A 32-year-old woman presents to your clinic for a skin checkup.

On
examination, she is found to have a skin lesion on her upper back. The lesion is
highly suspected of being melanoma. An excisional biopsy is performed with 2
mm margins and the specimen is sent to a laboratory for histopathological
studies. The result is a melanoma of 2.5 mm in depth. The margins, however, are
clear. Which one of the following would be the next best step in management?

A. A wider excision.
B. Radiation therapy.
C. Sentinel node biopsy.
D. CT scan of the head.
E. Chemotherapy.

Correct
45% answered correctly

Explanation:

Correct Answer Is A

Every lesion suspected of being melanoma should be surgically excised with 2

mm margins both as the initial management and the most appropriate step in
diagnosis. Further management is then guided by tne results of the biopsy. If the
lesion is proved to be melanoma, a wider excision is needed. The margins of the
second excision depend on the reported depth of melanoma, and is according to
the following table:

Margins of the
Depth of the lesion
second excision
Melanoma in situ
5 mm
(restricted to epidermis)
<1.0 mm 1 cm
Minimum 1 cm and
maximum 2 cm. for
1-4 mm
depths of 2-4mm, 2
cm is more desirable
2 cm ( maximum 3
>4mm
cm)

For melanomas greater than 1mm in depth, a sentinel node biopsy is

recommended during the second excision to assess the potential metastasis to
the subcutaneous tissue and lymph nodes.

References
• RACGP (AJGP) - Diagnosis and management of cutaneous melanoma
Last updated:
Time spent: QID:27
2023-2-12
Which one of the following is the most important prognostic factor in basal cell
carcinoma?

A. Depth of the lesion.

B. The color of the lesion.
C. Residual cancer cells in the margins of the excised lesion.
D. The width of the lesion.
E. The site of the lesion.

Incorrect. Correct answer is C

45% answered correctly

Explanation:

Correct Answer Is C

Generally, the prognosis for patients with BCC is excellent, with a 100% survival
rate for cases that have not spread to other sites. Typically, basal cell tumors
enlarge slowly and relentlessly and tend to be locally destructive. Periorbital
tumors can invade the orbit, leading to blindness, if diagnosis and treatment are
delayed. BCC arising in the medial canthus tends to be deep and invasive and
more difficult to manage; this type of BCC can result in perineural extension and
loss of nerve function.

Although BCC is a malignant tumor, it rarely metastasizes. The incidence of

metastatic BCC is estimated to be less than 0.1%. The most common sites of
metastasis are the lymph nodes, lungs, and bones. 

Treatment of BCC is curative in more than 95% of cases; however, BCC may
recur, especially in the first year, or develop in new sites. The prognosis of BCC
is, therefore, mostly based on the likelihood of recurrence.  

There are several prognostic factors affecting the chance of recurrence of a

BCC. Of which, the clinical location, the architectural pattern and excision
margins are the most important factors. Of these three, most reports consider
the presence or absence of tumor cells in the excision margins as the most
significant prognostic factor regarding recurrence.

(Options A and D) Although the width and depth of tumors are important, as long
as they can be excised with tumor-free margins the prognosis is good with
recurrence being less likely.

(Option C) Although different BCCs can vary in color and some with specific
morphological or histological characteristics more likely to recur, color alone is
not of great significance in determining the prognosis.
(Option E) The site of the lesion is important due to the fact that lesions in
specific areas are less likely to be excised with tumor-free margins. Some of
these areas are nose, eyelids, temples, pre- and post-auricular regions and
lower legs.

TOPIC REVIEW

The following parameters affect, to different extends, the outcome and

prognosis of BCC:

Recurrent tumors (poorer prognosis)

Multiple tumors (poorer prognosis)
Size and depth of invasion (stage)
Morphemic, infiltrating and micronodular (poorer prognosis)
Morphological and histological subtype
Treatment modality (Mohs surgery has been associated with best
prognosis)
Incomplete excision (probably the poorest prognosis)
Perineural spread
Nevoid basal cell carcinoma syndrome (poorer prognosis)
Special sites (poorer prognosis):

Nose
Eyelids
Temple
Pre- and post-auricular
Lower legs

References

• Cancer Council Australia - Basal cell carcinoma, squamous cell carcinoma

(and related lesions) – a guide to clinical management in Australia
Last updated:
Time spent: QID:47
2023-2-12

A 59-year-old farmer presents to your clinic with a lesion on his upper chest.
The lesion has appeared and progressively enlarged in the past 2 months.
Examination establishes a diagnosis keratoacanthoma with  high certainty.
Keratoacanthoma is more likely to be confused with which one of the following?

A. Basal cell carcinoma.

 
B. Squamous cell carcinoma.

 
C. Pyogenic granuloma.

 
D. Seborrheic keratosis.

 
E. Granuloma fissuratum.

Incorrect. Correct answer is B

45% answered correctly

Explanation:

Correct Answer Is B

Keratoacanthoma (KA) is a rapidly growing tumor of keratinocytes. They are

almost exclusively seen in sun-exposed areas. The characteristic feature is the
crater; the central part of the lesion is necrotic, giving the lesion the appearance
of a volcano.

KAs are now considered a low-risk variant of squamous cell carcinoma (SCC).
The major diagnostic problem is confusion with SCC, especailly for KAs of the
nose and the lips. Interestingly, sometimes KAs cannot be told apart from SCCs
based on cytological studies and the whole specimen is needed for
differentiation.

(Option A) An ulcerated nodular BCC may resemble KA, but SCC remains the
most confusing differential diagnosis.

(Options C and D) Pyogenic granuloma and seborrheic keratosis are very unlikely
to be confused with KA.

(Option E) Granuloma fissuratum is a firm red fissured fibrotic granuloma found

in the gums and buccal mucosa. It is usually caused by ill-fitting dentures.
A 32-year-old female patient presents to your practice complaining of a skin
lesion on the ventral aspect of her right forearm, which has developed during the
past 6 weeks. The lesion is shown in the accompanying photograph. She had a
successful renal transplant last year. Which one of the following would be the
most appropriate treatment?

A. No active treatment is needed, as it resolves spontaneously.

B. Surgical removal of the lesion.
C. Radiotherapy.
D. Topical podophyllin.
E. Removal with liquid nitrogen.

Incorrect. Correct answer is B

45% answered correctly

Explanation:

Correct Answer Is B

The lesion in the photograph is a domed nodule with a necrotic plug in the
center. The appearance is characteristic of Keratoacanthoma (KA). KAs are
keratinizing skin tumors which grow more rapidly (6-8 weeks) compared
with basal cell carcinoma, squamous cell carcinoma and melanoma. They are
usually seen as a solitary nodule in sun-exposed areas. It often develops later in
life with a predilection for women.

If the lesion is left untreated, spontaneous healing and resolution may occur
within 3 to 6 months; however, at instances it may continue to grow or even
metastasize.

Since KA is clinically indistinguishable from malignant lesions, especially

squamous cell carcinoma, the preferred management would be the same as for
squamous cell carcinoma which is elliptical surgical excision with margins of 3-
5mm (the same that would be done for squamous cell carcinoma of the skin).
KAs share features such as infiltration and cytological atypia with SCCs; hence
they are considered to be a variant of SCC called SCC-KA type.

Although a shave biopsy may be used for diagnosis, it is not an adequate final
treatment and complete excision should eventually follow.

The need for complete surgical removal is even more in patients who have
undergone organ transplantation, because these patients are on
immunosuppressive medications drugs; therefore, the lesion is more likely to be
malignant.  Even if the case is KA, spontaneous resolution is far less likely in the
presence of immunosuppression. 
A 36-year-old woman presents to your clinic concerned about a lesion on her
right shin. The lesion appeared several days after the site was stung by a bee. On
examination, there is a 0.6mm nodule on the lateral aspect of the right shin as
illustrated in the photograph. It is not tender to touch. Which one of the following
could be the most likely diagnosis?

A. Basal cell carcinoma.

B. Squamous cell carcinoma.
C. Dermatofibroma.
D. Molluscum contagiosum.
E. Pyogenic granuloma.

Incorrect. Correct answer is C

45% answered correctly

Explanation:

Correct Answer Is C

The appearance, history, and exam findings are suggestive of dermatofibroma

as the most consistent diagnosis.

Dermatofibroma, also called sclerosing hemangioma or histiocytoma, is a

common pigmented nodule in the dermis due to the proliferation of fibroblasts,
usually following minor trauma. Dermatofibroma is more commonly seen in
women on the lower leg. The lesion is a button-like nodule that is firmwell-
circumscribedribed. The size may vary from 0.5 to 1cm. It can be pink, brown,
tan, gray, or violaceous. The nodule is freely mobile over the deeper structures.
The characteristic feature on examination is a dimpling of the nodule when it is
pinched laterally (dimple sign). The lesion is often asymptomatic but may be
itchy or tender.

Other options have different characteristic features.

A 47-year-old man presents because of a lesion on the back of his right shoulder.  The
lesion is illustrated in the following photograph. Which one of the following is the most
appropriate advice?

A. The lesion should be excised, as it is malignant and can extend locally, but not
through lymph nodes.
B. The lesion is benign and does not need to be excised.
C. The lesion is benign, but should be excised because it can become malignant.
D. The lesion is benign, but should be excised because it can become infected.
E. The lesion is malignant and should be excised because it can metastasize through
adjacent lymph nodes.

Incorrect. Correct answer is D

45% answered correctly

Explanation:

Correct Answer Is D

The photograph shows a well-circumscribed lesion, which appears to arise from within the
epidermis. It also has a punctum in the center. These features are characteristic of an
epidermoid (sebaceous) cyst.

Epidermoid cysts originate the from dermis and are attached to the skin. Since they are
related to the pilosebaceous follicle, they can occur in any hair-bearing region such as the
scalp or scrotum.

Of note, the yellow cheesy material within the cyst is desquamated keratin, not sebum.

Epidermoid cysts are benign and do not progress to malignancy; however, it is

recommended that they be removed, as superinfection may lead to suppuration and
abscess formation.

 
Jane, 21 years old, presents with a painless lesion on the distal interphalangeal
joint of her right middle finger. The lesion has been present for the past 2 months
and increased in size. The lesion is shown in the following photograph. On
examination, she is otherwise healthy. Which one of the following is the most
likely diagnosis?

A. Abscess.
B. Pyoderma gangrenosum.
C. Pyogenic granuloma.
D. Basal cell carcinoma.
E. Epidermoid cyst.

Incorrect. Correct answer is C

45% answered correctly

Explanation:

Correct Answer Is C

The fleshy red lesion on the distal interphalangeal joint of this patient is

consistent with the diagnosis of pyogenic granuloma (PG). PG is a common
benign acquired vascular neoplasm of the skin and mucous membrane. The
etiology is unknown. Some think it might be due to minor trauma, especially for
PGs of fingers. Pyogenic granuloma is a misnomer because the lesion is neither
pyogenic nor granuloma. 

It is an erythematosus (fleshy red) dome-shaped papule or nodule that bleeds

easily and is prone to ulceration, erosion, and crusting. It is most often seen in
adolescents and young adults. Up to 5% of pregnant women may experience it.

Although very rare, PGs have been reported in the gastrointestinal tract, the
larynx, nasal mucosa, conjunctiva, and cornea.

(Options A, D, and E) Abscess, epidermoid cyst, and mucous cyst are covered

with skin.
(Option B) Pyoderma gangrenosum typically presents with a well-defined
border, which is usually violet or blue. 

References

• DermNet NZ - Pyogenic granuloma

• Medscape - Pyogenic Granuloma (Lobular Capillary Hemangioma)

Last updated:
Time spent: QID:37
2023-2-12

There are a number of skin lesions which are related to cumulative sun-exposure. Which one
of the following is most likely to be caused by chronic sun exposure?

A. Actinic (solar) keratosis.

B. Junctional nevus.
C. Seborrheic keratosis.
D. Tinea versicolor.
E. Keratoacanthoma.

Incorrect. Correct answer is A

45% answered correctly

Explanation:

Correct Answer Is A

Actinic keratosis and Bowen’s disease are seen frequently in light-skinned individuals, who
have had significant sun-exposure. They are precancerous lesions for squamous cell
carcinoma.

(Option B) Junctional nevus is not associated with sun-exposure.

(Option C) Seborrheic keratosis does not seem to have strong association with sun-
exposure because it frequently appears in areas not exposed to and affected by the sunlight.

(Option D) Tinea versicolor is a skin infection caused by Malassezia furfur and is aggravated
by heat and damp, but not related to sun exposure.

(Option E) Keratoacanthoma is a rather benign tumor arising from pilocebaceous glands,

mostly in sun-exposed areas such as face. The association with sun-exposure is not as
significant compared with actinic keratosis or Bowen's disease.

References

• Medscape - Actinic Keratosis

• DermNet NZ - Actinic Keratosis

• RACGP - Actinic Keratoses

Last updated:
Time spent: QID:57
2023-2-12

A 50-year old farmer presents to your practice with a dark mole on his left cheek. The mole
has been there for 20 years, but has enlarged and become slightly lumpy and itchy over the
past 4 months. Which one of the following would be the most appropriate management
option for this patient? 

A. Treat the lesion using liquid nitrogen.

B. Ask the patient to return for review in 3 months.
C. Remove the lesion using the laser.
D. Use topical imiquimod for 6 weeks.
E. Excisional biopsy of the lesion for histopathology.

Incorrect. Correct answer is E

45% answered correctly

Explanation:

Correct Answer Is E

A changing mole, a mole with an irregular border, bleeding, itching, or color variegation is
melanoma until proven otherwise. When melanoma is suspected, the next best step is an
excisional biopsy of the lesion with 2 mm margins. Elliptical incisions are made so that
reconstruction of the wound is more straightforward. If histopathological results confirm the
diagnosis, referral to a plastic surgeon is necessary for a wider excision with margins of 5
mm to 3 cm depending on the depth of the lesion.

NOTE - in GP settings, patients with suspected lesions on sensitive areas such as the

head and neck should be referred to a plastic surgeon even for the initial excision. If the
referral was an option, it would be the correct answer. 

 
Which one of the following is the most important risk factor for melanoma?

A. Family history of basal cell carcinoma or squamous cell carcinoma of the skin.
B. A cousin with melanoma in family history.
C. Working outdoors since the age of 18.
D. Multiple sunburns in childhood.
E. Presence of solar keratosis.

