DERMATOLOGY

Questions & Answers

Q-1
A 4 year old child is brought to your GP practice by her mother. She has painful
crusted lesions on her face and neck, mostly localized around her mouth. Her
face feels hot to the touch. She is other well. What is the SINGLE most likely
diagnosis?

A. Contact dermatitis
B. Impetigo
C. Measles
D. Chickenpox
E. Eczema

ANSWER:
Impetigo

EXPLANATION:
Contact Dermatitis: usually presents with itching and redness of a single affected area.

Chicken pox: presents with systemic symptoms such as pyrexia, malaise. Vesicles
present on the face, neck and trunk

Measles: Hard K sounds → Koplik spots, Cough, Conjunctivitis, Coryza

Impetigo:
Impetigo is a common condition. It most often affects children although it can occur at
any age. Risk factors include poor hygiene and skin conditions that lead to a break in
the protective layers

Types and presentation:

• Non-bullous impetigo
o Non-bullous lesions usually start as tiny pustules or vesicles that evolve rapidly
into honey-coloured crusted plaques that tend to be under 2 cm in diameter. It is
usually on the face (particularly around the mouth and nose)
• Bullous impetigo
o Bullous lesions have a thin roof and tend to rupture spontaneously. They are
usually on the face, trunk, extremities, buttocks, or perineal regions. They are
more likely to occur on top of other disease like atopic eczema.
• Ecthyma
 o This begins as a non-bullous impetigo but ulcerates and becomes necrotic. It is
deeper and may occur with lymphadenitis.

Treatment:
The National Institute for Health and Care Excellence (NICE) Clinical Knowledge
Summary on impetigo advises that fusidic acid is used first-line in localised infections,
three times a day for seven days. Mupirocin should be reserved for cases where MRSA
is the causative organism, to avoid resistance.

Flucloxacillin is recommended as first-line treatment when oral antibiotics are required.

Clarithromycin or erythromycin are recommended as second-line for those who are
allergic to penicillin, with clarithromycin being preferred, as side-effects are less
common.

Treatment summary:
1. Topical fusidic acid
2. Topical Mupirocin if MRSA is involved
3. Systemic antibiotics namely flucloxacillin (or clarithromycin) in resistance to topical
treatment

Q-2
A 33 year old woman who recently came from India has a nodular patch on both
her shins which is reddish brown. The nodules are slightly raised above the
surrounding skin. She also has a fever and feels unwell. What is the SINGLE
most probable diagnosis?

A. Lupus vulgaris
B. Erythema nodosum
C. Pyoderma gangrenosum
D. Erythema marginatum
E. Solar keratosis

ANSWER:
Erythema nodosum

EXPLANATION:
Erythema nodosum is the most likely diagnosis here. The reason they give a history of
coming from India with fever and feeling of being unwell is to point you towards the
direction of tuberculosis. Erythema nodosum can occur with the primary infection of TB.

THE DIFFERENT ERYTHEMAS

Erythema Multiforme Erythema Nodosum

o Target lesions • Tender, erythematous, nodular
o If symptoms are severe and involve lesions
blistering, think Steven Johnson • Usually over shins
 Syndrome • May also occur elsewhere e.g.
o Causes forearms, thighs
o Herpes simplex • Causes
o Mycoplasma o IBD
o Penicillin o Sarcoidosis
o Drugs e.g. Penicillins

Erythema Marginatum Erythema Chronicum Migrans

• Pink rings on torso or inner surface • Target lesions
of limbs • Causes
• Barely raised and non-itchy o Only Lyme disease
• Causes
o Rheumatic fever (considered
major Jone’s criteria)
Erythema Infectiosum (fifth disease) Erythema Ab Igne
• Caused by parvovirus B19 • Reaction caused by chronic
• Childhood infectin causing a exposure to infrared radiation in the
slapped cheek appearance and a form of heat
rash • Usually an elderly who sits too
• Appears a few days later with firm close to an open fire for electric
red cheeks space heater
• Lasts 2 to 4 days, and is followed
by a pink rash on the limbs and
occasionally the trunk

Q-3
A 29 year old man has developed a red, raised rash on his trunk after playing
football. The rash is becoming increasingly itchy over the past few hours and
has now spread to his arms. His past medical history includes asthma which was
diagnosed when he was 7 years old. What is the SINGLE most appropriate
management?

A. Oral chlorpheniramine
B. Oral amoxicillin
C. IM adrenaline
D. Nebulized salbutamol
E. No treatment necessary

ANSWER:
Oral chlorpheniramine

EXPLANATION:
This man is suffering from urticaria. Oral antihistamines would be indicated.

Since this is an allergic reaction, the only two reasonable options are A and C in this
question. However, in the context of allergic reactions, IM adrenaline should only be
used in anaphylactic shock whereby the patient would have breathing difficulties.

The followings are the indications of adrenaline in anaphylaxis:

1. Hoarseness of voice
2. Wheeze
3. Shortness of breath
4. Shock
5. Stridor
6. Swelling of the tongue and cheek
7. Facial swelling

If you see an urticaria like allergic reaction, with none of the following indications stated
above for adrenaline, then pick the oral antihistamine as the answer.

