syearolcl girl presents with hyperkeratotic placiues on the skin. especially at the scalp
margin. Mycology of hair pullings no growth.
What is the likely cliagnosis?
A Rsoriasis
R Selaorrhoeic clermatitis
C Tirie.-a capi'fi'.s
[ll Lichen simplex
E Elliscoici eczema
Submit
B
B Seborrhoeic clermatitis C
C Tiriea caplhis E
G H
D Lichen simplex
E Discoicl eczema Respons
Respons
Explanation Respons
The cliagnosis is psoriasis. Chronic placiue psoriasis is characterisecl by pinkishrecl Respons
hyperkeratotic plagues, which occur especially on extensor surfaces such as knees anol
ellaows. The lower laack_. ears ancl scalp are also commonly inyolyecl. New placiues of
psoriasis occur particularly at sites of skin trauma the l/ioebner phenomenon. Skin laiopsy
of psoriatic plagues reyeals acanthosis ancl parakeratosis. reflecting increasecl skin turnoyer
Capillary clilatation within the clermis also occurs. surrouncleci lay a mixecl neutrophilic ancl
lymphohistiocytic periyascular infiltrate.
A 2~yearolcl iaoy. who has recently been circumcisecl. presents with purple papules on the
scar ancl on his fingers, with eyiclence of excoriation. A white, lacy. reticulate appearance
oyerlying lesions in the lauccal mucosa is eyiclent on oral examination.
What is the most likely cliagnosis?
A l\lociular prurigo
B Rsoriasis
C Discoicl eczema
D Pyogenic granuloma
E Lichen planus
F-..uhr'niiI'
Explanation
Lichen planus is an intensely pruritic eruption of unknown aetiology. It has a yery
characteristic clinical appearance, composecl of groupecl, small ancl shiny, flat-toppecl
yiolaceous papules with an oyerlying network of fine white lines (Wickhams striae). The
usual clistribution inyolyes the flexor aspects of the knees, elbows, ankles ancl wrists, with
the mouth being more commonly affectecl. Lichen planus exhibits i<oebner's phenomenon, in
which lesions tenci to occur at the sites of trauma. This is also the case for yitiligo, psoriasis
ancl plane warts. The clisease tencls to remit spontaneously between six months ancl two
years. Although topical steroicls ancl antihistamines are helpful for symptomatic relief, often
no treatment is reciuirecl in milcl cases. Facling skin papules leaye post inflammatory
hyperpigmentation, while scalp inyolyement may procluce a scarring alopecia.
The lesions clescribeol are untypical of psoriasis: although these tencl to be non-itchy, they
can be if there is a seconclary infection. Rsoriatic plagues show a silyery-white scaling on an
erythematous base that bleecl on abrasion.
L1 I I ' I I |I" 1| * ' l- I I I I ' ll '- I I 'l I 1
|.-I" I I -" T |.-I" T T
The lesions described are untypical of psoriasis: although these tend to be non-itchy, they
can be if there is a secondary infection. Rsoriatic plagues show a silyery-white scaling on an
erythematous base that bleed on abrasion.
Nodular prurigo may deyelop following insect bites, characterised by persistent itching,
lichenified papules and nodules oyer the trunk and limbs.
Discoid eczema is a constitutional pattern of eczema; here, the lesions are often yesicular
and exudatiye and may become secondarily infected. The lesions are well-demarcated coin-
shaped areas, with one or two patches predating a general eruption by weeks or months.
Rruritus may be intense. lt typically occurs in middle-aged men (executiyes), and can be
caused by stress, oyer-washing and a lowhumidity enyironment (air conditioning, central
heating).
Ryogenic granuloma is an abnormal proliferation of capillaries following trauma or infection,
usually occurring in the mouth. The lesion is often a fleshly, pedunculated yascular nodule
that bleeds easily when traumatised.
Rate this ciuestion;
I-I
A l?-year-old youth presents with a purpuric rash on his buttocks and legs. There is joint
pain and one yomit containing coffee grounds. Blood testing reyeals mild eosinophilia and a
small rise in lgA leyels. Urine testing reyeals microscopic haematuria.
What diagnosis fits best with this clinical picture?
A Traumatic injury
B Thrombotic thrombocytopenic purpura
C idiopathic thrombocytopenic purpura
D Rolyarteritis noclosa
E HenochSchonlein purpura
Explanation
Henoch-Schonlein purpura presents with purpura in dependent areas (e.g. buttocks and
lower legs), similar to the rash seen in meningococcal septicaemia. Although it mostly
occurs in children between 4 and l5 years of age, it may be seen in slightly older indiyiduals.
A 2:1 male to female ratio exists. Rostulated aetiology is an exaggerated antigen-antibody
reaction with lgA deposition. Antigen triggers may inclucle drugs, foods, immunisation and
an upper respiratory tract infection.
There may be no specific abnormalities on blood testing, although lgA is eleyated in 50% of
cases, with a leucocytosls or eosinophilia. Rlatelet leyels are typically normal. Joint pain and
renal inyolyement (leading to microscopic haematuria) are common, as are minor G1 bleeds.
Rrednisolone is giyen for seyere G1 or renal inyolyement, although properly conducted
efficacy studies of steroids are hard to come by. Usually recoyery occurs within -ii weeks, but
seyere renal disease may occur in 5% of patients.
A l2-year-old girl is admitted to the hospital with a history of an epileptic fit. The admitting
doctor has documented hypopigmented macules on her abdomen and acne-like eruption on
her face. Examination of her fingers shows small periungal fibrous papules. She is also known
to haye learning disabilities.
What is the most likely diagnosis?
A Tuberous sclerosis (Bourneyilles disease)
B Neurofibromatosis
C Refsum's disease
D Oslers clisease
E Blooms syndrome
B Neurofibromatosis
C Refsums disease
D Oslers disease
E Blooms syndrome
Explanation
Tuberous sclerosis is an autosomal-dominant disorder characterised by hamartomas located
throughout the body, often prominently inyolying the central neryous system and skin. Two
loci on chromosomes S and lb haye been identified. The condition has a yariable expression
|- l I '- I" II I l '- -II! ' l""I * .1-" ll ' l"' l'l
I-|.|l'=l"'|-|.|-PF I-|.|il' "1-.-l'l'=l'I-|.|l"'I-.-I"l-.-'l'I-|.|l""l-.|-I"
E Bloorns syndrome
Explanation
Tuberous sclerosis is an autosomal-dominant disorder characterised by hamartomas located
throughout the body, often prominently inyolying the central neryous system and skin. Two
loci on chromosomes S and lb have been identified. The condition has a yariable expression
and penetrance and is further characterised by angiofibromas, seizures (usually infantile
spasms) and deyelopmental delay. Facial/cutaneous angiofibromas (adenoma sebaceum),
periungual fibromas (pink projections from the nail folds), shagreen patches (leathery
thickenings of the skin usually on the back) and ash leaf macules (areas of dipigmentation
that become yisible under a Woods light) are pathognomonic features. Fundoscopy may
reyeal white streaks along the fundal yessels.
Rate this cjuestion:
A 6-year-old girl presents with a fine, hyperpigmented. streaky whorl rash oyer her left thigh
and a wart-like lesion. She has suffered from seizures since she was S years of age, and she
has complained of stubborn warts in the past. Her mother ha.s had two in utero stillbirths but
no other family history of note. On examination, crops of small yesicles are found on the
yentral surface of the girls left wrist. She has a mild scoliosis but a normal gait, thin wiry hair
and peg-shaped teeth. Cardioyascular, respiratory and abdominal examination is
unremarkable. Her Ruth Griffiths score has shown her to haye a reduced subduotient in the
categories of social skills, language and hearing, and performance. A skin biopsy confirms a
large number of intradermal eosinophils but no inflammatory cells.
What is the cause of this girls hyperkeratotichypermelanotic lesion?
A Herpes simplex infection
B Bullous impetigo
C Erythema bullosa
D lncontinentia pigmenti
E Warts
E Warts
Explanation
lncontinentia pigmenti is a multisystem disorder that shows dominant inheritance. It affects
only girls ancl women clinically as the condition is lethal in males in utero. if a diagnosis is
difficult, a look at the mother is always suggested. Clinically there are three phases: (l) the
bullous phase - crops of yesicles appear in the first 2 weeks of life; (2) the popular phase
warty papules that flatten out oyer the skin; and (3) the hyperpigmented phase
pigmentary changes in the form of whorls and streaks that are hypo- and hyperpigmented in
nature. There is a different leyel of melanosis present in each whorl. As this is a multisystem
disorder, other clinical symptoms and signs include dental and ocular anomalies, seizures in
30% of cases, rarely learning difficulties, although some children will haye a decreased IQ,
musculoskeletal abnormalities, alopecia and wiry hair.
I -I I H ||I II--I I I J II-I J I ||I -I I 'II- I I I ||I I I
Explanation
lncontinentia pigmenti is a multisystem clisorcler that shows dominant inheritance. It affects
only girls and women clinically as the condition is lethal in males in utero. If a diagnosis is
difficult, a look at the mother is always suggested. Clinically there are three phases: (l) the
bullous phase - crops of yesicles appear in the first 2 weeks of life; (2) the popular phase -
warty papules that flatten out oyer the skin; and (3) the hyperpigmented phase -
pigmentary changes in the form of whorls and streaks that are hypo- and hyperpigmented in
nature. There is a different leyel of melanosis present in each whorl. As this is a multisystem
disorder, other clinical symptoms and signs include dental and ocular anomalies, seizures in
30% of cases, rarely learning difficulties, although some children will haye a decreased IQ,
musculoskeletal abnormalities, alopecia and wiry hair.
On skin biopsy, there will be a marble-like lesion that runs in a linear streak, and the skin may
appear blistered with a normal or decreased number of melanocytes and hyperkeratosis.
There are a large number of intradermal eosinophils but no inflammatory cells. As the child
grows older, there will be residual hyperpigmented whorls. The lesions appear in early
childhood and then leaye a grey streaky pigmentation in adulthood. The differential
diagnosis is as in the cjuestion.
A A-year-old boy is found by the school nurse to haye an annular erythematous scaly lesion
on his left forearm. lle has been playing with his pet dog oyer the weekend. This lesion is
pruritic in nature and on palpation has a raised circumferential edge with a clear, flat centre
Skin scrapings are sent to the laboratory for analysis. and the boy is treated with antifungal
medication for his skin, hair and nails.
What is this diagnosis?
A Tinea yersicolor
B Tinea capitis
C Tinea corporis
D Discoid psoriasis
E Diabeticorum annulare
D Discoid psoriasis
E Dlabeticorum annulare
Explanation
There are three main types of tinea infection, which are yery difficult to distinguish clinically
but haye different aetiological factors.
l. Tinea yersicolor. The fungus responsible for this infection is Pftyrosporum orbiculare
(Malassezia furfur). On dark skin, multiple hypopigmented macules with a scaly
component are yisible. Cin fair skin, hyperpigmented lesions can be seen. This is not
yitiligo, which has a conyex edge to it and when inyestigated has an associated
autoimmune component.
2. Tinea capitis. This skin disease is caused by Trichophyton.
Explanation
There are three main types of tinea infection, which are yery difficult to distinguish clinically
but haye different aetiological factors.
l. Tinea yersicolor. The fungus responsible for this infection is .Ri'fyrosporum orbfculare
(Malassezra furfur). On dark skin, multiple hypopigmented macules with a scaly
component are yisibie. On fair skin, hyperpigmented lesions can be seen. This is not
yitiligo, which has a conyex edge to it and when inyestigated has an associated
autoimmune component.
2. Tinea capitis. This skin disease is caused by Trichophyfon.
S. Tinea corporis. This is commonly known as ringworm and is caused by a dermatophyte
infection Microsporurn canils. The lesions appear to be annular and erythematous with a
scaly, pruritic border and a clear centre. The diagnosis is made by skin scrapings.
Treatment is antifungal medication for the skin, hair and nails.
Rate this ciuestion: Q
-ll-iiiiii ii ii ii ii
A child with atopic eczema presents with a flare-up of the eczema.
You would suspect herpes simplex yirus (HSV) rather than bacterial infection if which ONE
of the following occurred?
A The lesions affected the face
B There were constitutional symptoms such as yomiting, diarrhoea and pyrexia
C Lesions were present at different stages
D Extensor sites were affected
E Rustules were present