Incorrect. Correct answer is D

45% answered correctly

Explanation:

Correct Answer Is D

The following table classifies risk factors for developing melanoma in a descending order are
as follows:

Risk factor Comments Relative Risk

With a history of previous melanoma,
Previous history of the person is more than 10 times likely to
>10
melanoma develop another melanoma. The risk is
greatest at the first 1-2 years
A simple melanotic nevi count of greater
than 100 is associated with a 7-fold
Multiple melanotic nevi
increase in risk of contracting 7
(benign)
melanoma compared to general
population
A dysplastic nevi count of greater than 5
is associated with a 6-fold increase in
Multiple dysplastic nevi 6
risk of contracting melanoma compared
to general population
A history non-melanoma skin cancer is
Previous history of
associated with 4-time increase in
nonmelanoma skin 4
melanoma compared to general
cancer
population.
Family history of melanoma in a first-
Family history of degree relative almost doubles the risk
melanoma of melanoma. This risk is higher if the
2
family member has had melanoma at
  younger age as it could be an indicator
of familial melanoma.
Fair complexion Compared to individuals with Fitzpatrik ~2
type IV skin, those with type I (pale skin,
bright eyes, freckles who easily burn
and never tan) have near 2-fold
increase in risk of contracting
 melanoma compared to general
population.
There is higher rates of melanoma in
people with extensive or repeated
intense exposure to sunlight. The risk is
highest if exposure occurs intermittently
in adolescence or childhood. One
UV exposure episode of severe blistering sunburn 1.5
confers about the same risk of
intermittent sun exposure. However, the
relative risks for the highest categories
of exposure, compared with the lowest,
are rarely > 1.5.

Among the given options multiple sunburns in childhood predispose to the most significant
risk (it is associated with only slightly elevated risk factor, yet the greatest among other
options).

(Option A) A family history of non-melanoma skin cancers (NMSC) is an important risk factor
for NMSC but not for melanoma; however, personal history of NMSC is a significant risk
factor for melanoma.

(Option B) Family history of melanoma is not that significant if not in the first-degree relatives
(parents, siblings). 

(Option C) Working outdoors since the age of 18 years is another risk factor, but not as
important as multiple sunburns. 

(Option E) Solar keratosis is a significant risk factor for squamous cell carcinoma, not
melanoma.
The mother of a 5-year-old boy, who has recently undergone removal of a melanoma on her
back asks you what can play a major role in developing melanoma in her child in the future.
Which one of the following options would be your answer to her question?

A. Family history of melanoma.

B. Sunburn.
C. Fair skin.
D. UV exposure.
E. The presence of multiple dysplastic moles.

Incorrect. Correct answer is E

45% answered correctly

Explanation:

Correct Answer Is E

The following table categorizes the risk factors for developing melanoma in a descending
order of significance:

Risk factor Comments Relative Risk

With a history of previous melanoma,
Previous history of the person is more than 10 times likely to
>10
melanoma develop another melanoma. The risk is
greatest at the first 1-2 years
A simple melanotic nevi count of greater
than 100 is associated with a 7-fold
Multiple melanotic nevi
increase in risk of contracting 7
(benign)
melanoma compared to general
population
A dysplastic nevi count of greater than 5
is associated with a 6-fold increase in
Multiple dysplastic nevi 6
risk of contracting melanoma compared
to general population
A history nonmelanoma skin cancer is
Previous history of
associated with 4-time increase in
nonmelanoma skin 4
melanoma compared to general
cancer
population.
Family history of Family history of melanoma in a first- 2
melanoma degree relative almost doubles the risk
of melanoma. This risk is higher if the
 
family member has had melanoma at
 younger age as it could be an indicator
of familial melanoma.
Compared to individuals with Fitzpatrik
type IV skin, those with type I (pale skin,
bright eyes, freckles who easily burn
Fair complexion and never tan) have near 2-fold ~2
increase in risk of contracting
melanoma compared to general
population.
There is higher rates of melanoma in
people with extensive or repeated
intense exposure to sunlight. The risk is
highest if exposure occurs intermittently
in adolescence or childhood. One
UV exposure episode of severe blistering sunburn 1.5
confers about the same risk of
intermittent sun exposure. However, the
relative risks for the highest categories
of exposure, compared with the lowest,
are rarely > 1.5.

All the given options are potential risk factors for developing melanoma, but the presence of
multiple moles (>100 nevi or more than 5 dysplastic nevi) is the most significant risk factor.

Red hair and blue eyes are associated with a highly- and moderately-increased risk of
melanoma respectively. Fair complexion is another risk factor, but the degree of association
with melanoma depends on the age of the patient. In patients over the age of 45 years, fair
skin can be as significant a risk factor as multiple nevi.

UV exposure and sunburns are associated with a slightly increased risk of melanoma. In sun-
related melanomas, acute intense and intermittent blistering sunburns, especially on areas of
the body that only occasionally receive sun exposure, are the most significant risk factors for
the development of sun exposure-induced melanoma. This sun-related risk factor for
malignant melanoma differs from squamous or basal cell carcinomas.

NOTE - lentigo malignant melanoma (LMM) is an exception to this rule because it

frequently appears on the head and neck of older individuals who have a history of long-
term sun exposure; therefore, prolonged sun (UV) exposure is the greatest risk factor for
LMM.

Exposure to ultraviolet radiation (UVR) is a critical factor in the development of sun-related

melanomas. Ultraviolet A (UVA), wavelength 320-400 nm, and ultraviolet B (UVB), 290-320
nm, potentially are carcinogenic and can attribute to melanoma induction. The suggested
mechanisms through which UV exposure can play its role are:
 Suppression of the immune system of the skin
Induction of melanocyte cell division
Free radical production
Damage to melanocyte DNA

Interestingly, melanoma does not have a direct relationship with the amount of sun exposure
because it is more common in white-collar workers than in those who work outdoors. Also, it
is more common on the back of men's and women's lower legs when there is no significant
sun exposure.
On a routine health examination, the lesion shown in the following photograph is
found on the inner side of the lower lip of a 37-year-old man. The lesion is
painless. Which one of the following is the most likely diagnosis?

A. Sebaceous cyst.
B. Peutz - Jegher's syndrome.
C. Squamous cell carcinoma of the lip.
D. Mucous cyst. 
E. Basal cell carcinoma.

Incorrect. Correct answer is D

45% answered correctly

Explanation:

Correct Answer Is D

The lesion shown has a bluish-glistening color and is dome-shaped. These are
characteristics of a benign mucoid cyst. A mucous cyst, also known as a
mucocele forms when mucus or saliva escapes into surrounding tissues. A lining
of granulation or connective tissue is formed to create a smooth, soft round
fluid-filled lump. They most commonly occur on the inner surface of the lower lip
(75% of cases) but may also appear on the floor of the mouth or on the gums,
buccal mucosa, and tongue. If persistent or bothersome, an incision and
evacuation of the cyst are performed. 

(Option A) Sebaceous cysts are caused by obstruction of a sebaceous gland in

hair-bearing skin. It does not occur in the lip.

(Option B) Peutz - Jegher's syndrome is associated with melanocytic spots on

the buccal mucosa and in the gastrointestinal tract.
 The lip of a female patient with Peutz-Jegher's syndrome

(Options C and E) Both squamous cell carcinoma (SCC) and basal cell
carcinoma (BCC) of the lip occur at the mucocutaneous junction of the lip. The
mucus membrane of the lip is unlikely to be the site an SCC or BCC arises.
Moreover, patients with SCC or BCC typically are older.

References

• DermNet NZ - Mucocoele of the lip

• Medscape - Dermatologic Manifestations of Mucocele (Mucous Cyst)

Last updated:
Time spent: QID:35
2023-2-12

Which one of the following lesions of squamous epithelium is not premalignant?

A. Solar (actinic) keratosis.

B. Leukoplakia.
C. Intradermal nevus.
D. Bowen's disease.
E. Chronic radiation dermatitis.

Incorrect. Correct answer is C

45% answered correctly

Explanation:

Correct Answer Is C

Of the given options, the only one not associated with skin cancers is intradermal nevus.
Benign melanocytic nevi have three major types, classified according to the position of the
melanocytes in relation to epidermal:

Intradermal nevus: all of the nevus cells are within dermis. This type accounts for a
majority of benign congenital nevi.
Junctional nevus: the nevus cells are located at the junction of the basal epidermal
layers and dermis.
Combined nevus: nevus cells are both intradermal and junctional.

(Option A) Solar (actinic) keratosis is usually a raised plaque usually on sun-exposed area of
the skin. It is a precursor of SCC.

(Option B) Leukoplakia is whitish lesion in the oral cavity and associated with SCC.

(Option D) Bowen disease is considered SCC in situ, and is malignant.

(Option E) Chronic radiation dermatitis may result in SCC.

References

• Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology – McGraw Hill - 6th Edition

• http://emedicine.medscape.com/article/279269-overv

• http://emedicine.medscape.com/article/1099775-over

• http://www.therapeutique-dermatologique.org/spip.p
Last updated:
Time spent: QID:61
2023-2-12

Which one of the following skin malignancies is most likely to arise from a burn scar?

A. Basal cell carcinoma.

B. Malignant melanoma.
C. Squamous cell carcinoma.
D. Fibrosarcoma.
E. Sweat gland adenocarcinoma.

Incorrect. Correct answer is C

45% answered correctly

Explanation:

Correct Answer Is C

The most common skin malignancy arising from a burn scar is squamous cell carcinoma
(SCC). Marjolin ulcer is a less common type of SCC of the extremities found on chronic
ulcers or burn scars.Marjolin ulcers occur on average approximately 30 years after an injury
to the skin that results in a scar or an ulcer (range 10–75 years). Rarely, an acute Marjolin
ulcer may develop between 6 weeks and 1 year of injury. It is estimated that around 2% of
thermal burns scars turn into Marjolin ulcers.

Marjolin ulcer can affect people of all ages, most commonly between 40 and 60 years of
age. Men are 2–3 times more likely be diagnosed with Marjolin ulcer than women. All races
and skin types can develop Marjolin ulcers. The most common sites for Marjolin ulcers are
the legs and feet. The ulcers can also form on the head and neck.

Other options are malignancies not seen or very rarely seen in areas with a burn scar.
Which one of the following is the most likely diagnosis of the lesion shown in the
accompanying photograph? 

A. Keratoacanthoma.
B. Basal cell carcinoma.
C. Seborrheic dermatitis.
D. Malignant melanoma.
E. Simple nevus.

Incorrect. Correct answer is D

45% answered correctly

Explanation:

Correct Answer Is D

The photograph shows a pigmented lesion on the left side of the nose. With pigmentation,
the two most likely diagnoses are simple nevi or malignant melanoma. Early melanomas may
be differentiated from benign nevi by the ABCD:

A - Asymmetry
B - Border irregularity
C - Color that tends to be very dark black or blue and variable
D - Diameter ≥ 6 mm

The lesion is asymmetrical (A) and has irregular borders (B). It shows variegation (variation in
colors) (C) and seems to be larger than 6mm; therefore, melanoma seems to be the most
likely diagnosis.

Keratoacanthoma, basal cell carcinoma, and seborrhoeic dermatitis present quite differently.

References

• Cancer Council Australia - Clinical practice guidelines for the diagnosis and management
of melanoma

• Medscape - Malignant Melanoma

Last updated:
Time spent: QID:615
2023-2-12

A 52-year-old golfer man presents to your GP clinic with an ulcer on his right pinna. He says
the lesion is itchy and easily bleeds on scratching. On examination, deeply sunburned
areas around the lesion are noted. The lesion is shown in the accompanying photograph.
Which one of the following can be the most likely diagnosis?

A. Basal cell carcinoma.

B. Squamous cell carcinoma.
C. Malignant melanoma.
D. Bowen’s disease.
E. Keratoacanthoma.

Incorrect. Correct answer is B

45% answered correctly

Explanation:

Correct Answer Is B

The photograph shows a flat amelanotic lesion on the left pinna that has undergone
ulceration and is slightly crusted. The appearance of the lesion is consistent with cutaneous
squamous cell carcinoma (SCC) as the most likely diagnosis.

The classic presentation of a cutaneous SCC includes a shallow ulcer with heaped-up
edges, often covered by a plaque usually in a sun-exposed area. Typical surface changes
may include the following:
 Scaling
Ulceration
Crusting
A cutaneous horn

Less commonly, cutaneous SCC presents as a pink cutaneous nodule without overlying
surface changes. Regional spread of head and neck cutaneous SCCs, may result in enlarged
preauricular, submandibular, or cervical lymph nodes.

NOTE - Although, the appearance of the lesion resembles SCC, it should be noted that at
times SCC, keratoacanthoma, BCC, or even amelanotic forms of melanoma may look similar
and the definite diagnosis cannot be made unless biopsy and histologic studies are
performed. However, because of the classic features of the lesion and also the fact that
squamous SCC is the most common skin cancer, SCC would be the most likely diagnosis in
this case.

(Option A) Although basal cell carcinoma (BCC) of this area is more common than SCC, the
characteristic features of BCC, especially in its most common from – nodular, is different.

(Option C) Malignant melanoma is often pigmented. This amelanotic lesion is less likely to be
melanoma.

(Option D) Bowen’s disease (SCC in situ) presents with an asymptomatic well-demarcated

erythematous patch or plaque. The presence of symptoms makes Bowen’s disease a less
likely yet possible diagnosis. Moreover, ill-defined borders of this lesion is not in favor of
Bowen’s disease.

(Option E) Keratoacanthoma often has a nodular structure with central crater which is absent
here.

References

• Cancer Council - Clinical Practice Guide

• DermNet NZ - Cutaneous squamous cell carcinoma

• http://emedicine.medscape.com/article/1965430-overview
Last updated:
Time spent: QID:616
2023-2-12

Which one of the following statements is correct regarding nail apparatus melanoma? 

A. It is a common form of melanoma.

B. It has a good prognosis.
C. The 5-year survival depends on the depth (thickness) of the lesion.
D. Nail removal maybe curative.
E. There is a strong association to sun exposure.

Incorrect. Correct answer is C

45% answered correctly

Explanation:

Correct Answer Is C

Nail apparatus melanomas (subungual melanoma) are rare but frequently fatal neoplasms.
They account for between 1.5-3% of all melanomas. All age groups can be affected;
however, it is most common in the 7th decade of life.

Melanoma of the nail initially presents as a longitudinal pigmented streak. Later, the proximal
nail fold may become pigmented (Hutchinson’s sign). As the disease advances, the nail
plate may be destroyed. By this stage, the disease is often advanced, with lymph node
metastasis frequently present.

As with other melanomas, increased tumor depth and the presence of ulceration are
associated with a worse prognosis and decreased five-year survival.

70% of subungual melanomas occur on the thumb or great toe. Subungual melanomas
involving the toes can be managed easily with digital amputation at the metatarsal-
phalangeal joint. If the first toe (big toe) is involved, complete amputation should be avoided
when the lesion is amenable to less invasive oncological treatments because of the
importance of the toe in balance.

Whenever possible, subungual melanomas of the fingers should be resected at the distal
interphalangeal joint to preserve function. Melanomas located more proximally on the fingers
can often be managed with wide local excision of soft tissue, skin grafts, or local flaps for
soft tissue coverage.

NOTE - Longitudinal melanonychia occurs in other conditions, including benign nevi of the
nail matrix and the multiple linear streaks that are common in people with dark skin.
However, patients with a solitary, widening, irregularly shaped, or irregularly pigmented
streak in the nail should undergo a biopsy of the nail matrix to evaluate for melanoma.

(Option A) Nail apparatus melanoma accounts for 1.5-3% of all melanomas. It is not the most
common form of melanoma.

(Option B) Nail apparatus melanoma has a poor prognosis.