If there was a choice to pick a non-sedating antihistamine (e.g. cetirizine or loratadine),

pick it over a sedating antihistamine (e.g. chlorpheniramine), unless there was a reason
to pick a sedating antihistamine e.g. difficulty sleeping.

URTICARIA
The typical lesion is a central itchy white papule or plaque due to swelling of the surface
of the skin (wheals). This is surrounded by an erythematous flare. The lesions are
variable in size and shape and may be associated with swelling of the soft tissues of the
eyelids, lips and tongue (angioedema).

Individual lesions are typically transient. They come and go within a few minutes to
hours.

Acute urticaria is defined as urticaria present for less than 6 weeks

Chronic urticaria is when urticaria persist beyond 6 weeks

Remember that urticarial rashes tend to last less than 24 hours.

Acute urticaria – “Here today and gone tomorrow”

Management
• Where possible, identify and treat the cause. Nonspecific aggravating factors
• should be minimised, such as overheating, stress, alcohol, and caffeine
• Antihistamines:
o Non-sedating H1 antihistamines are the mainstay of treatment.
o In pregnancy chlorphenamine is often the first choice of antihistamine

Q-4
A 39 year old man presents with numerous pink umblicated papules on his
genitals, thighs, and lower abdomen. They are small measuring 1-3 mm. White
material can be expressed when pinching the papules. He is a known HIV
positive patient. What is the SINGLE most likely diagnosis?
 A. Mycobacterium avium intracellulare
B. Verruca vulgaris
C. Molluscum contagiosum
D. Condylomata acuminata

ANSWER:
Molluscum contagiosum

EXPLANATION:
Molluscum contagiosum (pox virus) are white or pink papules with an umblicated
(depressed) central punctum. They may be found anywhere on the skin. They resolve
spontaneously but can take around 6 to 24 months. If squeezed, they produce a
cheesy material. They usually affect children. They are also especially seen in patients
with decreased immunity and so if a patient presents with extensive pink umblicated
papules, consider AIDS.

Remember these two typical groups of patients when thinking molluscum contagiosum:
1. Children
2. HIV

Q-5
A 22 year old woman complains of recent onset of severe itching and wheals
which followed a viral infection. On inspection, numerous wheals of all sizes are
noticed on her skin. The wheals tend to come and go within hours. What is the
SINGLE most likely diagnosis?

A. Primary sclerosing cholangitis

B. Urticaria
C. Pyschogenic itching
D. Atopic eczema
E. Primary biliary cirrhosis

ANSWER:
Urticaria

EXPLANATION:
Majority of urticarial wheals tend to last less than 24 hours. New lesions would tend to
appear within hours or days. They are intensely itchy.

Acute urticaria – “Here today and gone tomorrow”

Aspirin is one of the medications that could elicit an episode of urticaria by causing
direct release of histamine from mast cells. Other medications that could result in direct
release of histamine include opiates.

Q-6
A 15 year old girl presents with an itchy and scaly rash over her face and the
extensor surfaces of her arms. Her grandmother also suffers from a similar skin
disease. Her mom is worried that the rash is contagious. Which of the following
is the best advice that you can give her?

A. The rash is not contagious

B. Isolate the young girl and her grandmother until the rash disappears
C. Use permethrin 5% solution
D. Change towels frequently
E. Apply sunscreen

ANSWER:
The rash is not contagious

EXPLANATION:
The diagnosis here is psoriasis. The stem mentions presence on the extensor surfaces
and a familial predisposition. Therefore the correct answer is to tell her that the rash is
not contagious and reassure her.

Note: Scabies arises on the flexor surfaces and very rarely on the extensor surfaces.

PSORIASIS
The level of PLAB is rather superficial and it would be unlikely that they would ask you
about types of psoriasis. However, you do need to know how it presents.

Presentation:
• Itchy, well-demarcated circular-to-oval bright red/pink elevated lesions (plaques) with
overlying white or silvery scale, distributed symmetrically over extensor body
surfaces and the scalp
• Nail changes: pitting, onycholysis
• Relapses
• May have a family history

Q-7
A 39 year old woman is treated with amoxicillin for a community acquired
pneumonia. Four days into her treatment, she develops a flattish rash over the
backs of her hands and feet. Since the initial presentation of the rash, the flattish
lesions have hence gotten bigger to form slighly raised patches. The patches,
which resemble papules, have also started to spread toward her trunk. These
lesions have a dusky red blistering centre with a surrounding pale area and the
patient reports mild itching. What is the SINGLE most likely diagnosis?

A. Erythema multiforme
B. Erythema nodosum
C. Erythema migrans
D. Erythema marginatum
 E. Urticaria

ANSWER:
Erythema multiforme

EXPLANATION:
The lesion in this stem describes a target lesion. This is consistent with erythema
multiforme. Mycoplasma pneumoniae, which is the likely pathogen that she has been
infected with, is one of the common pathogens known to cause erythema multiforme.

