Section 1

: Answers & Comments

.196
PQ :
Answer b

Comments
~Mercaptobenzothia
zole isarubber.allergenItshould
therefore
besuspected
incas
-
s wherethereis asuspicion
e of rubberallergysuchastheuseofglovesorinsuspected
shoe dematitis
.
~ Otherrubberallergens
includecarbaandthiurammix
.
~ Othe
r ves
preservati
include
theisothiozilinone
,
s e
gluteraldehyd
andall the
de
formaldehy.
releasers
.197
PQ :
Answer b

Comments

~Leishmania
sis donovani
istheonlyleishmaniasis
species
thatcauses
visceral
-
leish
is
maniasd typically
an s
present
withpancytopenia
andsplenomegaly
duetoinvolve
-
mentof both the spleenandbone marrow
.
~ All otherleishmaniasis
speciesgivecutaneous
lesionsthat aredividedintonewand
old world cutaneousleishmaniasis
.
~Ol
d worl
d cutaneou
s s
leishmaniasi
isduetoL.tropica
, ,
L.major
L.ethiopica
andLin
-
.
fantum
~Ne
w worldleishmanias
is isduetoL.brasiliensis
andL.mexicana
.
~L
. brasiliensi
s canresultin mucosal
.
involvement

.198
PQ :
Answer b

Comments

~ Necrobio
sis lipoidica
canbe differentiated
fromgranuloma
annulare
by the
ce
abundan ofplasma
,
cellssclerosis
andtheabsence
ofmucin
.
~Whils
t e cases
som ofgranuloma
annulare
canextend
deepintothesubcutis
it is
typicallymoresuperficialthan necrobiosislipoidicaandsubcutaneousinvolvementis
y
generall not afeature
.
~ Bot
h granulom
a annulare
andnecrobiosis
lipoidica
are"necrobioticgranulomas
.
.199
PQ :
Answer c

Comments
~Th
e useofimmunosuppress
ive therapy
should
beavoided
inpatients
withactive
s
hepatitiBandadvicefromthehepatologist
shouldbesought
.
~Ciclospo
rin isanabsolut
e -indication inactive
contra hepatitis
.
B
~Anti
-TNF therapy canbeusedprovided
thatadequate
-viral therapy
anti hasbeen
.
established

146
Section 1
: Answers & Comments

.200
PQ :
Answer d

Comments
~ Benzalkoniumchloride is ananti
-microbial chemical added in many preparationsof
emollients and antiseptics
.
~ Oilatumpluscontainsbenzalkoniumchloridehowever
, all otherproductsof oilatum
do not contain this chemical
.

.201
PQ :
Answer c

Comments

~ Merkel cell carcinoma is a rare neuro

-endocrine cutaneous malignancy that may
arise in transplant patients
.
~ Recentlya virushasbeenimplicatedas a possiblefactorin the developmentof
el
merk cellcarcinoma
calledpolyoma
.virus
~ CK20is avery sensitivemarkerfor merkel cellcarcinoma
.
~ CD34 and Factor XIlla are helpful to distinguish between dermatofibroma and
dematofibrosarcomaprotuberans
.
~ CDia and S100 are helpful to differentiatebetweenLangerhan'scells and
.
melanocytes

.202
PQ :
Answer a

Comments
~ Bullous pemphigoid is a blistering diseasewhich is subepidermal and acantholysis
doesnottakeplace
.
~ Hailey
-Hailey and Darier's diseases are both inherited forms of acantholytic
.
disorders
~ Grover's disease is also known as transient acantholytic dematosisand often pre
-
sents with discrete pruritic papulesand vesiclesoften on the back of middle aged or
elderly people
.

.203
PQ :
Answer c

Comments
~ Primin is the allergen found in the primula plant
.
~ Peri
-oral dermatitis to mangoesmay occurin sensitizedindividuals
.
~ Banana can cross react with latex
.
~ The highest rate of sensitization to urushiol (responsible for poison ivy
) is in North
.
America
~ Urushiol is soluble in rubber and therefore vinyl gloves should be worn for
.
protection

147
 Section 1
: Answers & Comments

.204
PQ :
Answer c

Comments
~Lymphadenopat
hy isfoundin100
% ofcases
ofcatscratch
.disease
~Th
e conditio
n iscommo
n inchildren
andpresents
withapapulo
-pustular eruption
with scratchmarks
, mostly on the hands
.
~ Azithromyci
n hasbeenusedin somecasesbut no treatmentis requiredin
immunocompetent individuals
.

.205
PQ :
Answer c

Comments

~Chron
ic versus
graft
h
-d ost
isease generally
develops
3months
aftertransplantation
andmanynotoccuraftertheacutevariantofthedisease
.
~Th
e conditio
n ismost
likelytodevelop
inthesetting
ofallogeneic
, unmatched
and
unrelateddonor
.
~Th
e 2variant
s ofthechronic
forminclude
lichenoid
andsclerodermoid
.
~Advanc
ed , malegender
age andthepresence
ofHLA
-DR4 allele
intherecipient
are
allriskfactor
s forthedevelopme
nt ofthecondition
.
.206
PQ :
Answer a

Comments
~Patholo
gic on
calcificati
ofcutaneou
s tissue
canbedystrophic
, metastatic
oridiopath
-
.
ic
~Dystrophi
c s
calcinosi
cutisconsists
ofdeposition
ofcalcium
saltsinabnormal
ordam
-
d tissu
age,
e mostly
c fibres
elasti
, andoccurs
inthesetting
ofnormal
serum
calcium
levelsparticularly
in connectivetissuedisorders
.
~ Metasta
tic is
calcinos
cutisoccurs
inthesetting
ofhypercalcaemi
a andinvolves
the
n
calcificatio
ofnormaltissues
.
~Idiopat
hic is
calcinos
cutis
consist
s ofcalcification
ofnormal
tissues
inthesetting
of
normal calcium levels
.
~ Primar
y a
osteomcutis
canoccurin thesetting
of Albright's
hereditary
-
osteod
,
hy
ystrop sia
fibrodyspla
s
ossifican
a
progressiv
andprogressive
osseous.
heteroplasia
~Second
ary ma cutis
osteo may
occurfollowing
previousdermatoses
such
asmilitary
a
osteomcutisonthefacesecondary
toacnevulgaris
.

148
Section 1
: Answers & Comments

.207
PQ :
Answer c

Comments
~Neutrophiliceccrinehidradenitisisaself
-limiting conditionoccurring
mostlywithin3
weeks of cytarabine in the treatment of acute myeloid leukaemia
.
~ Otherchemotherapy
agentsthathavebeenreportedto causetheconditioninclude
,bleomycin cyclophosphamideand doxorubicin
.
~ Systemicsteroids and dapsonehave been usedin caseswhere the lesions are very
painful and oedematous
.
~ Dapsonehasbeen reported to be used successfullyasprophylactic therapy
.

.208
PQ :
Answer a

Comments
~ Chromium and cobalt are both present in cement
.
~ Re
d tattoos cancontainmercury
, ferrichydrateand
/or .
oxide
~ Manganeseis aninorganic salt often found in purple tattcos
.

.209
PQ :
Answer a

Comments
~ Reactionsto tattoos caneither be acute or delayed
.
~ The majority of allergic contact dermatitis is related to red tattoos
.
~ Red tattoos are either due to inorganic salts of metals such as mercury or cinnabar
;
or due to organic preparationssuch assandalwood and brazilwood
.
~ Patchtesting will only be positive to the inorganic salts .(i.e mercury
) andnot to the
c
organisaltsduetothewaterinsolubility
ofthelatter
.
~ Mercurypigmentis alsoresponsiblefor thedelayedlichenoid reactionsto tattoos
but patchtesting will be negativeand the clinical and histologicalappearanceswill
differfrom thoseof allergiccontactdermatitis
.
~ In pseudolymphomas thelymphocytesarepolyclonalasopposedto monoclonalin
cutaneouslymphomas
.

