Dermatology Postgraduate MCQs and Revision Notes 1st

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Foreword
There is a lot to learn in Dermatology. Trainees must master an enormous
range of diagnoses in patients of all ages, a variety of clinical skills and
laboratory investigations, and a great number of medical, physical and
surgical treatments.
Earlier generations enjoyed a leisurely training, free to develop our own
interests, dabbling here, exploring there, hopefully absorbing the essentials
along the way. The idea of an exit exam was anathema, cramping inquisitive
minds. The result was small pockets of erudition and large areas of woeful
ignorance.
Over the last two decades, higher specialist training in dermatology has
been compressed to four years. Targets and assessments became essential.
The Specialty Specific Examination (SCE) in dermatology, introduced
in 2009, is only one of many hurdles UK dermatology trainees must jump
before applying for a Certificate of Completion of Training in Dermatology.
But compared to workplace-based assessments, this annual, centralised
examination, run jointly by the British Association of Dermatologists and
the Royal College of Physicians, seems the most daunting.
James Halpern has created this revision guide to demystify the SCE and
to help dermatology trainees prepare for it. It is not a crammer. Browsing
through it will help you understand the standards expected. Working through
the examples will focus the mind and expose your weak spots. But remember
that the exam is a means to an end, not an end in itself.

Celia Moss DM, FRCP, MRCPCH

Professor of Paediatric Dermatology
Birmingham Children’s Hospital
April 2010

vii
 Preface
Early in 2009 I embarked on revision for the Royal College of
Physicians postgraduate specialist certificate examination in dermatology.
Whilst revising I was frustrated by the lack of an appropriate revision aid.
The great tomes of dermatology were simply too voluminous for exam
revision and were not sufficiently up to date with the latest guidelines and
treatments. Whereas undergraduate and introductory texts lacked the detail
and depth required for a postgraduate examination. Many months ensued
whilst I combined guidelines, read review articles and summarised chapters
to produce my revision notes. It is these revision notes that form the basis of
this book.
This book is not a textbook and should not be used as such; it is a revision
aid for postgraduate examinations. Common and introductory topics are
only briefly discussed and an understanding of basic dermatology is assumed.
A ‘best of five’ multiple choice format has been used as this is now the
mainstay of postgraduate examinations worldwide. Each chapter should be
worked through in sequence as each question builds on the previous one to
give the reader an encompassed understanding of the topic. Unlike similar
books for other specialties this is not a ‘cheat sheet’ of questions taken from
examinations, in fact an effort has been made to avoid duplication of exam
questions. But candidates can be reassured that the detail in this book will
answer the vast majority of exam questions.
It is my hope that reading this book will save postgraduates from making
their own notes and allow them more time to concentrate on what is truly
important – looking after patients.

James Halpern
April 2010

I am keen to continually improve this book and I would appreciate feedback

from its readers. Please contact me at [email protected].

viii
About the authors
James Halpern is a third year dermatology registrar in the West Midlands
deanery. He qualified from Birmingham medical school in 2003 having
undertaken an intercalated degree in cell and molecular biology. Once
qualified, he undertook training in general medicine at City Hospital
Birmingham passing the MRCP in 2006. He joined the West Midlands
dermatology rotation in 2007 and passed the specialist certificate examination
in dermatology in 2009.

Asad Salim is a consultant dermatologist at Countess of Chester NHS Trust.

He completed his dermatology training at West Midlands deanery in 2004. He
has served on the West Midlands training committee for dermatology from
2005–08. His areas of interest in dermatology are paediatric dermatology,
skin cancer, general dermatology and skin surgery.

ix
 Acknowledgements
I would like to start by thanking those who nurtured and encouraged my
interest in dermatology, if not for the kindness of these few people I would
never have found my true vocation – Shireen Velangi, Camilo Diaz, Jai
Bhat, Nigel Langford and all the staff of the dermatology department, City
Hospital Birmingham. Special thanks must also go to all the consultants and
registrars I have worked with at Stoke, Stafford, Selly Oak and Birmingham
Children’s Hospital.
In writing and editing this book I have received help from both colleagues
and family. Without their help and support this book simply would not
have been possible. I would like to thank Celia Moss for her support and
encouragement, Ian Halpern for proof reading the manuscript and Clare
Defty who has advised on content and question difficulty.
Last, but certainly not least, thanks must also go to my wife who has
managed to juggle our young baby, spend untold time correcting my frankly
atrocious spelling and grammar and advise on paediatric content.

x
Chapter 1

Eczematous and
papulosquamous disorders
QUESTIONS

1 A six-month-old child presents with a symmetrical eczematous

eruption on the cheeks, elbows and anterior aspects of the knees. The
rash responds to a mild topical steroid cream but flares whenever the
cream is stopped. What is the most likely cause of the rash:

A seborrhoeic dermatitis
B contact dermatitis to steroid cream
C atopic eczema
D food intolerance
E acrodermatitis enteropathica.