Q-8
A 3 year old male patient presents to the clinic with his mother. His mother
complains that he has developed a rash localized at his flexures particularly at
the popliteal and antecubital fossae, which manifested this morning. Upon
further questioning, it was revealed that the patient had been ill because of an
upper respiratory tract infection two days ago. He was diagnosed with eczema a
year ago and has been using emollients. He was delivered via uncomplicated
vaginal delivery and appears to be healthy and well nourished. He has no other
medical history of note and is taking no other chronic medications. What is the
SINGLE most appropriate management for this patient?

A. Systemic antibiotics
B. Systemic antifungals
C. Topical corticosteroids
D. No treatment required
E. Antivirals

ANSWER:
Topical corticosteroids

EXPLANATION:
Atopic eczema usually begins between ages 3 and 12 months and usually starts on the
scalpe and face. As they get older, it may localize in the flexures.

If flare-ups of atopic eczema occur, then corticosteroids are effective in controlling and
supressing symptoms in most cases. Topical corticosteroids for atopic eczema should
be prescribed for application only once or twice daily as long term use of topical steroids
may result in skin atrophy, striae and telangiectasia. During the course of topical
steroids, he should continue to use emollients regularly.

Any physiological or emotional stressor can cause a flare up of eczema as well as a

variety of environmental factors, temperature and diet.

COMPARISON OF PSORIASIS, ECZEMA AND SEBORRHEIC DERMATITIS

Psoriasis Eczema Seborrheic Dermatitis
• Itchy, well demarcated • Chronic relapsing, • Scaling rash
circular reddish elevated inflammatory skin condition • Affects sebaceous glands
 lesions (plaques) with • Itchy red rash • Found on face, scalp and
overlying scale • Affects skin creases such as chest
• Affects the extensor body the folds of the elbows or • Inflammatory reaction to a
surfaces and the scalpe behind the knees yeast
• Has a strong genetic basis • Triggered by environmental • Presents as inflamed, greasy
• Vigorous scraping causes irritants and allergens areas with fine scaling
pinpoint bleeding – Auspitz’s • Often associated with other • Can present as dandruff
sign atopic disease such as when manifested on the
• New lesions appear at sites asthma and hay fever scalp
of injury to the skin – Management Management
Kobner’s reaction • Emollients and topical • Regular antifungal
Management steroids medication and intermittent
• Corticosteroids, vitamin D topical steroids
analogues and tar
preparations

MANAGING FLARE-UPS of ATOPIC ECZEMA

• Emollients routinely for moisturizing, bathing and washing (first line)
• Topical corticosteroids for eczema itself (second line)
o Mild strength – Hydrocortisone
o Moderate strength – Betamethasone 0.025%
o Potent strength – Betamethasone 0.1%
o Very potent strength – Clobetasol
• Treat bacterial infection if present with oral antibiotics
o Oral antibiotics (Flucloxacillin as first line choice) are used for a week only
o Topical antibiotics or steroid-antibiotic mixtures may be considered (In the exam,
topical antibiotics for eczema is rarely the correct choice as we are moving away
from this because of regular use which can promote antibiotic resistance)
• Change the emollient to one with a higher lipid content and advise on applying more
emollient each time as well as applying it more often
o Remember to use emollients at least twice a day
• If awake at night, consider sedative antihistamine
• Avoid environmental irritants and stresses where possible

Q-9
A 4 year old male patient presents to the GP surgery with the complaint of a rash.
His mother, who accompanies him, complains of a rash that occurs on her son’s
creases of his elbows, behind his knees and his hands. This rash has been
worsening over the past few weeks. She reports that her son tries to scratch the
aforementioned areas and that the itching causes him distress. He has no other
medical conditions and is not on any medication. His mother reports the
pregnancy and birth to have had no complications. On examination, there is
dryiness of the skin and redness at the flexures of the elbows and knees. What is
the SINGLE most appropriate treatment for this patient’s condition?

A. Topical clobetasone
B. Topical hydrocortisone
C. Topical emollients
 D. Topical fusidic acid
E. Topical clotrimazole

ANSWER:
Topical emollients

EXPLANATION:
This child has atopic dermatitis or eczema. Children often have skin flexures involved.
Emollients form the basis of eczema management and should be used as first line. It
should be used at least twice a day and after a bath even when eczema is under
control.

Topicl steroids is used as second line. They are especially usefl during flare-ups after
trying emollients first. Hydrocortisone is considered a mild topical steroid and
clobetasone is considered a very potent topical steroid.

Fusidic acid is a topical antibacterial preparation. Topical antibacterials are not routinely
prescribed for eczema and are reserved for an infection of the skin.

Clotrimazole is a topical antifungal agent. It is used in athlete’s foot, fungal groin

infections and in fungal nappy rash.

Q-10
A 44 year old man complains of a solitary, shiny, red nodule which has been
growing on his nose for several months. It is firm with a central depression. It is
0.6 cm in size. What is the SINGLE most likely diagnosis?

A. Basal cell carcinoma

B. Squamous cell carcinoma
C. Molluscum contagiosum
D. Keratocanthoma
E. Kaposi’s sarcoma

ANSWER:
Basal cell carcinoma

EXPLANATION:
The clues for basal cell carcinoma in the exam are descriptions of a pearly white
umbilicated ulcer with central depression anywhere in the face with rolled edges or
inverted edge. These are hints pointing towards the diagnosis of basal cell carcinoma.
Ulcers presenting above the neck in the PLAB exam are almost inevitably basal cell
carcinoma.