149
 Section 1
: Answers & Comments

.210
PQ :
Answer a

Comments
~Granul
omas are als
o prese
nt inWegene
r's osis
granulomat
butinChurg
-Strauss there
is oftentissueeosinophiliaaswell
.
~Inerythe
ma elevatu
m m
diutinutheinfiltrate
ispredominantl
y neutrophilic
with-are
asoffibrosis(in chronic).
case
~Ingranulom
a faciale
therearenogranulomas
butaGrenz
zoneispresent
separating
the dermisfrom the epidermis
.
~Incryoglobulinae
mia ahomogenou
s eosinophilic
material
isfound
withinblood-ves
.
sels

.211
PQ :
Answer c

Comments
~Althou
gh d spongio
mil sis cansometime
s befound
incutaneous
Tcelllymphoma
, this
isabsen
t incutaneou
s Bcell.lymphomas
~Oth
er caus
es ofspongio
sis includepigmented
purpuric
,
dermatosis
,
erythroderma
n's balaniti
Zoo ,
s t bitesand
insec thepre
-bullous stage
ofimmunobullous
.
disorders

.212
PQ :
Answer c

Comments

~Oth
er cause
s ofCD3
0 positivity
include
chronic
tickbitesandSezary
.
syndrome
~In margi
nal zon
e Bcelllymphom
a theinfiltrate
ispositive
for,CD20
CD79a
and
;bcl
-2
d isnegativ
an e forbc
-6 (positiveinfolliclecentreBcell).
lymphoma
.213
PQ :
Answer b

Comments
~Stag
e IlaisBreslo
w thickness
-2
1.01 mmwithulceration
oraBreslow
thickness
-
be
n 2.01
twee-4 mmwithout
n
ulceratio
intheabsence
ofclinical
, radiographic
orhisto
-
al
logic e
evidenc
oflymphnodeinvolvement
.
~Sta
ge IbisBreslo
w s
thicknes
less
than1mmbutwithulceration
ormitoses
equal
to
or more than 1 per mm
?.
~ StageIVispresenceof distantmetastases
.

150
Section 1
: Answers & Comments

.214
PQ :
Answer c

Comments
~ The supra
-trochlear nerve innervates part of the frontal scalp
.
~ Theauriculotemporal nerve innervatesthe parietal part andthe lesser occipital pari
-
-occipital
eto part of the scalp behind the ear
.

.215
PQ :
Answer e

Comments
~ Fabry'sdiseaseis anX
-linked recessivedisorder
.
~ Female carriers can still manifest the disease but it tends to be milder
.
~ The angiokeratomas and lymphoedema generally do not respond to enzyme
replacementtherapy
.
~ Hypohidrosi
s andneuropathicpaincrisesareothermanifestations
of thedisease
.

.216
PQ :
Answer c

Comments
~ Therare Cowden'ssyndromeshould besuspectedwhen apatient presentswith oral
,
cobblestoning -plantar
palmo ,
keratoses tricholemmomasand ahistoryof internalma
-
lignany(mostly breast
, thyroid or uterus
).
~ Muir
-Torre syndrome can alsobe associatedwith internal malignanciesbut the cuta
-
neous manifestations are of sebaceous tumours or eruptive keratoacanthomas
.
~ Gardner'ssyndromeis associatedwith polyposiscoli (risk of coloncarcinoma
) and
multiple epidermoid cystsand
/or .
lipomas
~ Baze
x syndromeis alsocalledacrokeratosisparaneoplastica
and is aparaneoplastic
phenomenonthat often presentswith a psoriasiformappearanceof the handsand
t accentuat
fee ed around
thenailswithassociated
nailchanges
, -plantar
palmo -
kerato
a
derm andalopecia
.
.217
PQ :
Answer e

Comments
~ Peutz
-Jeghers syndromeis associatedwith intestinal polypsand typicallypresents
with )-
(peri
oral .
lentigines
~ Other oral manifestations of Crohn'sdiseaseinclude aphthous ulcerations and gran
-
ulomatous .
cheilitis
~ Thecobblestoning
in Darrer'sdisease
is mostlyapparentinthe hardpalate
.

151
 Section 1
: Answers & Comments

.218
PQ :
Answer e

Comments
~InNetherton'
s e
syndrom
thereisichthyosis
withhairshaftdefects
butdentalabnor
-
malitiesarenot afeature
.
~ Othe
r s
condition
thatcanbeassociated
withdentalanomalies
includeectodermal
,
ia
dysplas al
congenitc
erythropoieti
,
porphyria
focaldermal
,
hypoplasia
-
Sjogren
-
Lars
n syndrom
so e andPapillon
-Lefevre .
syndrome
.219
PQ :
Answer a

Comments
~Th
e infra
-orbital nerve
isabranch
ofthemaxillary
branch
)(V2 ofthetrigeminal
.
nerve

~Oth
er branch
es ofthemaxillar
y branch
)(V2 include
thezygomaticofaci
al andzygo
-
maticotemporal .
nerves
~Th
e extern
al l nerve
nasa isabranch
oftheophthalmic
division
oftrigeminal
)(V1
.
nerve

.220
PQ :
Answer b

Comments
~Pella
gra isclassic
ally adiseas
e ofthe"4 Ds
": dermatitis
, ,
diarrhoea
dementia
and
.
death
~Itisduetodeficiency
invitaminB3().
Niacin
~Pellag
ra y
typicall
spares
thenailsandhairandcanalsobecaused
bydeficiency
in
.
tryptophan
~ Photosensitivityisoften present
.
~6
,-Mercaptopurinisoniazid
e and5
-flurouracilaredrugs
thatcaninrarecases
cause
.
pellagra
~Berib
eri isduetodeficien
cy invitamin
B1)(Thiamine
andtypically
gives
-genital
oro
titis wit
derma h encephalop
,
athy c
cardia
failure
andlperiphera
.
neuropathy
.221
PQ :
Answer c

Comments

~Th
e negati
ve stainin
g totheT
-cellmarker
s , CD4
CD3 and
CD5
rules
outmycosis
-
fun
.
goides
~Th
e negativ
e staining
to theB
-cell markers
CD20
andCD79a
rulesoutcutaneous
B
cell lymphomas
.
~CD4
3 positivit
y isaclueformyeloid
leukaemia
(leukaemia
cutisinthiscase
) inthe
e
absencofpositivitytoBandTcell.markers
~Myeloi
d a
leukaemi alsostainspositivetomyeloperoxidase
.

152
Section 1
: Answers & Comments

.222
PQ :
Answer b

Comments
~ Full thickness skin graft can be used as a method of reconstruction for certain defects
particularly on the nasal alae
, ,
ears lower eyelidsand temple
.
~ Severalfactors can influence the survival of the graft tissue andit is important to be
aware of these
.
~ Donorsitesskinshouldmatchthe skincolourandtextureof therecipientsiteand
are is often harvested from the pre
- or post
-auricular or sites or from the -supra
clav
icular area
.

.223
PQ :
Answer e

Comments
~ Secondar
y intentionhealingcanbe asuitableoptionparticularlyin theconchalbowl
,
medial,canthus scalp
, foreheadandthe dorsumof the handsandfeet
.
~ As the wound heals a degree of contraction will occur and it is essential to monitor
that the contraction force doesnot result in anunwanted pull onafree margin such as
the eyebrow or nasal ala
.

.224
PQ :
Answer b

Comments
~ Ablation is simply the removal of tissue and in the casesof laser ablation is due to
vaporization of the tissue
.
~ Other ablative laser modality is carbon dioxide laser
.

.225
PQ :
Answer b

Comments
~ Bruising maylast up to 2 weeks if apurpuric mode has been used
.
~ In someinstances
, if a non
-purpuric mode(often with longer pulse durationand
lower fluence
) isused
, resultsmaytakerequireseveralmoretreatmentstoachievea
similar outcomesas to the purpuric mode
.
~ All otherside
-effects mentionedin theanswersarepossible
, but arelessfrequent
.

153
Section : Answers & Comments
1

.226
PQ :
Answer c

Comments
~Whils
t it isgood
practice
todefermostnon
-urgent andbenign
lesions
removal
till
afterdelivery
, pregnancy
shouldnot beacontra
-indication for awidelocalexcisionof
a melanoma
.
~ Melanom
a isnotveryradiosensitive
however
adjunctive
radiotherapy
maybeused
t positiv
pose l
sentine
lymphnodelymphadenectom
y particularly
if therewasex
-
-capsular spreadofthetumourormorethan3lymphnodes
tra wereinvolved
.
.227
PQ :
Answer a

Comments

~Incase
s ofskintumours
whicharelarge/o
arnd tethered
andattached
tounderlying
s
structure
imaging
should
bearranged
toassess
forlocalinvasion
.
.228
PQ :
Answer a

Comments
~ Perineuralinvasionportendsa poorer prognosiswith increasedriskfor recurrence
and metastasis
.

~Desmopla
stic ma
trichoepithelio
isararefollicular
tumour
thathistologically
isinthe
differential
ofmicrocystic
adnexalcarcinoma
andmorphoeic
basalcellcarcinoma
but
,
typically perineural invasionis not seen
.