B II'lEl'E WBFB CCll'iS'tl"EL|'lIllI1l"lEl'IS:\,i'l'll|CllI11'.IIll'"l'lS SLlCll E1-l5 y'Cll'l'"l|lIll'lg, CIIEIFFHOEB =:'5ll'lCi l3fy"l"E.*~iiE:l
D Extensor sites were affected
E Rustules were present
Explanation
This is eczema herpeticum. Lesions may affect the face and constitutional symptoms may be
present with both bacterial and I-ISV infection. Lesions present at different stages is one of
the features of llSy infection. Seyere eczema may affect extensor surfaces and both
bacterial and HSy' infection are associated with flare-up of the eczema. Rustules may be
present in both conditions.
Rate this ojuestion:
You are writing a departmental advice sheet on scabies. Which is the MOST appropriate
recommendation for the treatment period?
A Wash all clothes. towels and bed-linen at the start of treatment
B Apply treatment only from the neck downwards
C Reapply treatment each time the hands are washed
D Use a benzyl benzoate lotion
E Use an alcohol-based preparation
Submit
L |
D Use a benzyl benzoate lotion
E Use an alcohol-based preparation
Explanation
When treating scabies the lotion must be reapplied eyery time the hands are washed. If not,
this is a common cause of treatment failure. Clothes, towels and bed-linen should be washed
at the end of treatment. if there are lesions on the head then treatment will not be successful
unless the lotion is applied to these lesions. Benzyl benzoate is not recommended for
treatment of children because it is an irritant and is less effectiye than malathion-based
treatments. Alcohol-based preparations tend to sting and are therefore not recommended
for use in children.
An S-year-old girl presents with a l-day history of urticarial rash.
in your adyice to the girl and her parents, what would you be MOST likely to say?
A The rash may be due to a yiral infection
B lndiyidual lesions tend to last for fa 24 hours and then resolye
C Cool bedroom temperatures help to improye symptoms
D Aspirin helps symptoms
E A causal agent is identified in 90% of cases

B lndiyidual lesions tend to last for P 24 hours and then resolye
Explanation
Viral infections are a common cause of urticarial rashes. lndiyidual lesions typically are short-
liyed and last less than 24 hours. Urticaria can be due to or can be made worse by cold
temperatures. Salicylic acid is a cause of urticaria. About 50% of cases of urticaria are
Explanation
yiral infections are a common cause of urticarial rashes. lndiyidual lesions typically are short-
liyed and last less than 24 hours. Urticaria can be due to or can be made worse by cold
temperatures. Salicylic acid is a cause of urticaria. About 50% of cases of urticaria are
idiopathic.
Rate this ::|uestion:

A 9-month-old boy has a 4-month history of a fine, white, scaly rash that is most prominent
on the e.x.tensor surfaces of his limbs and spares the flexures but also affects the trunk. His
face and neck are not affected.
Which of the following is most likely?
A ichthyosis yulgaris
B Lamellar ichthyosis
C Rsoriasis
D Recessiye ><-linked ichthyosis due to steroid sulphatase deficiency
E Treatment with acitretin is reduired
Submit
B Lamellar ichthyosis
C Psoriasis
Explanation
ichthyosis yulgaris is present in l in 250 people and is the commonest and most mild form of
ichthyosis. it typically presents between 3 months and 6 months of age and shows flexural
sparing. ><-linked ichthyosis presents in the first few weeks of life and the scales are large
Explanation
ichthyosis yulgaris is present in l in 250 people and is the commonest and most mild form of
ichthyosis. it typically presents between 3 months and E5 months of age and shows flexural
sparing. ><-linked ichthyosis presents in the first few weeks of life and the scales are large
and brown, affecting the neck. Many children with lamellar ichthyosis are born as collodian
babies; the scales tend to be large and plate-like and in infancy erythroderma is usually
present. Erythema will be present with psoriasis.
A baby is born at term with absent skin on both feet to mid-calf. There is no family history of
note. You are called to see the baby in the Neonatal Unit and talk to the parents.
You are most likely to:
A Counsel that this type of epidermolysis bullosa is fatal
B Coyer the affected areas in cling film
C Explain that the diagnosis is epidermolysis bullosa simplex
D Explain that this is due to a defect in keratin l4
E Take off all monitoring electrodes immediately
Submit
C Explain that the diagnosis is epidermolysis bullosa simplex
Explanation
It is important to remember that you cannot tell the type of epidermolysis bullosa (EB) by
looking at the lesions, although this type of presentation is strongly suggestiye of dystrophic
EB due to a collagen yll defect. EB simplex commonly has an autosomal dominant
inheritance and only rare forms are autosomal recessiye. They are associated with keratin 5
and keratin l4 defects. If electrodes are in place these should be gently remoyed with
Explanation
It is important to remember that you cannot tell the type of epidermolysis bullosa (EB) by
looking at the lesions, although this type of presentation is strongly suggestiye of dystrophic
EB due to a collagen yll defect. EB simplex commonly has an autosomal dominant
inheritance and only rare forms are autosomal recessiye. They are associated with keratin 5
and keratin l4 defects. If electrodes are in place these should be gently remoyed with
WSR/LR 50:50 or Appeel spray. Initial management is to protect the skin, including coyering
it with cling film if more sophisticated dressings are not ayailable.
Rate this guestion:
A 3-year-old girl presents with a l-week history of yellow-brown crusted lesions on her face
arms and legs, and you make a diagnosis of impetigo.
Which one of the following is most likely to apply?
A Streptococcal infection is the most common cause
B The lesions started as bullae which haye crusted oyer
C The lesions will heal and leaye scars
D Topical Fucidin for l4 days is the treatment of choice
E Towel sharing with her cousin, who has a boil, is the cause
Submit
D Topical Fucidin for l4 days is the treatment of choice
Explanation
Impetigo is more commonly due to Staphylococcus aureus than to streptococcal infection,
although both organisms can be present. Non-bullous impetigo occurs in around two-thirds
of children. Lesions heal without scarring. Topical Fucidin can be used if lesions are relatiyely
localised but only for ? days because of concern about bacterial resistance and sensitisation
resulting in an allergic contact dermatitis. Impetigo is highly contagious and contact with the
towels or sheets of an infected child can lead to spread.
A 4-year-old boy presents with multiple flesh-coloured. dome-shaped papules with central
umbilication.
Which one of the following is correct?
A Aswab should be taken foryiral culture
B Curettage is the treatment of choice
C Lesions are present in clusters
D Secondary bacterial infection is common
E There are lesions on the palms and soles
Submit
in
D Secondary bacterial infection is common
E There are lesions on the palms and soles
Explanation
The lesions are molluscum contagiosum. Ralms and soles are typically spared and common
sites are those where there is rubbing and friction from clothes, such as the neck, axillae and
trunk. Secondary bacterial infection is exceedingly rare. Lesions occur in clusters due to
autoinoculation of yirus to nearby skin. A clear eyidence base for any treatment was lacking
in the Cochrane Reyiew of 2009 and reassurance that the condition will resolye (it lasts 6
months to 4 years) is the first line of management.
A l2-year-old girl presents with generalised excessiye hair growth. most prominent on her
limbs.
Which one of the following is most likely?
A Ciclosporin was started to control her eczema S months ago
B Her excessiye hair growth is associated with hereditary gingiyal hypertrophy
C She is on phenytoin to control seizures
D She has polycystic oyarian syndrome
E There is a Beckers naeyus present
Submit
D She has polycystic oyarian syndrome
E There is a Beckers naeyus present
Explanation
Hypertrichosis occurs in 5-l2% of patients on phenytoin and is most prominent on the
extremities. Hypertrichosis is excess hair growth, whereas hirsutism is the deyelopment of
male-pattern-dependent hair growth, as seen in polycystic oyarian syndrome. A Beckers
naeyus is associated with localised hypertrichosis in the naeyus. With ciclosporin, typically
hair growth is diffuse and begins within 2-4 weeks of starting the drug. Hereditary gingiyal
fibromatosis is associated with yariable hypertrichosis occurring on the eyebrows, face,
limbs and mid-back.
r_'I-'|.'I".|-1 'I"I-\.Ir~ .|-"'-|||.i-:r=I'I.|-In-Hir D.
A l4-year-olcl girl has a S-day history of feyer. general malaise and headache, and has
deyeloped raised oedematous papules which you diagnose as target lesions typical of
erythema multiforme. Which one of the following is most likely?
A Herpes simplex yirus infection is rarely a cause in children
B Lesions are present predominantly on the trunk
C The lesions can be distinguished from urticaria as they are normal in the centre
D The lesions haye an asymmetrical distribution
E The lesions will heal without scarring
Submit
C The lesions can be distinguished from urticaria as they are normal in the centre
D The lesions haye an asymmetrical distribution
Explanation
In erythema multiforme lesions are typically symmetrical and acral, i.e. on the hand, feet and
limbs. HSy is a common cause of erythema multiforme in children, accounting for at least
50% of cases; the lesions typically haye damaged skin in the centre and are dusky and
bullous (in contrast to urticaria, where the centre of the lesion is normal). Erythema
multiforme lesions heal without scarring.
You are undertaking a routine E5-week check in the community and examine a S-week-old
baby with a l.5-cm strawberry naeyus on the left upper eyelid which according to the
mother has been present since 3 weeks of age and is oiaseryed to be growing guite rapidly
Which of the following is most appropriate course of action?
A Book a follow-up appointment for 4 weeks time
B Refer for an urgent MRI scan to look for RHACES syndrome
C Refer for laser therapy
D Refer to the ophthalmologists
E Start treatment with oral propranolol