BASAL CELL CARCINOMA

Basal cell carcinomas (BCCs) are slow-growing, locally invasive malignant epidermal
skin tumours
Risk factors:
• Genetic predisposition
• Exposure to ultraviolet (UV) radiation

Presentation:
• The sun-exposed areas of the head and neck are the most commonly involved sites
• Early lesions are often small, translucent or pearly and have raised areas with
telangiectasia
• Indurated edge and ulcerated centre

Q-11
A 67 year old builder has a persistent nodular lesion on upper part of his right
pinna. On examination, there is a central depression and raised areas with
telangiectasia around the lesion. It is 0.5 cm in size. What is the SINGLE most
likely diagnosis?

A. Basal cell carcinoma

B. Squamous cell carcinoma
C. Keratocanthoma
D. Actinic keratosis
E. Bowen’s disease

ANSWER:
Basal cell carcinoma

EXPLANATION:
Please see Q-10

Q-12
A 38 year old man presents with an acute infection of the skin on the leg. A
diagnosis of cellulitis has been made. He has no known allergies. What is the
SINGLE best choice of antibiotic to be prescribed?

A. Flucloxacillin
B. Metronidazole
C. Vancomycin
D. Ceftriaxone
E. Clindamycin

ANSWER:
Flucloxacillin

EXPLANATION:
Cellulitis is an infection of the dermis and subcutaneous tissue.The most common
causative organisms are Streptococcus or Staphylococcus spp. but they can be caused
by a wide range of both aerobic and anaerobic bacteria.

Flucloxacillin in adults is usually given as first-line in uncomplicated infection. In

sufficient doses, this covers both beta-haemolytic streptococci and penicillinase-
resistant staphylococci.

Erythromycin or Clindamycin can be used if the patient is penicillin-allergic.

Q-13
A 34 year old cab driver presents with an urticarial rash that is very pruritic. Due
to his job, he has requested for any medication to help with the itch which will not
make him drowsy. What is the SINGLE most appropriate medication to
prescribe?

A. Oral chlorpheniramine
B. Oral prednisolone
C. Oral cetirizine
D. Emollients
E. Hydrocortisone ointment

ANSWER:
Oral cetirizine

EXPLANATION:
Cetirizine is a second generation antihistamine. It’s use will help reduce the symptoms
of the pruritus. Second generation antihistamines like cetirizine are less able to cross
the blood–brain barrier and therefore have diminished effects on the central nervous
system and thus less likely to cause drowsiness when compared to first-generation
antihistamines like chlorpheniramine.

Corticosteroids have very little use in urticarial rashes. There may be times when
steroids are used but it usually involves severe cases and the suspicion of rarer forms
of urticaria such as urticarial vasculitis.

Q-14
A 58 year old man complains of nose disfigurement. He has a history of facial
erythema particularly on the cheeks and nose. Red papules and pustules have
been erupting at intervals over the last 10 years. He notices that his face
becomes flushed commonly after consumption of alcohol. On examination, he is
noted to have rhinophyma. What is the SINGLE most likely diagnosis?

A. Eczema
B. Acne rosacea
C. Pemphigus vulgaris
D. Dermatomyositis
E. Tinea versicolor
ANSWER:
Acne rosacea

EXPLANATION:
ACNE ROSACEA
Rosacea is a common rash, usually occurring on the face, which predominantly affects
middle-aged (age range 40 to 60 years old) and fair skinned people.

Clinical features:
• Red papules and pustules on the nose, forehead, cheeks and chin
• Frequent blushing or flushing
• Red face due to persistent redness and/or prominent blood vessels - telangiectasia
• Aggravation by sun exposure and hot and spicy food
• Fibrous thickening causing rhinophyma → Rhinophyma is an enlarged nose
associated with rosacea which occurs almost exclusively in men

For a diagnosis to be confirmed the erythema should have been present for at least
three months

Note: Flushing after alcohol or spicy food is a hint usually put in exams

Q-15
An 8 year old child presented to her GP with eczema. She was given emollient
and topical steroids by the GP. What SINGLE most appropriate advice shuld be
given to her regarding application of the ointments and cream?

A. Use steroids only when itchy

B. Apply emollients first, then steroids 30 minutes later
C. Apply steroids first, then emollient 30 minutes late
D. Mix emollient & steroid before use
E. Apply emollient at night together with steroids

ANSWER:
Apply emollient first, then steroids 30 minutes later

EXPLANATION:
If a topical steroid is also being used with an emollient, the emollient should be applied
first followed by waiting at least 30 minutes before applying the topical steroid. Creams
soak into the skin faster than ointments.

Q-16
A 22 year old man presents to the Accident and Emergency department with pain
on his left leg. On examination, the area is tender, slightly swollen and inflamed.
He has a temperature of 38.6oC. His blood results show:
Haemoglobin 138 g/L
White cell count 28 x 109/L
CRP 58

The patient has no known allergies and takes no other regular medications. What
is the SINGLE most appropriate first liine antibiotic to be prescribed?

