Which of the following are mild to moderately potent topical steroids?



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  1. Which of the following are mild to moderately potent topical steroids?

    1. Hydrocortisone 1% T

    2. Betnovate (betamethasone butyrate 0.1%) F

    3. Flucinalone T

    4. Locoid (Hydrocortisone butyrate 0.1%) F

e) Diprosalic (Betamethasone dipropionate 0.1%) F


  1. Which of the following is true?

a) Discoid lupus is usually associated with SLE F

b) Dermatomyositis is associated with a violaceous heliotrope rash T

on the eyelids, elbows and knuckles.


  1. Neurofibromatosis is characterized by adenoma sebaceum, F

ash leaf macules and shagreen patches

d) Pretibial myxoedema is seen in Graves disease T

e) Granuloma annulare is commonly associated with F

Diabetes mellitus




  1. Which of the following statements are true?

    1. A nodule is a raised lesion >0.5 cm in diameter T

    2. Dermatitis is characteristically scaly F

    3. A macule in a raised lesion <1cm in diameter F

    4. A golden yellow crust on the skin is suggestive of T

Streptococcus pyogenes infection

e) Violaceous lesions are suggestive of connective tissue disease T




  1. The following statements are correct:

a) A bulla is a collection of fluid under the skin T

b) Weals are pathognognomic of dermatitis F

c) Small pus-filled blisters are called vesicles F

d) A rash lasting less than 24 hours is virtually T

diagnostic of urticaria

e) A plaque is a raised lesion with a flat surface T




  1. In relation to systemic malignancy, the following statements are correct:

a) Pruritis is a cutaneous marker T

b) Bullous pemphigoid is a cutaneous marker F

c) Dermatomyositis is a cutaneous marker T

d) Acanthosis nigricans is a cutaneous marker T

e) Alopecia areata is a cutaneous marker F
6. Patch testing is useful in following circumstances:

a) diagnosing allergic contact dermatitis T

b) diagnosing food allergy F

c) diagnosing latex allergy (Type 1 hypersensitivity) F

d) diagnosing atopic dermatitis F

e) investigation of occupational dermatitis T

7. The following are types of endogenous dermatitis:

a) atopic dermatitis T

b) seborrheic dermatitis T

c) irritant contact dermatitis F

d) nummular (discoid) dermatitis T

e) allergic contact dermatitis F




  1. In relation to acne, the following statements are true:

    1. most patients have increased circulating androgen levels F

    2. most patients have increased sebum production T

    3. narrowing of the sebaceous gland duct is an important factor F

    4. S.aureus is the main bacterium seen F

    5. Penicillin is the first line treatment of choice F




  1. The following statements are correct:

    1. Rosacea is commoner in women than men T

    2. Rosacea can be treated with topical steroids F

    3. Rosacea is associated with tinnitus F

    4. Rosacea is associated with conjunctivitis T

    5. Rosacea is commonly treated with oral oxytetracycline T




  1. In relation to syphilis, the following statements are correct:

    1. the primary chancre is usually painful ulcer of genitalia F

    2. the interval between the primary chancre and the eruption F

of secondary syphilis is usually 6-12 months

    1. the disease may be transmitted by shared needles F

    2. a rash on the palms and soles is characteristic T

of secondary syphilis

e) alopecia is a recognized feature T




  1. The following statements are correct:

    1. Grouped vesicles on an erythematous base are suggestive F

of herpes simplex infection.

    1. Post herpetic neuralgia can follow untreated herpes simplex F

    2. Eczema herpeticum often requires treatment with IV Aciclovir T

    3. Herpes zoster is not contagious T

    4. Herpes simplex infection is a common trigger T

for erythema multiforme


  1. The following statements are correct:

    1. Candida albicans infection can cause paronychia T

    2. Candida albicans infection of the scalp can result F

in kerion formation

    1. Candida albicans is frequently found in babies with nappy rash T

    2. Tinea pedis is commonly caused by Trichophyton rubrum T

    3. Tinea pedis is usually treated with oral antifungals F

  1. The following are appropriate treatments for acne vulgaris:

    1. Oxytetracycline T

    2. Dietary advice F

    3. Rifampicin F

    4. Iso-t-retinoin T

    5. Minocycline T




  1. The following statements are correct:

    1. onychomycosis describes fungal infection of the nails T

    2. 3% of the population has a fungal nail infection T

    3. fungal nail infections respond well to topical antifungals F

    4. Trichophyton tonsurans causes tinea capitis T

    5. Tinea capitis can cause scarring alopecia T




  1. The following associations are correct:

    1. Gianotti crosti syndrome and hepatitis T

    2. Kawasaki disease and coronary artery aneurysms T

    3. Chicken pox and pneumonitis T

    4. Guttate psoriasis and staphylococcal infection F

    5. Leishmaniasis and sand fly T




  1. The following are true of psoriasis:

    1. Affects 10% of population F

    2. Peak age of onset is first decade F

    3. Frequently involves palm F

    4. May follow episode of sort throat T

    5. Demonstrates dominant inheritance pattern F




  1. The Koebner (isomorphic) phenomenon is observed in the following:

    1. Psoriasis T

    2. Plane warts T

    3. Dermatitis herpetiformis F

    4. Lichen planus T

    5. Herpes simplex infection F




  1. The following might be considered as first line treatment options

in an 18 year old female with generalized psoriasis:

    1. dithranol ointment T

    2. oral tetracycline F

    3. Vitamin D analogues T

    4. Oral steroids F

    5. Oral retinoids F



  1. Psoriasis may be aggravated by:

    1. Lithium T

    2. Sunlight T

    3. Stress T

    4. Dithranol ointment T

    5. Oral tetracycline F




  1. Actinic keratoses:

    1. are common on the ears of females F

    2. common on the palms F

    3. some 20% will progress to SCC F

    4. responds well to liquid nitrogen therapy T

    5. are common on the shins of females T




  1. Basal cell carcinomas

    1. frequently metastasize F

    2. may be pigmented T

    3. usually presents as a scaling patch F

    4. best treated with liquid nitrogen F

    5. may present on the legs T




  1. Squamous cell carcinomas

    1. readily metastasize T

    2. commonly occur on legs T

    3. may develop following PUVA therapy T

    4. early lesions are typically cystic in appearance F

    5. are less common in transplant patients F




  1. Photosensitivity is seen in the following

    1. Paracetamol F

    2. thiazide diuretics T

    3. oral erythromycin F

    4. NSAIDs F

    5. psoralen ingestion T




  1. Erythema multiforme may be precipitated by

    1. herpes simplex infection T

    2. radiotherapy T

    3. mycoplasma infection T

    4. PUVA therapy F

1. Which of the following are mild to moderately potent topical steroids?



    1. Hydrocortisone 1%

    2. Betnovate (betamethasone butyrate 0.1%)

    3. Flucinalone

    4. Locoid (Hydrocortisone butyrate 0.1%)

    5. Diprosalic (Betamethasone dipropionate 0.1%)




  1. Which of the following is true?

a) Discoid lupus is usually associated with SLE

b) Dermatomyositis is associated with a violaceous heliotrope rash

on the eyelids, elbows and knuckles.


  1. Neurofibromatosis is characterized by adenoma sebaceum,

ash leaf macules and shagreen patches

d) Pretibial myxoedema is seen in Graves disease

e) Granuloma annulare is commonly associated with

Diabetes mellitus




  1. Which of the following statements are true?

    1. A nodule is a raised lesion >0.5 cm in diameter

    2. Dermatitis is characteristically scaly

    3. A macule in a raised lesion <1cm in diameter

    4. A golden yellow crust on the skin is suggestive of

Streptococcus pyogenes infection

e) Violaceous lesions are suggestive of connective tissue disease




  1. The following statements are correct:

a) A bulla is a collection of fluid under the skin

b) Weals are pathognognomic of dermatitis

c) Small pus-filled blisters are called vesicles

d) A rash lasting less than 24 hours is virtually

diagnostic of urticaria

e) A plaque is a raised lesion with a flat surface




  1. In relation to systemic malignancy, the following statements are correct:

a) Pruritis is a cutaneous marker

b) Bullous pemphigoid is a cutaneous marker

c) Dermatomyositis is a cutaneous marker

d) Acanthosis nigricans is a cutaneous marker

e) Alopecia areata is a cutaneous marker
6. Patch testing is useful in following circumstances:

a) diagnosing allergic contact dermatitis

b) diagnosing food allergy

c) diagnosing latex allergy (Type 1 hypersensitivity)

d) diagnosing atopic dermatitis

e) investigation of occupational dermatitis

7. The following are types of endogenous dermatitis:

a) atopic dermatitis

b) seborrheic dermatitis

c) irritant contact dermatitis

d) nummular (discoid) dermatitis

e) allergic contact dermatitis


8. In relation to acne, the following statements are true:

    1. most patients have increased circulating androgen levels

    2. most patients have increased sebum production

    3. narrowing of the sebaceous gland duct is an important factor

    4. S.aureus is the main bacterium seen

    5. Penicillin is the first line treatment of choice




  1. The following statements are correct:

a) Rosacea is commoner in women than men

    1. Rosacea can be treated with topical steroids

    2. Rosacea is associated with tinnitus

    3. Rosacea is associated with conjunctivitis

    4. Rosacea is commonly treated with oral oxytetracycline




  1. In relation to syphilis, the following statements are correct:

a) the primary chancre is usually painful ulcer of genitalia

    1. the interval between the primary chancre and the eruption

of secondary syphilis is usually 6-12 months

    1. the disease may be transmitted by shared needles

    2. a rash on the palms and soles is characteristic of secondary syphilis

e) alopecia is a recognized feature


  1. The following statements are correct:

  1. Grouped vesicles on an erythematous base are suggestive

of herpes simplex infection.