E Start treatment with oral propranolol
Explanation
Haemangiomas affecting yital structures such as the eyelids need yery careful eyaluation
and referral to a centre of expertise, including ophthalmology. This lesion is growing duite
rapidly and the concern is that the yision will be affected. RHACES syndrome is usually
associated with posterior fossa malformations, large facial haemangiomas, arterial
anomalies, coarctation of the aorta and other cardiac defects, eye abnormalities (including
glaucoma) and sternal defects. Rropranolol has been used to treat haemangiomas but only
in specialised centres and trials are ongoing. Laser therapy is difficult on the eyelids because
of the danger of damaging the eye.
Rate this ojuestion:
A 6-year-old girl presents with a S-month history of widespread, itchy, excoriated papules
that are symmetrically distributed and predominantly affecting the extensor surfaces of the
elbows and knees. Thero aro also less prominent patches on the trunk. The face is spared
and she is otherwise well.
Which one of the following is correct?
A A moderately potent topical steroid should be used
B Ciclosporin is the treatment of choice
C Coeliac antibodies should be measured
D Darrier's sign will be positiye
E This is a classic presentation of chronic bullous disease of childhood

f I
D Darriers sign will be positiye
E This is a classic presentation of chronic bullous disease of childhood
Explanation
This is dermatitis herpetiformis associated with gluten-sensitiye enteropathy and coeliac
antibodies should be measured. Females are more commonly affected in childhood. Chronic
bullous disease of childhood characteristically presents in a preschool child with a string of
pearls being the characteristic lesion and facial inyolyement common. Ciclosporin and a
moderately potent topical steroid would be used to treat atopic eczema. Darriers sign
(where the skin urticates when it is stroked) is positiye in urticaria pigmentosa.
A l4-year-olcl girl who has had atopic eczema since she was S months old presents to the
Outpatient Department iaecause her parents are worried about a number of skin changes
and are wondering if these could be caused by topical steroid ointments.
Which of the following is most likely to be present due to her eczema, rather than as a side-
effect of treatment?
A Easy bruising
B Hypopigmentation
C Skin atrophy and thinning
D Striae
E Telangiectasia
C Skin atrophy and thinning
D Striae
E Telangiectasia
Explanation
These are all potential side-effects of topical steroid therapy, usually when too high a
potency has been used or inappropriate amounts applied. FTU or fingertip unit application is
what is recommended, with caution, in delicate areas such as the face. Hypopigmentation
can occur in eczema and is a post-inflammatory response, in contrast to the total
depigmentation which is seen in yitiligo. Chronic eczema causes lichenification of skin, where
the epidermis is thickened, and not skin atrophy.
A ?-year-old boy presented with a l-year history of two thickened, discoloured nails on his
left foot.
Which of the following is rnost appropriate?
A Cutting of these two nails with a separate pair of scissors from that used for the
others
B Ensuring that the family dog is treated for fungal infection
C l\lo treatment, as there is a high incidence of spontaneous resolution
D Remoyal of the affected nails by the surgeons
E Treatment with an antifungal nail lacduer for 2 months

----._--_. _.._._--_.-.--__I,-_.-.____.|_|_._._--_-__.
B Ensuring that the family dog is treated for fungal infection
C l\lo treatment, as there is a high incidence of spontaneous resolution
E Treatment with an antifungal nail lacojuer for 2 months
Explanation
E Treatment with an antifungal nail laccjuer for 2 months
Explanation
This is fungal nail infection. Oral antifungal treatment will be needed, either with griseofulyin
or an azole for seyeral weeks. Treatment with antifungal nail laccjuers is used if oral
treatment is contraindicated but will be needed for at least 6-l2 months and is associated
with a low cure rate. Most fungal nail infection is due to a Trichophyton species, which shows
human-to-human spread. Although a few types of dermatophyte infection are self-limiting,
most recjuire treatment. Remoyal of the nail has been done in the past for treatment failures
(in combination with antifungal treatment), mainly in adults. A separate pair of scissors is
needed to preyent infection spreading to the other nails.
E7... ..".3.-
You reyiew a 9-month-old boy who on examination appears to haye multiple blisters
especially of the feet and knees. His mother explains that blisters started appearing on the
knees and palms since starting crawling, and that his father and uncles also had a similar
condition.
This disease is caused by dysfunction at which site in the skin anatomy?
A Dermo-epidermal junction
B Epidermis
C Papillary dermis
D Reticular dermis
E Subcutaneous tissue
B Epidermis
C Papillary dermis
D Reticular dermis
Explanation
The answer; is Derrno--ejiai'cierrn.al ji.rric;ii'ori (O,i.aiioii
Epidermolysis bullosa sim BI-it HE rm gr up ne ye

Explanation *3-
I -
_| I I
I
This ari..~-."i--1:--"tar is C1e.riii:;i-isy'a_.-"r.i'pi".iiiii l' ,i:ri"'icfi'ia_.-i r'CI=_pri:ari
Epidermolysis bullosa simplex (EBS) is the commonest form of a group of connectiye

tissue diseases characterised by blistering of the skin and mucosal membranes,
especially at sites of friction. It is caused by a mutation affecting genes coding for
keratin l4 and 5 and is inherited in an autosomal dominant manner. The site of pathology
is at the dermo-epidermal junction resulting in weakness and blistering.
Epidermis (Option B) is incorrect. Although the epidermis is affected (with shedding and
blistering as seen in the case), its main function is to proyide a waterproof coyering to the
tissues underneath. It is not the primary site of weakness in EBS.
Papillary dermis (Option B) is incorrect. The papillary dermis is characterised by small

rounded protuberances (papilla) and is the top layer of the dermis. It contains multiple
capillaries and its primary function is of nutrient supply to the skin layers. it is not inyolyed in
EBS.
Epidermis (Option B) is incorrect. Although the epidermis is affected (with shedding and
blistering as seen in the case), its main function is to proyide a waterproof coyering to the
tissues underneath. It is not the primary site of weakness in EBS.
Papillary dermis (Option B) is incorrect. The papillary dermis is characterised by small

rounded protuberances (papilla) and is the top layer of the dermis. lt contains multiple
capillaries and its primary function is of nutrient supply to the skin layers. it is not inyolyed in
EBS.
Reticular dermis (Option D) is incorrect. The reticular dermis is the inferior layer of the
dermis and is characterised by rich yasculature and also contains the base of hair follicles
and sweat glands. Although it does function as proyiding strength to the skin, it is not the
primary site of pathology in EBS.
Subcutaneous tissue (Option E) is incorrect. The subcutaneous tissue is mainly made up of

fat and functions as insulation and allows for the passage of blood yessels and neryes. Its
primary function is not structural and it is not affected in EBS.
You reyiew a 4-year-old boy who had been preyiously admitted under the orthopaedic team
following a fall off his bike when he sustained a fracture together with a skin laceration. On
examination you note a raised area at the site of injury and diagnose a keloid scar.
This finding is a result of excess actiyity of which type of cell?
A Eosinophils
B Erythrocytes
C Fibroblasts
D Macrophages
E Neutrophils
D Macrophages
E Neutrophils
Explanation
The correct r-iiisi--irer is Fi'larciiai'asfs (C3,cifi'cli'i C).
l<eloid scars are common phenomena and are characterised by a raised thickened area
at the site of preyious skin injury, which extends beyond original margins. These are
more commonly found in darker-skin indiylduals and often do not regress
spontaneously. The principle underlying mechanism is of excess collagen production
and as such fibroblasts play a central role.
_..._._._ __._--..._._._._.___|_-_.H||. _. __.-_._..._._.
Eosinophils (Option A) is incorrect. They play a central role in immunity to parasites and are
also key part of hypersensitiyity reactions such in allergy and asthma. They do not produce
collagen and do not play a central role in scar formatipn as seen in the case.
Erythrocytes (Option B) is incorrect. Although increased blood supply to areas of damaged

skin is an early feature of skin healing, the principle role of erythrocytes is oxygen carriage,
and thus they do not play a part in collagen and scar formation.
Macrophages (Option D) is incorrect. The principle role of macrophages is as part of the
innate immune system and in this role they play a key part in normal skin healing. Their role
howeyer is in phagocytosis of damaged cells and bacteria and not collagen production in
scar formation.
Neutrophils (Option E) is incorrect. These are a central part of the innate immune system,
haying a role in phagocytosis and degranulation in response primarily to bacterial infections
They do not produce collagen and thus are not thought to be central to scar formation.
C Papillary dermis
D Reticular dermis
Explanation
The arlswer is Erai'deriiii's (Cliafr'ciri El)-
The child in the scenario has presented with symptoms suggestiye of diabetic
ketoacidosis, probably as a first presentation of diabetes meliitus type i. This is
associated with yitiligo, which explains the well-demarcated hypopigmentation. Vitiligo
1 J~|.* r" | ~ |'l r"|" 1* I-I l I |i..|l. | II I
In-I II. '- .|. - - . -I. - I .- F .' '- .r- I -'.. I - .- I - - .-'- 4'-I '\.I- I .- . J-d-1 I
I-I '- I I ._ . |' " r -' I -'| ' - ' ' L: l_ I _ r|l._ 1|
if f r it? : f i i'..:- I.-ii i"f la E, ii; l' I1_i"r.f'.-" 1' i i'=._a i L_:'_f_:l t if L: f i t__i y .
The child in the scenario has presented with symptoms suggestiye of diabetic
ketoacidosis, probably as a first presentation of diabetes meliitus type i. This is
associated with yitiligo, which explains the well-demarcated hypopigmentation. Vitiligo
is a condition of autoimmune aetiology affecting the melanocytes. Melanocytes reside in
the epidermis.
Dermo-epidermal junction (Option A) is incorrect. The junction separating the dermal and
epidermal layers plays a mainly structural role and is important for skin integrity. It does not
contain melanocyte cells which play a central role in skin pigmentation as seen in the aboye
CElSE'.
Papillary dermis (Option C) is incorrect. The papillary dermis is characterised by small

rounded protuberances (papilla) and is the top layer of the dermis. it contains multiple
capillaries and its primary function is of nutrient supply to the skin layers. The dermis
contains fibroblast cells, rather than melanocytes which are inyolyed in the skin
pigmentation aboye
B
P
Dermo-epidermal junction (Option A) is incorrect. The junction separating the dermal and
epidermal layers plays a mainly structural role and is important for skin integrity. It does not
contain melanocyte cells which play a central role in skin pigmentation as seen in the aboye
C5515.
Papillary dermis (Option C) is incorrect. The papillary dermis is characterised by small

rounded protuberances (papilla) and is the top layer of the dermis. it contains multiple
capillaries and its primary function is of nutrient supply to the skin layers. The dermis
contains fibroblast cells, rather than melanocytes which are inyolyed in the skin
pigmentation aboye.
Reticular dermis (Option D) is incorrect. The reticular dermis contains multiple fibroblast
cells and as such its principle function is to sustain the epidermis by proyiding a network of
collagen fibres. it does not contain melanocytes which are inyolyed in skin pigmentation.
Subcutaneous tissue (Option E) is incorrect. The subcutaneous tissue consists primarily of

fat and proyides an insulation layer under the top two layers of the skin. lt contains no
melanocytes and is thus not inyolyed in skin pigmentation.
You reyiew a S-year-old boy who has been referred due to a long history of oyerheating in
the summer. You note a thin male with frontal bossing and coarse sparse hair, together with
areas of hypopigmentation. On examination of the oral cayity you find seyeral peg-shaped
teeth with loss of the incisor teeth. You also note that his father has seyeral similar features.
With regards to the syndrome in question, which embryological germ layer is affected?
A Ectoderm
B Endoderm
C Intermediate mesoderm
D Neural crest cells
E Paraxial mesoderm
B Endoderm
C intermediate mesoderm
D Neural crest cells
E Paraxial mesoderm
Ex p I a n a t i o n
Tile i?iris"w'er' is Ecto derrri (Op ficin .Ajji
The child presents with seyeral featu IIDCI dy l"lC he YE