(Option D) Nail removal has no role in the management of melanoma, as the lesion is in the
subungual matrix.
(Option E) Nail apparatus melanomas occur with almost equal incidence in people with black
skin, Asians, and Caucasians, and in people in tropical versus nontropical climates, sun
exposure does not seem to be an etiology.

References

• Therapeutic Guidelines – Dermatology; available from http://tg.org.au

• UpToDate - Surgical management of primary cutaneous melanoma or melanoma at other

unusual sites
Last updated:
Time spent: QID:617
2023-2-12

A 42-year-old male, accountant by profession,  comes for screening and risk assessment
for melanoma. Which one of the following, if present in the history, would be of highest risk
for developing melanoma?

A. Sunburns in childhood.
B. Irish background.
C. Family history of basal cell carcinoma.
D. A cousin who has recently been diagnosed with melanoma.
E. Working outdoors in early adulthood.

Correct
45% answered correctly

Explanation:

Correct Answer Is A

The following table categorizes risk factors for developing melanoma in a descending order
of significance::

Risk factor Comments  Relative risk

With a history of previous melanoma,
Previous history of the person is more than 10 times likely to
>10
melanoma develop another melanoma. The risk is
greatest at the first 1-2 years
A simple melanotic count of greater
than 100 is associated with a 7-fold
Multiple melanotic nevi
increase in risk of contracting 7
(benign)
melanoma compared to general
population
A dysplastic nevi count of greater than 5
is associated with a 6-fold increase in
Multiple dysplastic nevi 6
risk of contracting melanoma compared
to general population
A history nonmelanoma skin cancer is
Previous history of
associated with 4-time increase in
nonmelanoma skin 4
melanoma compared to general
cancer
population.
Family history of Family history of melanoma in a first- 2
melanoma degree relative almost doubles the risk
of melanoma. This risk is higher if the
 
family member has had melanoma at
 younger age as it could be an indicator
of familial melanoma.
Compared to individuals with Fitzpatrik
type IV skin, those with type I (pale skin,
bright eyes, freckles who easily burn
Fair complexion and never tan) have near 2-fold ~2
increase in risk of contracting
melanoma compared to general
population.
There is higher rates of melanoma in
people with extensive or repeated
intense exposure to sunlight. The risk is
highest if exposure occurs intermittently
in adolescence or childhood. One
UV exposure episode of severe blistering sunburn 1.5
confers about the same risk of
intermittent sun exposure. However, the
relative risks for the highest categories
of exposure, compared with the lowest,
are rarely > 1.5.

Of the given options, multiple sunburns in childhood are the most significant risk factor for
melanoma. Of UV-related risk factors, sunburns in the first and second decades of life,
especially if acute and blistering, carries the most significant risk factor compared with other
options, but not in general because UV exposure is associated with only a slightly increased
risk of developing melanoma (relative risk ~1.5).

(Options B and E) Irish background (Caucasian) and working outdoors since early adulthood
may be associated with slightly increased risk, but not as significant as sunburns in
childhood.

(Option C) A family history of non-melanoma skin cancers (NMSC) does not appear to be a
risk factor; however, personal history of NMSC is a risk factor with a relative risk of
approximately 4.

(Option D) A family history of melanoma in a second-degree relative is not a risk factor for
melanoma, but melanoma in first-degree relatives at least doubles the risk of developing
melanoma in a person.

References

• Cancer Council Australia - Clinical practice guidelines for the diagnosis and management
of melanoma

• Medscape - Malignant Melanoma

 Last updated:
Time spent: QID:623
2023-2-12
Ben, 10 years old, is brought by his mother to your GP clinic for advice on melanoma
screening. Which one of the following puts Ben at the highest risk of developing melanoma?

A. Family history of melanoma in first-degree relatives.

B. Red hair.
C. Freckles.
D. Multiple sunburns.
E. Outdoor activities.

Correct
45% answered correctly

Explanation:

Correct Answer Is A

The following table classifies risk factors for developing melanoma in descending order:

Relative
Risk factor Comments
Risk
With a history of previous melanoma, the
Previous history of person is more than 10 times likely to
>10
melanoma develop another melanoma. The risk is
greatest at the first 1-2 years
A simple melanotic nevi count of greater
than 100 is associated with a 7-fold
Multiple melanotic nevi
increase in the risk of contracting 7
(benign)
melanoma compared to the general
population
A dysplastic nevi count of greater than 5
is associated with a 6-fold increase in
Multiple dysplastic nevi 6
the risk of contracting melanoma
compared to the general population
A history of nonmelanoma skin cancer is
Previous history of
associated with a 4-fold increase in the
nonmelanoma skin 4
risk of melanoma compared to the
cancer
general population.
Family history of A family history of melanoma in a first- 2
melanoma degree relative almost doubles the risk of
melanoma. This risk is higher if the family
 
member has had melanoma at a
 younger age as it could be an indicator
of familial melanoma.
Compared to individuals with Fitzpatrick
type IV skin, those with type I (pale skin,
bright eyes, freckles who easily burn and
Fair complexion ~2
never tan) have a nearly 2-fold increase
in the risk of contracting melanoma
compared to the general population.
There are higher rates of melanoma in
people with extensive or repeated
intense exposure to sunlight. The risk is
highest if exposure occurs intermittently
in adolescence or childhood. One
UV exposure episode of severe blistering sunburn 1.5
confers about the same risk of
intermittent sun exposure. However, the
relative risks for the highest exposure
categories, compared with the lowest,
are rarely > 1.5.

The following table classifies risk factors for melanoma as high, moderate, and lower than
average:

High Risk
Changing mole
Dysplastic nevi in familial melanoma
 Multiple numbers of naevi (>100) or >10 dysplastic naevi

Moderate Risk
One family member with melanoma
Previous history of melanoma
Sporadic dysplastic naevi
Congenital naevus

Lower than average risk

Immunosuppression
Sun sensitivity
History of acute, severe blistering sunburns
Freckling  
Of the given options, a family history of melanoma carries the most significant risk (RR of at
least 2), followed by red hair/freckling and then multiple sunburns, and prolonged sun
exposure caused by outdoor activity.

References

• Cancer Council Australia - Clinical practice guidelines for the diagnosis and management
of melanoma

• Medscape - Malignant melanoma

Last updated:
Time spent: QID:624
2023-2-12

The following photograph shows skin lesions on the hand of a 73-year-old woman, who
resides in a nursing home. The lesions are severely itchy and she keeps scratching them,
especially in the night. The itch prevents her from a good night sleep. On examination, she
looks disheveled and poorly cared for. Which one of the following would be the most
appropriate treatment for her?

A. Permethrin 5% cream.
B. Itraconazole cream.
C. Topical corticosteroids.
D. Gamma benzene hexachloride.
E. Topical erythromycin.

Correct
45% answered correctly

Explanation:

Correct Answer Is A

The itching, the appearance of the lesions and living in a nursing home all favor of scabies as
the most likely diagnosis. First-line medication for treatment of scabies is permethrin 5%
cream. If treatment with permethrin fails or the patient is sensitive to this drug, benzyl
benzoate can be used as second-line therapy. Benzyl benzoate is more irritating to skin and
the treatment is likely to fail due to inadequate adherence.

(Option B) Itraconazole cream is used for treatment of fungal skin infections. It has no role in
treatment of scabies.

(Option C) Topical corticosteroids of moderate potency may be used in conjunction with

permethrin or benzyl benzoate, with no effect on the scabies.

(Option D) Gamma benzene hexachloride (Lindane®) was formerly used for treatment of
scabies. It is no longer approved for this purpose in Australia, as well as many other parts of
the world.

(Option E) If a bacterial infection superimposes scabies, the antibiotics of choice would be

topical mupirocin or oral cephalexin in more severe cases. Erythromycin is not routinely used
for
References

• Therapeutic Guidelines - Dermatology; available from http://tg.org.au

Last updated:
Time spent: QID:625
2023-2-12

A 50-year-old woman presents to your clinic with multiple lumps. She has had these lumps
for 20 years. The only complaint, apart from her concerns about the look of the lumps, is that
they become painful at times. On examination, about 30 mobile subcutaneous lumps feel
soft, rubbery, and lobulated when palpated. They are distributed bilaterally in her upper and
lower extremities, chest, and back. She mentions that her mother has the same problem.
She is otherwise healthy. Which one of the following is the most likely diagnosis?

A. Adipose dolorosa.
B. Multiple desmoid tumors.
C. Multiple epidermoid cysts.
D. Multiple symmetrical subcutaneous lipomas.
E. Neurofibromatosis type I (Von Recklinghausen disease of nerve).

Incorrect. Correct answer is D

45% answered correctly

Explanation:

Correct Answer Is D

The clinical findings such as mobility, subcutaneous location, and the consistency of the
lumps make the multiple symmetrical lipomas the most likely diagnosis. Being lobulated is
another important clue, as is the positive family history.

Lipomas are benign tumors of mature fat cells. They are quite common and can be found in
subcutaneous tissue. Although the subcutaneous fat layer is the most common site for
lipomas to arise, they may be subfascial, intramuscular, or be found in many other sites.
There is usually a genetic predisposition.

(Option A) Adipose Dolorosa (Dercum disease) is a syndrome characterized by diffusely

painful subcutaneous fat deposition without focal discrete lumps. This syndrome is most
common in middle-aged women. The painful fat deposits are mostly confined to and seen in
the abdomen and thighs.

(Option B) Desmoid tumors arise from the deeper layers of the abdominal wall.

(Option C) Epidermoid cysts contain keratinized material and are confined to the dermis.
They are invariably attached to the overlying skin and are not mobile. They have a central
punctum and may become infected and form abscesses. Like lipomas, epidermoid cysts do
not progress to malignant lesions.

(Option E) Neurofibromatosis type I, also called Von Recklinghausen disease, is a disease of

nerves presenting with café-au-lait spots and pedunculated and sessile skin lesions
(molluscum fibrosom). Given the history and characteristics of the lesions, neurofibromatosis
is unlikely to be the diagnosis.

References

• DermNet NZ - Lipoma and liposarcoma

• Medscape - Lipomas
Last updated:
Time spent: QID:626
2023-2-12
The lesion shown in the following photograph is found on the back of a 50-year-old man. It
has been present for the past 8 years and has grown slowly. Which one of the following is
the most appropriate next step in management?

A. Review in 12 months.
B. Resection.
C. Excisional biopsy with 2 mm margins.
D. Radiotherapy.
E. Topical imiquimod.

Incorrect. Correct answer is C

45% answered correctly

Explanation:

Correct Answer Is C

A changing mole, especially this one with color variegation evident in the photograph, should
be considered melanoma until proven otherwise. Even when a clinical diagnosis of
melanoma is made with certainty, an excisional biopsy should be performed. This confirms
the diagnosis and allows further planning of definitive treatment in terms of the width and
orientation of excision margins, and whether or not a sentinel lymph node (SLN) biopsy is
performed.

Immediate wide excision with margins based on a clinical estimate of tumor thickness may
result in inadequate or excessive tumor clearance. It may also compromise subsequent
management by making it impossible to perform accurate lymphatic mapping to identify
draining lymph node fields and SLNs within those fields.

The Clinical practice guidelines for the management of cutaneous melanoma in Australia and

New Zealand, endorsed by the Australian National Health and Medical Research Council
(NHMRC), recommend excision biopsy with 2 mm margins whenever possible.

Partial biopsies such as punch biopsies, incisional biopsies and shave biopsies are frequently
unsatisfactory and may result in misdiagnosis due to unrepresentative sampling. However,
an incision, punch or shave biopsy from the most suspicious area of a large pigmented lesion
may be appropriate when complete excision is difficult.

References
• RACGP - AJGP - Diagnosis and management of cutaneous melanoma
Last updated:
Time spent: QID:627
2023-2-12
The lesion shown in the accompanying photograph has been present on the
finger of a 56-year-old woman for the past 8 months. It has slowly enlarged
since then and is causing mild discomfort. Which one of the following is the most
likely diagnosis?

A. Chronic paronychia.
B. Heberden’s node of osteoarthritis.
C. Pyogenic granuloma.
D. Mucous (synovial) cyst of the finger.
E. Rheumatoid nodule.

Incorrect. Correct answer is D

45% answered correctly

Explanation:

Correct Answer Is D

The shiny nodule shown in the photograph which appears to be fluid-filled is

suggestive of the digital synovial cyst (mucous cyst of the finger ).

Mucous (synovial) cysts of the finger are subcutaneous cystic lesions found on
the dorsal aspect of the distal phalanx, distal to the distal interphalangeal joint,
and overlying the germinal nail bed. They may cause distortion of the nail
growth. They are located in the midline or laterally. They grow slowly and may
undergo spontaneous resolution. Recurrence is likely if they are inadequately
excised.

(Option A) Chronic paronychia is nail fold inflammation usually caused by

staphylococcus aureus or fungi. The characteristic feature is a painful swelling
and erythema of the whole nail fold (crescent-shaped).

(Option B) Heberden’s node of osteoarthritis is a bony lesion over the distal

interphalangeal joints.

(Option C) Pyogenic granuloma is a fleshy red vascular structure usually followed

by minor trauma to the fingers. It is painless.
(Option E) Rheumatoid nodules are periarticular nodules seen in patients with
rheumatoid arthritis. 

References

• DermNet NZ - Cutaneous cysts and pseudocysts

• Medscape - Digital Mucous Cyst

Last updated:
Time spent: QID:36
2023-2-12

Which one of the following statements is correct about lipomas?

A. Lipoma is a premalignant lesion.

B. Lipomas are usually lobulated.
C. Lipomas cannot be tethered to the skin.
D. Lipomas often occur in the scrotum.
E. Lipomas are invariably subcutaneous.

Incorrect. Correct answer is B

45% answered correctly

Explanation:

Correct Answer Is B

Lipomas are common benign tumors of mature fat cells that can be seen in any site of the
body containing fatty tissue. They are not premalignant (option A).

Although they frequently occur in the subcutaneous fat tissue, it is not uncommon to see
lipomas in the deeper layers such as beneath the fascia or within muscles. Therefore, they
are not invariably subcutaneous (option E) and can be found in deeper layers as well 

As there is very little fat in the scrotum, lipomas almost never occur there (option D), but fat
deposition within the spermatic cord may be seen. Unlike lipomas, epidermoid cysts of the
scrotum are common.

Lipomas are usually freely mobile and not attached to the overlying skin; however, in areas
such as the back of the neck or the trunk, where the skin has less mobility, they could be less
mobile or even immobile. This fact makes option C incorrect.

A lipoma's most characteristic physical feature is the lobulated contour, which can reliably
differentiate it from an epidermoid cyst and its smooth contour.

References

• Medscape - Lipomas
Last updated:
Time spent: QID:628
2023-2-12

On a health check, a 75-year-old man is found to have a lesion on his left cheek. He
mentions that he has had it for three years. The lesion is illustrated in the accompanying
photograph. Which one of the following is the most likely diagnosis?

A. Benign nevus.
B. Seborrheic keratosis.
C. Bowen’s disease.
D. Lentigo maligna melanoma.
E. Pigmented basal cell carcinoma.