A. Flucloxacillin
B. Metronidazole
C. Vancomycin
D. Gentamicin
E. Terbinafine

ANSWER:
Flucloxacillin

EXPLANATION:
Cellulitis is usually caused by gram positive bacteria such as staphylococci or
streptococci which are commonly present on the skin. Flucloxacillin is a narrow-
spectrum beta lactam antibiotic which covers susceptible Gram positive bacteria and
should therefore be given.

COMMON ANTIMICROBIALS
This is a list of drugs for common conditions in the exam
(Choice of antibiotics many differ on local guidelines and sensitivities in practice)

Respiratory
• Mild community acquired pneumonia
o Amoxicillin
• Moderate community acquired pneumonia
o Amoxicillin + clarithromycin
• Severe community acquired pneumonia
o Co-amoxiclav+clarithromycin
• Hospital acquired pneumonia
o Microbiology and local hospital guided
• Pneumocystis jirovecii pneumonia
o Co-trimoxazole
• Tuberculosis
o 8 weeks of rifampicin, pyrazinamide and ethambutol followed by 16 weeks of
rifampicin and isoniazid
• Aspiration pneumonia
o Amoxicillin + metronidazole
Neurological
• Out of hospital meningitis
o Benzylpenicillin
• Meningococcus/Pneumococcus/Haemophilus meningitis in hospital
 o Ceftriaxone
• Listeria meningitis
o Ceftriaxone+ampicillin+gentamicin
• Meningits prophylaxis
o Rifampicin or ciprofloxacin (preferably ciprofloxacin)
• Cryptococcal meningitis
o Amphotericin B
Genitourinary
• Lower uncomplicated UTI in non-pregnant women
o Trimethoprim or nitrofurantoin
• Candida albicans
o Clotrimazole or fluconazole
• Trichomonas vaginalis
o Metronidazole
• Bacterial vaginosis
o Metronidazole
• Cervicitis (Gonorrhoea and Chlamydia)
o Ceftriaxone stat and azithromycin stat
• Syphilis
o Penicillin G
• Genital herpes
o Acyclovir
Gastrointestinal
• Salmonella/Shigella/Campylobacter
o Erythromycin, azithromycin or ciprofloxacin (differ according to local guidelines)
• Clostridium difficile
o Oral metronidazole or vancomycin (in severe disease)
• Helicobacter pylori
o Amoxicillin+Clarithromycin
ENT
• Acute bacterial otitis media
o Amoxicillin
• Upper respiratory infections (Pharyngitis/Laryngitis/Tonsillitis)
o Phenoxymethylpenicillin
Other
• Cellultis
o Flucloxacillin
• Mastitis
o Flucloxacillin
• Diabetic foot infection
o Flucloxacillin
• Osteomyelitis/septic arthritis
o Flucloxacillin with sodium fusidate
• Scabies
o 5% permethrin
• Toxoplasmosis
o Pyrimethamine+sulfadiazine

Q-17
A 9 year old child presents with multiple, discrete, pearly white, 2 to 5 mm dome-
shaped smooth papules on the face with central umbilication. The lesions appear
in clusters. He has a history of atopic eczema. What is the SINGLE most likely
diagnosis?

A. Verruca vulgaris
B. Verruca plana
C. Condylomata acuminata
D. Dermatofibroma
E. Molluscum contagiosum

ANSWER:
Molluscum contagiosum

EXPLANATION:
Please see Q-4

Q-18
A 29 year old woman has developed an itchy scaly rash particularly over her wrist
with fine white streaks overlying the lesion. Her nails have ridges and her buccal
mucosa is lined with a lacy white pattern. What is the SINGLE most likely
diagnosis?

A. Psoriasis
B. Scabies
C. Lichen planus
D. Dermatitis herpetiformis
E. Candida infection

ANSWER:
Lichen planus

EXPLANATION:
Lichen planus
Lichen planus is a skin disorder of unknown etiology, most probably being immune
mediated.

Features
• Purple, pruritic, papular, polygonal rash on flexor surfaces
• Lacy white pattern on buccal mucosa

Mnemonic: 4P
Purple
Pruritic
Papular
Polygonal rash

DIFFERENCES BETWEEN CANDIDA, LICHEN PLANUS AND LEUKOPLAKIA

Oral Candidiasis Oral Lichen Planus Leukoplakia

History of Lace like appearance Also history of smoking

immunosuppression or
smoking Also with purple, pruritic, Raised edges/ bright white
e.g. taking oral/inhaled papular, polygonal rash on patches and sharply defined
steroids flexor surfaces and cannot be rubbed out
like a candida patch.
Thick white marks
Treatment
Treatment
If using inhaled steroids, Stop smoking
good inhaler technique,
spacer device, rinse mouth
with water after use.

Stop smoking

Oral fluconazole 50 mg/day for

7 days.

Q-19
A 19 year old man complains of shortness of breath, wheeze, and cough. He also
has dry scaly skin with rashes that are itchy. His brother suffers from similar
symptoms. What is the SINGLE most likely diagnosis?