Th e i i-s e r is Ec f :a cf ri ii ifICi ia frcl ii J.
The child presents with seyeral features that point to dysfunction in the deyelopment of
the ectoderm (skin, nails, sweat glands, teeth). Ectodermal dysplasia (ED) is a group of
inherited syndromes that are inherited in either an autosomal dominant or a recessiye
manner. There are seyeral methods of classification but they haye in common features
which affect the ectodermal germ layer. The ectoderm is the germ layer which forms the
outer layer of the embryo and deyelops structures which are affected in the boy.
Endoderm (Option B) is incorrect. The endoderm is important in forming the digestive

system as well as the pancreas and bladder. Cells from the endoderm do not play a role in
connectiye tissue formation in skin and nails and thus the endoderm is not inyolyed in ED.
intermediate mesoderm (Option C) is incorrect. The intermediate mesoderm contributes to

the production of the kidneys and the gonadal system. Cells from the mesoderm are not
inyolyed in skin and nail formation, which are affected in ED.
Neural crest cells (Option D) is incorrect. The neural crest cells form from the precursors in
wnicn aiiec: tne ectodermal germ layer. ine ectoderm is tne germ layer wnicn iorms ine
outer layer of the embryo and deyelops structures which are affected in the boy.
Endoderm (Option B) is incorrect. The endoderm is important in forming the digestiye

system as well as the pancreas and bladder. Cells from the endoderm do not play a role in
connectiye tissue formation in skin and nails and thus the endoderm is not inyolyed in ED.
Intermediate mesoderm (Option C) is incorrect. The intermediate mesoderm contributes to

the production of the kidneys and the gonadal system. Cells from the mesoderm are not
inyolyed in skin and nail formation, which are affected in ED.
Neural crest cells (Option D) is incorrect. The neural crest cells form from the precursors in
the ectoderm, which is inyolyed in skin and nail formation. Howeyer, they go on to
differentiate to precursors of the neryous system and are thus not the cells affected in ED.
Paraxial mesoderm (Option E) is incorrect. The paraxial mesodermic cells are important in
the deyelopment of the skeletal system. They are not inyolyed in skin and nail formation and
are thus not the primary site of pathology in ED.
You reyiew a l5-year-old girl who is being treated with cyproterone acetate for seyere
comodonal and papular acne lay her OP-
This drug acts by inhibiting which of the following enzymes?
A l?-alpha-hydroxylase
B Aldosterone synthetase
C Aromatase
D P450 cholesterol side chain cleayage
E Peroxidase
Submit
B Aldosterone synthetase
C Aromatase
D P450 cholesterol side chain cleayage
E Peroxidase
Ex p I a n a t i o n
The correct answer is i7-iallalia-hyclr;d.i:yl.ase ('Opfr'ori .A)
| I -I ~ II r' :l -I I |.* I
vH- - _-'.._ ___'__ |-l- _- . r _-I. __.._ I-I -1. .- __ I. __. . .- - . . I "I-II .1... r .... III. -1. ii. . I. ... Iil . 9 .l __ I. -r- _ .I_ ."-- -._-'I| __ -IL |- I. __. . __'-1 ll
if fr i if" i-. Lil" f i.-Fl... I ri ." fl: i--"tr t:". l'.t:- ."' Ell. . " :'.' .-" .f..il' .i:'f " 5 T]-I '1 i T _";l."J..'- I::".'ri.'.-lf:- if i f-_x' r"..-1 : . i._.' l' 1'
I -|.- - I .-'
.i'-
Cyproterone acetate is a synthetic steroidal anti-androgen, which is used in resistant

acne in females, especially if there are concurrent problems of excess androgen
production such as hirsutism. in this regard, it acts to inhibit enzymes important in
androgen production. l?-alpha-hydroxylase acts upon pregnenolone, aiding in the
addition of a hydroxyl group (OH) to form l?-OH pregnenolone (a precursor in the
androgen pathway).
Aldosterone synthetase (Option B) is incorrect. lt is inyolyed in the mineralocorticoid

pathway which leads to the formation of aldosterone and is thus unaffected by cyproterone
acetate.
Aromatase (Option C) is incorrect. Although aromatase is inyolyed in the androgen

pathway, it acts to conyert testosterone to estradiol, and thus its inhibition would lead to an
increase in androgen leyels.
P450 cholesterol side chain cleayage (Option D) is incorrect. This acts as the primary step in
Aldosterone synthetase (Option B) is incorrect. lt is inyolyed in the mineralocorticoid
pathway which leads to the formation of aldosterone and is thus unaffected by cyproterone
acetate.
Aromatase (Option C) is incorrect. Although aromatase is inyolyed in the androgen

pathway, it acts to conyert testosterone to estradiol, and thus its inhibition would lead to an
increase in androgen leyels.
P450 cholesterol side chain cleayage (Option D) is incorrect. This acts as the primary step in
cholesterol breakdown to form pregnenolone. This is the common step in all three
production pathways (mineralocorticoid, glucocorticoid and androgen), and thus its
blockage would be too widespread in its effect.
Peroxidase (Option E) is incorrect. Peroxidases are important in thyroid hormone function
and are not inyolyed in androgen production.
Rate this question:

You see a i0-year-old girl who presents to Accident and Emergency with an extremely itchy
rash, which according to the mother has come and gone" oyer the past few weeks. On
examination you note a distressed girl with a pruritic papuloyesicular rash affecting both
elbows and back.
Which inyestigation would decipher the underlying condition of the aboye rash?
A Abdominal ultrasound
B Glucose tolerance test (OTT)
C lgA ariti-transglutaminase antibodies
D Rectal tissue biopsy
E Thyroid isotope scan

D Rectal tissue biopsy
E Thyroid isotope scan
Explanation
The answer is lg.-A anfi'-frarxsglufarni'ria.se an-rr'iaooi'es (Option C)-
Dermatitis herpetiform consists of an extremely itchy, chronic, papuloyesicular rash
which symmetrically affects extensor surfaces and back. It fluctuates in intensity based
on gluten ingestion and diet. The underlying condition is of coeliac disease with an
autoimmune aetiology and cross-reactiyity causing the rash described in the girl. An
anti-transglutaminase blood test would demonstrate lgA and lgO antibodies and is an
ideal, simple inyestigation for the diagnosis of coeliac disease.
Abdominal ultrasound (Option A) is incorrect. The underlying condition leading to the girls
presentation is of coeliac disease with an autoimmune aetiology and cross reactiyity causing
the rash described. Abdominal ultrasound would not be the most suitable inyestigation for
diagnosing this as specific bowel changes would not be demonstrated.
Glucose tolerance test (GTT) (Option B) is incorrect. This test is used for the diagnosis of
glucose intolerance and is primarily used in the diagnosis of suspected diabetes meliitus
(DM). The underlying condition in this case does not present with glucose intolerance and
thus this would not be a suitable test.
Rectal tissue biopsy (Option D) is incorrect. This is useful in obtaining pathology samples.
Although a rectal tissue sample might show some changes associated with the girl's
condition (yillus atrophy and crypt hypertrophy), it is more suitable for the diagnosis of
inflammatory bowel disease.
Thyroid isotope scan (Option E) is incorrect. Thyroid isotope scanning plays a yital role in
diagnosis of thyroid dysfunction, specifically of hyperthyroidism. Thyroid dysfunction is not
associated with the girls skin lesion and thus this inyestigation would not be warranted as
first line in this case.
An l9-month-old boy presents to Accident and Emergency as his mother is concerned that
he is haying symptoms of itching, being yery upset and unsettled. There is no feyer. On
examination an itchy. papular rash is seen on the palms of his hands as well as in the groin
region. She explains that his sister also has similar symptoms.
What is the likely cause?
A Herpes simplex yirus type l (HSy-i)
B Human papillomayirus (HPy)
C Poxyirus
D Sarcop tes scablel
E Staphylococcal infection
E Staphylococcal infection
Explanation
The correct .ansi.-yer is Sarcopfes scabiei (Op tron D).
The boy in the scenario presents with a pruritic rash affecting the palms of the hands
and also the groin. The fact that his sister is showing similar symptoms is an indication of
its infectiyity. The Sarcoptes scabief homi'ni's mite burrows into the webs of fingers and
the sides of digits as seen in the child.
Herpes simplex yiral infection type i (HSy'-l; Option A) is incorrect. This can affect this age
group but would usually present with a yesicular perioral rash with associated erythema.
This does not fit the description of a pruritic rash seen in the boy.
Herpes simplex yiral infection type l (HSy-i; Option A) is incorrect. This can affect this age
group but would usually present with a yesicular perioral rash with associated erythema.
This does not fit the description of a pruritic rash seen in the boy.
Human papillomayirus (HPy; Option B) is incorrect. Cutaneous human papillomayirus

infection causes warts, which can form dome and fleshy shaped lesions on the palms of the
hands, but these are not usually itchy. Similar to the causatiye agent in the boy they are
contagious.
Poxyirus (Option C) is incorrect. The poxyirus causes molloscum contagiosum which
presents as dome-shaped lesions anywhere on the body, rather than specifically in palms of
hands or finger webs as seen in the boy. Poxyiruses are also yery infectious.
Staphylococcal infection (Option E) is incorrect. This causes impetigo, which presents with
yellow discharge and underlying erythema. Impetigo is not usually itchy, and can present on
any part of the body, rather than the specific areas seen in the boy.
Rate this cjuestion: Q