Incorrect. Correct answer is D

45% answered correctly

Explanation:

Correct Answer Is D

The irregular borders and different color shades of the lesion are suggestive of melanoma.
Since the lesion has been stable for 3 years, lentigo maligna melanoma (Hutchinson
melanotic freckles) is the most likely diagnosis.

Lentigo maligna melanoma is classically a pigmented macular skin lesion found on the sun-
exposed facial skin of the elderly. The color varies from black to light tan and is often
variegated.

(Option A) Benign nevus tends to have smoother borders and more even coloration.

(Option B) Seborrheic keratoses are well-defined lesions with surfaces ranging from velvety
to verrucous. The color can vary from black to light tan. Color variegation is not usually a
feature.

(Option C) Bowen’s disease (squamous cell carcinoma in situ) is a scaly plaque most
commonly in sun-exposed areas. The plaque of Bowen’s disease can be mistaken for
psoriasis or dermatitis.

(Option E) Basal cell carcinoma has different characteristic features such as being pearly,
raised, and associated with telangiectasis in nodular BCC, pearly thready borders in
superficial BCC, and scar-like appearance in morphoeic BCC, none of which are present
here.
References

• DermNet NZ - Lentigo maligna and lentigo maligna melanoma

• Medscape - Lentigo Maligna Melanoma

Last updated:
Time spent: QID:630
2023-2-12

A 45-year-old woman presents with a mole on the lower eyelid of her left eye as shown in
the following photograph. Which of the following would be the most appropriate
management?

A. Excision of the lesion under local anesthesia.

B. Review in one month.
C. Reassure that the lesion is benign.
D. Refer the patient to a plastic surgeon.
E. Apply topical imiquimod.

Incorrect. Correct answer is D

45% answered correctly

Explanation:

Correct Answer Is D

The photograph shows an irregular pigmented lesion on the lower eyelid of the left eye. The
appearance of the lesion is suggestive of melanoma and complete excision and
histopathological studies are indicated. Due to the anatomical location of the lesion, excision
should be performed by a plastic surgeon to avoid tissue destruction or loss of function in
such an anatomically delicate area.

When melanoma is suspected, excisional biopsy should be done as soon as possible;

therefore ‘review in one month’ (option B) and ‘reassurance’ (option C) are incorrect
answers. Imiquimod (option E) is not an appropriate management option for melanoma. 

References

• Cancer Council Australia - Clinical Practice Guidelines for the Management of Melanoma in
Australia and New Zealand
Last updated:
Time spent: QID:631
2023-2-12

An 8-year-old boy is brought to your practice by his mother, who is concerned about a patch
of hair loss on his head. According to the mother, the hairfall started 2 weeks ago and left the
area bald. On examination, there is a 2x3cm patch of hair loss on the scalp. There is no
scarring, inflammation, or flaking of the area. The region is completely bald with no hair.
Which one of the following is the most likely diagnosis?

A. Psoriasis.
B. Tinea capitis.
C. Alopecia areata.
D. Trichotillomania.
E. Discoid lupus erythematosus.

Incorrect. Correct answer is C

45% answered correctly

Explanation:

Correct Answer Is C

Sudden-onset patchy hair loss, no hair growth, and a normal-appearing scalp favor alopecia
areata as the most likely diagnosis.

Alopecia areata is a term used for a hair disorder characterized by one or more discrete
areas of hair loss. Although hair loss can occur anywhere in the body, hair loss of the scalp,
eyebrow, or beard often brings the patient to medical attention.

The physiopathology of alopecia areata is an autoimmune inflammation of anagen hair bulbs

leading to the cessation of hair growth, but not the destruction of the hair follicle. The
etiology of this autoimmune reaction is unknown. Probably, a genetic factor is involved, as
20% of the patients have a positive family history of alopecia areata.

The most common presentation of alopecia areata is the appearance of one or many round-
to-oval completely hairless patches. The presence of exclamation point hairs (i.e. hairs
tapered near the proximal end) is pathognomonic but is not always found. No epidermal
changes are associated with hair loss, and the scalp remains intact. Additionally, hair loss in
other hair-bearing areas supports the diagnosis. A positive ‘pull test’ in the periphery of
the hair loss patch indicates that the disease is active and more hair loss can be expected.

Nail involvement is seen in up to 50% of patients and is associated with poor prognosis. Nail
pitting is the most common form of nail involvement but other abnormalities have been
reported as well. Fingernails (rather than toenails) are predominantly affected.

 The course of the disease is extremely variable. The patch(es) may resolve spontaneously,
remain unchanged, or expand and coalesce with other patches to result in alopecia totalis
(entire scalp) or alopecia universalis (entire body).

With a single patch of hair loss, there is a 33% chance of hair re-growth in 6 months which
will increase to 50% in one year.

Poor prognostic factors for hair re-growth include the following:

 Younger age of onset (<10 years of age)
Alopecia totalis
Peripheral rather than central hair loss
Associated nail pitting
Coincidental atopy
Organ-specific autoimmune disease
Persisted hair loss for many years

The chance of relapse is very high (86% in one study), although the time of relapse cannot
be predicted.

(Option A) Psoriasis is characterized by erythematous scaly plaques, usually with a shiny

silver appearance. In this patient, the scalp is intact; therefore, psoriasis is not likely.

(Option B) Tinea capitis is associated with flaking and hairs of different lengths and different
stages of growth, often broken and damaged.

(Option D) Trichotillomania is compulsive pulling out of the hair. Although the scalp appears
normal, hairs of different lengths are observed.

(Option E) Discoid lupus erythematosus would have inflammation of the scalp of the affected
area and probably scarring.

References

• Therapeutic Guidelines – Dermatology

• Medscape - Alopecia Areata

Last updated:
Time spent: QID:632
2023-2-12

A 45-year-old woman presents to your clinic concerned about a solitary patch of hair loss
sized 5x6 cm. On examination, the scalp of the affected area is completely hairless, but
normal-appearing with no scarring, inflammation, or flaking. Which one of the following is
the next best step in management?

A. Hydrocortisone 1% cream.
B. Intradermal injection of triamcinolone.
C. Scraping of the scalp and microscopy after preparation with KOH.
D. Reassure her that the condition is self-limiting and she will not go bald.
E. Clotrimazole cream.

Incorrect. Correct answer is B

45% answered correctly

Explanation:

Correct Answer Is B

Unaffected scalp skin and complete hair loss are suggestive of alopecia areata. Alopecia
areata is used for a hair disorder characterized by one or more discrete areas of hair loss.
Although hair loss can occur anywhere in the body, hair loss of the scalp, eyebrow, or
beard often brings the patient to medical attention.

The physiopathology of alopecia areata is an autoimmune inflammation of anagen hair

bulbs, leading to the cessation of hair growth, but not the destruction of the hair follicle. The
etiology of this autoimmune reaction is unknown. Probably, a genetic factor is involved
because 20% of patients have a positive family history of alopecia areata.

The course of the disease is highly variable. Hair growth may occur and patches resolve
spontaneously; however, patches may remain unchanged, or expand and coalesce with
other patches to result in alopecia totalis (entire scalp) or alopecia universalis (entire body).

With a single patch of hair loss, there is a 33% chance of hair re-growth in 6 months which
will increase to 50% in 12 months.

Alopecia areata is managed as follows:

Intralesional or topical potent corticosteroids are the initial treatment for most patients with
patchy alopecia areata.

Intralesional corticosteroid injection has a high probability of success. It is appropriate for

eyebrows and small areas on the scalp, but not for wide or multiple scalp or eyelash
involvement. Injection of corticosteroids for alopecia of the eyelashes can cause cataracts,
glaucoma, and cutaneous atrophy. The two commonly used preparations for intradermal
injections are:

Triamcinolone acetonide 10mg/ml

Betamethasone (acetate + sodium phosphate) 5.7mg/ml
The injections should be 6 weeks apart.

While potent topical corticosteroids are frequently used to treat alopecia areata, evidence for
their effectiveness is limited. Topical corticosteroids are usually reserved as first-line therapy
for children and adults who cannot tolerate intralesional injections.

The choices of topical therapy are outlined in the following table:

Very potent
Betamethasone dipropionate                  0.05%
in  optimized vehicle
Potent
Betamethasone dipropionate                  0.05%
Betamethasone valerate                         0.1%
Methylprednisolone aceponate              0.1%
Mometasone furoate                               0.1%
Triamcinolone acetonide                         0.1%

For those with extensive lesions (>50% of scalp hair loss) or recurrences, topical
immunotherapy is probably the most effective treatment and should be considered first-line.
A potent contact allergen is applied to the scalp weekly to precipitate an allergic contact
dermatitis. The consequent mild inflammatory reaction is associated with hair regrowth
through an unknown mechanism.

For children younger than 10 years, minoxidil solution and/or topical corticosteroids are
considered first.

Dithranol cream can be used for those chronic stable areas of hair loss that may have
previously failed to respond to corticosteroid therapy.

(Option A) Hydrocortisone 1% is a mildly potent topical corticosteroid. Mildly potent

corticosteroids are not effective in the treatment of alopecia areata.

(Option C) Scraping of the scalp and preparation with KOH for microscopy would be the
correct answer if tinea capitis were suspected. Tinea capitis would have flaking and hairs of
different lengths as other presenting symptoms in addition to patches of hair loss.

(Option D) While in a good percentage of affected individuals alopecia areata can persist or

even progress to alopecia totalis or universalis, reassurance is not an appropriate option.

(Option E) Clotrimazole cream is used for fungal skin infections. It is not effective against
alopecia areata. Even if tinea was the case, this option was incorrect because tinea of hair
should be treated with oral antifungal agents.

References

• Therapeutic Guidelines – Dermatology

• UpToDate - Management of alopecia areata

Last updated:
Time spent: QID:633
2023-2-12

A 17-year-old boy presents to your practice with lesion shown in the accompanying
photograph. The lesions have failed to improve with conventional therapy. Which one of the
following would be the most appropriate management?

A. Doxycycline.
B. Hydrocortisone 1% cream.
C. Isotretinoin.
D. Benzoyl peroxide.
E. Occlusive makeup.

Incorrect. Correct answer is C

45% answered correctly

Explanation:

Correct Answer Is C

The photograph shows severe cystic acne and scarring. Systemic isotretinoin (Raccutane®)
is the treatment of last resort for severe cystic acne or acne with scarring if conventional
therapy fails. In this patient with no response to conventional therapy, systemic isotretinoin is
the most appropriate management option.

For mild papulopustular acne, the use of either a topical retinoid or benzoyl peroxide is
recommended. If the treatment fails, topical clindamycin or erythromycin is added. Salicylic
acid,  3% to 5% in 70% ethanol, can be used for mild truncal acne.

For moderate papulopustular acne +/- trunk involvement +/- nodules, not only the strength
of topical retinoids or benzoyl peroxide should be increased, but oral rather than topical
antibiotics should be used. Oral doxycycline is the first-line option. Tetracycline or
minocycline can be used alternatively as second- and third-line options, respectively.
Erythromycin (250-500mg, twice daily) is the choice if tetracyclines are not tolerated or
contraindicated (e.g. in pregnancy).

For moderate to severe acne +/- nodules +/- cysts, topical adapalene or tretinoin plus
antibiotics is used. If there is no improvement by 6 weeks or insufficient response by 12
weeks, the antibiotic is changed or the dose is increased. If such measures fail, referral for
systemic treatment with isotretinoin is the most appropriate management. 
References

• Therapeutic Guidelines – Dermatology

Last updated:
Time spent: QID:634
2023-2-12

Which one of the following parts of the nail is more commonly affected by tinea unguium?

A. Nail fold.
B. Nail bed.
C. Nail plate.
D. Cuticle.
E. Entire nail including nail bed. 

Incorrect. Correct answer is C

45% answered correctly

Explanation:

Correct Answer Is C

Tinea unguium is the infection of the fingernails or toenails caused by dermatophytes.

Generally, fungal infection of the nails is termed onychomycosis (plural: onychomycoses).
Onychomycoses which are specifically caused by dermatophytes are referred to as tinea
unguium. There are three distinctive presentations:

Distal subungual

This presentation is the most common form of fungal nail infection. The most common culprit
to this presentation is Trichophyton rubrum. It begins with a whitish, yellowish or brownish
discoloration of the distal corner of the nail, which gradually spreads to the entire width of the
nail plate and then slowly extends toward the cuticle.

Proximal subungual

The most common cause is Trichophyton rubrum. It presents with whitish, yellowish, and
brownish discoloration of the nail, starting from around the cuticle and spreading distally.

White superficial

The most common cause is Trichophyton mentagrophytes. It starts with a dull white spot on
the surface of the nail plate. The whole nail plate may eventually be involved. The white areas
are soft and can be scraped gently to obtain a sample.

In all three types, the nail plate is the often affected part.

References

• Medscape - Onychomycosis
Last updated:
Time spent: QID:635
2023-2-12

A 15-year-old boy presents to your practice with a lesion shown in the following photograph.
The lesion is itchy. Which one of the following is the most likely diagnosis?

A. Psoriasis.
B. Tinea of the face.
C. Seborrheic dermatitis.
D. Allergic reaction.
E. Tinea versicolor.

Incorrect. Correct answer is B

45% answered correctly

Explanation:

Correct Answer Is B

The photograph shows a circular erythematous scaly lesion with a central clearing. This
picture along with the itchiness as the main symptom is highly suggestive of tinea infection
of the face (Tinea faciei) as the diagnosis.

Tinea is caused by dermatophytes - fungi that affect any part of the skin. The typical rash of
tinea has the following characteristic features:

Annular or arcuate (arc-shaped)

Scaly and itchy
Definite edges and central clearing as it expands

(Option A) Psoriasis is a systemic disease. Although the rashes of psoriasis may resemble
tinea at some stages, they tend to appear bilaterally and in a symmetrical fashion. In addition,
silvery scaling is often present; however, scaling may be absent in some forms of psoriatic
lesions. Central clearing is not a feature of psoriatic rash.

(Option C) Dermatitis may present similar to tinea infection, but central clearing makes tinea
a more likely diagnosis.

(Option D) Allergic drug reactions can cause various clinical pictures such as urticaria,
different types of rash, and dermatoses. The photograph however illustrates a typical case of
tinea.

(Option E) Tinea versicolor is a common skin fungal infection caused by Malassezia furfur. It
presents with a well-demarcated macular rash that is hyperpigmented or hypopigmented
and slightly itchy. It is more commonly seen in the upper trunk, however, it may involve the
whole trunk, neck, and even upper limbs. Tinea versicolor lesions do not have central
clearing. 

Tinea versicolor - note the widespread hypopigmented lesions

References

• Medscape - Tinea Faciei

• Therapeutic Guidelines – Dermatology

Last updated:
Time spent: QID:636
2023-2-12

An 8-year-old  boy is brought to your practice with a complaint of itchy lesions shown in the
following. He has been recently prescribed cotrimoxazole. Which on of the following could
be the most likely diagnosis?

A. Tinea infection.
B. Psoriasis.
C. Contact dermatitis.
D. Allergic drug reaction.
E. Tinea versicolor.

Correct
45% answered correctly

Explanation:

Correct Answer Is A

The photograph shows multiple round lesions of different sizes over the face, chest,
abdomen, and arm. The lesions have prominent circular edges with centers being clear. With
itchiness in the history, dermatophytic infection (tinea) is the most likely diagnosis.