  1. Post herpetic neuralgia can follow untreated herpes simplex

  2. Eczema herpeticum often requires treatment with IV Aciclovir

  3. Herpes zoster is not contagious

  4. Herpes simplex infection is a common trigger

for erythema multiforme


  1. The following statements are correct:

  1. Candida albicans infection can cause paronychia

b) Candida albicans infection of the scalp can result

in kerion formation

c) Candida albicans is frequently found in babies with nappy rash

d) Tinea pedis is commonly caused by Trichophyton rubrum

e) Tinea pedis is usually treated with oral antifungals


  1. The following are appropriate treatments for acne vulgaris:

a) Oxytetracycline

b) Dietary advice

c) Rifampicin

d) Iso-t-retinoin



  1. Minocycline




  1. The following statements are correct:

a) onychomycosis describes fungal infection of the nails

    1. 3% of the population has a fungal nail infection

    2. fungal nail infections respond well to topical antifungals

    3. Trichophyton tonsurans causes tinea capitis

    4. Tinea capitis can cause scarring alopecia




  1. The following associations are correct:

a) Gianotti crosti syndrome and hepatitis

    1. Kawasaki disease and coronary artery aneurysms

    2. Chicken pox and pneumonitis

    3. Guttate psoriasis and staphylococcal infection

    4. Leishmaniasis and sand fly




  1. The following are true of psoriasis:

a) Affects 10% of population

    1. Peak age of onset is first decade

    2. Frequently involves palm

    3. May follow episode of sort throat

    4. Demonstrates dominant inheritance pattern




  1. The Koebner (isomorphic) phenomenon is observed in the following:

a) Psoriasis

    1. Plane warts

    2. Dermatitis herpetiformis

    3. Lichen planus

    4. Herpes simplex infection




  1. The following might be considered as first line treatment options

in an 18 year old female with generalized psoriasis:

a) dithranol ointment



    1. oral tetracycline

    2. Vitamin D analogues

    3. Oral steroids

    4. Oral retinoids



  1. Psoriasis may be aggravated by:

a) Lithium

    1. Sunlight

    2. Stress

    3. Dithranol ointment

    4. Oral tetracycline




  1. Actinic keratoses:

a) are common on the ears of females

    1. common on the palms

    2. some 20% will progress to SCC

    3. responds well to liquid nitrogen therapy

    4. are common on the shins of females




  1. Basal cell carcinomas

a) frequently metastasize

    1. may be pigmented

    2. usually presents as a scaling patch

    3. best treated with liquid nitrogen

    4. may present on the legs




  1. Squamous cell carcinomas

a) readily metastasize

    1. commonly occur on legs

    2. may develop following PUVA therapy

    3. early lesions are typically cystic in appearance

    4. are less common in transplant patients




  1. Photosensitivity is seen in the following

a) Paracetamol

    1. thiazide diuretics

    2. oral erythromycin

    3. NSAIDs

    4. psoralen ingestion




  1. Erythema multiforme may be precipitated by

a) herpes simplex infection

    1. radiotherapy

    2. mycoplasma infection

    3. PUVA therapy

1. Topical steroids are classified by potency into four groups:



Group Classification Examples .

1 Very potent Betamethasone dipropionate, Clobetasol

2 Potent Fluticasone, Betamethasone valerate, Hydrocortisone butyrate, methylprednisone

3 Moderately potent Clobetasone/Flucinalone/Triamcinolone

4. Mildly potent Hydrocortisone (0.5-1.0%)
Topical steroids can be combined to use in ointments (for dry skin) or creams (for weeping or wet skin). They have therapeutic use in both eczema and psoriasis.

Side effects: - epidermal atrophy (thinning)



  • telangiectasia (blood vessels)

  • striae (stretch marks)

  • premature aging due to collagen loss

  • exacerbation of skin infection

2. a) Lupus erythematosus is an autoimmune disorder which occurs in two main forms-SLE (systemic lupus erythematosus), which affects both the skin and internal organs, and discoid lupus erythematosus (DLE), in which the skin alone is affected. A small proportion of people suffering from DLE may subsequently develop SLE. A third variant, SCLE (subacute cutaneous lupus erythematosus) is characterized by distinctive skin lesions which MAY be associated with systemic features.

b) Dermatomyositis is an autoimmune inflammatory disease of skin and muscle which may occur in childhood or adult life. There are no differences in the manifestations of the disease of these two age groups, although only the adult variant may be associated with systemic malignancy (and may not) and the childhood variant shows vasculitis and calcinosis, which are NOT seen in the adult variant.
SKIN changes:

- violaceous (violet color) erythema on face and anterior neck. This is known as “heliotrope erythema”



  • periorbital edema

  • erythema to dorsa of hands, dorsa of fingers, over knees and elbows

  • erythematous papules on knuckles

  • CHILDHOOD variant has vasculitis whichskin ulceration in axillae and groins

MUSCLE changes:

- anywhere from no muscle disease to profound muscle weakness can be found.