You are called to reyiew a newborn by a concerned midwife. She explains that the
pregnancy was a low-risk pregnancy with normal scans throughout. She is concerned as on
examination she has found a patch of poor hair growth. You note a 0.5 cm circular, well-
demarcated area of no hair growth with a layer of scar tissue at its base. The rest of the
examination is unremarkable.
What is the likely diagnosis?
A Alopecia ariata
B Aplasia cutis
C Telogen effluyium
D Tinea capitis
E Trichotillomania
C Telogen effluyium
D Tinea capitis
E Trichotillomania
Explanation
The correct answer is Aiafiasila ctifis (Cljiafipii B)-
The newborn baby is described to haye been born with a well-defined area of skin
abnormality and associated loss of hair. Aplasia cutis congenita is present from birth and
fits the description giyen. it describes a relatiyely rare group of disorders of unclear
l' I .1-I I I I ' I :l' I I I -I I I I I"-.. I I II * I I I
T- r--I I-'..I II-F-I ...-I I- .r I-'.|I I_.._ Ira -I.II .-.:I -- I I. II. .I - -I... I".-I ...|I II -r ..- .. .. I-I I :.- -I_'. "- -J_TI| - IIIII I. I.-.I_ . -III
I T .= ii" i-. L.-T T iii... t i".=T ii: i--"1-' 1: T l' La .--'"iT...-'.li.'.T_':-1': T if- Li l. T-.T= [_ I-d=',T..T i'i._.il' 1' lI:,..
The newborn baby is described to haye been born with a well-defined area of skin
abnormality and associated loss of hair. Aplasia cutis congenita is present from birth and
fits the description giyen. lt describes a relatiyely rare group of disorders of unclear
aetiology (but to which genetic links haye been postulated) whereby there is a localised
absence of skin with associatecl poor or no hair growth. It can sometimes be associated
with other abnormalities but is usually a benign solitary lesion. As such treatment is
usually conseryatiye.
Alopecia ariata (Option A) is incorrect. It does present as a well-circumscribed area of hair

loss, as seen in the newborn, but it is not present at birth. There is also usually a family
history and associated symptoms such as nail pitting.
Telogen effluyium (Option C) is incorrect. This is the sudden shedding of hair around 5-5
months following an illness. it is seen in older children and is not present from birth as is the
case in the newborn.
Alopecia ariata (Option A) is incorrect. It does present as a well-circumscribed area of hair
loss, as seen in the newborn, but it is not present at birth. There is also usually a family
history and associated symptoms such as nail pitting.
Telogen effluyium (Option C) is incorrect. This is the sudden shedding of hair around S-5
months following an illness. it is seen in older children and is not present from birth as is the
case in the newborn.
Tinea capitis (Option D) is incorrect. it is secondary to a fungal infection and is usually seen
in older children. The underlying skin is scaly and it is not present at birth as is the case in
the newborn.
Trichotillomania (Option E) is incorrect. This describes the condition whereby a patient pulls
out his or her hair, and it is not a congenital problem. Trichotillomania is thus seen in older
children. Treatment inyolyes a multidisciplinary approach including behayioural therapy.
Rate this guestion:

C Local antibiotic affect
D Reduction in eosinophilic infiltration
E Reduction in neutrophil infiltration
Explanation
The answer is iiidi-icti'oi-i of p_yi"i'ini'di'i"ie di'rneri'safi'oii (Oiafion S)-
Phototherapy with narrow band ultrayiolet light is a relatiyely new therapy for difficult-
to-treat psoriasis and can be combined with topical treatment. Psoriasis is the result of
increased skin turnoyer and thus rapid/uncontrolled growth of the epidermal layer of
-' _
Pi-I
. - . -. ,_ ,.__ .- , :, ,...,.-E ., __,-,.- _., - _,_ L-I-I-III ,-___,-. -"-,_: it _
i fit-'
|'
niis is. iiii...li.iLfi:.iii ,:.-.ii.--iii.ii.-i.i'.i.-lie :.:i.iie.- ift-i,i.-iii:a.ii i_-.i__i-
Phototherapy with narrow band ultrayiolet light is a relatiyely new therapy for difficult-
to-treat psoriasis and can be combined with topical treatment. Psoriasis is the result of
increased skin turnoyer and thus rapid/uncontrolled growth of the epidermal layer of
the skin. In this regard, ultrayiolet light induces small areas of DNA damage with
resultant pyrimidine dimers, which in turn disrupt the cell cycle. This results in slowing of
the rapid cell turnoyer central to the disease.
lncrease in fibroblast (Option A) is incorrect. Fibroblasts play a central role in collagen

production and skin turnoyer. The underlying patholophysiology of psoriasis is that of
increased skin turnoyer and as such increasing fibroblast actiyity would haye a
counterproductiye role.
Local antibiotic affect (Option C) is incorrect. Psoriasis is the result of increased skin
turnoyer and thus rapid/uncontrolled growth of the epidermal layer of the skin rather than
an infectiye process. As such its treatment is not directed towards antibiotics.
FT-Il. I I' ' ' I 'I' ' I.-'II I .|I'.|I""1-|. .I' F_"I|."Is ' I ""'I_I I II ' II I ' I
Increase in fibroblast (Option A) is incorrect. Fibroblasts play a central role in collagen
production and skin turnoyer. The underlying patholophysiology of psoriasis is that of
increased skin turnoyer and as such increasing fibroblast actiyity would haye a
counterproductiye role.
Local antibiotic affect (Option C) is incorrect. Psoriasis is the result of increased skin
turnoyer and thus rapid/uncontrolled growth of the epidermal layer of the skin rather than
an infectiye process. As such its treatment is not directed towards antibiotics.
Reduction in eosinophilic infiltration (Option D) is incorrect. The underlying pathophysiology
of psoriasis is an increased skin proliferation and turnoyer rather than an infectiye or
autoimmune destructiye process. As such eosinophilic infiltration does not play a role.
Reduction in neutrophil infiltration (Option E) is incorrect. Psoriasis is the result of increased
skin turnoyer and thus rapid/uncontrolled growth of the epidermal layer of the skin. lt is not
an infectiye process and neutrophil infiltration is not inyolyed. Rather T-helper lymphocytes
are inyolyed in the later stages of the pathophysiology.
You are called urgently to reyiew a 2-year-old child who was brought in by ambulance
following an alleged accidental burns injury by hot oil. There is a large burn on the shoulder
and extending to the arm. Specifically, there is a central area of necrosis which is white and
charred. Surrounding this is a pale area of skin and followed by an area of extreme redness
outlining this. You suspect that the burn is a third-degree burn and an urgent transfer to a
burns centre is arranged.
Concerning the histology of such an injury, which layer of skin anatomy would be affected?
A Epidermis and all of the dermis layer
B Epidermis and most of the dermis
C Epidermis and superficial dermis only
D Epidermis only
E Superficial blood yessels only

B Epidermis and most of the dermis
C Epidermis and superficial dermis only
D Epidermis only
E Superficial blood yessels only
Explanation
The ans":--yer is iEiai"'rie"-i"n"ii'-s and all of the cierrriis i.a_yei" (Oi-ii i'ion )
The depth of burns is an important determinant of outcome. C Cd
W -l""I- l'\-F"I"I-"I'I"I"lI|I-"I"E|'I'I-F"'I'I'
The ..;'ii'i-s i--i.--"er is E_i-;ii'cie'.i"'iiii'.s nri n ii iai iii e :'.iei"'.ini'-s" in yer (Cii.-ii'i'ciii ..-A.__).
The depth of burns is an important determinant of outcome. Classification into first-,

second- and third-degree burns is a useful classification. Third-degree (fullthickness)
burns as seen in the child inyolye all layers of skin (epidermal and dermal). There is a
loss of elasticity which results in the leathery appearance. Third-degree burns do not
heal spontaneously and result in widespread scarring and contractures.
Epidermis and most of the dermis (Option B) is incorrect. Third-degree (full thickness) burns
as seen in the child inyolye all layers of skin (epidermal and dermal) and this is the case in
the patient.
Epidermis and superficial dermis only (Option C) is incorrect. Third-degree (fullthickness)

burns as seen in the child inyolye all layers of skin (epidermal and dermal). Second-degree
burns would affect the epidermis and part of the dermis.
Epidermis only (Option D) is incorrect. First-degree burns affect the epidermis only and
Epidermis and most of the dermis (Option B) is incorrect. Third-degree (full thickness) burns
as seen in the child inyolye all layers of skin (epidermal and dermal) and this is the case in
the patient.
Epidermis and superficial dermis only (Option C) is incorrect. Third-degree (full-thickness)

burns as seen in the child inyolye all layers of skin (epidermal and dermal). Second-degree
burns would affect the epidermis and part of the dermis.
Epidermis only (Option D) is incorrect. First-degree burns affect the epidermis only and
result is reddening of the skin and some pain. The aboye scenario describes all skin layers
being affected.
Superficial blood yessels only (Option E) is incorrect. If only superficial layers of the skin are
affected this would be classed as a first- or second-degree burn. The aboye scenario
describes full-thickness burns affecting all layers of the skin.
Rate this guestion:

Theme: Rashes
A Chronic idiopathic urticaria
B Hereditary angioneurotic oedema
C Erythema multiforme
D Steyens-Johnson syndrome
E Erythema nodosum
F Insect bite
G Scalded skin syndrome
H Erysipelas
I Kawasaki disease
J Slapped cheek syndrome
Match the fol/owing three clinical scenarios to one of the clinical diagnoses aboye.
Scenario l
A 4-year-old girl presents to the ASE department with a 3-day history of feyer (39.1
A 4-year-old girl presents to the ASE department with a 3-day history of feyer (5B.4C),
prodromal illness, concurrent malaise and arthralgia. She has recently been commenced
penicillin for a sore throat. On examination, she has characteristic target lesions, which a
macularpapular on palpation, with a surrounding purplish hue and a central erythematoi.
white wheal. These heliotrope papules inyolye the hands, feet and extensor surfaces.
What is the diagnosis?
APISWAFI Select one...
Scenario 2
A l3-year-old girl recently returned from a snorkelling holiday in Malta. She presents acu
with a 5-day history of high feyer, malaise, purulent conjunctiyitis, arthralgia and
photophobia. On examination, she is unwell, with mucositis and inflamed conjunctiy
has swelling of both knees and the left ankle, and a marked non-desduamating rash.
Scenario 2
A l3-year-old girl recently returned from a snorkelling holiday in Malta. She presents acu
with a 5-day history of high feyer, malaise, purulent conjunctiyitis, arthralgia and
photophobia. On examination, she is unwell, with mucositis and inflamed conjunctiyae. S
has swelling of both knees and the left ankle, and a marked non-desciuamating rash.
lnyestigations confirm a right lower lobe pneumonia, hypercalcaemia, hyponatraemia, a
leukocytosis, and a raised C-reactiye (CRP) leyel of 240. This episode resolyed with freci
benzydamine hydrochloride (Difflam) spray, chlorhexidine mouthwashes and a 6-week
course of intrayenous ceftriaxone, acycloyir and clarithromycin, with hydrocortisone
support. The girls ophthalmic lesions were managed with protectiye eye care.
ATTSWEFI Select one... '

AHEWEFI Select one...
Scenario 3
An 6-year-old girl presents with a 2-year history of an erythematous, urticarial, pruritic rash
associated with episodes of stress, heat, cold baths and trauma. On examination, she
appears fit and well with no eyidence of hay feyer, rhinitis, mucosal pleats, asthma or
urticarial rash. All inyestigations are unremarkable, including a moderately low Cl esterase
inhibitor leyel. The girl's symptoms resolye with chlorpheniramine for acute episodes of
urticaria.
Answeri Select one...