.229
PQ :
Answer e

Comments
~Allfacialsensory
nerves
arebranches
ofthetrigeminal
.
nerve
~Th
e mot
or nerv
es oftheface
are
sbranche
ofthefacial
nerve
andare
the,temporal
c,zygomatibuccal
, marginal
,
mandibular
andcervical
.
nerves
~Infacialskinsurger
y the2 danger
zones
thateverydermatologist
should
beaware
ofaretheanatomi
c location
ofboththetemporal
andmarginal
mandibuiar
.
nerves
.230
PQ :
Answer c

Comments
~Mostpatients
withpemphigus
vulgaris
havemucosal
membrane
.
erosions
~Th
e blister
s ofpemphigu
s vulgaris
develop
inthedeeper
portion
oftheepidermis
,
just above the basalcelllayer
.
~Patient
s withpemphigu
s foliaceus
haveonlycutaneous
involvement
withoutmu
-
al lesion
cos,
s andthesplits
occur
inthesuperficial
partoftheepidermis
, mostly
atthe
granular layer
.

154
Section 1
: Answers & Comments

.231
PQ :
Answer a

Comments
~ Dueto thelack of cohesionwithin theepidermis
, its upperlayerseasilymovelater
-
ally with slight pressure or rubbing in patients with active pemphigus
. This is known as
Nikolsky's sign
.
~ The bulla
-spread phenomenon is when gentle pressureon anintact bulla forcesthe
fluid to spread under the skin away from the site of pressure -H
(Asboe
ansen's ,
sign
alsoreferredto asthe'indirect Nikolsky
' or 'NikolskyIl' sign
).

.232
PQ :
Answer d

Comments
~ Pemphiguserythematosus isalocalizedvariant of pemphigusfoliaceus
.
~ Scalyand crustedlesionsof pemphigusfoliaceus are seen onthe malar region ofthe
face and in seborrhoeic .
distribution
~ Theterm 'pemphiguserythematosus
' describespatientswith immunologicfeatures
of both lupus erythematosus andpemphigus
, . in vivoIgG and C3deposition on cell
i.e
s
surface of keratinocytes
aswell asthe basementmembrane,zone inadditionto cir
-
culating antinuclear antibodies
.

.233
PQ :
Answer b

Comments
~Patients
' serumistestedonELISAplatespre
-coated with recombinantDsg1or Dsg3
protein leading to detection of specific antibodies against Dsg1or Dsg3
.
~ In pemphigusfoliaceusthe serum ispositive against Dsg1but negative against Dsg3
.
~ In mucosal
-dominant type ofpemphigusvulgaristheserum isnegativeagainstDsg1
but positive against Dsg3
.
~ In mucocutaneous
type of pemphigusvulgaristheserumis positiveagainstboth
Dsg1and Dsg3
.
~ ELIS
A scores demonstrateparallel fluctuations with diseaseactivity and are useful in
monitoring disease activity
.

.234
PQ :
Answer c

Comments
~ Cyclophosphamide
isgivenat a doseof 1
-3 kgay
mg
/d (usually 50
-200 /day
)mg and
its major side effects arehaemorrhagic cystitis
, sterility and leukopenia
.

155
 Section 1
: Answers & Comments

.235
PQ :
Answer c

Comments
~Daps
one isthedrug
ofchoic
e inIgApemphigu
,
s although
colchicine
can
beused
in
some .
cases

~Aclinicale
responsusuallyoccurswithin24
-48 hours
.
~Alternativel
y, sulphapyridine
oracitretincanbeused
.
~Lo
- tomedium
w -dose ,
e
prednison
orphotochemothera
py )(PUVAareotheraiter
-
.
natives

.236
PQ :
Answer d

Comments
~Insever
al -control
case ,
studies
theprevalence
ofHCV
washigher
inpatients
withLP
n incontrol
tha s. Thisn
associatio
seems
tobestrongest
inJapanese
andMediterrane
-
an populations
.
~O
f th
e variou
s types
ofLP
, it istheoralformthatismostcommonly
viewed
asaman
-
ifestationof HCVinfection
.
~Transfusion
-transmitted virus
)(TTVishighly
prevalent
inpatients
withliver,diseases
g
includinthosewithchronic
HCVinfection
. DirectroleofTTVincausation
oflichen
planusis lacking
.
~B
y insit
u hybridizati
on andimmunohistoche
mical ,
techniques
-6 was
HHV detected
in
-100
67
% oforalLPlesions
andit wasabsent
fromnormal
oral.tissues
~HHV
7 DN
A hasbeendemonstrat
ed inlesional
samples
oflichen
planus
more
often
than non lesionalLP
.

.237
PQ :
Answer a

Comments

~Differen
tial es
diagnosoflichen
striatus
include
linear,
s
porokeratosilinear
-
psoria
, inflammat
s
si ory linear
s
verrucou
l
epiderma,
nevuslinearDarrier's
,
diseaselinear
,
LP
s
blaschkiti andlinearGVHD
.
~Line
ar LP an
d liche
n striatu
s can
occasiona
lly beindistinguisha
ble .
histologically
~ Hypopigmentati
on isafrequent
sequela
oflichenstriatus
.
~Hyperpigment
ation s
appear
more
commonly
associated
withLP
.
~Lic
n stria
he tus is.also characte
rized byal
which can be very pruritic
,minim
ifany
, pruritu
s, unlike
lichen
planus
~Spontane
ous n
resolutio
occurs
withinashortperiod
oftimeinlichen
.striatus

156
Section 1
: Answers & Comments

.238
PQ :
Answer c

Comments
~ Externalauditorycanal
, , clitorisand labiaminoradonot haveeccrineglands
lips .
~ Apartfrom theabove
, approximately1.6 to 4.0million eccrinesweatglandsaredis
-
tributed over the entire body skinsurface
.

.239
PQ :
Answer b

:
Comments
~ Theterm 'chronic urticaria
' isappliedto continuousurticariaoccurringat least twice
a week off treatment
.
~ Urticariaoccurringlessfrequentlythanthisis calledepisodic(or recurrent
).
~ Episodicurticaria is more likely to haveanidentifiable environmentaltrigger
.

.240
PQ :
Answer e

Comments
~ Immediatedermographism can be either simple or symptomatic
.
~ Simpleimmediate dermographism occursin about 5 % of normal people
.
~ It occursin responseto moderate stroking of the skin
.
~ Symptomaticdermographismis the most common type of the physicalurticarias
.
~ It manifests as linear wheals at sites of scratching or friction
.
~ Delayeddermographismoften occursafter 30 mins of stroking the skin
.
~ Delayedpressureurticaria is characterizedby the development of deep erythema
-
tous swellingsat sitesof sustainedpressureto the skin
, 30minutesto 12hourslater
.
~ Cholinergi
c urticariapresentswithmultipletransientpapularwheals2
-3 mmin di
-
ameterwhich occurwithin 15 minutes of physical,exertion hot baths
, or emotional
.
stress
~ Exercise
-induced anaphylaxis )(EIA and Food
- and exercise
-induced anaphylaxis
)(FEIA areincreasinglyrecognizedsyndromes
.
~In FEIA
, angioedema
arnd
/o anaphylaxis
occurwithinminutesof exercise
if it follows
either prior ingestion of aspecific food .(e.g wheat
), or sometimeswithin 4 hours of a
heavy meal
.
~ EI
A is producedbyexercise
, butunlikecholinergicurticaria
, notby anincreasein core
temperature induced by other means
.

157
 Section 1
: Answers & Comments

.241
PQ :
Answer c

Comments
~Erythe
ma m
chronicu
migrans
isseen
in60
-90
% ofpatients
diagnosed
withLyme
.
disease
~Ifuntreate
,
d ely
approximat
% ofpatients
60 willgoontohave
oligoarticular
arthritis
(usually the knee
).
~Approximat
ely % develop
10 aneurologic
manifestation
suchasfacialnerve
.paisy
~ Approximat
ely % develop
5 acardiac
complication
suchasvarying
degrees ofatrio
-
r
ventricula).
block

.242
PQ :
Answer e

Comments
~ sCholestasiof pregnancyisdefinedby:
- Generalizedpruritus
, with or withoutjaundice
.
- Absenceof viralor drug inducedhepatitis
.
- Absenceof primary lesions
.
-Biochemic
al s
abnormalitie
consistent
withcholestasis
.
- Disappearan
ce ofsigns
andsymptoms
following
.pregnancy
-Recurre
nce during
nt
subseque
(s)
gestation
andostrogen
containing
-
oralcontra
ceptives is common
.
- Levelsof maternalbile saltsabove40umol
/l arecorrelatedwithan increased
incidenceoffetal(but notmaternal
) .
complications
-Meconi
um g
stainin
and
prematur
e labor
occur
inasmany
as45
% of.patients
.243
PQ :
Answer d

Comments
~Grove
r's se characteristic
disea ally shows
s
acantholysi
(separation
androunding
offof
)
tes
keratinocywithorwithout
s
dyskeratosi
(abnormal
).
keratinisation
~Bullo
us Pemphig
oid isasub
-epidermal disorder
witheosinophils
.
~Dermati
tis mis
herpetiforisachronic
blistering
condition
withasub
-epidermal split
d neutrophili
an c s.
microabscesse
~Erythe
ma e
multiform
andlupus
erythematos
us show
aninterface
)(lichenoid
-
reac
tion pattern
.