  • proximal, symmetrical weakness and wasting.

  • Arthralgia, pulmonary fibrosis may be present

c) There are two forms of neurofibromatosis, NFT-1 (chromosome 17) and NFT-2 (chromosome 22) both autosomal dominantly inherited syndromes with cutaneous manifestations.

NFT-1 multiple café-au-lait spots, axillary freckling, Lisch nodules (iris hamartomas), neurofibromas

NFT-2 cataracts, bilateral acoustic neuromas and CNS tumors
Tuberous sclerosis is a dominantly inherited disorder, but many cases are sporadic and represent new mutations. There are hamartomatous malformations in skin and internal organs. The condition contains cutaneous and non-cutaneous lesions:

Cutaneous:

- numerous pink papules on face (aka adenoma sebaceum) which are angiofibromas (CT and small blood vessels)


  • CT naevus on back (aka shagreen patch)

  • Periungual fibromas

  • Hypopigmented macules (aka ash-leaf macules)

Ash leaf macules present at birth usually, but the other lesions (adenoma sebaceum and shagreen patch) present about age 5-6.
Non-cutaneous: mental retardation, epilepsy, hamartomas (pulmonary, renal) and cardiac rhabdomyomas.
d) Graves disease is a form of hyperthyroidism, whose cutaneous signs may include:

- excessive sweating

- palmar erythema

- diffuse alopecia

- nails clubbing and onycholysis

- pretibial myxoedema (subcutaneous deposition of excessive amounts of mucopolysaccharide leading to erythema and thickening over shins and dorsa of foot.

- Pruritis (seen in hypothyroidism and hyperthyroidism)
HyPOthyroidism leads to:

- dry thick skin due to subcutaneous mucin deposition (myxoedema)

- yellowish skin due to carotene deposition

- periorbital edema

- thin hair

- loss of outer part of eyebrow


  1. There is NO significant association between classical Granuloma annulare and diabetes, but in a much RARER generalized form of granuloma annulare there IS an association with diabetes. Typically, lesions are firm skin-colored papules arranged in rings, occurring on the dorsa of hands and feet. CUTANEOUS manifestations of diabetes mellitus include:

  • cutaneous infections

  • neuropathic ulcers

  • necrobiosis lipoidica diabeticorum (erythematous yellowish brown, atrophic, typically on shins. May ulcerate).

  • Diabetic dermopathy (small brown scar like lesions on shins, thought to be associated with diabetic microangoipathy)

  • Diabetic bullae (uncommon)

  • Xanthomas (due to hyperlipidemia)

  • Acanthosis nigricans (associated with insulin resistance)

  • Lipoatrophy




  1. Characteristics of dermatological lesions can be summarized as:

Macule: circumscribed FLAT area of skin discoloration

Papule: circumscribed ELEVATION of skin LESS than 0.5 cm in diameter.

Nodule: circumscribed ELEVATION of skin MORE than 0.5 cm in diameter

Plaque: circumscribed, disc-shaped, elevated area of skin:

Small LESS than 2 cm diameter

Large MORE than 2 cm diameter

Vesicle: small visible collection of fluid (less than 0.5 cm diameter)

Bulla: large visible collection of fluid (more than 0.5 cm diameter)

Pustule: Visible accumulation of pus

Ulcer: loss of epidermis, often with loss of underlying dermis and subcutis as well

Weal: Circumscribed elevated area of cutaneous edema
Dermatitis is not characteristically scaly-it’s characteristically itchy

Typically scaly is psoriasis


Golden yellow crust on the skin refers to impetigo. Impetigo is a highly infectious skin disease in children, which presents as weeping, exudative areas with a honey- colored crust on the surface. It’s spread by direct contact. Group A -Strep (aka Strep.pyogenes) and Staph Aureus are the causative agents.
Violaceous lesions are found in dermatomyositis. Since dermatomyositis is a autoimmune connective tissue disorder causing erythematous regions on elbows, knees, knuckles, face and neck, this statement is true.



  1. Bulla is a large visible collection of fluid more than 0.5 cm in diameter, while vesicle is a small visible collection of fluid less than 0.5 cm in diameter.