2 An eight-year-old boy of Indian descent presents to your clinic with

ill-defined hypopigmented patches on his cheeks. He has a history of
moderate atopic eczema controlled with 1% hydrocortisone ointment
and a simple emollient. What is the most likely diagnosis:

A melasma
B pityriasis alba
C steroid induced hypopigmentation
D vitiligo
E lepromatous leprosy.

1
 Dermatology Postgraduate MCQs and Revision Notes

3 A 26-year-old man with a recent diagnosis of HIV infection presents

with a rash and dandruff. The rash consists of small, scaly red patches
and is prominent on the ears, face and trunk. What organism is most
likely to have precipitated the rash:

A malassezia furfur
B streptococcus
C tinea mentagrophytes
D trichophyton rubrum
E tinea versicolor.

4 You are asked to see an 88-year-old lady who has recently become
resident in a nursing home. She gives a worsening history of a
moderately itchy rash on her lower legs. On examination she has an
eczematous rash with extreme xerosis and ‘riverbed’ cracking over the
shins. Despite advice on using copious amounts of greasy emollients
the rash does not improve. Which of these tests is likely to be the
most useful for this lady:

A patch testing to emollients

B a full blood count with a blood film examination
C a skin biopsy
D skin scrapings for mycology
E thyroid function tests.

5 A 55-year-old man presents with a new onset very itchy rash. On

examination he has slightly weepy, eczematous, well defined annular
patches worse on the limbs in an extensor distribution. He has had
little benefit from regular clobetasone butyrate (Eumovate). Which
treatment is the most appropriate:

A refined coal tar +/– dithranol

B 1% hydrocortisone ointment + aqueous cream
C oral prednisolone 40 mg/day for 5 days
D betamethasone/clioquinol (Betnovate-C) + antiseptic emollient
E PUVA phototherapy.

2
 Eczematous and papulosquamous disorders: questions

6 An 82-year-old lady has been under your care for some time with a
rash on her legs. She presented with a bilateral itchy, red, eczematous
rash associated with haemosiderin deposition and varicosities. The
rash was controlled with a combination of regular emollients, support
stockings and betamethasone/neomycin ointment (Betnovate-N).
Two years later she presents to you with a widespread eczematous
eruption covering much of her body. What is most likely to have
happened:

A disseminated eczema with allergic contact dermatitis to neomycin

B disseminated eczema with allergic contact dermatitis to
betamethasone
C secondary asteatotic eczema
D superimposed zoster infection with koebnerization
E development of nummular eczema.

7 You review an eight-year-old boy with known behavioural problems

and asthma who presents in shabby sportswear. His mum gives a six
month history of worsening rash on the soles of his feet. The rash has
not responded to a number of topical steroid preparations prescribed
by his general practitioner. On examination over the balls and toepads
of the feet the skin is dry, scaly and fissured with a glazed appearance.
What treatment is most appropriate:

A regular emollients only

B a super-potent topical steroid
C wear shoes less and use leather shoes rather than trainers
D a short course of oral terbinafine
E topical miconazole.

3
 Dermatology Postgraduate MCQs and Revision Notes

8 A 52-year-old Englishman is admitted to coronary care after

suffering an anterior myocardial infarction. After thrombolysis with
streptokinase the patient is started on aspirin, clopidogrel, metoprolol,
ramipril and simvastatin. During his recovery you are asked to see the
patient as he has developed a rash. On examination he has multiple
small beefy red plaques with silvery scale most prominent on the
extensor surfaces. The patient’s identical twin brother has psoriasis.
What is the most likely diagnosis:

A he has caught psoriasis from another patient on the ward

B latent psoriasis precipitated by beta-blocker
C psoriasiform drug reaction to aspirin
D latent psoriasis precipitated by ACE inhibitor
E latent psoriasis precipitated by streptokinase.