.244
PQ :
Answer e

Comments
~Apilar
/ l
trichilemma
cystlacksa granular
celllayerandshows
trichilemmal
-
kerati
.nisati Th
on e cys
t isfilledwithhomogenou
,
s eosinophilic
keratin
unlike
thelaminated
in foun
keratd inanepidermo
id .
cyst
158
Section :
1 Answers & Comments

.245
PQ :
Answer b

Comments
~ Dermatitis herpetiformis shows papillary neutrophilic .
microabscesses
~ Psoriasiscanshow Munro's microabscesses
; these are collectionsof polymorphonu
-
clear inflammatory cellinfiltrate in the stratum cornem
/ granularcell layer
~ Pautrier'smicroabscessesare alocalised epidermal collectionsof atypical lymphoid
cells asseenin T
-cell lymphoma andmycosisfungoides
.

.246
PQ :
Answer d

Comments

~ CD31 is a vascular .
marker
~ CD3
0 isa markerfor lymphomatoidpapulosisandanaplasticlargecell lymphoma
.
~ MNF116 is a broad spectrum cytokeratin
.
~ AlphaSMA(Smooth MuscleActin
) is a markerof smoothmuscletumoursandmy
-
oepithelial tumours
.

.247
PQ :
Answer c

Comments
~ If there is granulmatousinflammation onskin biopsyan infection shouldbe excluded
by performing specialstains
.
~ Mycobacterium tuberculosis canbe visualisedusing the Ziehl
-Neelsen .
stain
~ PAS
-Alcian blue is a pan
-mucin .
combination
~ Ber
-EP4 and Melan
-A are immunohistochemical antibodies
.
~ Verhoeff
-Van GiesonStainis an elastic stain
.

.248
PQ :
Answer a

Comments
~ Ber
-EP4 ispositive in basal cell carcinomaand negative in squamouscell carcinoma
.
~ Epithelialmembraneantigen()EMA ispositivein squamouscell carcinomaandneg
-
ative in basal cell carcinoma
.
~ CEAis a marker of ductal differentiation
.
~ S10
0 protein
, -45
HMB andMelan
-A aremelanocyticmarkers
.

159
 Section 1
: Answers & Comments

.249
PQ :
Answer d

Comments
~ Ifyouseeneutrophil
polymorphs
in thestratumcorneum
always
ruleoutadermato
-
e infectio
phyt n byperformin
g aPASD (Periodic
acid
-S chiff stain
) withdiastase
. Diastase
remov glycoge
es n inkeratinocyte
s making thefungieasiertosee
.
~Wit
h PAS
D thecellwallsoffungistainmagenta
.
~ AlternativefungalstainisGrocott'smethenaminesilver
.

.250
PQ :
Answer a

Comments
~Ahalonaevu
s onbiopsy
shows
a dense
lymphocytic
infiltrateatthedermo
-epider
maljunctionwhichoftenobscures
themelanocytic.component
~Ree
d's naev
us isavariant
ofaSpitz's
.
naevus
.251
PQ :
Answer c

Comments
~Liche
n s
planu
hasaband
ofchronic
inflammatory
cells
atthedermo
-epidermal -
junc
tionwithnumerousCivatte.bodies

.252
PQ :
Answer d

Comments
~Interfac
e /
change
lichenoid
reaction
pattern
isnotseeninpsoriasis
.
~Abiops
y g
showin
acombine
d reaction
pattern
such
asinterface
change
withpsorias
-
iformhyperplasia
orpsoriasiform
hyperplasia
with spongiosis
. oneshouldconsider
etc
a drug reaction
.

.253
PQ :
Answer b

:
Comments
~Featur
es ed
describarethose
ofthehaircollar
; arelatively
sign specific
marker
of
meningocelesandother typesof cranial.dysraphism
~C
T orMRIimagin
g isnecessary
to determine
whether
anintracranial
connection
is
.
present

160
Section 1
: Answers & Comments

.254
PQ :
Answer c

:Comments
~ There exists an increasingly well
-recognised association between Ehlers
-Danlos -
syn
,drome specificallyof the hypermobilitytype
, andresistanceto localanaesthetics
.
~ Thiscan necessitatea higherlocal anaestheticdose
, a greatertime betweendeliv
-
ering analgesiaand starting surgery
, or even consideration for generalanaesthesia
.
~ The underlying mechanism awaits full elucidation
.

.255
PQ :
Answer b

:
Comments
~ Aquagenicwrinkling of the palms is a cutaneousmanifestation of cystic fibrosis that
mayalsobe seen in carriers of cysticfibrosis gene mutations
.
~ It usually presents with translucent papules that coalesceto form oedematous
.
plaques
~ -o
tonset
Time is typicallya few minutes
, but is usuallylonger in carriersof cystic
fibrosis mutations
.
~ Theexact causeis unclear andmost authorities agreethat it isrelated to dysfunction
in sweating
.
~ Reported treatments include topical aluminium preparations and botulinum toxin
.
injections

.256
PQ :
Answer e

:
Comments
~ Epidermodysplasi
a verruciformis(or Lewandowsky
-Lutz )
dysplasiais a raredisorder
,
typically inherited in an autosomal recessivefashion
.
~ Mutations inEVER1 or 2 genesresultin defective cell
-mediated .
immunity
~ Patients are predisposedto HPVinfection andsquamouscell carcinoma
.
~ NumerousHPVserotypes are associated
, although not HPV16.
~ HPV5
, 8
, 10
, and 47serotypeshavebeenisolatedin over 90
% of epidermodysplasia
-associated
verruciformis squamous cell carcinomas
.

.257
PQ :
Answer d

:
Comments

~ Bart
-Pumphrey syndromeis characterised by the clinicaltriad of prominent knuckle
,
pads leuconychiaand deafness
.
~ Inheritance is autosomal recessive and arises from mutation in the GJB2
/connexin
26 gene
.
~ Other disorders resulting from mutation in connexin 26 include Palmoplantar Kerato
-
derma with Deafness and Vohwinkel syndrome
.

161
 Section 1
: Answers & Comments

.258
PQ :
Answer b

:
Comments
~LAM
B s,(LentigineAtrialMyxomas
, us
Mucocutaneo
,
Myxomas
Blue)Naeviisatype
of Myxomasyndrome
.
~Oth
er recognis
ed s
disorder
onthisdisease
spectrum
areNAME,(naeviatrialrnyx
-
, myxo
as
om id neurofibro
,
ma andephelide
)
s andCarney
syndrome,(atrialcutaneous
andmammary,myxomaslentigines
, bluenaevi
, endocrinedisordersandtesticular-tu
).
mours
~Myxom
a syndrome
maybeautosomal
dominant
orsporadic
.
~On
e implicat
ed e infamilial
gen cases
isPRKAR1
,
A acellcycle
.
regulator
.259
PQ :
Answer e

:
Comments
~Juveni
le ma
xanthogranulo
isatypeofnon
-Langerhan'scellhistiocytosis
.
~ Itismos
t commonl
y seen
inmalechildren
butcanoccur
inbothsexes atanyage
.
~Itscaus
e isunknow
n anddiagnosi
s isconfirmed
byskinbiopsy
withcollections
,
of
oftenfoamy
, -full
lipid histiocytesseenin the dermis
.
~Ther
e isnoassociate
d .
dyslipidaemia
~Ophthal
mic ,
nt
involveme
,
however
canbeassociated
withspontaneous
hyphema
g
leadin to secondar
y glaucoma
andblindness
. Thoseat greatest
riskarechildren
younger than 2yearswith multiple skinlesions

.260
PQ :
Answer b

:
Comments
~Th
e numb
er ofprivatel
y owned
-thubs
ut intheUKisestimated
at100,000
andis
.
rising
~Inturn
, case
s ofhot
-tub folliculitis
-acondition
caused
bytheopportunistic
-
patho
n Pseudomon
ge as aeroginosa
andthoughttoarisefrominadequate
chlorination
-are
alsoincreasing
.
~Diagn
osis islargel
y l,
clinica
withapredominant
iy truncal
eruption
appearing
within
a few days of exposure to contaminated water
.
~Typic
,
ally theconditi
on isself
-limiting and
requires
notreatment
. Extensive
,
disease
ally inimmunosuppre
especi ssed ,
individuals
may necessitate
-gram negative
anti -
sys
temic therapy
.