Tinea is caused by dermatophytes fungi that affect any part of the skin. The typical rash of
tinea has the following characteristic features:

Annular or arcuate (arc-shaped)

Scaly and itchy
Definite edges and central clearing as it expands

(Option A) Psoriasis is characterized by erythematous patches distributed symmetrically. A

unique feature of psoriasis is the silvery scaling of the patches absent here. Moreover,
psoriatic lesions do not have central clearing.
(Option C) Contact dermatitis can cause an itchy scaly erythematous rash without central
clearing.

(Option D) Allergic reactions to the medication (e.g. cotrimoxazole) can cause various

clinical pictures, including an itchy erythematous rash but without central clearing. Wheels
(hives) have clear centers, but the lesion's appearance differs from those shown in the
photograph. There is usually no scaling.

(Option E) Tinea versicolor presents with hypo/hyperpigmented macules of different sizes

with slight scaling and itching. There is no central clearing of the lesions.

References

• Medscape - Tinea Corporis

• Therapeutic Guidelines
Last updated:
Time spent: QID:637
2023-2-12

A 23-year-old woman presents to your GP clinic with a rash on her back. The rash appeared
two months ago as a 3x4 cm oval patch on her upper back that later on was followed by an
eruption of smaller spots with occasional itching. The spots are paler than the surrounding
skin. She has tried tanning oils and salons but the rash persists. On examination, there are
multiple 3- to 5-mm macules on her back distributed in a ‘Christmas tree pattern. Which
one of the following is the most likely diagnosis?

A. Lichen simplex chronicus.

B. Pityriasis rosea.
C. Allergic contact dermatitis.
D. Atopic dermatitis.
E. Tinea corporis.

Incorrect. Correct answer is B

45% answered correctly

Explanation:

Correct Answer Is B

The clinical picture and the course of symptoms are highly suggestive of pityriasis rosea (PR)
(fine pink scale) is a common skin disorder seen in otherwise healthy people, especially in
children and young adults. The cause is thought to be a viral infection (possibly herpes virus
6 or 7).

The eruption begins with a 'herald patch' that may be mistaken for tinea. This rash is then
followed in approximately 2 weeks by the development of multiple, scaly, salmon-colored
macules, each about 1 to 2 cm in size and oval in shape. The eruption is symmetric and most
commonly involves the chest, back, abdomen, and adjoining areas of the neck and limbs.
Lesions are not usually seen on the face, hands, and feet. The lesions are arranged along the
skin creases to form an appearance similar to a Christmas tree. The rash may be itchy.

The herald patch of pityriasis rosea

 The herald patch of pityriasis rosea and subsequent evolving macules of different
sizes 

Christmas Tree appearance of pityriasis rosea

Pruritus is commonly evident in 25-75% of patients and is usually of mild-to-moderate

severity. Secondary eczematous changes can occur if pruritus is severe. A small number
(approximately 5%) of patients with PR have mild prodromal symptoms (e.g. malaise,
fatigue, headache, nausea, anorexia, chills, fever, and arthralgia) that precede the
appearance of the herald patch. Lymphadenopathy may occur before the onset of the rash.

As a rule, PR only needs symptomatic management. Menthol is often effective for mild
itching. Moderately potent corticosteroids are used for more severe cases of itching.
Exposure to sunlight may be effective for the alleviation of itching as well as hastening the
resolution of the rash.

The condition resolves spontaneously in 6-8 weeks in most cases, but some lesions may
persist for as long as 3-4 months. With the resolution of the eruption, post-inflammatory
pigment change can be observed. Both hypopigmentation and hyperpigmentation can follow
the rash. Dark-skinned people may experience hyperpigmentation that takes a few months
to resolve.

PR-like eruptions are differential diagnoses. This condition is associated with many drugs
such as acetylsalicylic acid, barbiturates, bismuth, captopril, clonidine, gold, imatinib,
isotretinoin, ketotifen, levamisole, and metronidazole, as well as vaccines such as BCG, HPV,
and diphtheria. 

References

• DermNet NZ- Pityriasis rosea

• Medscape - Pityriasis Rosea

• Therapeutic Guidelines – Dermatology

Last updated:
Time spent: QID:638
2023-2-12

A 45-year-old woman presents to your GP clinic for review. A few months ago, she
developed redness around her nose and cheeks that became worse after she drank alcohol.
Recently, she was asked, by one of her colleagues at work, if she has alcohol problems
because her appearance resembles those with excessive alcohol use. She drinks an average
of 10 units of alcohol per week. Her facial appearance is shown in the accompanying
photograph. Which one of the following is the most likely diagnosis?

A. Seborrheic dermatitis.
B. Erysipelas.
C. Acne rosacea.
D. Systemic lupus erythematous.
E. Alcohol-related skin disease.

Incorrect. Correct answer is C

45% answered correctly

Explanation:

Correct Answer Is C

The photograph shows an erythematous butterfly rash. Additionally, the chin is also involved.
Several papules and pustules are noted as well. The clinical picture presented in the
photograph, along with the history, is suggestive of rosacea (also known as acne rosacea)
as the most likely diagnosis.

Rosacea is a common chronic disorder that mainly involves the face. It tends to present in
middle-aged people but may start at earlier ages. It is more common in cold climates.

The condition often begins as an exaggerated or prolonged flushing tendency, with erythema
affecting the central face or the butterfly area in particular. Sometimes erythema can be
seen in the chin and forehead. Initially, the erythema occurs intermittently but later becomes
persistent. Sometimes, rosacea is associated with edema. Telangectiasis is often
present. Sterile inflammatory papules, pustules, and nodules may be present
mimicking acne. The distinguishing feature is the absence of comedones.
Patients often complain that their faces feel hot, burn, sting or itch. The patient often reports
that their face is increasingly easily irritated by topical products.

The etiology of rosacea is unknown. Alcohol is not a cause but it can trigger the flushing and
worsen the symptoms. Other triggering factors include:

Hot or cold temperatures

Wind
Hot drinks
Caffeine
Exercise
Spicy foods
Emotions
Topical products that irritate the skin and decrease the barrier
Medications that cause flushing

In about 50% of the patients, blepharoconjunctivitis is observed. It presents with itching,

burning, grittiness or foreign body sensation in the eye and erythema and swelling of the
eyelid. More advanced cases can develop enlarged sebaceous glands and connective tissue
changes resulting in a bulbous, rhinophymatous nose.

Seborrheic dermatitis, SLE, and erysipelas are among the differential diagnosis but not
consistent with the history. None of these conditions have alcohol as a triggering factor.

(Option A) Seborrhoeic dermatitis has scaling of the skin as a prominent feature.

(Option B) Erysipelas is associated with the abrupt onset of erythematous butterfly rash
almost always caused by streptococcus pyogenes. There is often fever and constitutional
upset. It is not a chronic condition and is not triggered by alcohol use.

(Option D) Although the rash resembles that of SLE, the lack of other signs and symptoms
favoring SLE makes it least likely.

(Option E) Alcohol-related skin disease is a general term, not a diagnosis. Rosacea worsens
by alcohol but is not caused by it.

References

• DermNet NZ - Rosacea

• RACGP - AFP- Rosacea

Last updated:
Time spent: QID:682
2023-2-12

A 17-year-old girl presents to your GP practice with redness and swelling of the sun-
exposed areas of her face after he spent 60 minutes in the sun. She is on treatment for acne.
On examination, erythema and edema of the sun-exposed areas of her face, neck and
upper chest are noted. There are bullae all over the area. Which one of the following is the
most likely diagnosis?

A. Doxycycline phototoxicity.
B. Allergic contact dermatitis.
C. Erythromycin phototoxicity.
D. Stevens – Johnson syndrome.
E. Benzoyl peroxide phototoxicity.

Correct
45% answered correctly

Explanation:

Correct Answer Is A

The scenario describes a typical case of photosensitivity associated with medication, namely
drug-associated photoeruption.

There are two basic types of photoeruptions, which differ in clinical appearance and
pathogenesis:

Phototoxic eruptions  —  by far, phototoxic eruptions are the

most common drug-induced photoeruptions. They are
caused by absorption of ultraviolet light by the causative
drug resulting in cell damage. Ultraviolet A light (UVA) is the
most common wavelength implicated; ultraviolet B light (UVB)
and visible light can elicit reactions with some drugs. The
eruption is typically an exaggerated sunburn, often with
blisters. The following drugs are the most common causes of
phototoxic eruptions:
NSAIDs
Quinolones
Tetracyclines (e.g.doxycycline)
Sulfonamides
Phenothiazines

Photoallergic eruptions  — photoallergy is a lymphocyte-mediated reaction caused by

exposure to UVA. It is postulated that the absorbed radiation converts the drug into an
immunologically active compound that is then presented to lymphocytes, causing a
spongiotic dermatitis (eczema). The eruption is characterized by widespread eczema in
photo-exposed areas: face, upper chest, and back of the hands.

Most photoallergic reactions are caused by topical agents including biocides added to soaps
(halogenated phenolic compounds) and fragrances such as musk ambrette and 6-methyl
coumarin. Systemic photoallergens such as the phenothiazines, chlorpromazine, sulfa
products, and NSAIDs can produce photoallergic reactions; however, most of their
photosensitivity reactions are phototoxic.

The characteristic skin lesion in this patient (edema, erythema and blistering) suggests a
phototoxic eruption to one of the medications she is on for treatment of acne. Of the options,
doxycycline (a tetracycline) is most likely to have caused this presentation.

(Option B) Allergic contact dermatitis, as the name implies, require skin contact with an
specific allergen to trigger a cutaneous immune response, most often characterized by
eczema (spongiotic dermatitis). Moreover, contact dermatitis is not associated with UV
exposure.

(Option D) Stevens – Johnson syndrome, sometimes called erythema multiforme major, is a

hypersensitivity response that can be triggered by the same drugs mentioned above, but
with a different presentation. Furthermore, UV exposure does not play a role. Stevens –
Johnson syndrome presents with epidermal and muscosal necrosis and sloughing of the skin
and mucous membrane.

(Options C and E) Benzoyl peroxide and erythromycin have not shown proven association
with photoeruptions.

References

• UpToDate - Drug eruptions

• Medscape - Drug-Induced Photosensitivity

Last updated:
Time spent: QID:711
2023-2-12

A 2-year-old boy is brought to the emergency department, by his mother, after he

developed a rash following a bee sting 20 minutes ago. The appearance of the rash is shown
in the following photograph. On examination, there is no breathlessness, wheezing,
abdominal pain, or hemodynamic instability. Which one of the following is the most
appropriate management?

A. Intravenous epinephrine.
B. Intravenous diphenhydramine.
C. Intramuscular epinephrine.
D. Oral promethazine.
E. Oral corticosteroids.

Incorrect. Correct answer is D

45% answered correctly

Explanation:

Correct Answer Is D

The picture shows generalized urticaria (hives) of the trunk. The rash also has involved the
buttocks and arms but not the eyelids. In approach to patients with immediate
hypersensitivity, the initial assessment should be focused on airway, breathing and
circulation (ABC).  

In the presence of any of the following situations, intramuscular epinephrine is always the
most appropriate immediate management:

Any acute onset of hypotension or bronchospasm or upper airway obstruction, even if

typical skin features are not present.
Any acute-onset illness with typical skin features (urticarial rash or erythema/flushing,
and/or angioedema) PLUS Involvement of respiratory and/or cardiovascular and/or
 persistent severe gastrointestinal symptoms.

NOTE - An adrenaline autoinjector (EpiPen® or Anapen®) may be used instead of an

adrenaline ampoule and syringe. For children 10–20 kg (aged 1–5 years) EpiPen Junior®
or Anapen Junior® should be used. Intravenous boluses of epinephrine are not
recommended without specialized training, as they may increase the risk of cardiac
arrhythmias. 

In the absence of the above mentioned presentations, management revolves around

treatment of urticaria (and not anaphylaxis). Oral antihistamines (e.g. promethazine) are
mainstay of therapy in most cases. Intravenous route is used when the urticaria is severe or
eyelids are involved.  If there is no response to antihistamines, oral corticosteroids are
considered. 

References

• Therapeutic Guidelines

• ASCIA Guidelines - Acute management of anaphylaxis

Last updated:
Time spent: QID:740
2023-2-12

Jane, 53 years, presents to your GP practice with facial weakness, right ptosis, and drooling
from the right corner of her mouth since this morning. She mentions a history of right ear
pain a few days earlier. On examination, an erythematous vesicular rash is noted in the right
ear canal.  Which one of the following would be the most appropriate next step in
management?

A. Oral aciclovir.
B. Oral prednisone.
C. Methotrexate.
D. Clindamycin.
E. Gabapentin.

Correct
45% answered correctly

Explanation:

Correct Answer Is A

The clinical findings and history suggest Ramsay Hunt syndrome as the most likely diagnosis.
The syndrome is defined as an acute peripheral facial neuropathy caused by the reactivation
of a latent varicella-zoster virus infection. The syndrome is associated with an erythematous
vesicular rash of the skin of the ear canal, auricle (also known as herpes zoster oticus),
and/or oropharyngeal mucous membrane.

Varicella zoster virus (VZV) infection causes two distinct clinical syndromes. Primary
infection, also known as varicella or chickenpox, is a common pediatric viral disease.  After a
chickenpox infection, VZV remains latent in the neurons of cranial nerves and dorsal root
ganglia. Subsequent reactivation of latent VZV can result in a vesicular rash in a dermatomal
distribution, known as herpes zoster. VZV infection or reactivation involving the geniculate
ganglion of the 7th cranial nerve (CN VII) within the temporal bone is the main
pathophysiological mechanism of Ramsay-Hunt syndrome.

Ramsay-Hunt syndrome is estimated to account for 16% of all causes of unilateral facial
palsies in children, and 18% of facial palsies in adults. Ramsay Hunt syndrome is thought to
be the cause of as many as 20% of clinically diagnosed cases of Bell palsy. Although VZV
reactivation is the cause in most cases of this syndrome, herpes simplex virus (HSV) II has
been implicated in some cases.

The syndrome usually presents with paroxysmal pain deep within the ear. The pain often
radiates outward into the pinna of the ear and may be associated with a more constant,
diffuse, and dull background pain. The onset of pain usually precedes the rash by several
hours or even days.

The classic triad includes (1) ipsilateral facial palsy, (2) ear pain, and (3) vesicles in the
auditory canal and auricle. In some patients taste perception, hearing (tinnitus, hyperacusis),
and lacrimation may occur.
Ramsay-Hunt syndrome is generally considered a polycranial neuropathy, with frequent
involvement of cranial nerves V, IX, and X. With the involvement of the geniculate ganglion,
the inflammation can spread to the 8th cranial nerve (CN VIII), resulting in auditory and
vestibular disorders.