Erythema multiforme is a self-limiting and recurring condition that affects the skin and
mucosal surfaces. The disease inyolyes inflammatory eruptions characterised by symmetrical
erythematous, oedematous or bulbous lesions of the skin and mucosal membranes. They
look like target lesions with a purple or pale centre surrounded by red rings from macules
that then form blisters. lnyolyement of the mucosal membranes includes debilitating
stomatitis and conjunctiyitis. Children may suffer from a persistent feyer, malaise,
photophobia and arthralgia.
Causes of erythema multiforme are multiple, but important ones to consider include herpes
simples yirus, iriycopiasrria and orf yirus. Bacterial causes include Streptococcus, iersinia
enterocoii'ti'ca, ll/iycobacteri'umtuberculosis and Salmonella tyjohi/oaratyphi'. Systemic lupus
erythematosus, polyarteritis nodosa and collagen yascular diseases are all autoimmune
disorders. Histoplasmosis, carcinoma, lymphomas and leukaemias may be associated
oncological factors. Important drugs to consider include sulphonamide, penicillin,
barbiturate, sulphonylurea, salicylate, phenytoin, L-dopa and chlorpropamide.
Scenario 2
A TS-year-old girl recently returned from a snorkelling holiday in Malta. She presents acutely
with a S-day history of high feyer, malaise, purulent conjunctiyitis, arthralgia and
photophobia. On examination, she is unwell, with mucositis and inflamed conjunctiyae. She
has swelling of both knees and the left ankle, and a marked non-descjuamating rash.
nyestigations confirm a right lower lobe pneumonia, hypercalcaemia, hyponatraemia, a
eukocytosis. and a raised C-reactiye (CRP) leyel of 240. This episode resolyed with freciuent
oenzydamine hydrochloride (Difflam) spray, chlorhexidine mouthwashes ancl a 6-week
course of intrayenous ceftriaxone, acycloyir and clarithromycin, with hydrocortisone
support. The girl's ophthalmic lesions were managed with protectiye eye care.
There are two clinical alternatiyes that may present as erythema multiforme. There is mild
erythema multiforme that presents with symmetrical target lesions that are non-pruritic and
may be bulbous in nature and resolye after 4-6 weeks. Seyere erythema multiforme may,
howeyer, present as 5teyensJohnson syndrome whereby a seyere erythema multiforme
There are two clinical alternatiyes that may present as erythema multiforme. There is milcl
erythema multiforme that presents with symmetrical target lesions that are non-pruritic and
may be bulbous in nature and resolye after 4-6 weeks. Seyere erythema multiforme may,
howeyer, present as Steyens-Johnson syndrome whereby a seyere erythema multiforme
rash appears with bullae of the mouth, anogenital region and conjunctiyae. Death occurs in
S-20% of cases. Systemic effects include polyarthritis, pneumonia and seyere fluid and
electrolyte imbalance. Treatment options include mouthwashes, antibiotics to treat
secondary infection. steroids, ophthalmic care and intensiye care support.
Scenario 3
An B-year-old girl presents with a 2-year history of an erythematous, urticarial, pruritic rash
associated with episodes of stress, heat, cold baths and trauma. On examination, she
urticarial rash. All inyestigations are unremarkable, including a moderately low Cl esterase
inhibitor leyel. The girls symptoms resolye with chlorpheniramine for acute episodes of
urticaria.
Scenario 3
An B-year-old girl presents with a 2-year history of an erythematous, urticarial, pruritic rash
associatecl with episodes of stress, heat, cold baths and trauma. On examination, she
urticarial rash. All inyestigations are unremarkable, including a moderately low Ci esterase
inhibitor leyel. The girls symptoms resolye with chlorpheniramine for acute episodes of
urticaria.
Chronic idiopathic urticaria is always part of the differential diagnosis for the aboye two
clinical scenarios.
Rate this iauestion: Q

Theme: Photosensitiye rashes
A Neonatal lupus erythematosus
B Juyenile spring eruption
C Hartnup disease
D Z?-{eroderma pigmentosa
E Congenital erythropoietic protoporphyria
F Rothmund-Thomson syndrome
G Bloom syndrome
H Cockayne syndrome
For each chiici described iaeiow with a photosensitiye rash, seiect the MOST iiireiy condition
from the aboye iist. Each option may be used once, more than once, or not at aii.
Scenario l
A 3-month-old girl presents with erythematous scaly lesions on the face after being outside
in the sunlight. Physical examination is otherwise unremarkable.
Ai"i-EWAFI Select one...

E 'i"'%'|'T%3"I_IE I-l'II'EI|'-IF-I
Scenario 2
A 5-year-old boy whose parents are first cousins presents with a history of erythema and
telangiectasia on his face. and the dorsa of the hands and forearms. His mother is concerned
about this because her brother died in this late-SOs with leukaemia. Physical examination
shows his height and weight to be less than the third centile, and well-demarcated areas of
hypopigmentation and hyperpigmentation on his trunk.
AAEWAFI Select one...
Scenario S
A S-year-old boy has recently failed a hearing test for school entry. Examination shows his
height and weight to be below the third centile, as well as cataracts and dental caries_. and
he has difficulty walking.

Scenanoi
A 3-month-old girl presents with erythematous scaly lesions on the face after being outside
in the sunlight. Physical examination is otherwise unremarkable.
Neonatal lupus erythematosus (NLE) may be present at birth but can deyelop a number of
weeks later. It can be induced by Uy light and there haye been a few reports of NLE after
phototherapy for hyperbilirubinaemia.
Scenario 2
A 5-year-olcl boy whose parents are first cousins presents with a history of erythema and
telangiectasia on his face, and the dorsa of the hands and forearms. His mother is concerned
Scenario 2
A S-year-old boy whose parents are first cousins presents with a history of erythema and
telangiectasia on his face, and the dorsa of the hands and forearms. His mother is concerned
Bloom syndrome is an autosomal recessiye condition characterised by growth retardation,

photosensitiyity, pigment abnormalities, and telangiectasia. There is a cancer predisposition
in Bloom syndrome which includes leukaemia and lymphomas. Poikiloderma (atrophic
pigmentary telangiectasia) is characteristic of Rothmund-Thomson syndrome in which the
malignancies tend to be of the skin or bone (osteosarcoma).
Scenario 3
A 5-year-old boy has recently failed a hearing test for school entry. Examination shows his
height and weight to be below the third centile, as well as cataracts and dental caries, and
malignancies tend to be of the skin or bone (osteosarcoma).
Scenario 3
A 5-year-old boy has recently failed a hearing test for school entry. Examination shows his
height and weight to be below the third centile, as well as cataracts and dental caries, and
Cockayne syndrome is an autosomal recessiye condition characterised by growth failure,

progressiye neurological deterioration, dental caries, eye abnormalities including cataracts,
and sensorineural hearing loss. Keroderma pigmentosum is an autosomal recessiye condition
characterised by extreme photosensitiyity, freckling and skin malignancy in infancy.
Neurological complications occur in 20%. Eye abnormalities include loss of lashes, ectropion,
photophobia, conjunctiyal telangiectasia and corneal abnormalities.
Rate this iauestion:

Theme: Blistering disorders
A Herpes simplex yirus infection
B Dermatitis herpetiformis
C Erythema multiforme
D Epidermolysis bullosa
E Chronic bullous disease of childhood
F Hand_, foot and mouth disease
G Pompholyx
H Pemphigus foliaceus
For each chiid described below with a i:>iisteri'ng disorder_. seiect the MOST iiireiy condition
from the iist aboye. Each option rnay be used once, more than once, or not at aii.
Scenaoi
A 4-year-old boy presents with a l-week history of tense blisters in groups on the abdomen
and buttocks. He has a normal diet and has no past medical history of note. Physical
examination shows lesions in the mouth, no feyer, and no other abnormalities
A 4-year-old boy presents with a l-week history of tense blisters in groups on the abdomen
examination shows lesions in the mouth, no feyer. and no other abnormalities
Scenario 2
An ll-year-old girl presents with a S-day history of tense clear yesicles in a bilateral
distribution affecting the sides of her toes and soles of the feet. She has had three preyious
episodes. She had mild flexural eczema until she was 3 years of age. Physical examination is
otherwise normal and she is apyrexial.
AHEWETI Select one...
Scenario 3
A14-month-old boy presents with a history of tense small blisters on the hands and feet for
the last 2 months. Physical examination shows no other abnormalities. He is noted to be
deyeloping normally.
examination shows lesions in the mouth, no feyer, and no other abnormalities
Chronic bullous disease of childhood is also known as linear immunoglobulin A disease. it

typically presents in children aged oyer 3 years with tense small (i-3 mm) blisters on an
erythematous background. Lesions characteristically affect the perianal area and spread to
the trunk, thighs, limbs, hands and feet. There may be mucosal lnyolyement of the mouth,
the genitals, and eyes and nose. Lesions usually appear abruptly but may present as a
pruritic rash oyer a number of weeks. Dermatitis herpetiformis tends to present later than
chronic bullous disease of childhood and affects symmetrically the elbows, knees and
buttocks. Mouth lnyolyement is rare. Herpes simplex yirus infection would usually be a
primary one with mouth and other sites of the body affected and the child would be
expected to haye constitutional symptoms including feyer. Pemphigus is yery rare in
childhood and tends to occur in adults in middle age. In pemphigus foliaceus, mucous
membranes are rarely affected and mouth lesions are atypical. In erythema multiforme the
esions are symmetrical red papules, some of which form target lesions and blister. Mouth
esions may be present.
Scenario 2
An ll-year-old girl presents with a 3-day history of tense clear yesicles in a bilateral
distribution affecting the sides of her toes and soles of the feet. She has had three preyious
episodes. She had mild flexural eczema until she was S years of age. Physical examination is
otherwise normal and she is apyrexial.
Pompholyx is rare in children aged less than 10 years. It is characterised by sudden onset of
crops of clear yesicles and is usually bilateral, affecting the sides of fingers and toes, palms
and soles. A history of preyious episodes is common. It is commonly found in children who
haye a personal or family history of atopy. Hand, foot and mouth disease is characterised by
lesions on the hands and in the mouth. as well as on the feet, and it is not usually recurrent.
Dermatitis herpetiformis can inyolye the palms and soles but usually affects the flexural
aspects of digits rather than the sides and would also usually be found on other sites of the
body.
Scenario S
Dermatitis hercietiterrhis cari ihyelye the calrris ahcl seles leut usually affects the tlesural
asiaects cf cligits rather than the sicies ahci yyeulci alse usually i::>e feuhcrl eh ether sites cf the
heay.
Sceriarie 3
f5w1-4-lT|Ul'"lth-Gilli lacy iaresehts with a histc-ry c~f terise srriall lc-listers eh the haricis ahci feet fer
the last 2 raehths. Physical esarhihatieh shcws he ether F.-E?|lI)I"i'.'IIJii"|"i5|i|IlEE.-. i|e is ric-tecl te be
czleyeleciihg herhhally.
Eeiclerrriclysis iaullc-sa sirricles is lccalisecl tc= trictieh sites, usually the hahcls arici feet, aricl
tyiaically has its chset ih early Chl|IZI|l'iDUCll areuhcl the tirhe the chilcl begins te crawl er Walk.
Rate this ciuesticin: Q