A. Scabies
B. Eczema
C. Rheumatism
D. Seborrheic dermatitis
E. Psoriasis
ANSWER:
Eczema

EXPLANATION:
The shortness of breath, wheeze and cough is probablydue to asthma. Eczema fits the
symptoms perfectly as atopic eczema has a family history and also is associated with
asthma.

Q-20
A 35 year old woman has a butterfly rash on her face and suffers from
symmetrical joint painsin the knee and elbow. Recent laboratory resultsshow an
elevated ESR and normal CRP. What is the SINGLE most discriminative
investigation?

A. Anti-dsDNA
B. Anti-histone
C. Antinuclear antibodies
D. Anti-Jo-1
E. Anti-Scl-70

ANSWER:
Anti-dsDNA

EXPLANATION:
The signs and symptoms here point towards systemic lupus erythematosus (SLE). The
3 best initial tests to order are anti-dsDNA titre, complement (C3 and C4) and ESR.

ESR may be raised but CRP may be normal unlessthere is intercurrent infection or
serositis.

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Important must know features for the PLAB exam

• Remitting and relapsing illness
• Mouth ulcers → large, multiple andpainful
• Lymphadenopathy
• Malar (butterfly) rash: spares nasolabialfolds
• Discoid rash: scaly, erythematous, well demarcated rash in sun-exposedareas
• Photosensitivity
• Arthralgia
• Raynaud's phenomenon occurs in about one fifth of patients but is oftenmild
• Cardiovascular:pericarditis
• Respiratory: pleurisy, fibrosingalveolitis
• Renal: Glomerulonephritis (nephritis is often asymptomatic and is detected by proteinuria,
haematuria, hypertension or a raised serum urea orcreatinine)
• Neuropsychiatric: anxiety and depression arecommon

Investigation
FBC andESR:
• Mild normochromic normocytic anaemia iscommon
• ESR israised

Autoantibodies:
• Antinuclear antibody(ANA)
o Screening test with a sensitivity of 95% but not diagnostic in the absence of clinical
features. It is a nonspecific antibody that is also present in many patients with
systemic autoimmuneconditions
• Anti-dsDNA
o Highly specific (> 99%), but less sensitive (70%)
• Anti-Smith
o Most specific (> 99%), but even less sensitive(30%-40%)
• Anti-histone: drug-induced lupus ANA antibodies are often thistype
o 20% are rheumatoid factorpositive

Complement levels (C3, C4) are low during active disease (formation of complexes leads to
consumption of complement)

Q-21
A 31 week primiparous pregnant woman presents to the dermatology clinic with
complains of an itchy rash across her abdomen. On examination, there are
raised papules and plaques across her abdomen and lower limbs with sparing of
the umbilicus. There are no blisters seen. What is the SINGLE most likely
diagnosis?

A. Eczema
B. Psoriasis
C. Polymorphic eruption of pregnancy
D. Pempiphoid gestationis
E. Obstetric cholestasis

ANSWER:
Polymorphic eruption of pregnancy

EXPLANATION:
Polymorphic eruption of pregnancy (PEP) also known as pruritic urticarial papules and
plaques of pregnancy (PUPPP) is a skin disorder in women during pregnancy
characterised by an itchy urticaria-like rash, raised lumps and inflamed areas of the skin
that begins on the abdomen. It has a classic feature of sparing the umbilicus. It usually
happens in the woman’s first pregnancy around the third trimester.

Pemphigoid gestationis are itchy rashes that develop into blisters. It is occasionally
mistaken for polymorphic eruption of pregnancy as both my look similar during the early
form.

Obstetric cholestasis does not present with a rash.

Q-22
A 24 year old woman complains of recent onset of severe itching and wheals
which followed a viral infection. She first noticed the rash 2 weeks ago. She is
unable to sleep at night due to the itch. On inspection, numerous wheals of all
sizes are noticed on her skin. The wheals tend to come and go within hours.
Eyelids, lips and tongue appear normal with no swelling. What is the SINGLE
most appropriate management?

A. Antihistamines
B. Adrenaline
C. Ursodeoxycholic acid
D. Ganciclovir
E. Benzodiazepine

ANSWER:
Antihistamines

EXPLANATION:
This is a clear episode of acute urticaria. In this question, her eyelids, lips and tongue
appear normal but remember that in acute urticaria, they can be either normal or
associated with swelling (angio-oedema).

Antihistamines especially non-sedating ones would be the treatment of choice. The

preference for non-pregnant women would always be non-sedating and long acting
such as cetirizine or loratadine.

If in extreme cases, intraveous chlorpheniramine 10 mg would be given. In life

threatening swelling of the larynx or tongue, then administer adrenaline intramuscularly
(adult dose: 0.5 ml of 1:1000)

Q-23
A 55 year old woman has fatigue and arthralgia. She has been feeling
increasingly tired over the last few months with aches and pains especially in the
morning. On examination, a ring-shaped, raised scaly lesions are noticed on sun-
exposed areas. Her past medical history includes chronic heart failure which is
treated with isosorbide dinitrate and hydralazine. What is the SINGLE most likely
positive antibody?