162
Section 1
: Answers & Comments

.261
PQ :
Answer c

:
Comments
~ Molluscum contagiosum is a DNA poxvirus
, asis Orf virus
~ Diagnosisof SLEis based on a combination of clinical findings and laboratory evi
-
.
dence The American College of Rheumatology )(ACR uses astandard diagnostic clas
-
sification requiring at least 4 out of the following 11 criteria to be met
: Malar rash
,
discoidrash
, ,
photosensitivityoral ulcers
, -erosive
non ,
arthritis pleuritis orpericarditis
,
renaldysfunction
, neurologicaldysfunction
, haematologicaldisorder(such asleuko
-
),
paenia immunologicaldisorderand positiveantinuclearantibody
.

.262
PQ :
Answer e

:
Comments
~ Eosinophilicfolliculitis is afeature of cell
-mediated ,
immunodeficiency although no
definitive infective aetiology hasbeen identified
.
~ With HIVinfection it is seen when the CD4lymphocyte count falls below 300 cells
/
mm3and typically improveswith Highly Active Anti -Retroviral .
Therapy
~Papuloerythroderma of Ofuji or"Ofuji disease
" isa variant ofeosinophilicfolliculitis
that istypicallyfoundin Japanandisnot associatedwith immunodeficiency
.

.263
PQ :
Answer d

:
Comments
~ Sarcoidalor naked granulomasconsist of loose groupings of epitheloid histiocytes
,
giant cells andlymphocytes
.
~ Asteroid bodies mayalso be seen within the cytoplasm of macrophages
.
~ DifferentialdiagnosesincludesarcoidosisandCrohn'sdisease
. Oncesarcoidosishas
n exclude
bee ,
d y
colonoscop
wouldbewarranted
to exclude
metastatic
cutaneous
Crohn's disease
.
~ Secondarysyphiliscanpresent with sarcoidalgranulomasbut the absenceof plasma
cellspointsawayfrom thisdiagnosis
.
~ Mycobacterium tuberculosisgranulomasclassicallyoccur with caseousnecrosis
.

163
Section 1
: Answers & Comments

.264
PQ :
Answer e

:
Comments
~Mid
-dermal elastolysi
s isarare
, ,
acquiredskincondition
.
~Foc
al lossofelastic
fibresresults
fromincreasedelastase
enzyme
.
activity
~Itsexa
ct caus
e isunknow
n butns
associatio
include
ultraviolet
,
radiation
pregnancy
andthe oralcontraceptive
.
pill
~Itmos
t y
commonl
presents
withwell
-demarcated areas
offinewrinkling
butcanalso
t
manifeswithperifollicularpapulesofreticularerythema
.
~Transepithel
ial elimination
ofelasticfibresisahistological
featurecharacteristic
of
is
elastos
s
perforan
,
a
serpiginos
acondition
associated
withbothEhlers
-Danlos -
syn
me an
dro d pseudoxanth
oma .
elasticum
Other
s
association
include
Down's
,
syndrome
n
Marfa,
e
syndromis
osteogenes
,
imperfecta
,
scleroderma
and.D
-penicillamine
~Derm
al s
fibrosiisseeninscarring
disorders
suchasacrodermatitis
chronica
-
atrophi
s (whichalsodemonstrate
can s dermalatrophy
) andcutaneous
.
morphea
~Acroderm
atitis a
chronic
ns
atrophica
isassociate
d withLyme's
.
disease
.265
PQ :
Answer c

:
Comments
~Th
e Lew
is reactio
/
n s
hunter'
reflex
s
describe
thenormal
pallor
offingers
andother
extremitiesin responseto cold
.
~Th
e glomu
s s
apparatu
orbodyisadermalstructure
consisting
ofanarteriovenous
shunt under autonomicnervoussystemcontrol
. Mostnumerousin the extremitiesit
s animporta
play nt roleintemperatur
e regulation
byshunting
bloodaway
fromthe
n surfac
ski e whenexposed
tocoldtemperature
.
~Th
e eccrin
e d pilosebaceo
an us unitsalso
play
aroleintemperature
regulation
butvia
swe productio
at n andhaircontracture
, .
respectively
~Th
e Pacinia
n e
corpuscl
detectsvibration
andtheMeissner's
corpuscle
detects
fine
.
touch

.266
PQ :
Answer a

:
Comments
~Ausef
ul aid
-memoireisSNo
W DRoP
, where
southern
blotting
relates
toDNA
, North
-
ernblottingtoRNAandWesternblottingtoprotein
.
~East
ern blottin
g s analysi
allows ofpost
-translationalprotein
modifications
(PTM
).
~ Revers
e R wouldbeusedto amplifyRNA
PC .

164
Section :
1 Answers & Comments

.267
PQ :
Answer a

:
Comments
~ Phosphorus sesquisulfide is found in match tips and friction strips of safety match
-
.
boxes
~ Theother agentslisted are formaldehydereleasers
.

.268
PQ :
Answer d

:
Comments
~ Genital psoriasistypically presents in the context of more generalisedpsoriasis but
can present in isolation
.
~ Diagnosticallyhelpfulfeaturesincludeasymmetrical,distribution markederythema
,
occasionalfissuring andhealing without scarring
.
~ First
-line treatment iswith aweak or moderate potency steroid
.
~ Blandemollients play animportant role in protecting againstchemicaland mechani
-
cal irritation and subsequentkoebnerization
.

.269
PQ :
Answer a

:
Comments
~ The clinical features described are those of the autosomal recessive
, or Hallope
-
-Siemans
,au type of dystrophic epidermolyis bullosa ).
(EB
~ Otherfeaturesinclude enameldefectsand dental caries
, nail dystrophyand high
propensity to squamous cell carcinoma
.
~ AnswerCrelates to the autosomaldominantform of dystrophicEB
, which isless
severe and improves with age
.
~ AnswerBrelatesto junctionalEB
, classicallysubdividedinto Herlitz andnon
-Herlitz
.
types
~ AnswerDrelatesto EBsimplex
, whichin turn canbesubdivided
into localised-(We
berCockayne
), d
generalise
(DowlingMeara
) andsuperficial
.
types

.270
PQ :
Answer e

:
Comments
~ Cobbsyndrome(also knownasCutaneousVertebralMedullaryAngiomatosisorSpi-
nal ArteriovenousMetamericSyndrome
) isdefinedby coexistenceof vascular-malfor
mationsin all tissue layers of asegmentaldermatome
.
~ Venous or arteriovenous malformations over the back are present from birth may be
the only clue to anunderlying spinal cord AVM
.
~ Neurologicalmanifestationstypicallyinvolvelower limb motor or sensorydeficit
/or
and sphincter deficits
.

165
 Section 1
: Answers & Comments

.271
PQ :
Answer c

:
Comments
~Pemphig
oid is
gestation
occurs
withanincidence
ofapproximately
1in 50,000
in
e patient
thos s withhighrisk(DR3orDR4
) HLAtypes
.
~Oth
er ris
k factor
s e
includ
apersona
l history
ofthedisease
, Caucasian
heritage
and
otherautoimmune
.diseaseThereis alsoa recognised
association
with choriocarcino
-
ma andhydatidiform moles
.
~Th
e targe
t n
antige
s
concern
bullous
pemphigoid
antigen
2().
BP180
~Presentati
on mayrarely beinthefirsttrimester
butismoretypically
inthesecond
r thirdtrimeste
o r orpost
,-partum ashere
. Animportant
clinical
clueisthattheitchy
s
lesion y
commonl
startaroundtheumbilicus
, beforespreading
therestof thetorso
d othe
an r area
s such
astheintertriginou
s areas
and.extremities
The,facepalms
and
s areusuaily.sparedMucosal
sole involvement
occurs
in fewerthan20
% ofcases
~ Diagnosi
s iswith skinbiopsy
.
~H
E analy
& sis demonstra
tes anidentical
pattern
tobullous
,
pemphigoid
withsplitat
the DEJ
.