9 A 12-year-old boy attends your clinic as an emergency. The previous

week shortly after a sore throat and coryzal illness, he has developed a
rash. On examination he has a widespread rash consisting of multiple,
small, deep red papules and plaques with some overlying scale. What
initial treatment is most appropriate:

A admission to hospital and treatment with a potent topical steroid

B start on 1 mg/kg/day oral prednisolone
C work up for ciclosporin
D topical dithranol
E a coal tar preparation/mild topical steroid and consideration of
UVB phototherapy.

10 You are called to the antenatal ward to see a pregnant lady who
has become quite unwell. On examination she has extensive areas of
confluent erythema and numerous pustules. Despite being pyrexial
initial swabs from a pustule grow no organisms. What is the likely
diagnosis:

A generalised pustular psoriasis

B staphylococcal scalded skin syndrome
C toxic epidermal necrolysis
D eczema herpeticum
E gestational pemphigoid.

4
 Eczematous and papulosquamous disorders: questions

11 A recently married 24-year-old nurse presents to you with a flare

of palmo-plantar pustular psoriasis. She has previously maintained
reasonable control of her condition with super potent topical steroids
and vitamin D analogues. What would be the next reasonable step in
treatment:

A methotrexate
B infliximab
C acitretin
D hand and foot PUVA
E hydroxycarbamide.

12 A 26-year-old woman presents with a rash. She describes the rash

as occurring in crops with lesions tending to self resolve within a
few weeks. On examination she has multiple erythematous to purple
crusty papules with some small ulcers, vesicles and pustules. In some
areas where lesions have resolved varioliform scarring has been left
behind. A biopsy is taken that shows an interface dermatitis with
necrotic keratinocytes, T-cell clonality studies show a predominantly
CD8+ monoclonal infiltrate. What is the most likely diagnosis:

A pityriasis lichenoides et varioliformis acuta (PLEVA)

B pityriasis lichenoides chronic (PLC)
C mycosis fungoides
D guttate psoriasis
E small plaque parapsoriasis.

13 A 62-year-old man presents with diffuse erythroderma of

gradual onset. He is systemically well. On examination follicular
hyperkeratosis is seen on an erythematous base and there are large
orange-red patches with distinctive islands of sparing. The palms and
soles show an orange-red waxy keratoderma and there is fine diffuse
scale on the scalp. The nails show a yellow-brown thickened nail plate
with subungual debris. Which of the following treatments would you
not consider for this patient:

A hydroxychloroquine
B methotrexate
C acitretin
D isotretinoin
E combination methotrexate and acitretin.
5
 Dermatology Postgraduate MCQs and Revision Notes

14 A 15-year-old girl presents with a two week history of a rash. She

describes a single lesion appearing on her back that gradually enlarged
over a few days, then multiple lesions appeared over the trunk and
upper arms. The lesions are oval shaped, skin coloured and have a
slightly raised margin. They vary from 2–4 cm in size, have central
fine scale and a collarette of scale at the free edge. The lesions are
asymptomatic and the patient is not unduly distressed by the rash.
What is the appropriate course of action:

A book the patient for UVB phototherapy

B start a course of erythromycin
C reassure the patient and advise a little sun exposure
D start a topical steroid
E give a course of oral prednisolone.

15 A 52-year-old man is seen in clinic as an urgent referral. He

gives a 2-week history of a spreading rash that now covers his whole
body. The patient feels generally unwell, lethargic and thirsty. When
you examine him he is shivering and has difficulty standing. He is
erythrodermic with over 95% of his skin showing a non-specific
confluent erythema. He has no history of skin disease and there are
no clues to aetiology of the erythroderma in the history. What should
you do next:

A give an immediate dose of intramuscular corticosteroid and see

him for review in one week
B organise for daily emollients and dressings on the day case unit
C admit to intensive care for consideration of inotropic support
D admit the patient to the dermatology ward for assessment and
stabilisation
E take an urgent skin biopsy and organise for review when the
histology is available.

16 You review a 60-year-old woman who has been admitted to the

ward with erythroderma. Her medical condition has been stabilised
and a skin biopsy has been performed. She has no previous history of
skin conditions and there are no clues to the aetiology on examination.