Clinical manifestations of Ramsay Hunt syndrome may include:

Vesicular rash of the ear or mouth (as many as 80% of cases)

The rash might precede the onset of facial paresis/palsy (involvement of the seventh
cranial nerve [CN VII])
Ipsilateral lower motor neuron facial paresis/palsy (CN VII)
Vertigo and ipsilateral hearing loss (CN VIII)
Tinnitus
Hyperacusis
Otalgia (ear pain)
Headaches
Dysarthria
Gait ataxia
Fever
Cervical lymphadenopathy
Facial weakness usually reaches maximum severity by one week after the onset of
symptoms.
Other cranial neuropathies might be present and may involve cranial nerves (CNs) VIII,
IX, X, V, and VI.
Ipsilateral hearing loss has been reported in as many as 50% of cases.
Blisters of the skin of the ear canal, auricle, or both may become secondarily infected,
causing cellulitis.

Antiviral treatment should be started in all patients within 72 hours of the onset of the rash.
This time limit does not apply to patients with herpes zoster ophthalmicus and
immunocompromised patients, meaning that such patients should receive antiviral therapy
even beyond 72 hours of presentation.

Treatment options include famciclovir, valaciclovir, and aciclovir.

NOTE - Aciclovir is the preferred medication in children and pregnant women.

For this patient, oral acyclovir is the most appropriate option to consider as the next step in
management.

(Option A) Therapy with oral corticosteroids (e.g. prednisolone daily for 7 days, tapering to 5
mg daily over the next 2 weeks) can reduce symptoms in the acute (inflammatory) phase of
herpes zoster, but only when used in combination with an antiviral agent. Corticosteroids are
recommended for patients over the age of 50 if not contraindicated and should be used with
caution in patients with comorbid conditions such as diabetes.

(Option C) Methotrexate has no role in the treatment of herpes zoster.

(Option D) Antibiotics other than mentioned antiviral agents are ineffective in treating herpes
zoster.  
(Option E) Gabapentin and tricyclic antidepressants are the most effective treatment options
for neuropathic pain associated with herpes zoster infection, but given the time of
presentation, antiviral therapy should be considered as the cornerstone of therapy first.

References

• Medscape - Ramsay Hunt Syndrome

• DermNet NZ - Ramsay Hunt Syndrome

• UpToDate - Epidemiology, clinical manifestations, and diagnosis of herpes zoster

Last updated:
Time spent: QID:819
2023-2-12

Jane, 53 years, presents to your GP practice with facial weakness, right ptosis, and drooling
from the right corner of her mouth since this morning. She mentions a history of right ear
pain a few days earlier. On examination, an erythematous vesicular rash is noted in the right
ear canal.  Which one of the following would be the most appropriate next step in
management?

A. Oral aciclovir.
B. Oral prednisone.
C. Methotrexate.
D. Clindamycin.
E. Gabapentin.

Correct
45% answered correctly

Explanation:

Correct Answer Is A

The clinical findings and history suggest Ramsay Hunt syndrome as the most likely diagnosis.
The syndrome is defined as an acute peripheral facial neuropathy caused by the reactivation
of a latent varicella-zoster virus infection. The syndrome is associated with an erythematous
vesicular rash of the skin of the ear canal, auricle (also known as herpes zoster oticus),
and/or oropharyngeal mucous membrane.

Varicella zoster virus (VZV) infection causes two distinct clinical syndromes. Primary
infection, also known as varicella or chickenpox, is a common pediatric viral disease.  After a
chickenpox infection, VZV remains latent in the neurons of cranial nerves and dorsal root
ganglia. Subsequent reactivation of latent VZV can result in a vesicular rash in a dermatomal
distribution, known as herpes zoster. VZV infection or reactivation involving the geniculate
ganglion of the 7th cranial nerve (CN VII) within the temporal bone is the main
pathophysiological mechanism of Ramsay-Hunt syndrome.

Ramsay-Hunt syndrome is estimated to account for 16% of all causes of unilateral facial
palsies in children, and 18% of facial palsies in adults. Ramsay Hunt syndrome is thought to
be the cause of as many as 20% of clinically diagnosed cases of Bell palsy. Although VZV
reactivation is the cause in most cases of this syndrome, herpes simplex virus (HSV) II has
been implicated in some cases.

The syndrome usually presents with paroxysmal pain deep within the ear. The pain often
radiates outward into the pinna of the ear and may be associated with a more constant,
diffuse, and dull background pain. The onset of pain usually precedes the rash by several
hours or even days.

The classic triad includes (1) ipsilateral facial palsy, (2) ear pain, and (3) vesicles in the
auditory canal and auricle. In some patients taste perception, hearing (tinnitus, hyperacusis),
and lacrimation may occur.
Ramsay-Hunt syndrome is generally considered a polycranial neuropathy, with frequent
involvement of cranial nerves V, IX, and X. With the involvement of the geniculate ganglion,
the inflammation can spread to the 8th cranial nerve (CN VIII), resulting in auditory and
vestibular disorders.

Clinical manifestations of Ramsay Hunt syndrome may include:

Vesicular rash of the ear or mouth (as many as 80% of cases)

The rash might precede the onset of facial paresis/palsy (involvement of the seventh
cranial nerve [CN VII])
Ipsilateral lower motor neuron facial paresis/palsy (CN VII)
Vertigo and ipsilateral hearing loss (CN VIII)
Tinnitus
Hyperacusis
Otalgia (ear pain)
Headaches
Dysarthria
Gait ataxia
Fever
Cervical lymphadenopathy
Facial weakness usually reaches maximum severity by one week after the onset of
symptoms.
Other cranial neuropathies might be present and may involve cranial nerves (CNs) VIII,
IX, X, V, and VI.
Ipsilateral hearing loss has been reported in as many as 50% of cases.
Blisters of the skin of the ear canal, auricle, or both may become secondarily infected,
causing cellulitis.

Antiviral treatment should be started in all patients within 72 hours of the onset of the rash.
This time limit does not apply to patients with herpes zoster ophthalmicus and
immunocompromised patients, meaning that such patients should receive antiviral therapy
even beyond 72 hours of presentation.

Treatment options include famciclovir, valaciclovir, and aciclovir.

NOTE - Aciclovir is the preferred medication in children and pregnant women.

For this patient, oral acyclovir is the most appropriate option to consider as the next step in
management.

(Option A) Therapy with oral corticosteroids (e.g. prednisolone daily for 7 days, tapering to 5
mg daily over the next 2 weeks) can reduce symptoms in the acute (inflammatory) phase of
herpes zoster, but only when used in combination with an antiviral agent. Corticosteroids are
recommended for patients over the age of 50 if not contraindicated and should be used with
caution in patients with comorbid conditions such as diabetes.

(Option C) Methotrexate has no role in the treatment of herpes zoster.

(Option D) Antibiotics other than mentioned antiviral agents are ineffective in treating herpes
zoster.  
(Option E) Gabapentin and tricyclic antidepressants are the most effective treatment options
for neuropathic pain associated with herpes zoster infection, but given the time of
presentation, antiviral therapy should be considered as the cornerstone of therapy first.

References

• Medscape - Ramsay Hunt Syndrome

• DermNet NZ - Ramsay Hunt Syndrome

• UpToDate - Epidemiology, clinical manifestations, and diagnosis of herpes zoster

Last updated:
Time spent: QID:819
2023-2-12

A 65-year-old man presents with an exquisitely painful vesicular rash, which has been
present for the past 7 days and is increasingly painful. The rash is shown in the following
photograph. His past medical history is unremarkable. Physical examination is otherwise
inconclusive. Which one of the following is the most appropriate immediate management?

A. Oral famciclovir.
B. Intravenous famciclovir.
C. Oral amitriptyline.
D. Intramuscular immunoglobulin.
E. Oral Phenergan® (promethazine).

Incorrect. Correct answer is C

45% answered correctly

Explanation:

Correct Answer Is C

The appearance of the rash and the history suggest herpes zoster (shingles) infection as the
most likely diagnosis.

Herpes zoster (shingles) is caused by the reactivation of the varicella-zoster virus (VZV). It
usually occurs in adults but can be seen in children and in the first 2 years of life if there has
been a history of maternal varicella.

Pain is a significant complaint in patients with shingles. Tricyclic antidepressants and the
anticonvulsant gabapentin are the most effective medications for pain control in neuropathic
pain associated with shingles. 

(Options A and B) Antiviral agents such as famciclovir, valacyclovir, or acyclovir should be

used in any patient seen within 72 hours of the onset of vesicles, all patients with ophthalmic
herpes zoster, and in immunocompromised patients. For pregnant women, only acyclovir
(first line) or valaciclovir (second line) are used because the safety of famciclovir during
pregnancy has yet to be established.

(Option D) Varicella zoster immunoglobulin (VZIG) and vaccine are used for prophylaxis.
Their use is not effective in the treatment or for pain control after the infection has
established.

(Option E) Promethazine is not effective for pain control in shingles.

References

• Medical Journal of Australia - The prevention and management of herpes zoster

• Therapeutic Guidelines – Antibiotics

• Therapeutic Guidelines – Neurology

Last updated:
Time spent: QID:820
2023-2-12

A 60-year-old man presents to your clinic with complaints of fever and a painful swollen
right thigh. He has diabetes well controlled on metformin 500mg 8-hourly and hypertension
for which he is taking valsartan 80mg, daily. He is on atorvastatin 20 mg daily for
hypercholesterolemia as well. His recent medical history is remarkable for deep vein
thrombosis (DVT) of his right leg, for which he is currently on warfarin. One week ago, he
was admitted to the hospital after one episode of syncope and started on amiodarone after
he was diagnosed with ventricular tachycardia (VT). Physical examination is remarkable for a
temperature of 38.3°C and a warm swollen tender right thigh that is erythematous. The right
thigh circumference is 3 cm greater than that of the left thigh. Which one of the following
could be the most likely cause of this presentation?

A. Deep vein thrombosis (DVT).

B. Cellulitis.
C. Drug interaction.
D. Hematoma.
E. Rhabdomyolysis.

Incorrect. Correct answer is B

45% answered correctly

Explanation:

Correct Answer Is B

 At first glance, there are a number of differential diagnoses for a swollen painful thigh
including DVT, cellulitis, and hematoma. This patient is on warfarin for treatment of a
previous DVT, which is a risk factor for another venous thromboembolic event (VTE) such as
another DVT or pulmonary embolism (PE). However, it is less likely, yet not impossible, for
this patient to develop another VTE while on treatment with warfarin. Therefore, DVT of the
right leg (option A) is a weak possibility.

The interaction between warfarin and amiodarone is well-known. Amiodarone results in the
decreased metabolization of warfarin through hepatic pathways and leads to increased
bleeding tendency. Considering that the patient has been recently started on amiodarone
while on warfarin, a hematoma (option D) can also be a possibility. However, the presence of
fever, warmth, and erythema of the swelling makes this diagnosis less likely. Pressure from a
hematoma on surrounding tissues such as skin or deeper layers (e.g. muscles can
compromise circulation and results in complications such as necrosis or a superimposed
infection that can justify, to some extent, the clinical picture; however, the expected
sequence would be hematoma formation first and then the development of signs such as
tenderness, warmth, and erythema later. It is also worth reminding the fact that hematomas
present as bruises or bluish not red discoloration. Hematomas are not warm and are often
non-tender. Swelling is a feature though.

Drug interaction (option C) between warfarin and amiodarone can result in increased
bleeding tendency and the development of a hematoma, and interaction between
atorvastatin and amiodarone can lead to an increased potential for the development of
statin-related muscle problems. None of these events are associated with the given
presentation and are very unlikely to be the cause of this clinical picture.
Rhabdomyolysis (option E) is a serious condition followed by muscle fibers breakdown and
release of muscle cell contents such as myoglobin and potassium. Myoglobinuria results in
the deposition of myoglobin in the kidneys and renal failure. Release of excess potassium
from damaged muscle cells leads to hyperkalemia and serious complications such as
cardiac arrhythmias.  Statins such as atorvastatin and simvastatin in particular are
metabolized by cytochrome P450-3A4 (CYP3A4), and amiodarone is a potent inhibitor of
this cytochrome. Concomitant use of amiodarone and statins can result in increased activity
of statins and rises the likelihood of statin-related adverse effects such as muscular pain,
myopathy, and rarely rhabdomyolysis. However, in the event of statin-induced
rhabdomyolysis, a systemic presentation is expected. Rhabdomyolysis never causes the
focal signs mentioned in the scenario.

Of the given options, this clinical picture is most consistent with cellulitis of the left thigh as
the most likely diagnosis. Cellulitis presents with systemic signs such as fever and focal
findings of induration, warmth, redness, and tenderness of the affected area. Diabetes can
be a risk factor.

References

• Medscape - Cellulitis

• RACGP - Warfarin: indications, risks and drug interactions

Last updated:
Time spent: QID:1208
2023-2-12

John, 60 years of age, presents to your office because he is concerned about a skin lesion
on his forearm. The dermatoscopic view of the lesion is shown in the following photograph.
Which one of the following could be the most likely diagnosis?

A. Actinic keratosis.
B. Bowen’s disease.
C. Malignant melanoma.
D. Dermatosis papulosa nigra.
E. Seborrheic keratosis.

Incorrect. Correct answer is E

45% answered correctly

Explanation:

Correct Answer Is E

The photograph shows an oval brown plaque on a sun-exposed area in an old man. There is
also keratotic plugging in the surface of the lesion (yellowish-colored). These features are
characteristic of seborrheic keratosis as the most likely diagnosis.

Seborrheic keratosis (SK) is the most common benign skin tumor in older adults with the
incidence increasing with age. It is typically oval or round and brown lesions mostly in sun-
exposed areas with adherent greasy scales. The color may range from black to tan. Usually,
SK has a velvety verrucous (warty) surface and appears stuck on. However, some lesions
are so verrucous that may resemble warts.

(Option A) Actinic keratosis is characterized by flat small scaly lesions on the sun-exposed
area of old adults, especially the back of the hands. Lesions can be multiple. Actinic keratosis
is precancerous with the potential to become squamous cell carcinoma.
 Multiple actinic (solar) keratoses on the back of the hand and forearm

Actinic keratosis - Note the flat appearance and scales of the lesion

(Option B) Bowen’s disease, similar to AK, is seen in the sun-damaged area of skin in older
adults and is precancerous. It is flat and scaly such as AK but is larger in diameter and tends
to be thicker with well-demarcated borders.
 Bowen disease - similar to actinic keratosis but
larger and well-demarcated

Bowen disease

(Option C) Malignant melanoma commonly presents with a rather flat lesion of various colors
and irregular borders and shapes. Although nodular melanomas can present with a
pigmented dome-shaped lesion, the commonality of SK, the presence of keratotic plugs,
and the lack of color variety make malignant nodular melanoma a far less likely diagnosis
compared to SK.

Nodular melanoma - note the different colors and lack of

keratotic plugs which differentiate this lesion from seborrheic keratosis

 

Nodular melanoma

(Option D) Dermatosis papulosa nigra is a variant of SK consisting of multiple brown-black

dome-shaped, small papules found in the face of young to middle-aged people with colored
skin, especially black. This single lesion on the forearm of an old man is SK not its variant
dermatosis papulosa nigra.

Dermatosis papulosa nigra

NOTE – Stucco keratosis is another variant of SK that consists of large numbers of

superficial grey-to-light brown flat keratotic lesions usually on the tops of the feet, ankle,
and the back of the hands and forearms.