Theme: Hair less
Oetiens:
A. Aleeecia areata
B. Aeiasia cutis cencienita
C. Hyeethyreiclism
D. Pachyenychia ceneenita
E. Pseriasis
F. Seleaceeus naeyi
G. Systemic iueus erythematesus
li. Telegen effluyium
l. Tinea caeitis
J. Trichetiliemania
l<. Zinc cleficiency
lnstructiens:
Match the felleyying three clinical scenaries te ene ef the clinical cliagneses listecl aleeye.
Each eetien may he usecl ence_. mere than ence er net at ail.
Scenarie 1
11x12-yearelei eirl eresents te the Paeciiatric Ciuteatient Dee-artment. Fer the last 3 menths
she has hacl seyeral yyellciemarcateei_. circular eatches ef hair less in her scale. She has ne
east meclical histery ef nete hut in the family histery it is netecl that her 22yearelcl lerether
Scenarie 1
A 12-yearelci girl eresents te the Paecliatric Outeatient Deeartment. Fer the last 3 menths
she has hacl seyeral yyeilclemarcateci_. circular eatches ef hair less in her scale. She has ne
east meclical histery ef nete hut in the family histery it is neteci that her 22yearelci hrether
has eeen similarly affectecl. She has hacl ne ereyieus skin ciiserclers. On esaminatien, she has
seyeral ealcl eatches. seme measuring seyerai centimetres in ciiameter. ancl eitting ef all ef
her fingernails.
AABWE-"i"I Select ene...
Scenarie 2
A 3-year-elci ieey eresents te the Ciuteatient Deeartment yyith a 2menth histery ef eatches
ef hair less. There is ne family histery ef nete. On esaminatien, he has a yyellciemarcatec| 5-
cm eatch ef hair less with milcl scaling ancl erythema ef the scale in the right earietal area
ancl seyeral ether eatches all measuring less than i cm.
AAEWEFI Select ene...
Scenarie 3
A i-4 year elci girl eresents te the Outeatient Deeartment yyith a histery ef hair iess. This
IICI III |"_-:;|'E'.'l I ICJEII-III.
AHEWEFI Select ene...
Scenarie 2
A 3yearelcl hey eresents te the Outeatient Deeartment with a 2menth histery ef eatches
ef hair less. There is ne family histery ef nete. Cln esaminatien, he has a wellciemareatecl S-
ancl seyeral ether eatches all measuring less than i cm.
AHBWEFI Select ene...
Scenarie 3
A 14 year ele girl eresents te the Cluteatient Eleeartment with a histery ef hair less. This
eegan 6 menths age when she neticeel that her eillew was ceyerecl in hair in the merning
ancl that mere fell eut than usual when she was cemeing her hair. Aleeut S menths age she
hacl seyere glanciular feyer fer which she was heseitalisecl. She feels that the hair less is net
getting any werse. On esaminatien. there is generalisecl thinning ef the hair. leut ne lealel
eatches, ancl the scale is nermai.
Ant-weri Select ene...

Scenanel
A i2yearelcl girl eresents te the Faecliatric Outeatient Deeartment. Fer the last S menths
she has hacl seyeral wellclemarcatecl, circular eatches ef hairless in her scale. She has ne
east meclical histery ef nete ieut in the family histery it is neteci that her 22yearelel lerether
has eeen similarly affectecl. She has hag ne ereyieus sl<in cliserclers. Dn esaminatien, she has
seyeral iealcl eatches. seme measuring seyeral centimetres in cliameter. ancl eitting ef all ef
her fingernails.
In aleeecia areata hair less is well circumscrileecl ancl the scale is nermai. Nail eitting is
eeseryecl in ?iSS% ef cases. A family histery is reeertecl in 5-2596 ef cases. l\lail changes can
lee feuncl in eseriasis laut this eliagnesis is less lil<ely in this case as there is ne histery ef skin
cliserclers. In eachyenychia cengenita there is ciisceleratien ancl thickening ef the nails,
usually frem the first menth ef life.
Scenarie 2
A 3-year-elci leey eresents te the Outeatient Deeartment with a 2menth histery ef eatches
usually frem the first menth ef life.
Scenarie 2
A 3yearelcl eey eresents te the Cluteatient [Ileeartment with a 2menth histery ef eatches
ef hair less. There is ne family histery ef nete. On esaminatien, he has a wellclemarcatecl S-
ancl seyeral ether eatches all measuring less than 1 cm.
in tinea caeitis, there is hair less ancl yarialele ameunts ef erythema ancl scaling ef the scale.
There are multiele eatches. The scale weulcl lee nermal in trichetillemania, usually with
lecalisecl hair less. in systemic lueus erythematesus there can lee scarring aleeecia with scale
erythema eut it is rare in chilciheecl ancl has a female erecleminance. Aelasia cutis cengenita
ancl seleaceeus naeyi will haye laeen there since leirth.
Scenarie 3
A 14 year elci girl eresents te the Outeatient Deeartment with a histery ef hair less. This
ieegan S menths age when she neticecl that her eillew was ceyerecl in hair in the merning
Scenarie 3
A 14yearelcl girl eresents te the Outeatient Deeartment with a histery ef hair less. This
ieegan S menths age when she neticeci that her eillew was ceyerecl in hair in the merning
ancl that mere fell eut than usual when she was cemlaing her hair. Aeeut Si menths age she
hacl seyere glanciular feyer fer which she was heseitalisecl. She feels that the hair less is net
getting any werse. Eln esaminatien, there is generalisecl thinning ef the hair, l::-ut ne lealel
eatches, an-cl the scale is nermal.
In telegen effluyium there is suclclen increase in hair sheclcling, cliffusely, 3-4 menths after an
inciting eyent. which can inclucle meclical er systemic illness, meclicatiens ancl nutritienal
cleficiencies. Anagen is the grewth ehase ef hair ancl telegen the resting ehase. Areunel 10-
40'?/:5 ef hairs meye raeiclly frem anagen te telegen, causing the shecicling. llyeethyreiclism
ancl zinc cleficiency can therefere lee a cause ef cliffuse hair less leut the mest eleyieus cause
in this case is the glanciular feyer.
Rate this guestien: H

T heme: E:-tanthema
Oetiens:
Drug reactien
. Entereyirus infectieri
. Erythema infectiesum
EesteinElarr yirus
. l\leasles
.Eaeu|ar acreclermatitis
Fleseela infantum
.EueeHa
cresne e
Scarlet feyer
lnstructiens:
lvlatch the fellewing three clinical sceriaries te ene ef the clinical ellagneses listeci aeeye.
Each eetien may he usecl ence, mere than ence er net at all.
Scenarie 1
An 1S-menth-elci leey eresente-cl te the Emergency Deeartment with a cenyulsien. He has a
3--clay histery ef feyer ancl sueeccieital lymehacier'ieeathy. He suiesee|uentIy cleyelees a rese-
eintt macular rash which startecl en his trunl< ancl sereacls te his face ancl limies. His
temeerature is nermal 24 heurs after acimissien.
Arewert Select ene...

-111 -_-I -'I -r I I ' --- L -h- I J -_- I I '1- I -1- I 'l1'I ' I --I -- 'L'I -"- -- -F -- ' |-- ' 'I- --I I ' J I I ' |'l- I - ''I '5" -1' I I -I- ['- L" 'I ' I J I I I -1- -_- 'L'I -"1- --" W-' --| I-1 --" I I 'I- I -F -L-"I -1' - 'I_- I 'I- r1 - -_- -_- -1
eink macular rash which startecl en his trunk ancl sereacls te his face ancl limes. His
temeerature is nermal 24 heurs after aclmissien.
Scenarie 2
A 2-yearel-cl girl eresents te the Emergency Deeartment with a 1-week histery ef feyer ancl
reluctance te eat er clrink. Her GP hag eiagnesecl tensillitis anel treateci her with a S--clay
ceurse ef amesicillin. Cln e:=~:aminatien_, she has yery large tensils. ceryical lymeha-cleneeathy
ancl an erythemateus maculeeaeular rash en her trunk ancl limes.
Ant-weft Select ene...
Scenarie 3
A 2-year-elci leey eresents te the Emergency Eleeartment as he has cleyeleeecl an
erythemateus eaeular rash eh his thighs, leuttecks. ueeer arms ancl cheeks. He has eeee
unwell eyer the last 2 weeks with an ueeer reseiratery tract infectien hut is new well aeart
frem the rash.
Answer: Select ene...