6
 Eczematous and papulosquamous disorders: questions

Her medications include salbutamol, simvastatin and hormone

replacement therapy. Her skin biopsy shows a superficial lichenoid
infiltrate composed mostly of lymphocytes some of which are atypical.
What is the likely aetiology:

A eczema
B drug reaction to simvastatin
C cutaneous T-cell lymphoma
D sofa dermatitis
E eruptive lichenoid keratosis.

17 A 32-year-old female pharmacist presents with hand dermatitis.

On examination her hands are dry and cracked with erythema and
mild paronychia. At work she wears vinyl gloves whenever handling
medicines and washes her hands regularly. She has no particular
hobbies as she is busy with her three young children. What is the
likely diagnosis:

A irritant hand dermatitis

B atopic hand dermatitis
C allergic contact dermatitis to vinyl gloves
D allergic contact dermatitis to medications
E pompholyx eczema.

18 The emergency department rings you for advice about a patient

who claims to have an allergy to corticosteroids. The patient has been
admitted with an exacerbation of inflammatory bowel disease and the
team are keen to start systemic steroids. You have the patient’s recent
patch testing results to hand which showed a 3+ reaction to tixocortol-
21-pivalate, the patient is awaiting further patch testing to the steroid
series. Which of the following steroids is likely to be the safest:

A hydrocortisone
B methylprednisolone
C dexamethasone
D prednisolone
E diflucortolone.

7
 Dermatology Postgraduate MCQs and Revision Notes

19 You are asked to see a 12-year-old girl in the emergency

department. She has bizarre configurations of erythema, oedema and
bullae on her exposed arms and legs. Three days previously she had
been playing in a field on a hot summer’s day. You suspect a diagnosis
of phytophotodermatitis. Which of the following plants is the most
likely culprit:

A urticaceae (nettle family)

B asteraceae (thistle family)
C solanaceae (chilli pepper family)
D apium graveolens (celery)
E toxicodendron radicans (poison ivy).

20 Whilst on holiday in Thailand an 18-year-old girl has a henna tattoo

of a dragon drawn on her right forearm by a beach vendor. Three days
later her tattoo becomes progressively more inflamed and sore to the
point of developing bullae. When she sees you three months later
the reaction and henna have faded but an area of postinflammatory
pigmentation remains. What important information should you give
the patient:

A now the reaction has settled it is safe to get another henna tattoo
B it will be safe to get another henna tattoo in six months
C she needs to carry an adrenalin containing pen as she is at risk of
anaphylaxis
D she must not use permanent hair dyes in the future
E she must avoid all henna containing products in the future.

8
 Eczematous and papulosquamous disorders: answers

ANSWERS

1 C. Atopic eczema
This child is likely to have simple atopic eczema. The pattern of atopic
eczema is dependent on the age of the patient with classical flexural
eczema often not appearing until later. As with any inflammatory
dermatoses when topical treatments are stopped the rash will flare up
soon afterwards.

Table 1.1 Typical distributions of atopic eczema according to age

Type Age Areas of skin affected

Infantile 2 months–5 years Facial, scalp, extensor surface of limbs, nappy
area often spared
Childhood 2–12 years Antecubital fossa, popliteal fossa, posterior
neck, wrist and hands
Adult 12 years+ Flexural surfaces of limbs, may be extensive and
favour head or hands

The description of the rash is not typical of seborrhoeic dermatitis

which presents in infants with greasy scale and a predilection for the
face and scalp. Contact dermatitis to a steroid is unlikely in such a
young age group and does not fit with the rash flaring when treatment
is stopped. Acrodermatitis enteropathica is a rash related to zinc
deficiency that presents as an eczematous eruption favouring the face
and nappy area; in this case the nappy area is not involved. The role of
food intolerance in atopic eczema is highly controversial; in this case
there is no mention of specific foods exacerbating the rash and the
rash is typical of simple atopic eczema.

2 B. Pityriasis alba
Pityriasis alba is an uncommon feature of atopic dermatitis that presents
in children and adolescents. Ill-defined hypopigmented patches occur,
often on the face in a symmetrical distribution frequently on the cheeks.
It is more common in patients with atopy and darkly pigmented skin.
The patches represent a significant cosmetic challenge but do tend to
resolve over time. There is no effective treatment for this condition.
Melasma is a condition of hyperpigmentation, with dark patches
appearing on the face of patients with pigmented skin. It is associated
with pregnancy and the oral contraceptive pill. Vitiligo is amelanotic
9