References

• Medscape - Seborrheic Keratosis

Last updated:
Time spent: QID:1447
2023-2-12

The 7-year-old Evie is brought to your general practice by her mother who is concerned
about a rash she has developed and is shown in the following photograph. The rash
appeared almost two months ago on her abdomen and has spread to the extent evident in
the photo. There is no complaint of pain or itching, but a few lesions have ulcerated (one
shown in the photograph). Evie is otherwise healthy and has not had any serious illnesses so
far. Her growth charts are all normal. Physical examination is otherwise normal. She goes to
school and has two younger brothers and sisters at home. Which one of the following is the
correct advice to give?

A. She should be excluded from school until the resolution of the rash.
B. She can go to school but should use separated towel and other personal items.
C. She should be given oral acyclovir.
D. Cryotherapy with liquid nitrogen is the treatment of choice for the rash.
E. She should use topical steroids.

Incorrect. Correct answer is B

45% answered correctly

Explanation:

Correct Answer Is B

The lesions shown in the photograph are pearly dome-shaped papules with central
umbilication characteristic of molluscum contagiosum as the most likely diagnosis.
Molluscum contagiosum is a common viral infection of childhood caused by
molluscipoxvirus a member of the poxvirus family.

The infection presents with firm, smooth, spherical papules that are pearly white and have a
central dimple (umbilicus). Most papules range from 1 to 3 mm; however, lesions of up to 1-2
cm have been reported mostly due to coalescing smaller lesions.

Seeking medical attention can be due to concerns about the rash itself, or more frequently
the development of eczema in the surrounding skin. The latter can make a diagnostic
challenge because eczema can obscure the primary lesions.
Lesions can develop anywhere, but flexures and areas of friction are more frequently
involved. Lesions may also occur in the anogenital area and are not usually associated with
sexual abuse of the child. Involvement of the eyelid margins may lead to chronic
conjunctivitis.

Molluscum contagiosum has a benign course and nature. Most of the patients experience
the spontaneous resolution of the lesions within three to six months, but on occasion, it may
take up to three years.

In most cases, active treatment is not recommended because spontaneous resolution

usually occurs upon activation of the immune response which may take from three months
to three years. For individual lesions, removal by cryotherapy (option D) or curettage may be
considered but is not generally recommended as a routine treatment for the lesions.

Children with molluscum contagiosum do not require isolation or exclusion from school
(option A). however, it is better to avoid sharing towels or bathing together as these may
increase the risk of spread to their brothers and sisters or other children.

(Option C) Active topical or oral antiviral therapy, such as acyclovir, is unnecessary and
recommended.

Option E) Short-term use of a topical steroid for the treatment of associated eczema is
recommended. There is no associated eczema in the photograph, so topical steroids are not
indicated.

NOTE - Inflamed lesions do not require antibiotics either orally or topically. 

References

• RCH – Molluscum

• Health – VIC – Molluscum contagiosum

Last updated:
Time spent: QID:1468
2023-2-12

A 51-year-old man presents to the hospital with a swollen hand shown in the following
photograph. He was gardening in his courtyard yesterday when his left index finger was
injured. This morning, he noticed that his left hand is tender, swollen, and red. On
examination, he has a blood pressure of 134/78 mmHg, a pulse of 88, a respiratory rate of 16
breaths/min, and a temperature of 38.1°C. Which one of the following is the most appropriate
next step in management?

A. Ultrasound of the hand.

B. MRI of the hand.
C. Admission to the hospital and commencement of intravenous antibiotics.
D. CT scan of the hand.
E. Discharge him home on oral antibiotics and review in 24-48 hours.

Incorrect. Correct answer is E

45% answered correctly

Explanation:

Correct Answer Is E

The swollen, red, and tender hand following a recent injury makes cellulitis the most likely
diagnosis. Cellulitis is a clinical diagnosis and no imaging studies such as ultrasound (option
A), MRI (option B), or CT scan (option D) are required.

Streptococcus pyogenes (S.pyogenes) or other Streptococcus species such as group B,C,

or G  are the most common causes of nonpurulent, recurrent (e.g., associated with
lymphedema), or spontaneous rapidly spreading cellulitis. Staphylococcus aureus is less
common for cellulitis and is often associated with penetrating trauma, ulceration, or an
abscess. Purulent cellulitis is typically caused by Staphylococcus aureus.

Antibiotics are the mainstay of treatment. Oral antibiotics are adequate for cellulitis not
associated with systemic features and are usually appropriate for patients with a single
systemic feature of infection (e.g., fever alone).

For adults with two or more of the following clinical features, admission to the hospital and
commencement of intravenous antibiotics (option C) should be used initially:
 Temperature more than 38°C or less than 36°C
Heart rate of more than 90 bpm
Respiratory rate of more than 20 breaths/minute
White cell count more than 12x109/L or less than 4x109/L, or more than 10% immature
(band) forms

Other indications for initial intravenous antibiotics (even without having 2 or more of the
above) are:

Intolerance of oral therapy

Immunocompromised patients
Comorbidities that could be associated with the rapid progression of  cellulitis such as
diabetes mellitus
Early follow-up is not possible

Patients who are discharged on oral antibiotics require early assessment (within 24-48
hours) for treatment response.

For this patient with a fever of 38.1°C as the only concerning factor besides the cellulitis,
discharging home on oral antibiotics with an early review is the most appropriate option to
consider at this stage. Intravenous antibiotics should be considered next if the response to
oral therapy is unsatisfactory.

Other advice to give this patient is rest and elevation of the affected area.

References

• Therapeutic Guidelines – Antibiotics

Last updated:
Time spent: QID:1654
2023-2-12

A 27-year-old man presents with extremely itchy rash on his buttocks and elbows as shown
in the following photograph. He has long-standing history of celiac disease. He was also
diagnosed with major depression seven months ago for which he is under treatment with
Zoloft. Which one of the following could be the most likely diagnosis?

A. Linear IgA dermatosis.

B. Neurotic excoriation.
C. SSRI-induced dermatitis.
D. Scabies.
E. Dermatitis herpetiform.

Incorrect. Correct answer is E

45% answered correctly

Explanation:

Correct Answer Is E

The photograph shows papules and vesicles of which some are eroded. Presence of such
features, the clinical picture, and the presence of long-standing celiac disease in history
make dermatitis herpetiform the most likely diagnosis. Dermatitis herpetiform is a rare
cutaneous condition presenting with persistent immunobulous disease with a strong link to
celiac disease.

The condition is called herpetiform because blisters/vesicles develop in clusters resembling

herpes simplex.

Dermatitis herpetiformis (aka Duhring-Brocq disease) is a rare skin condition presenting with
persistent immune-related bullous formation. The name herpetiformis is derived from the
tendency for blisters to appear in clusters, resembling herpes simplex. However, dermatitis
herpetiformis is not due to viral infection.

Dermatitis herpetiform and celiac disease are linked as both are due to intolerance to the
gliadin fraction of gluten. Gluten triggers production of IgA and an autoimmune response that
targets the intestine and skin. Over 90% of patients with dermatitis herpetiform have gluten-
sensitive enteropathy and 15-25% of patients with celiac disease have concurrent dermatitis
herpetiform. These patients tend to have a more severe intestinal pathology in comparison to
those without dermatitis herpetiformis.
Dermatitis herpetiformis symmetrically affects scalp, shoulders, buttocks, elbows, and
knees. Lesions come in form of extremely itchy papules and vesicles on normal-looking or
erythematous skin. Lesions form in clusters (herpes simplex-like). Vesicles are often
unroofed and flat due to scratching by the patient.

Other forms in which dermatitis herpetiform can present are digital petechia or flat red
patches, or wheels imitating other skin conditions such as scabies (option D), dermatitis, or
linear IgA dermatosis (option A).

Linear IgA dermatosis (LAD) is an autoimmune subepidermal vesiculobullous disease that

may be idiopathic or drug-induced. The clinical presentation is heterogeneous and appears
similar to other blistering diseases, such as bullous pemphigoid and dermatitis herpetiform.
The list of factors implicated in development of LAD continues to grow; however,
vancomycin is the most documented agent causing LAD thus far.

Dermatitis herpetiform can cause hypopigmentation or hyperpigmentation after resolution.

In neurotic excoriation (option B), skin abnormalities are caused by traumatizing effects of
scratching on skin. In this case presence of vesicles make such diagnosis unlikely.

SSRIs can cause an increase serotonin concentration in skin which results in allergic reaction
presenting with pruritus and other skin abnormalities including macular rash, xanthoma,
purpura, etc. However, given the history of celiac disease and the presence papules and
vesicles on elbows and buttocks make celiac disease more likely than SSRI-induced
dermatitis (option C).

References

• DermNet NZ- Dermatitis Herpetiform

Last updated:
Time spent: QID:1708
2023-2-12

A 61-year-old woman presents to your practice complaining of a rash on her left

shin. On examination, there is a well-demarcated 3x2cm erythematous lesion. It
is neither painful, nor itchy. The lesion is shown in the accompanying
photograph. Which one of the following is the most likely diagnosis?

A. Seborrheic keratosis.
B. Actinic keratosis.
C. Invasive squamous cell carcinoma.
D. Psoriasis.
E. Bowen’s disease.

Incorrect. Correct answer is E

45% answered correctly

Explanation:

Correct Answer Is E

The large raised scaly plaque shown in the picture has the characteristic features
of Bowen’s disease.

Bowen’s disease is squamous cell carcinoma in situ of the skin. The disease is
more commonly seen in those over 60 years of age, but it can be found at any
age (rare before 30 years). Sun exposure is the most significant risk factor.

Bowen’s disease presents as a well-demarcated erythematous and scaling

plaque that may be mistaken for psoriasis or dermatitis. It is usually
asymptomatic, but ulceration is a possibility. In 10-20% of cases there are
multiple lesions. Although Bowen’s disease can virtually occur anywhere in the
body, the sun-exposed areas, particularly the lower legs are the most common
site of presentation.

The diagnosis is confirmed and documented by punch or shave biopsy. All of the
following options can be successfully used for treatment with about the same
efficacy and a recurrence rate of 5-10%:
 Topical fluorouracil
Imiquimod
Cryotherapy
Curettage
Cautery
Excision
Photodynamic therapy
Laser therapy
Radiation therapy

Mohs’ surgery is used when the anatomic location of the lesion is of functional
consideration (e.g. penis, fingers) or for cosmetic issues. Occasionally,
observation may be considered if the lesion is progressing slowly and is located
in areas with poor healing ability such as the anterior leg of an old person.
Jesse, 57 years old, presents to your GP clinic with concerns about a spreading brown spot
on his left cheek. Physical examination suggests melanoma. Which one of the following is
the most appropriate step in management?

A. Excisional biopsy.
B. Punch biopsy.
C. Referral to a plastic surgeon.
D. Radiotherapy.
E. Chemotherapy.

Incorrect. Correct answer is C

45% answered correctly

Explanation:

Correct Answer Is C

Based on current guidelines, any suspicious lesion for melanoma should undergo an initial
excisional biopsy (option A) for confirmation. Other types of biopsies such as punch biopsy
(option B) are neither as accurate nor recommended.

However, lesions in sensitive anatomical areas such as the face and neck should be biopsied
by a plastic surgeon; therefore, referral to a plastic surgeon is the best action to take at this
stage.

The initial management of melanoma is excision. Other modalities such as chemotherapy

(option E) or radiotherapy (option D) might be considered later for advanced or metastatic
melanomas, but not at this stage.

References

• RACGP – Melanoma and other skin cancers: a guide for medical practitioners
Last updated:
Time spent: QID:1780
2023-2-12

Charlie, 65 years old, is concerned about recent changes in a mole on his chest. He had the
mole for a long time but recently it has grown bigger. The mole is shown in the following
photograph. Which one of the following is the most likely diagnosis?

A. Squamous cell carcinoma.

B. Superficial spreading melanoma.
C. Benign nevus.
D. Basal cell carcinoma.
E. Age-related skin changes.

Incorrect. Correct answer is B

45% answered correctly

Explanation:

Correct Answer Is B

 The photograph shows a pigmented lesion with color variation with recent growth. Of the
options, superficial spreading melanoma is the most likely diagnosis.

Superficially spreading melanoma, is the most common type of melanoma that presents with
an irregularly-pigmented plaque or macule. The first sign of melanoma is usually a new or
existing mole or spot which changes in color, shape, or size.    

Squamous cell carcinomas (option A) are usually flat and have no pigmentations.

Basal cell carcinomas (BCCs) have different forms of which nodular BCC is the most
common. This type presents with a pearly nodule with telangiectasis. BCC is not usually
pigmented.

Benign nevi (option C) often are of uniform color as do age-related pigmented skin lesions
(option E).

References

• DermNet – superficial spreading melanoma.

• RACGP - AJGP – Diagnosing and management of cutaneous melanoma
Last updated:
Time spent: QID:1782
2023-2-12
John, 42 years old, presents to your GP clinic to discuss skin cancer prevention. His past
medical history is significant for a cutaneous squamous cell carcinoma (SCC) excised which
was successfully treated years ago. He has fair skin with a tendency to tan rather than burn.
He denies a history of sunburns as a child. Which one of the following is the most significant
risk factor for developing another SCC?

A. Tendency to tan rather than burn with sun exposure.

B. History of SCC.
C. His age.
D. Absence of sunburns in childhood.
E. Fair skin.

Incorrect. Correct answer is B

45% answered correctly

Explanation:

Correct Answer Is B

SCC is the second most common skin cancer in Australia after basal cell carcinoma. Risk
factors for SCC are:

Unprotected exposure to ultraviolet (UV) radiation from the sun or tanning bed
Age over 50
Male gender
Fair skin (Fitz Patrick I and II)
Immunosuppression
Personal history of skin cancers  (non-melanoma or melanoma)
History of human papillomavirus (HPV) infection
Precancerous skin lesions such as Bowen’s disease and actinic keratosis (AK)
Chronic infections and skin inflammation from burns, scars, and other conditions

Of these risk factors, the presence of another SCC in history has the most significance (high
risk).  Fair skin (option E) is another high-risk factor for SCC but not as significant as the
history of another SCC. In the absence of past history of skin cancer, it would be the correct
answer. 

He is under 50 and his age (option C) is not a risk factor for now. He tends to tan rather than
burn (option A) which is a protective factor. While childhood sunburns are a risk factor, their
absence (option D) is not one.   

References

• RACGP – AJGP – Skin checks in primary care

Last updated:
Time spent: QID:1784
2023-2-12

A 43-year-old man presents with a painful rash on his back as shown in the following
photograph. The rash erupted one week ago and was itchy and slightly sore. The soreness
built up in intensity and now he has severe sharp pain. Which one of the following is the most
appropriate treatment option for him?

A. Gabapentin.
B. Opioids.
C. Amitriptyline.
D. Systemic steroids.
E. Famciclovir.

Incorrect. Correct answer is D

45% answered correctly

Explanation:

Correct Answer Is D

 The rash presents a typical case of shingles caused by varicella zoster virus (VZV) infection.