Weals are pathognomic of urticaria


Small pus-filled blisters are called pustules
Urticaria is the clinical term for disorders characterized by formation of “weals.” (swellings of skin which disappear leaving no visible sign). The main pathological change is dermal edema due to vascular dilatation, often in response to histamine released by mast cells. The skin itches and stings-weals develop and lesions become extensive and appear in many sites at once- “always clear spontaneously within a few hours.
A plaque is a raised flat lesion.


  1. Malignant tumors may metastasize to the skin, and tumors of the kidneys, ovaries, gastrointestinal system, breast and bronchus are most likely to do so.

Scalp metastases may produce areas of alopecia (alopecia neoplastica)


Alopecia areata is an autoimmune form of alopecia and is NOT associated with neoplasm

Lymphatic extension to skin can produce erythematous induration called carcinoma erysipeloides.

Metastases of ovarian and git can spread via ligamentum teres and present as an umbilical nodule (Sister Joseph’s nodule).
Cutaneous signs of underlying malignancy include:


  • dermatomyositis

  • acanthosis nigricans (esp. GIT adenocarcinoma)

  • generalized pruritis

  • thrombophlebitis migrans (esp. pancreas Ca)

  • acquired ichthyosis (“fish scale skin”: keratinization disorder causing extremely dry scaly skin) (esp. lymphoma)

  • pyoderma gangrenosum (esp. myeloma and leukemia)

  • necrolytic migratory erythema (esp. pancreatic glucagonoma)

  • flushing (esp. carcinoid syndrome)

  • hypertrichosis lanuginosa (sudden growth of profuse vellus hair over the face and body)

6. Patch testing is based on the delayed type (Type 4) hypersensitivity, mediated by macrophages and T-cells. It is useful in allergic drug reactions and eczema (dermatitis). Since occupational dermatitis may include a contact allergic component, patch testing may be useful. Since patch testing is to evaluate type four hypersensitivity, latex allergy (type 1) is not effectively evaluated using patch testing. Likewise, atopic dermatitis and food allergies are type 1, IgE mediated hypersensitivity and thus patch testing is not useful for their diagnosis.


    1. The principal symptom of eczema is itching. Erythema, edema, papules, vesicles and exudation are common. Chronic forms may show lichenification. Eczema is classified into exogenous and endogenous groups, with the following included in each:

Exogenous: - primary irritant contact dermatitis

- allergic contact dermatitis

Endogenous: - atopic eczema (IgE mediated, associated with atopic asthma and allergic rhinitis)



  • seborrheic dermatitis (involved Mallasezia yeasts, most commonly on scalp, face, flexures and upper back; no cure but steroid lotions, ketoconazole shampoo and combinations of steroid/imidazole may be useful)

  • discoid eczema (scattered and well-demarcated exuding/crusting eczema of unknown cause)

  • varicose eczema (chronic venous HTNeczematous changes on legs which spreads to forearms. Treatment=topical steroid)

  • palmoplantar eczema (long term topical steroids treat)

  • asteatotic eczema (“eczema craquele” (paving pattern over legs usually, secondary to aging effect on decreasing lipid content of stratum corneum)




    1. Acne is seen on face, neck (posterior mostly), upper back, anterior chest, shoulders and ears. Severe acne may extend to the arms. The skin appears greasy due to increased production of sebum. Lesions include comedones (whiteheads and blackheads), papules, pustules, nodules, scars and cysts.

Pathogenesis:

      1. Androgens stimulate increased sebum production

      2. Hair follicles in sebaceous gland block (not narrow) with hyperkeratinization

      3. The closed comedo results

      4. Within the follicle, obligate anaerobe (Propionibacterium acnes) proliferates.

      5. Propionibacterium acnes acts on sebum, releasing inflammatory chemicals

      6. Inflammatory chemicals leak into the dermis

      7. Body mounts an acute inflammatory response, leaving a pustule, papule or nodule.

Treatments: Topical:

  • Benzoyl peroxide (reduces comedones)

  • Retinoids

  • Sulfur and astringents

  • Topical antiseptics, antibiotics and combination products

Systemic:



  • Antibiotics (Tetracyclines and erythromycins)

  • Steroids

  • Iso-t-retinoin (Vitamin A derivative-may affect LFTs)

  • Cyproterone acetate (only in women-acts as anti-androgen)



    1. Rosacea is a common inflammatory rash affecting the face. Onset is middle age and it’s commoner in women. Cause is unknown. Clinically, it causes flushing, papules, pustules affecting nose, forehead and cheeks. There are NO comedones, but there MAY be telangiectasia, blepharitis, conjunctivitis. In men, keratitis and sebaceous gland hypertrophy of the nose causes rhynophyma.