~Dire
ct IM
F show
s linear
C3inall,cases
withadditional
IgG
onlyseen
inapproximately
% of cases
25 .
~Thi
s contras
ts tobullou
s d
pemphigoi
where
thetypical
pattern
ondirect
IMFislinear
IgG and C3 deposition

.272
PQ :
Answer d

:
Comments
~Line
ar IgAdiseas
e isthecommones
t autoimmune
bullous
disease
inchildren
.
~Itusual
ly arise
s spontaneo
usly butsometime atriggering
infection
canbeidentified
.
~Th
e classi
c on
presentati
iswithanannular
orcrown
-joewels
f configuration
~In adult
,
s themos
t commo
n n
associatio
iswithmedication
, especially
.
vancomycin
~Oth
er associati
ons e inflammat
includ
ory bowel
,
disease
al
rheumatologic
disorders
d bot
an h haematologi
cal andnon
-haematological.malignancy
~O
n ski
n biops
y, theH
E section
& s
demonstrate
asub
-epidermal splitwithneutrophilic
e
infiltratin alinear,fashionanddirectIMFdemonstrates
linearIgAdeposition
. This
sts
contra todermatiti
s s,
herpetiformi
wheregranular
neutrophils
predominate
~Th
e treatme
nt ofchoice
, aswithmany otherIgA
-associatedneutrophilic
,
disorders
is Dapsone
.
~ Secon
d lineagentsincludesulfapyridine

166
Section 1
: Answers & Comments

.273
PQ :
Answer d

:
Comments

~ Other dermoscopicfeaturesof pigmentedbasalcell carcinomas

, relating to mela
-
nininclusion
, mayinclude
: Absenceof a true pigmentnetwork
, -grey
blue dots and
,
globuleshomogenous pigmentedareas
, peripheral-like
eaf structuresandspecksof
brown and grey pigment
.

.274
PQ :
Answer b

:
Comments
~ Other poor prognosticmarkersin alopeciaareatainclude
: DQ7or DR haplotype
,
family history
, /childhood
early ,
onset associatedatopy (especiallywith fillagrin gene
)
mutation orautoimmunedisease
, extensivehair loss
, nail disease(especiallydystro
-
)
phy and chronicity
.

.275
PQ :
Answer b

Comments
~ The cause of plasma cell balanitis
/vulvitis is not known but established risk factors
include poor hygiene and being uncircumcised
~ Whilst all the listed treatments listed can be used for plasma cell balanitis
, only cir
-
cumcision is reliably curative

.276
PQ :
Answer c

:
Comments
~ Lichen sclerosus is associated with an increased risk of vulval squamous cell carcino
-
, necessitatinglong
ma -term follow up
.
~B
y contrast
, peniledisease
isextremelyunlikelytoprogresstosquamous
cellcarcino
-
ma with only one case reported in the literature
.
~ Extra
-genital ,
disease typicallyinvolving asymptomaticwhite patcheswith the ap
-
pearanceof cigarettepaper
, occursin around10% of cases
. Thereisnoassociatedrisk
of squamous cell carcinoma at these sites
.

167
Section 1
: Answers & Comments

.277
PQ :
Answer a

:
Comments

~Porphyri
as withcutaneou
s involvement , without,exception
are photosensitive
and
n beclassifie
ca d g
dependin
onhepatic/o
arnd erythropoietic
.
involvement
~Hepati
c as
porphyriwithcutaneou
s involvement
present
withlessacute
skinchanges
and concern
:

) Porphyria
1 cutaneatarda
: :
Inheritance
Autosomal
dominant%)
(20
-3 orac
-
.
quired Enzyme
:defect Uroporphyrinogen
decarboxylase
) Hereditary
2 :coproporphyria
:
Inheritance
Autosomal
.
dominantEnzyme
:
defect
Coproporphyrinogenoxidase
~ Mixedhepaticanderythropoieticporphyriawith cutaneousinvolvementalsodemon
-
strates less acute skin change and concerns
:
) Variegat
1 e .
Porphyria
:
Inheritance
Autosomal
.
dominant
Enzyme
:
defect-
Pro
toporphyrinogen oxidase
~ Erythropoietic
porphyrias
manifestswithacuteskinchangeandconcern
:
) Erythropoie
1 tic :
a
protoporphyri
:
Inheritance
Mostly
autosomal
dominant
(but
al
autosome
recessiv
cases
havebeenreported
)
) Congenit
2 al c
erythropoieti
:
porphyria
:
Inheritance
Autosomal
.
recessive
Enzyme
:
defect Ferrochelatase
) X
3 -linked sideroblastic
:
anaemia
:
Inheritance
-linked recessive
X defectin the
Z
ALAS .
gene Enzymedefect
: ErythroidALA
-synthase
Otherautosomalrecessivephotosensitivedisordersto beawareof include
:
- Rothmund
-Thompson syndrome
- -O
Lemi
Smith
pitz syndrome
- Trichothiodystrophy
- Xeroderm
a pigmentosum
.278
PQ :
Answer c

:
Comments

~ Startin
g inthebasallayerit takes14days
forthematuring
keratinocyte
toreachto
m
stratum
corneuandafurther
14days
toreach
totheverysurface
ofthislayer
, allow
-
ing it to be shed
.
~Th
e trans
-epidermal timeisconsiderabl
y shorter
indiseases
suchaspsoriasis
andis
prolonged in the elderly
.

168
Section 1
: Answers & Comments

.279
PQ :
Answer d

:
Comments
~ Narrow
-band UVB can also elicit HSV reactivation
~ Othe
r sideeffectssharedbybothtreatmentmodalities
includephoto
-aging andin
-
creasedrisk of skin cancer(although the risk with narrow
-band UVBis considerably
).
lower

.280
PQ :
Answer a

:
Comments
~ Allergyto soyais a contraindicationto isotretinoin
, assomebrandsof isotretinoin
contain soya oil
.

.281
PQ :
Answer b

:
Comments
~ Other dermoscopic features of seborrhoeic keratosesinclude
: -like
Comedo -
open
,
ings homogenous pigmentation and milia
-like .
cysts
~ Presenceof a pigment network is anatypicalfeatureand raisesthe suspicionof a
seborrhoeickeratosis
-like (or verrucous
) malignantmelanoma
.

.282
PQ :
Answer c

:
Comments
~ Unlikewarfarin
, noveloral anticoagulants
actindependentlyofthe vitaminKpath
-
wayand
, because
ofshorterhalf
-lives andmorepredictable
,pharmacokinetics donot
require routine therapeutic monitoring
~ Answer B is true for the novel oral anticoagulants rivaroxiban and apixaban
~ Answer A is true for warfarin
~ Answer D is true for heparin

.283
PQ :
Answer c

:
Comments
~ The maximum number of sessions for narrow
-band UVB is 300
.
~ A48
-hour gapis neededbetweeneachsession
, allowing3sessions
perweek
.
~ For PUVA a maximum of 250 sessions are allowed over a lifetime
.
~ A 72
-hour gapisneededbetweeneachsession
, allowing2 sessionsperweek
.

169
Section 1
: Answers & Comments

.284
PQ :
Answer d

:
Comments
~ PD
S )(polydioxanoneelicitsthegreatestscarreactionamongst
theabsorbable
-su
tureslisted andMonocrylthe least
.
~ Ethion elicitsa greaterscarreactionthan Prolene
.
~Th
e exten
t ofthescarreaction
canalsobereduced
byusing
asmaller
calibre
suture
andavoidingdelayedsuture removal
.

.285
PQ :
Answer b

:
Comments

~Ecthym
a m
gangrenosu
resultsfromhaematogenous
spread
ofinfective
.agents
~ Pseudomonas
aeriginosaisthemost commoncausebutall thoselisted canbe causal
.
agents
~ Fung
al infections
suchasAspergillosis
, Candida
andZygomycosis
mayalsocauseec
-
thyma gangrenosum
.
~ It usuallyoccursinimmune
-compromised orseverelyunwellpatients
.
~Characteris
tic lesions
concern
haemorrhagic
pustules
thatevolveintodeepnecrotic
.
ulcers

.286
PQ :
Answer a

:
Comments
~ BothMiescher
Mosenthal
-R elkersson Syndrome
andMelkersson
-Rosenthal -
Syn
me ar
dro e partoftheorofacia
l sis
granulomato
disease
,
spectrum
which
can
-demon
strate all the listed features
~ -R
Mosenthal
Miescher
elkersson Syndrome
is characterised
by granulomatous
change confined to the lips
~Melkersson
-Rosenthal Syndrome ischaracterised
bygranulomatous
change
-
involv
ingthelips
, tongue
together
withfacialnerveparalysis
~Strictl
y ,
g
speakinorofacial
s
granulomatosi
isadiagnosis
ofexclusion
thatcanonly
e mad
b e onc
e systemi
c us
granulomato
disease
such
asCrohn
,
disease
,
sarcoidosis
,
TB
r's
Wegenesis
granulomato
andallergic
contact
dermatitis
havebeenexpiredandex
-
cluded

~Foo
d allergie
s havebeenproposedto playaroleandin somecases
a-benzoate
/cin
-free
namon dietcanleadto improvement

170
Section 1
: Answers & Comments

.287
PQ :
Answer a

:
Comments
~ Lichenoid keratosis is a benign lesion that is thought to develop from such lesions as
a regressing solar lentigo or seborrhoeic keratosis
.
~ Theytypically occur asasolitary lesion on the upper trunk and can resemblesuperfi
-
cialbasalcellcarcinoma
, Bowen'sdiseaseorevenmalignant.melanoma
~ The presence of a grey granular pattern under dermoscopy is a clue to diagnosis but
aloneis not enough to exclude more serious differentials
.
~ Histologicalfeatures include acanthosis and a band
-like lichenoid lymphocytic infil
-
.
trate

~Parakeratosi
s mayalsobeseen
, servingasadistinguishingfeaturefromlichenplanus
.