Varicella zoster virus (VZV) infection causes two distinct clinical syndromes. Primary
infection, also known as varicella or chickenpox, is a common pediatric viral disease.  After a
chickenpox infection, VZV remains latent in the neurons of cranial nerves and dorsal root
ganglia. Subsequent reactivation of latent VZV can result in a vesicular rash in a dermatomal
distribution, known as herpes zoster (shingles). The lesions are painful, and the pain may last
long even after the resolution of the rash.

Pain that persists for 3 months or more is defined as post-herpetic neuralgia (PHN). The pain
associated with acute zoster infection and PHN can be burning, sharp, stabbing, and
constant or intermittent. More than 90 percent of patients with PHN also have allodynia,
defined as pain evoked by normally nonpainful stimuli such as light touch.

Of note, pain management for acute zoster infection is different. For pain associated with
acute herpes zoster infection, simple analgesia or systemic steroids are used as first-line
options. The tricyclic antidepressant (TCA) Amitriptyline or opioids (option B) may be
considered as the second line.
On the other hand, pregabalin, gabapentin, TCAs, or lignocaine patches are preferred first-
line options for PHN. Opioids and tramadol are used as second-line alternatives.

Antiviral agents such as famciclovir, valacyclovir, or acyclovir should be used in any patient
seen within 72 hours of the onset of the rash, all patients with ophthalmic herpes zoster, and
in immunocompromised patients. For pregnant women, only acyclovir (first line) or
valaciclovir (second line) are used because the safety of famciclovir during pregnancy has
yet to be established. Antivirals are often given for 7 days.

This patient has presented beyond the 72-hour window, and has no other indications for
antiviral therapy, and giving him famciclovir (option E) is futile. For him, pain control is the
most significant concern. Of the options, systemic steroids such as prednisolone (50mg daily
for 7 days) are the most appropriate. Gabapentin (option A) or amitriptyline (option C) was
the correct option if the case was PNH (pain persisting for 3 months or beyond.   

References

• Australian Prescriber - Herpes zoster: epidemiology, clinical features, treatment and

prevention

• Medscape - Herpes Zoster

Last updated:
Time spent: QID:1788
2023-2-12

A 52-year-old man presents with intense pain in his chest wall for the past 4 months. The
problem started with the eruption of a rash over the area. The rash resolved in 2 weeks, but
the pain has persisted and increased in intensity. He describes the pain as constant, sharp,
and unbearable, affecting his life. He has used Panadol and ibuprofen for pain control with
minimal effect. He also has diabetes, hypertension, and stage III chronic kidney disease, and
denies any pain or pins and needles elsewhere.  Which of the following is the most
appropriate option for him?

A. Gabapentin.
B. Tramadol.
C. Amitriptyline.
D. Systemic steroids.
E. Pregabalin.

Incorrect. Correct answer is C

45% answered correctly

Explanation:

Correct Answer Is C

The scenario represents post-herpetic neuralgia, defined as chronic pain associated with
herpes zoster infection (shingles) caused by the varicella zoster virus.

Varicella zoster virus (VZV) infection causes two distinct clinical syndromes. Primary
infection, also known as varicella or chickenpox, is a common pediatric viral disease.  After a
chickenpox infection, VZV remains latent in the neurons of cranial nerves and dorsal root
ganglia. Subsequent reactivation of latent VZV can result in a vesicular rash in a dermatomal
distribution, known as herpes zoster (shingles). The lesions are painful, and the pain may last
long even after the resolution of the rash.

Pain that persists for 3 months or more is defined as post-herpetic neuralgia (PHN). The pain
associated with acute zoster infection and PHN can be burning, sharp, stabbing, and
constant or intermittent. More than 90 percent of patients with PHN also have allodynia,
defined as pain evoked by normally nonpainful stimuli such as light touch.

Pain control in the acute phase of the infection is often achieved by simple analgesics and/or
systemic steroids (e.g., prednisolone 50mg/d for 7 days). Opioids or amitriptyline can be
used as second-line options if adequate pain control is not achieved.

For PHN, the anticonvulsants gabapentin or pregabalin, tricyclic antidepressants (TCAs), or

lignocaine dermal patches are used as first-line options. Of the TCA, amitriptyline is the most
effective and commonly prescribed one.

With pain lasting for 4 months, this patient has PHN. Gabapentin (option A) and pregabalin
(option E) are eliminated by renal excretion and should be used with caution and meticulous
dose adjustment in patients with renal insufficiency and avoided if better first-line options are
applicable. For him, amitriptyline is the most appropriate option for pain control.

TCAs inhibit the reuptake of norepinephrine and serotonin in the central nervous system.
They are thought to increase the inhibition of nociceptive signals from the periphery. The
preferred tricyclic drug for PHN is amitriptyline, starting at 10 mg each night and titrating
slowly as tolerated, with a maximum dose of 150 mg daily. Amitriptyline is excreted via the
liver and its metabolism and is the most appropriate option in this scenario. Its anticholinergic
adverse effects such as sedation and dry mouth) may limit the patient’s compliance.

Opioids (option B) or tramadol can be used as second-line agents, in those with

contraindications to the first-line options.

While steroids (option D) are used for treating acute herpes zoster pain where inflammation
seems to have a role, they have no effect on PNH as it has different pathophysiology.

References

• RACGP - Focus - Neuropathic pain A management - an update

• UpToDate - Post-herpetic neuralgia

• Australian Prescriber - Herpes zoster: epidemiology, clinical features, treatment and

prevention
Last updated:
Time spent: QID:1790
2023-2-12

Which one of the following is not correct regarding contact dermatitis?

A. Plants are the most common cause of contact dermatitis.

B. It can be treated with topical steroids.
C. It can be treated with oral steroids.
D. The application of skin moisturizers can assist the healing process.
E. Avoidance of the allergen is essential to the prevention of further flare-ups.

Correct
45% answered correctly

Explanation:

Correct Answer Is A

Allergic contact dermatitis is a type 4 or delayed hypersensitivity reaction and occurs 48–72

hours after exposure to the allergen. The mechanism involves CD4+ T-lymphocytes and the
release of cytokines that activate the immune system and cause dermatitis.

Contact allergy occurs predominantly from an allergen on the skin rather than from internal
sources or food. Of note, a patient might have been in contact with the allergen for years
without it causing dermatitis. Even small quantities of an allergen can induce dermatitis.

Allergic contact dermatitis is especially common in metal workers, hairdressers, beauticians,

healthcare workers, cleaners, painters, and florists.

Patients with impaired barrier function are more prone to contact dermatitis.

Allergic contact dermatitis develops hours after contact with the responsible material and
settles down over some days provided the skin is no longer in contact with the allergen.  The
condition is often limited to the site of contact with the allergen, but it may extend outside the
contact area or become generalized. Transmission from the fingers can lead to dermatitis on
the eyelids and genitals. Dermatitis is unlikely to be due to a specific allergen if the area of
skin most in

Some typical examples of allergic contact dermatitis include:

Eczema in the skin in contact with jewelry items, due to contact allergy to nickel
Reactions to fragrances in perfumes and household items
Eczema under adhesive plaster, due to contact allergy to rosin 
Swelling and blistering of face and neck in reaction to permanent hair dye, due to
allergy to paraphenylenediamine
Hand dermatitis caused by rubber gloves
Itchy red face due to contact with methylisothiazolinone, a preservative in wash-
off hair products and baby wipes
Fingertip dermatitis due to acrylates used in hair extensions and nail cosmetics.
Reactions after dental implants containing acrylates
Localized blistering at the site of topical medications
 Swelling and blistering on exposed sites (e.g., face and hands) due to contact with
plants such as poison ivy

Therefore, prevention of further contact with the allergen is the mainstay of the treatment. A
skin patch test may be required to find the culprit. Active lesions are often treated with
topical steroids (option B). More severe cases may necessitate a short course of oral
steroids (option C).

Depending on the severity and the clinical course, other treatment options can include
phototherapy/photochemotherapy, immune suppressants such as azathioprine or
ciclosporin, or immune system modulators tacrolimus ointment.

The application of skin moisturizers (option D) can promote general skin health conditions,
alleviate the symptoms, and accelerate the healing process.  

Although plants could result in contact dermatitis, they are not the most common cause of
contact dermatitis. Nickel and other metals/ chemicals are the most common cause of
contact dermatitis.

References

• DermNet - Allergic contact dermatitis

• Medscape - Allergic Contact Dermatitis

Last updated:
Time spent: QID:1796
2023-2-12

A 61-year-old male farmer presents to your clinic because he is concerned

about a skin lesion on his face. The lesion is shown in the accompanying
photograph. Which one of the following is the most likely diagnosis?

A. Keratoacanthoma.
B. Basal cell carcinoma.
C. Implantation dermoid cyst.
D. Amelanotic malignant melanoma.
E. Squamous cell carcinoma.

Incorrect. Correct answer is B

45% answered correctly

Explanation:

Correct Answer Is B

The appearance of the lesion is consistent with nodular basal cell carcinoma
(BCC).  BCC is the most common skin cancer. Unlike squamous cell carcinoma
(SCC), BCC can be seen in non-photoexposed areas as well. Nodular BCC is the
most common subtype. The pearly appearance, shiny surface and telangiectasis
are characteristic features. Additionally, the lesion in the photograph has
undergone ulceration at parts.

(Option A) Keratoacanthoma has the central crater filled with necrotic tissue,
which is not seen here.

(Option C) Implantation dermoid cysts are firm subdermal cystic nodules that
often occur following a penetrating trauma. The fingertips of mechanics are the
most common site for such lesions.

(Option D) Amelanotic melanoma can resemble a nodular BCC; although it will

lack the pearly appearance of BCC, which can be noted in this photograph.

(Option E) Squamous cell carcinoma does not fit the clinical picture. It usually
presents with an ulcerating plaque. 
A 41-year-old farmer has presented with a lesion on his right sole. The lesion
appeared 4 months ago and has progressively enlarged since then. The lesion is
shown in the accompanying photograph. Which one of the following could be
the most likely diagnosis?

 
A. Neuropathic ulcer.
B. Malignant melanoma.
C. Simple nevus.
D. Pigmentation from heat.
E. Squamous cell carcinoma.

Incorrect. Correct answer is B

45% answered correctly

Explanation:

Correct Answer Is B

The size and color of the lesion, the irregularity, and the rapid progression
are highly suggestive of malignant melanoma.

(Option A) Neuropathic ulcers occur over pressure points of areas with impaired
sensation due to conditions such as diabetes mellitus (the most common cause),
syphilis, leprosy, and other neuropathies. They present a completely different
picture.
 Neuropathic ulcer 

(Option C) The rapid progression, size, and irregularity are inconsistent with
melanoma rather than simple nevus as a diagnosis. A simple nevus usually has
regular borders, is often unicolor, and does not spread so fast. 

(Option D) Pigmentation from heat, also called ‘erythema ab igne’ is tanning

of the skin, where it is chronically exposed to heat.

Erythema ab inge (left thigh)

(Option E) Cutaneous squamous cell carcinoma (SCC) presents with a usually

amelanotic skin lesion in sun-exposed areas.

References

• DermNet NZ - Melanoma

• Medscape - Malignant Melanoma

Last updated:
Time spent: QID:41
2023-2-12

A 43-year-old farmer from Queensland presents with a pigmented lesion on his

upper chest, shown in the accompanying photograph. The lesion
appeared 4 months ago, but recently has enlarged. The lesion has been itchy
and oozing and painful for the past 3 weeks. Which one of the following is the
most likely diagnosis?

A. Malignant melanoma.
B. Keratoacanthoma.
C. Basal cell carcinoma.
D. Blue nevus.
E. Benign pigmentation.

Incorrect. Correct answer is A

45% answered correctly

Explanation:

Correct Answer Is A

Although the lesion shown in the photograph may be mistakenly considered as a

pigmented nodular basal cell carcinoma, a more careful inspection of the lesion
indicating pigmentation of different colors as well as the history of the rapid
progression over 4 months suggests malignant melanoma (nodular type) as the
most likely diagnosis.

(Option B) Keratoacanthoma has the typical crater which is absent here. The
crater often has keratin or dead skin cells inside.
 Keratoacanthoma - note the nodular structure and the presence of a
crater

(Option C) Pigmentation and color variegation of this lesion favors melanoma

rather than basal cell carcinoma. Moreover, the rapid progression and evolution
of symptoms such as itching and tenderness are more commonly seen in
melanoma.

(Options D and E) Clinical presentation and the history (rapid course of

progression and evolving of size and symptoms) definitely exclude blue nevus
and benign pigmentation as the likely diagnoses.
On a routine health examination of a 72-year-old man, you notice lesions
depicted in the following photograph on his back. Which one of the following
could be the most likely diagnosis?

A. Superficial spreading melanoma.

B. Mycosis fungoides.
C. Hutchinson melanotic freckles.
D. Seborrheic keratosis.
E. Solar keratosis.

Incorrect. Correct answer is D

45% answered correctly

Explanation:

Correct Answer Is D

The appearance of the lesions are suggestive of seborrheic keratosis. 

Characteristic features include variegated pigmentation from black to tan, the
verrucous greasy surface and occurrence in crops.

Seborrheic keratoses are well-defined benign lesions which are often pigmented
and can occur on the head, neck, trunk and limbs and areas not always
significantly exposed to sunlight. Although the etiology is unknown, sun exposure
may play a role.

They usually start to appear in the third decade of life and increase in number as
the age advances. Seborrheic keratoses are the most common benign
pigmented tumors in those aged 50 years and over.

Seborrheic keratoses are typically round plaques with adherent greasy scale.
They seem to be stuck on the skin. Their color may vary from black to tan. The
surface appears velvety to verrucous. Sometimes they are so verrucous that
may be mistaken with warts, particularly if not heavily pigmented. Sometimes
there are surface cracks and horn cysts.

Some seborrheic keratoses are flat. Flat lesions, particularly those of the face
and the limbs, may be difficult to be distinguished from melanoma or lentigo
maligna. This is even more true if the lesions are inflamed and consequently,
enlarged and itchy with tendency to bleed.

(Option A) Superficial spreading melanoma is another likely diagnosis, especially

if the lesions were more superficial. The large number of the lesions, smooth
margins and the greasy warty look of the lesion in the center make seborrheic
keratosis a more likely diagnosis. Biopsy and histological studies are required
if the diagnosis is in doubt.

(Option B) Mycosis fungoides is a misnomer describing a rare involvement of the

skin with lymphoma. The appearance would be irregular eczematous dermatitis
progressing to form plaques.

(Option C) Hutchinson melanotic freckles have more irregular borders and are
more flat than the lesions depicted. Furthermore, Hutchinson melanotic freckle
more commonly tends to be solitary and on sun-exposed areas.

(Option E) Solar keratoses are firm, hyperkeratinous plaques of 2 to 10mm in size

seen in sun-exposed areas e.g. dorsum of hands.

References

• Medscape - Seborrheic Keratosis

• DermNet NZ - Seborrhoeic Keratosis

• Therapeutic Guidelines – Dermatology; available from http://tg.org.au

Last updated:
Time spent: QID:44
2023-2-12