Treatment - topical metronidazole



  • oral tetracyclines

  • oral iso-t-retinoin (in resistant cases)


**steroids must be AVOIDED as they exacerbate or trigger this condition**


    1. Syphilis is a chronic systemic disease, acquired or congenital. The causative organism, Treponema pallidum, is acquired by close sexual contact or transplacentally. The disease is split into primary, secondary and tertiary stages

Exposure to pathogen

10-90 days passes

Primary: - papule develops at site of inoculation


  • papule ulcerates to form painless firm chancre

  • painless lymphadenopathy

30-70 days pass


Secondary: - General: fever, sore throat, malaise and arthralgia. Generalized lymphadenopathy is common (50%)

  • Skin:

Maculopapular NONitchy rash

Condyloma lata (warty, plaque-like lesions in perianal area and other moist sites

Ulcerated mucosal surfaces

Latency period may occur (may last 2 years)



Tertiary: - Gummas (granulomatous ulcerating lesion) found in skull, clavicle, tibia, fibula and viscera`

  • Cardiovascular and neurosyphilis can occur

  • Alopecia can occur




    1. The herpes viruses have several subtypes, each of which has a unique clinical presentation:

Herpes simplex:

- includes: HSV-1 cold sores on lips and face

HSV-2 genital herpes

While the trends above are generally true, there is NOT a rigid territorial demarcation and lesions anywhere may be caused by either antigenic type


  • Contact with HSV-1 is usually contracted in early childhood. Developing lesions are most often mild. RARELY, a severe gingivostomatitis develops with painful erosions on buccal mucosa and lips. Genital herpes results from sexual transmission of HSV-2 or orogenital transmission of HSV-1. Physical contact in sport can also cause HSV transmission.

  • HSV settles in sensory ganglia and is triggered by immunocompromise, etc.

  • Recurrent HSV can trigger erythema multiforme (target lesions). Prophylactic oral acyclovir is of great benefit in these cases.

Eczema herpeticum: widespread herpes simplex infection occurring in atopic eczema  lymphadenopathy in head and neck

If extensive, admit and give IV Aciclovir.


Herpes zoster (shingles):

Chicken pox and shingles are both caused by the VZV (varicella zoster virus). Following chicken pox, virus remains dormant in dorsal root ganglia until something restimulates it, causing shingles in the distribution of a dermatome, most often in abdomen or thorax. “grouped vesicles on an erythematous base” Immunocompromise may result in multiple dermatomes being affected.

Postherpetic neuralgia is the persistence of pain after the lesions have healed, associated with herpes zoster.
12. Candida infection: Candidiasis is a term applied to infections of the skin and mucous membranes by yeast of genus Candida. The yeast Candida albicans is commonest and is normally commensal in gastrointestinal tract. In pathogenic forms, budding and mycelial forms are usually present. When situations favor its multiplicationHerHerHer (topical and systemic steroids, immunosuppression, broadspectrum antibiotics, diabetes, etc), it can cause:

- buccal mucosal candidiasis (oral thrush)

- angular cheilitis (inflammatory process at corners of mouth)

- paronychia (thickened erythematous nail fold+loss of cuticle)

- balanitis and vulvovaginitis: creamy vaginal discharge and itchy vulval erythema.

- diaper rash

Generally, lozenge or topical nystatin or imidazoles are helpful in treatment.
Kerion is a nodular, boggy, exudative, circumscribed lesion covered in pustules, occurring usually in association with tinea barbae and tinea capitis, but occasionally by other fungi. It is more common in those of African origin and is often accompanied by severe alopecia.
Dermatophyte infections:


  • referred to as “ringworm of the”, followed by “feet,” “groin,” “scalp,” etc, or can also be referred to as “tinea” followed by “pedis” (foot), “cruris” (groin),”capitis” (head), “manuum” (hand), “unguium” (toenail), etc.

  • belong to one of three genus (Microsporum, Trichophyton, Epidermophyton).

  • Tinea unguium causes thick, discolored brittle nails (onychomycosis)

  • All dermatophytes secrete keratinase, which digests keratin, thus forming scaling of skin, loss of hair and crumbling of nails.

Treatment for:

  • small areas of skin for tinea pedis/ corporis/ cruris/ manuum:

topical antifungals (Imidazoles/Terbinafine)

  • extensive areas: oral griseofulvin, terbinafine, itraconazole

  • Tinea Capitis: MUST use oral griseofulvin. Terbinafine and Imidazoles are less effective against tinea capitis, probably because Trichophyton rubrum isn’t associated, instead it’s Trichophyton tonsurans or Microsporum that are implicated.

  • Tinea unguium: nail infections are not responsive to topical treatments and long-term oral therapy is needed with oral terbinafine for 6 weeks in fingernails and 12 weeks in toenail infections. Contraindications to terbinafine should use oral itraconazole pulse therapy.