.288
PQ :
Answer e

:
Comments
~ Catch scratch disease is caused by Bartonella henselae
.
~ Localised
, tenderlymphadenopathyoccursdistalto the site of a bite or scratch1
-3
weeks after inoculation
.
~ A discrete papule or vesiclemay alsobe seen at the site of inoculation
.
~Approximately 50
% patients experiencesystemicsymptomssuch asfever , headache
and malaise
.
~ In immunocompetentindividuals
, the infection is ,self
-limiting with conservative
management .
appropriate
~ Immunocompromised
,patients however
, are at significantrisk of developingcom
-
plicationssuch as bacillary angiomatosis(a vascularlesion that mayextend from the
skinand soft tissueinto underlying to bone
) and require treatment with antimicrobials
such as azithromycin
.

.
PQ 289 Answer
: c

:
Comments
~ Spitzor Reednaeviarerelativelyuncommon
, mostlyappearduringchildhoodor
earlyadultlife
.
~Theymaybe pigmentedor .non
-pigmented
~ The pigmented variety demonstrates a classic starburst pattern
.

171
 Section 1
: Answers & Comments

.290
PQ :
Answer d

:
Comments
~Clea
r cellacanthoma
(or Degos
)acanthoma
isabenignepithelialskintumour
.
~ Typic
al n
presentatio
iswitha solitaryshinypinknodule
, withwafer
-like scaling
around its edge
.
~ Mostcommonsitesarethelowerlegs
.
~Histolo
gy es
demonstrat
epidermal
accumulation
ofclearglycogen
-containing .
cells
.291
PQ :
Answer c

:
Comments
~ TheCLA
-4 proteinis found on the surfaceof cytotoxicT cellsandfunctionsto
-regulate
down immune responses
.
~Mutationsin the geneencodingthis protein predisposeto autoimmunediseasein
-
ng coeli
cludi ac diseas
,
e -dependent diabetes
insulin ,
mellitus
autoimmune
thyroid
-
dis
ease and lupus erythematosus
.
~Simila
,
rly gical
pharmacolo
inhibition
ofCTLA
,
-4 withagents
such
asipilimumab
, can
also trigger autoimmune .
phenomena

.292
PQ :
Answer c

:
Comments

~Us
e ofmonteluka
,
st aleukotriene
receptor,
inhibitor
isassociated
withahigher
-
inci
e
dencofChurg
-Strauss syndrome
. Aswithnon
-rdelated
rug ,
cases-ANCAleveis
p can
be elevated
.
~Calcineu
rin s
inhibitor
include
ciclosporin
(whichfirstmust
formacomplex
withcy
-
)
-A
clophilin
~Calcineu
rin n
inhibitioprevents
migration
oftheNFAT transcription
factorintothe
-cell nucle
T us andultirnatel
y results
inIL
-2 signalling
.
inhibition
~TheAnti
-IgE monoclonal
antibody
omalizumab
hasrecentlybeengrantedalicence
forus
e asasecond
-line agent
fortreatment
refractory
chronic
spontaneous
urticaria
.293
PQ :
Answer a

:
Comments
~ Poorl
y controlledasthmais citedasthesinglemostimportantriskfactorforfatalan
-
,
xis
aphylaally inchildre
especi n and
young
,
adults
andcanbeanindication
for-seif
in
jectable .
adrenaline
~Th
e life
-saving interventi
on during
s
anaphylaxi
isadrenaline
, delivered
viatheintra
-
muscular route
.
~Inadult
s thedoseis500micrograms
(0.5mLof1
:1000 adrenaline
).

172
Section 1
: Answers & Comments

.294
PQ :
Answer d

:
Comments
~ Bexaroteneisa retinoid receptoragonist
.
~ It is often combined with other therapies such asPUVAor extracorporeal photopher
-
.
esis
~ Sideeffectsinclude hypothyroidism anddyslipidaemia
, requiring regular monitoring
of thyroid function and lipids
.

.295
PQ :
Answer d

:
Comments
~ Gorlin'ssyndrome isinherited in an autosomal dominant fashion
.
~ Non
-basal cell carcinomaskin signscan include epidermal cysts
, lipomas andpalmo
-
plantar cysts
.
~ Bonymanifestationsincludebifidribs
, !
fronta bossingandontontogenicjaw cysts
.
~ Other associatedmalignanciesinclude medulloblastoma andovarian cancer
.

.296
PQ :
Answer c

Comments

~ Vismodegibinhibitsthe smoothenedreceptor
, a key mediatorin the Hedgehogsig
-
nalling pathway
.
~ Other commonly
-seen -effects
side include altered taste sensation anorexia
, -
diar
,
rhoea fatigue and alopecia
.

.297
PQ :
Answer a

:
Comments
~ Periungu
al skinisthemostcommonextra
-genital sitefor cutaneous
squamous
cell
.
carcinoma
~ Subungalsquamouscell carcinoma is commonly a diagnostic challenge
, presenting
with avariety of nail changesincluding verruciform hyperkeratosis
, ,
dystrophy -
longitu
dinalridging
, ,
onycholysis,
erythronychiasubungalhaematomasand paronychia
.
~ Whilst all subtypes listed are high
-risk for subungal squamouscell carcinoma
, the
mostimportant carcinogenicfactor is HPV16
.
~ Longitudina
l nailbiopsyis thegoldstandarddiagnosticapproachasthis allowssam
-
pling of the nail bed
, matrix andfold
.

173
Section 1
: Answers & Comments

.298
PQ :
Answer c

:
Comments

~A
s reporte
d bytheStatistic
al n
Informatio
Team
atCancer
Research
, thecommon
UK -
t siteformelanom
es a inmenisthetrunk(accounting
for41
% ofcases
), followed
by
th hea
e d andneck%)(22 andarms%).
(19
~Fo
r women
, thecommone
st siteisthelegs%),
(39 followed
bythearms%)
(24 and
trunk %).
(20

.299
PQ :
Answer a

:
Comments
~Heredita
ry orfamilialmelanoma
iscurrently
estimated
toaccount
forapproximately
% of all casesof melanoma
10 .
~Itisdefine
d byfamilie
s inwhich
atleast2first
-degree relatives
(or alternatively
at
least3memberswith anydegreeofrelationship
) havehadmelanoma
.
~Germ
-line n
mutatio
intheCDKN2
A , aregulator
gene ofcelldivision
, isthemostcom
-
moncauseof hereditarymelanoma
.
~Th
e lifetim
e riskformalignant
melanoma
insomeone
carrying
aCDKN2A
gene-mu
tation is nearly 30
%.
~Othe
r heritable
mutations
thatcarryanincreased
riskofmalignant
melanoma
-
in
e CDK
clud ,
4 , MDm2TY
RB1
,
R ,
TYRP1
ASIP
andMC1R
.genes
~ Th
e MC1Rgeneencodesthemelanocortin
-1 .
receptorThispromoteseumelaninpro
-
,
n
ductio y
therebcontrolling theratioofeumelanin
andpheomelanin
. Polymorphisms
thatreduc
e theabilityof themelanocortin
-1 receptor
resultin melanocytes
making
ly pheomelan
most.
in e areassociate
Thes d withredhair
, fairskinandfreckles
. Whilst
suchpolymorphismsareassociatedwith increasedriskof melanomaandnon
-melano
maskincancers
, therelativeriskis muchsmaller
.
~Non
-inherited orsomatic genemutations
thatincrease
theriskofmelanoma
include
e in NRA
thos ,
S -RAF and.C
B -KIT Interestingly
, NRAS mutations
aremorefrequent
in
sal melano
muco mas inthehead
andneck
,region
incomparison
toB
-RAFand.C
-KIT
.300
PQ :
Answer c