Scenane1
An 18-menth-elci hey eresentecl te the Emergency Deeartment with a cenyulsien. He has a
3-clay histery ef feyer ancl suheccieital lymehacleneeathy. He suhsecluently cleyelees a rese-
eink macular rash which startecl en his trunk ancl sereaels te his face ancl limhs. His
temeerature is nermal 24 heurs after aclmissien.
This is a tyeical histery fer reseela infantum, with the temeerature heceming nermal ence
the rash aeeears.
Scenarie 2
A 2-year-elci girl eresents te the Emergency Deeartment with a 1-week histery ef feyer ancl
reluctance te eat er clrink. Her GP hacl cliagnesecl tensillitis ancl treatecl her with a S-clay
ceurse ef amesicillin. On esaminatien, she has yery large tensils, ceryical lymehacleneeathy
ancl an erythemateus maculeeaeular rash en her trunk ancl limhs.
Scenarie 2
A 2-year-elci girl eresents te the Emergency Deeartment with a 1-week histery ef feyer ancl
reluctance te eat er clrink. Her GE hacl eliagnesecl tensillitis ancl treatecl her with a 5-clay
ceurse ef amesicillin. On e:=-taminatien, she has yery large tensils, ceryical lymehacleneeathy
ancl an erythemateus maculeeaeular rash en her trunk ancl limhs.
Areuncl 30% ef eeeele with EesteinBarr yirus whe are treatecl with amel-ticillin cleyelee an
erythemateus maculeeaeular rash.
Scenarie 3
A 2-year-elci hey eresents te the Emergency Deeartment as he has cleyeleeecl an
erythemateus eaeular rash en his thighs, huttecks, ueeer arms ancl cheeks. He has heen
frem the rash.
Areuncl 30% ef eeeele with Eesteinl3arr yirus whe are treatecl with amesicillin cleyelee an
erythemateus maculeeaeular rash.
Scenarie 3
A 2-year-elci hey eresents te the Emergency Deeartment as he has cleyeleeecl an
erythemateus eaeular rash en his thighs, huttecks, ueeer arms ancl cheeks. He has heen
frem the rash.
This clistrihutien is tyeical ef eaeular acreelermatitis (<SianettiCresti synclreme). It is

cemmener in yeung chilclren (1-6 years), with a male te female ratie ef 2:1. it is a symmetrical
rash ancl can he skin-celeurecl er recl. It is asseciatecl with many yiral infectiens. The rash
characteristically lasts fer 3-13 weeks se it is imeertant te recegnise it ancl te inferm earents
aeereeriately.
Hate this euestien: Q

Theme: Pigmentary changes
Cletiens
A. Ateeic eczema
E1. Cancliela infectien
C. Ei:=-tecl clrug eruetien
D. lncentinentia eigmenti
E. lrlengelian hlue seets
E. Piehalclism
G. Eityriasis resea
li. Pityriasis yersiceler
l. Clculecutaneeus alhinism
J. Seherrheeic clermatitis
I/<1. tfitilige
lnstructiens:
Match the fellewing three clinical scenaries te ene ef the clinical cliagneses listecl aheye.
Each eetien may he usecl ence_. mere than ence er net at all.
Scenarie 1
A 1S-year-elci girl eresents te the Outeatient Deeartment with white eatches ef skin en her
trunk, eyer the estenser surfaces ef her knees anel elhews ancl her fereheael. inyelying her
scale. She clyes her hair hlack. There are eigmentecl macules within the white eatches eyer
her knees ancl elhews. seme ef which are en the hercler hetween the affectecl area ancl
nermal skin. lier hancls ancl feet are searecl. The skin changes haye heen eresent fer as leng
Scenarie 1
A 1S-year-elci girl eresents te the Outeatient [Iieeartment with white eatches ef skin en her
trunk. eyer the estenser surfaces ef her knees ancl elhews ancl her fereheael. inyelying her
her knees ancl elhews, seme ef which are en the hercler hetween the affectecl area ancl
nermal skin. ller hancls ancl feet are searecl. The skin changes haye heen eresent fer as leng
as she can rememher ancl haye grewn with her. ller mether anel granelmether are similarly
affectecl.
Scenarie 2
A 14 year elci Asian girl cemes te the Outeatient Deeartment hecause ef three
hyeereigmente-cl lesiens en her trunk which haye heen eresent fer seyerai weeks. In her east
meclical histery she hacl ateeic ecrema. which reselyecl ley the age ef 2 years ancl has hael
meclerately seyere acne en her face. fer which she receiyecl a ceurse ef tetracycline 4
menths age.
Scenarie 3
affectecl.
Scenarie 2
A 14 year ele Asian girl cemes te the Cluteatient [Ileeartment hecause ef three
hyeereigmentecl lesiens en her trunk which haye heen eresent fer seyeral weeks. in her east
meclical histery she hacl ateeic ecsema. which reselyecl ley the age ef 2 years ancl has hacl
meclerately seyere acne en her face, fer which she receiyecl a ceurse ef tetracycline 4
menths age.
Aflswefi Select ene...
Scenarie 3
A E-}-menth-elci Afre-Carihleean girl attencls the Cluteatient Deeartment hecause ef multiele
hyeeeigmentecl lesiens en her trunk. She cleyeleeecl a rash at 2 menths ef age which
affectecl the face. scale, trunk ancl naekin area. On esaminatien, there is milcl erythema in the
well-clemarcatecl lesiens. which are slightly scaly.

C-ll.-1-2?lI|:1iI IU I
A 1S-year-elci girl eresents te the Cluteatient Deeartment with white eatches ef skin en her
trunk, eyer the estenser surfaces ef her knees ancl elhews ancl her fereheacl, inyelying her
her knees ancl elhews, seme ef which are en the hercler hetween the affectecl area ancl
nermal skin. Her hancls anel feet are searecl. The skin changes haye heen eresent fer as leng
as she can rememher ancl haye grewn with her. Her mether ancl granclmether are similarly
affectecl.
This is tyeical ef eiehalclism, which has autesemal cleminant inheritance. it is a cengenital

leukeclerma. Diagnesis is hy its characteristic clistrihutien eattern, as clescrihecl in the
guestien, ancl hy the fincling ef hyeereigmentecl macules ancl nermally eigmentecl enes
within the leukeclerma. Cafe-au-lait-like macules can he eresent at the hercler hetween
nermal ancl inyelyecl skin. In centrast te yitilige, the hancls ancl feet are searecl. A frental
white fereleck is feuncl in S0-510% ef eatients hut is eften clisguisecl hy hair clyes in elcler
chilclren. In eculecutaneeus alhinism, eigmentatien ef the hair, skin ancl eyes is reelucecl frem
hirth.
Scenarie 2
A 14 year elci Asian girl cemes te the Ciruteatient Deeartment hecause ef three
hyeereigmentecl lesiens en her trunk which haye heen eresent fer seyeral weeks. in her east
meclical histery she hacl ateeic eczema. which reselyecl hy the age ef 2 years ancl has hacl
meclerately seyere acne en her face, fer which she receiyecl a ceurse ef tetracycline 4
menths age.
This is a fi:-recl clrug eruetien ancl tetracylines are a cemmenly asseciatecl clrug. The
hyeereigmentatien eersists fer weeks after the acute stage, which can he hulleus. l_esiens
are usually few in numher. Ellisceicl eczema is a clifferential cliagnesis. Mengelian hlue seets
weulcl haye heen eresent since hirth ancl heceme less neticeahle with age, many
clisaeeearing hy the age ef 4 years.
Scenarie 3
A Si-menth-elci Afre-Carihhean girl attencls the Outeatient Deeartment hecause ef multiele
Scenarie 3
A Si-menth-elci Afre-Carihhean girl attencls the Outeatient Deeartment hecause ef multiele
affectecl the face, scale, trunk ancl naekin area. 0n esaminatien, there is milcl erythema in the
well-clemarcatecl lesiens, which are slightly scaly.
Seherrheeic clermatitis usually eresents in the first 3 menths ef life ancl eften causes markecl
hyeeeigmentecl lesiens in clark skins. It usually reselyes hy 1 year ef age. The scale is
tyeically affectecl (craclle cae'), as is the naekin area, in centrast te ateeic eczema.
Censiclering the histery makes eityriasis yersiceler (yeast) infectien unlikely as clees the face
ancl naekin area heing affectecl. Pityriasis resea has a heralcl eatch with smaller lesiens in a
Christmas-tree clistrihutien. which clear after S weeks.
Hate this euestien: Q

DERMA TAS Pastest Derma Part 1b

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DERMA TAS Pastest Derma Part 1b

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A ypung 1-it-,rearp|=:t giri presents with rnptzierate aene anel pustules at1e1::t1n~_g the tape pack

B Oral tetracycline fer three rnenths

E Uy'E?i phcitptherapy Fiiespt

E hlpne pt the apc;=ye

F | "=;= :-: 1: L i t'_;= i :e- st a - ~- | 1 ii} !-<1 i iii ill-Ii i : i ~: :~" 1

A llerpes sirnples infection

C Systemic lupus erythernatosus

[ll llerpes soster infection

l1lr=__~;'-._.-i-:;":-i._i?_;. I113 iie;'_+stir.j;i|'i ..ll:.iiji Iijli ...e ;1_-".ti=;j.ie'i

Rate this ciuestion:

A Rityriasis rupra pilaris

E Likely clrug reaction

[ll Lichen simplex

E Discoicl eczema Respons

The cliagnosis is psoriasis. Chronic placiue psoriasis is characterisecl by pinkishrecl Respons

Rate this ciuestion;

B Thrombotic thrombocytopenic purpura

C idiopathic thrombocytopenic purpura

A Tuberous sclerosis (Bourneyilles disease)

A Herpes simplex infection

Rate this ciuestion: Q

A The lesions affected the face

B There were constitutional symptoms such as yomiting, diarrhoea and pyrexia

C Lesions were present at different stages

D Extensor sites were affected

E Rustules were present

D Extensor sites were affected

E Rustules were present

A Wash all clothes. towels and bed-linen at the start of treatment

B Apply treatment only from the neck downwards

C Reapply treatment each time the hands are washed

D Use a benzyl benzoate lotion

E Use an alcohol-based preparation

D Use a benzyl benzoate lotion

E Use an alcohol-based preparation

A The rash may be due to a yiral infection

B lndiyidual lesions tend to last for fa 24 hours and then resolye

C Cool bedroom temperatures help to improye symptoms

D Aspirin helps symptoms

E A causal agent is identified in 90% of cases

C Cool bedroom temperatures help to improye symptoms

D Aspirin helps symptoms

E A causal agent is identified in 90% of cases

D Aspirin helps symptoms

E A causal agent is identified in 90% of cases

Rate this ::|uestion:

D Recessiye ><-linked ichthyosis due to steroid sulphatase deficiency

E Treatment with acitretin is reduired

D Recessiye ><-linked ichthyosis due to steroid sulphatase deficiency

E Treatment with acitretin is reduired

E Treatment with acitretin is reduired

A Counsel that this type of epidermolysis bullosa is fatal

B Coyer the affected areas in cling film

C Explain that the diagnosis is epidermolysis bullosa simplex

D Explain that this is due to a defect in keratin l4

E Take off all monitoring electrodes immediately

D Explain that this is due to a defect in keratin l4

E Take off all monitoring electrodes immediately

E Take off all monitoring electrodes immediately

A Streptococcal infection is the most common cause

B The lesions started as bullae which haye crusted oyer

C The lesions will heal and leaye scars

D Topical Fucidin for l4 days is the treatment of choice