  1. See question 8:

There is no evidence that changing diet alters acne vulgaris. Current treatments include: TOPICAL

  • benzoyl peroxide

  • retinoids and retinoid-like agents

  • sulfur and astringents (make skin flaky and unblock hair follicles)

  • topical antiseptics, antibiotics (tetracyclines, erythromycin and clindamycin) or combinations

SYSTEMIC


  • antibiotics (tetracyclines, erythromycin, clindamycin)

  • cyproteron acetate (anti-androgen, use only in women)

  • iso-t-retinoin (Vitamin A derivative)

  • steroids (esp. in acne fulminans)




  1. Onychomycosis is another term for tinea unguium (ringworm of the nail).

Since ringworms are in fact fungi, onychomycosis is in fact a fungal nail infection.
The population prevalence of fungal nail infections (tinea unguium) is between 2 and 8%, according to the Australian Association of dermatology (online)
Fungal nail infections do not respond well to topical treatments, unless the nail is thin and the infection is minimal (usually fungal infections make the nail thick, however, rendering the topical treatments useless). Effective treatment of tinea unguium requires 6 weeks (fingernail) or 12 weeks (toe-nail) oral terbinafine or oral pulse itraconazole.

Tinea capitis Trichophyton tonsurans



Microsporum andouinii

Microsporum canis

Tinea barbae Trichophyton verrucosum

Tinea corporis Trichophyton rubrum

Microsporum canis

Trichophyton tonsurans

Trichophyton verrucosum

Tinea cruris Trichophyton rubrum



Epidermophyton floccosum

Tinea pedis Trichophyton rubrum



Trichophyton mentagrophytes var interdigitaale

Tinea manuum Trichophyton rubrum



Trichophyton mentagrophytes

Tinea unguium Trichophyton rubrum



Trichophyton mentagrophytes var mentagrophyte

Tinea capitis can cause alopecia of a non-scarring variety (on its own). However, tinea capitis is associated with kerion formation, and kerion can cause scarring alopecia.




  1. Gianotti crosti syndrome (aka infantile acrodermatitis, popular acrodermatitis of childhood): a generally benign and self-limited disease of young children, characterized by nonpruritic, red, flat topped firm papules forming symmetrical eruption on face, buttocks and limbs (INCLUDES palms and soles!). Associated with malaise, low grade fever. Cause is viral infection, often Hepatitis B.

Kawasaki disease: syndrome of unknown cause, usually affecting young children, associated with vasculitis of large coronary vessels, causing cervical lymphadenopathy, and maculoerythematous skin eruption. Skin becomes indurated and edematous. Aneurysms of coronary vessels is common and thus echocardiography must be performed after resolution of symptoms
Varicella Zoster virus (VZV) causes chicken pox and shingles. Chicken pox most commonly, after a 2 week incubation period, causes fever, headache and rash. The rash starts on the face and trunk and spreads to cover the whole body, including mucus membranes. In immunocompromised, pneumonia (inflammation of lungs with consolidation) and encephalitis may occur. Pneumonitis (inflammation of lungs) thus also occurs.
Guttate psoriasis often develops suddenly, and may follow an infection, especially “strep throat.” It’s a common way for psoriasis to present in young adults. “Gutta” means “drop,” as most lesions are about 1cm in diameter and paler in color than established plaque psoriasis. The main differential for guttate psoriasis is pityriasis rosea. These can be distinguished as below:

Guttate psoriasis Pityriasis rosea

- parakeratotic scale - “herald patch” of large red oval scaly

- round lesion - oval lesion
Leishmania is zoonotic, carried by rodents,dogs and foxes, transmitted to humans by the bite of the sandfly. Following transmission, the leishmania invades phagocytic cells and multiplies within the phagocytic cells in the lymph nodes, spleen, liver and bone marrow (reticuloendothelial system). Leishmaniasis can form three different clinical pictures depending on the T-cell response of the host.

Cutaneous leishmaniasis:

A skin ulcer develops at the site of the sandfly bite, heals within a year if host responses are intact (simple cutaneous leishmaniasis). If immune system is deficient, nodular skin lesion arises without ulceration. Numerous nodular lesions are found across the body, especially around the nose (diffuse cutaneous leishmaniasis).



Mucocutaneous leishmaniasis:

Dermal ulcer at site of sandfly bite is followed by erosion of nasal septum, soft palate, and lips.

Visceral leishmaniasis:

Sandfly transmits leishmania who months later complains of abdominal discomfort and distension, low-grade fevers and weight loss. Invasion of the reticuloendothelial cells cause hepatomegaly and MASSIVE splenomegaly.



  1. Psoriasis affects up to 2% of the population of Western countries. Psoriasis generally doesn’t present until youth or early adulthood.

While one psoriasis variant is palmo-plantar pustulosis (erythematous patches with pustules on palms and plantar surfaces, that turn brown and scaly then peel off), most cases of psoriasis do NOT involve the palm.


Guttate psoriasis commonly presents after “strep throat” particularly in young adults.
Although a family history is common, there is no clear cut inheritance pattern and the “genetic” explanation may not be readily understood by patients.