A. Anti-dsDNA
B. Anti-Smith
C. Anti-histone
D. Anti-Jo-1
E. Anti-La

ANSWER:
Anti-histone
EXPLANATION:
Hydralazine can cause drug-induced lupus in which anti-histone antibodies are found in
95% ofcases.

Drug-induced lupus
In drug-induced lupus not all the typical features of systemic lupus erythematosus are
seen, with renal and nervous system involvement being unusual. It usually resolves on
stopping the drug.

Features
• Arthralgia
• Myalgia, fatigue
• Skin (e.g. malar rash) and pulmonary involvement (e.g. pleurisy) arecommon
• Anti-histone antibodies are found in 95% of cases

While these symptoms are similar to those of systemic lupus erythematosus, they are
generally not as severe unless they are ignored which leads to more harsh symptoms.

Symptoms of drug-induced lupus erythematosus generally disappear days to weeks after

medication use is discontinued

Q-24
A bluish discoloration is seen over the sacrum of a 2 year old baby. It is flat and
irregular in shape. His mother sayst hat it has been there since birth. Whatis the
SINGLE most appropriate action?

A. Inform social services

B. X-ray of the lumbosacral spine
C. Refer to dermatology
D. Admit and observe
E. Reassure

ANSWER:
Reassure

EXPLANATION:
The bluish discoloration most probably represents a Mongolian blue spot. They are
also known as dermal melanosis. They are a type of benign, pigmented, flat, congenital
birthmarks, which arise when the melanocytes are trapped deep within the skin. They
are typically found around areas at the base of the back and on the buttocks. They
usually fade after a few years and thus just reassurance would suffice.

Q-25
A 25 year old woman presents with pruritic purple papules on the flexor surface
of her wrist. A white lacy pattern is identified on her buccal mucosa. What is the
SINGLE most likely diagnosis?
 A. Leukoplakia
B. Candida infection
C. Lichen simplex
D. Lichen sclerosus
E. Lichen planus

ANSWER:
Lichen planus

EXPLANATION:
Please see Q-18

Q-26
A 7 year old girl has been treated with penicillin for a sore throat, fever and
cough. 3 days later she develops a skin rash and complains of burning sensation
and pruritus. The skin rash initially started at the dorsum of her hands and feet
and spread towards her torso. There are hundreds of lesions seen which are
concentric target shaped with raised patches. What is the SINGLE most probable
diagnosis?

ANSWER:
Erythema multiforme

EXPLANATION:
This is a classic description of erythema multiforme which in this stem could have
occurred secondary to strep throat or starting penicillin. It usually begins at the dorsum
of hands and feet and then spreads. The term target shaped lesion here is a give away.

ERYTHEMA MULTIFORME
These are small less than 1 cm diameter, round blisters made up of rings of different
colours called target lesions. The lesions are initially seen as flat (macules) which
gradually raise (papules) and later enlarge to form flat raised patches (plaques). The
centre of the plaque would undergo changes such as blistering and crusting. They
often start on the dorsum of the palms and feet and can be very itchy. It is acute and
lesions develop within a 24 hour period. They usually resolve without complications.

The rash usually occurs 10 to 14 days after a precipitating factor such as:
• Viral infections (especially herpes simplex)
o This is the commonest cause of recurrent episodes of erythema multiforme
• Mycoplasma pneumoniae infections
• Bacterial infections especially streptococcal sore throats
• Medications such as NSAIDs, penicillins, sulphonamides and anticonvulsants

Think of Steven-Johnson syndrome as erythema multiforme with extensive mucous

membrane involvement.
Q-27
A 19 year old girl has developed an itchy well-demarcated bright red elevated
lesions over the extensor surface of her body. She also complains of a dry itchy
scalp. Her mother suffers from a similar rash that often comes and goes. What is
the SINGLE most likely diagnosis?

A. Eczema
B. Seborrheic dermatitis
C. Impetigo
D. Lichen planus
E. Psoriasis

ANSWER:
Psoriasis

EXPLANATION:
Please see Q-6

Q-28
A 12 year old boy presents with pruritus especially around the wrists and palms
of his hands. On examination, his skin is dry and red. His mother is asthmatic
and older brother has hay fever. What is the SINGLE most likely diagnosis?

A. Dermatitis herpetiformis
B. Scabies
C. Eczema
D. Hand, foot mouth disease
E. Systemic lupus erythematosus

ANSWER:
Eczema

EXPLANATION:
The findings are consistent with eczema. Having atopic disease in a first-degree
relative favours the diagnosis of eczema.

Q-29
A 19 year old boy complains of severe itching at the site of an insect bite which
he noticed earlier today while camping. What is the SINGLE most appropriate
management?

A. Oral antihistamine
B. Doxycycline
C. Intramuscular adrenaline
D. Oral ciprofloxacin
 E. Reassurance

ANSWER:
Oral antihistamine

EXPLANATION:
The question here is quite straightforward. Itching without signs or symptoms of
anaphylaxis. Manage with oral antihistamines.

Q-30
A 32 year old woman has malaise, fatigue, weight loss and fever. On
examination, a malar rash with sparing of nasolabial fold can be seen. She also
complains of joint stiffness and pain. Her hands are very sensitive to cold and
her fingers often turn pale when exposed to cold for a period of time. What is the
SINGLE most likely positive antibody?