  1. The Koebner phenomenon (aka “isomorphic” phenomenon) is a cutaneous response of lesions on uninvolved skin typical of skin disease at sites of trauma, scars or points of pressure. It is seen in psoriasis (general plaque psoriasis), lichen planus, infectious eczematous dermatitis and plane warts (HPV virus is inoculated into scratches and abrasions).

Dermatitis herpetiformis, aka linear IgA disease, is associated with celiac disease, and most often presents with erythematous papules and vesicles on elbows, knees, shins, shoulders and scalp. The itch may result in excoriations, secondary eczematization and lichenification.


18. Dithranol is a first choice, but patient lifestyle or side-effects may make it impractical. If so, vitaminD analogues or topical steroids (with or without tar/salicylic acid) are often used. UV may help. Extensive lesions or poor response lead to PUVA, retinoid (2nd line) or cytotoxic drug use. Under no circumstances should oral steroids be used.
19. Drugs that can aggravate psoriasis include lithium, chloroquine and hydroxychloroquine, beta-blockers, NSAIDs and ACE inhibitors.
While difficult to quantify, it is generally agreed that stress can aggravate psoriasis.
Sun can exacerbate psoriasis in some patients, even though UV is more often helpful in psoriasis.

Dithranol is a first choice in plaque psoriasis and works by an unknown mechanism. It is often so effective that the plaque disappears completely. However, it can exacerbate psoriasis in some patients, especially when applied to previously non-affected skin.




  1. Actinic or solar keratoses are areas of dysplastic squamous epithelium without invasion, but they DO have low-grade malignant potential and their presence indicates unstable epithelium.

Red scaly patches wax and wane with time.

Common sites:light exposed areas (face, forearms, dorsa of hands, lower legs, bald scalp).


Treatment: For small numbers of lesions, use cryotherapy.

For large areas of face and scalp affected, use topical antimitotic agent 5-fluorouracil.

In elderly, may be best to do nothing

(old bastards croak before actinic keratosesSCC)


It is estimated (by www.skincancer.org/ak/index.ahp) that 2-5% of all actinic keratoses progress to SCC, but this usually takes a very long time.


  1. Basal cell carcinomas are the commonest malignant skin tumor and are also known as “rodent ulcers.”

Clinically: - rolled edge (spreads outward leaving central depression)

- pearly skin+ telangiectasias ( contact bleeding).



  • metastases are extremely rare but local invasion is extensive and destructive (can spread along bone into skull)

  • affects predominantly the face, but can be anywhere on sun-exposed areas (esp. scalp, behind ear, on trunk)

  • can be pigmented, superficial, or morphemic (ivory waxy) as well.

Treatment depends on type:

- SUPERFICIAL curettage, cryotherapy or photodynamic therapy

- Morphoeic or other excision, biopsy and radiotherapy


  1. SCCs are locally invasive and metastasize to regional lymph nodes and beyond. UV radiation is an important cause as is smoking (lip and mouth SCC) and HPV (genital SCC).

Clinically keratotic lump OR

Polypoid mass OR

Cutaneous ulcer.

SCC may be surrounded by actinic keratoses.

Sites: lips, mouth, genitals, sun-exposed areas (legs)

Treatment surgical removal and radiotherapy




  1. Photosensitive reactions have been reported for several drugs. Clinically, patients complain that sun exposure is followed by a burning sensation (not on urination), followed by erythema, swelling and eczematous changes on light-exposed areas.

Common causes include:

phenothiazines chlorpromazine, thioridazine,

fluphenazine, prochlorperazine

sulfonamides sulphamethoxazole, trimethoprim

tetracyclines tetracycline, oxytetracycline, minocycline

thiazides bendroflumethiazide, indapamide, xipamide

One of the macrolides (Azithromycin) has reported to have a risk of photosensitivity, none of the other macrolides (erythromycin, clarithromycin, telithromycin) has had such reports.


Of course, psoralen is also photosensitive and it is this benefit that allows it to be used in PUVA therapy in psoriasis and eczema (less commonly, but may be useful in atopic eczema)


  1. Erythema multiforme involves a classic lesion of “target” lesion- round or oval area of erythema with dusky purple center.

Lesions: - appear suddenly and enlarge over few days then fade

. - repeated episodes usually triggered by herpes simplex.

Clinically: - extensor surfaces including palms and soles

Pathology - vasculitis (the extent of the damage relates to seriousness of vascular damage)

Treatment - self-limiting, thus no treatment is usually required

Known triggers include:



  • viruses (EBV, HSV, Hepatitis, mumps)

  • mycoplasma infection

  • radiotherapy

  • carcinomas and lymphomas

  • CT diseases (SLE and polyarteritis nodosa)

  • Wegener’s granulomatosis

  • drugs (sulphonamides and anticonvulsants)



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