A. Anti-dsDNA
B. Anti-histone
C. Anti-centromere
D. Anti-Jo-1
E. Anti-Scl-70

ANSWER:
Anti-dsDNA

EXPLANATION:
Antinuclear antibodies (ANA) has the highest sensitivity meaning it is the most likely to
be positive in patients with systemic lupus erythematosus. However, ANA is not given
in the options. Anti-dsDNA would be next in line as it has a sensitivity of around 70%.

The 3 best initial tests to order for are lupus is usually anti-dsDNA titre, complement (C3
and C4) and ESR

Please see Q-20

Q-31
A 34 year old woman has fatigue, oral ulcers and a facial rash that is worse in the
summer. She complains of having joint pains and stiffness especially in the
morning. Urea and creatinine are slightly elevated with urinalysis demonstrating
red cell casts. What is the SINGLE most appropriate investigations?

A. Ultrasound of the Kidneys, Ureters & Bladder

B. Joint aspiration
C. Autoantibodies
D. Intravenous urogram
E. Schirmer test
ANSWER:
Autoantibodies

EXPLANATION:
The signs and symptoms here point towards systemic lupus erythematosus (SLE). The
3 best initial tests to order are anti-dsDNA titre, complement (C3 and C4) and ESR.
Given in the options are autoantibodies which include anti-dsDNA titres.

Q-32
A 25 year old woman presented to her General Practitioner with an acute onset of
rash on her legs, arms and trunk. It initially started on the back of her hands and
feet then within several hours spread to her limbs and trunk. The rash is absent
on the genitalia and face. They are quite painful with weeping and crusting. She
started on antibiotics for tonsillitis 7 days ago. On examination, her pulse rate is
89 beats/minute and her blood pressure is 134/70 mmHg. What is the SINGLE
most likely cause of her rash?

A. Erythema marginatum
B. Erythema multiforme
C. Erythema nodosum
D. Porphyria
E. Steven Johnson syndrome

ANSWER:
Erythema multiforme

EXPLANATION:
The stem here describes erythema multiforme which could be secondary to penicillin
use or to the streptococci that is causing tonsillitis.

Steven Johnson syndrome is considered the far end of the spectrum of erythema
multiforme where there are extensive mucosal membrane involvement. This is not seen
in this stem.

Q-33
A 35 year old woman has tiredness and joint pain. She has been undergoing
treatment for tuberculosis. On examination, erythematous macules and papules
are seen on face, upper chest, and arms in photodistribution. What is the SINGLE
most likely positive antibody?

A. Anti-dsDNA
B. Anti-histone
C. Anti-Smith
D. Anti-Jo-1
E. Anti-La
ANSWER:
Anti-histone

EXPLANATION:
Tuberculosis treatments such as isoniazid can cause drug-induced lupus in which anti-
histone antibodies are found in 95% of cases.

Q-34
A 14 year old girl has developed an itchy, scaly patch on her scalp. She had a
similar patch that cleared spontaneously 2 years ago. Her aunt has a similar
undiagnosed rash on the extensor aspects of her elbows and knees. What is the
SINGLE most likely diagnosis?

A. Eczema
B. Fungal infection
C. Impetigo
D. Lichen planus
E. Psoriasis

ANSWER:
Psoriasis

EXPLANATION:
The fact that she has an itchy, scaly patch on scalp are classic presentation of scalp
psoriasis. Her aunt’s presentations with a similar rash on extensor aspects of her elbow
and knees are suggestive of psoriasis.

Q-35
A 30 year old woman attends the GP surgery complaining of a 6 month history of
fatigue, bloading and loose stools. She describes occasional generalised
abdominal pain. She gives a history of developing a rash that is intensely itchy
especially at night. On examination, a widespread symmetrical rash composed
papules and vesicles around her elbows, knees, scalp and sacrum are seen. Her
blood test shows the following:

Haemoglobin 95 g/L (115-160 g/L)

Mean cell volume (MCV) 79 fL (76-96 fL)
Folate 1.2 mcg/L (2.0 – 11.0 mcg/L)
Ferritin 15 ng/ml (20-300 ng/ml)
Tissue transglutaminase IgA positive

What is the SINGLE most likely diagnosis?

ANSWER:
Dermatitis herpetiformis
EXPLANATION:
Questions in the associationbetween coeliac disease and dermatitis herpetiformis are
very commonly used.

Dermatitis herpetiformis is a skin condition liked to coeliac disease. Typical symptoms of

dermatitis herpetiformis are red, raised patches, often with vesicles and severe itching
especially at night. The rash is seen in elbows, knees, sacrum and scalp (similar
distribution to psoriasis). The rash can sometimes be mistaken for eczema. Finding
tissue transglutaminase IgA or endomysial antibodies are often the first clues to coeliac
disease (and thus dermatitis herpetiformis).

Mild anaemia with folate and irone deficiency is another clue to point you towards
coeliac disease (and thus dermatitis herpetiformis).

Remember, INTENSE ITCHING is the first and main symptom of dermatitis

herpetiformis.