:
Comments
~Vemurafe
nib isasmallmolecule
inhibitoroftheB
-RAF enzyme
.
~ Deliveryisvia the oral route
.
~ Ipilumumabwouldbefirstlinefor BRAF
-negative .
disease

174
Section 1
: Answers & Comments

.301
PQ :
Answer b

:
Comments
~ Ipilimumabismonoclonalantibodythat up
-regulates -surveillance
immuno bytarget
-
ing CTLA
-4 (an inhibitory protein on cytotoxic Tcells
)
~ Delivery is via the intravenous route
~ Vemurafenibwouldnot be indicatedfor BRAF
-negative disease

.302
PQ :
Answer e

Comments
~ CTLA
-4 inhibition cantrigger numerousautoi
-mmune phenomena
~ Themost commonof theseis autoimmunecolitis
, manifestingwith suchsymptoms
as abdominal painandbloody diarrhoea

.303
PQ :
Answer d

Comments
~ Dabrafeniband Vemurafenibare B-RAF enzymeinhibitors
.
~ Their most common side effects concernphotosensitivity
, other skin eruptions and
-like
flu .
symptoms
~ Approximately25
% of patientsdevelopskincancers
, especiallysquamouscell carci
-
.
noma

.304
PQ :
Answer e

:
Comments
~ Woolly hair may be an inherited as an isolated condition (usually in an autosomal
dominant fashion
) or as part of asyndrome (typically in an autosomal recessivefash
-
ion
).
~ Answer A is true for Carvajal syndrome
.

.305
PQ :
Answer a

:
Comments
~ Local anaesthetics comprise a lipophilic aromatic region attached to a basic amine
side chain
. For aminoesters this is via an ester link and for aminoamides this is via
amide link
.
~ Local anaesthetics block propagation of action potentials of sensory neurons by
-dependent
use inhibition of voltage
-gated Na receptors
, bindingto a site within the
open pore
.

175
 Section 1
: Answers & Comments

.306
PQ :
Answer c

:
Comments
~Sporad
ic ma
angiokerato
typically
present
assolitary
darkredtopurple
,plaques
-
of
ten with a scaly surface
~The
y arecompos
ed ofdilated
capillaries
andareoftenonlycome
tomedical
-
atten
n aftera
tio traumleadstobleeding
, thrombosis
andsudden
.
darkening
.307
PQ :
Answer d

:
Comments
~Oth
er medici
nes thatmay
r
trigge
mast
celldegranulati
,
on and thereby
worsen
mast
l mediat
cel
ed s
condition
such
asurticarial
,
pigmentosa
:
include
Amphotericin
, neu
B -
cular blocki
romus ng agent
s such
ase
,gallamin
,
opiates
NSAIDs
and
,aspirin
dextran
a
plasm ,
expander
polymyxinB
, quinineandreserpine
.
~Th
e othe
r ns
medicatio
listedaremore
classically
associated
withtriggering
orwors
-
ening psoriasis
.

176
Section 2
: Paper

Section 2
: Paper 1

1.1 Whichof thefollowing statementsregardingRaynaud'sphenomenonis correct

?

)
a Digitalskincolourchangesarein theorder of red
, white
, thenblue
.
)
b Ergotcompounds usedin anti
-migraine medicationsimprove the condition
.
This is most commonlyseen in patients with systemiclupus erythematosus
)
d This is most commonly seen in patients with systemic sclerosis
.
)
e Thisis often associatedwith interstitial lung diseasein the presenceof con
nective tissue disease
.

1.2A -o
year
62ld manwith a backgroundof rheumatoidarthritis presentedwith red
-
torown plaquesand nodules on the dorsalaspectof his hands
-b , which have been
present for two months
. Theseare mostly asymptomatic and tend to appear on the
metacarpophalangealjoints
. Full skin examination showed similar plaques and nod
-
ules on both his elbows
. There are no associated nail changes
.

Which of the following statements regardingthis condition isincorrect

?

Histologyfrom theselesionstypicallyshowsleukocytoclastic.vasculitis
Systemicsteroids often result in complete resolution of the lesions
.
Thecondition can be seenin HIVinfected patients
.
The condition responds well to treatment with dapsone therapy
.
)
e Thiscondition canbe associatedwith IgAmonoclonal gammopathy
.

1.3 A41
year
-o ld Caucasian man presented with a three
-year history of yellow papules
coalescinginto symmetricalplaqueson theaxillae
, groinand the peri
-orbital .
skin A
biopsy from two separate lesions showed dermal infiltrate with polymorphic cells con
-
g
sistin offoamy,histiocytes
whichstained
negative
forCDiaandpositive
forCD68
and
factorXIII
. Basedon the clinical and histological,features youdiagnosexanthomata
.
disseminatum

Which of the following statements regarding this condition isincorrect

?

Diabetes insipidus can be associated

.
Rectalmucosal
biopsyis oftenunhelpful
.
Thecondition respondspoorly to topical steroids
.
)
d Lipid profile is often normal in these patients
.
Thisconditionformspart of theLangerhans
' cell histiocytosis
.

179
 Section 2
: Paper

1.4A24
year
-o ld manpresented witha threemonthhistoryofasymptomatic
-
gen
d
eralize r
maculopapula
,
eruptionon his trunk andextremities
. Healsohadsome
l,
smalh
smoot greypatches
onhistongue
andhasbeencomplaining
ofheadaches
for fourweeks
. Further
questioning
revealed
arecenthistoryofunprotected
sexual
.
intercourse

Which of the following statements in this condition is correct

?

)
a Avesiculo
-bullous eruptionis common
.
-Robertson
Argyll pupilisa commonfinding
.
)
c Histology
oftenshowsparakeratosis
, lichenoidchanges
anderythrocyte
on
extravasati
intheabsence
ofplasma
.cells
Potential
adverse
reactions
occurring
withinthefirst24hoursoftherapy
includeheadache
, myalgiaandworseningof theeruption
.
)
e Response
to Penicillinisgenerallyverypoor
.

1. A40
5 year
-o ld womanpresented
withlongstanding
translucent
,
yellowsmall-pap
s appearin
ule g y
predominantl
onherperi
-orbital skin
. Clinically
, youmakethediagno
-
sis of syringomas
.

Whichof thefollowing statementsisincorrect

?

Carbon dioxidelasercanbeusedfor treatingthiscondition

.
Electronmicroscopy studieshaveidentifieddepositsofcalcium
.
)
c Theeruptiveformscanbeassociated withEhlers
-Danlos .
syndrome
Theselesionsarisefromtheintradermal portionsoftheeccrinesweat.ducts
)
e Theselesionsarisefromtheouter hairrootsheath
.

1.6Whichof thefollowing causesof genitalulcerationisnot a venereal?

disease

Behçet's disease
.
)
b Chancroid
Granulomainguinale
.
)d Herpes simplex
.
)
e Primary syphilis
.

180
Section 2
: Paper

1.7 Which of the following statements regardingpityriasis lichenoideschronica is cor

-
?
rect

,
Histologically
thishasa similarappearanceto pityriasislichenoideset
varioliformisAcuta().
PLEVA
Phototherapycan be useful in this condition
.
Thecondition appearspredominantly onthe face and neck .
)
d Thelesionstend to heal with significant pitted scarring
.
)
e Transformation to cutaneous lymphoma never occurs

1.8 Borrelia borgderfori has been linked to the pathogenesisof all of the following
:
except

)
a Acrodermatitis chronicaatrophicans
.
Erythemachronicum migrans
.
)
c Marginal zone B cell lymphoma
.
.
Morphea
)
e Rockymountain spotted fever
.

1.9 Which of the following statements regarding eosinophilic cellulitis (Well's syn
-
)
drome is correct
?

Dapsoneis the first line treatment

.
Flamefigures arepathognomonic of this condition
.
)
c Peripheral eosinophilia is extremely common and is found in almost all cases
.
The condition is often progressive with no spontaneous resolution
.
)
e Vasculitisis absent on histology and direct immunofluoresenceis negative
.

1.10Which of the following statements regarding dermatofibrosarcoma-protu

berans is correct
?

Chromosomal
,
abnormality whichcanbepresentin this condition
, isEWS
-
.FLI1
)
b Erlotinib canbe used in some cases
.
)
c Metastasesareextremely common in this condition
.
Positive CD34 with negative Factor XIlIa
.
)
e This condition is characterised immunohistochemically by CD34 negative and
Factor XIlla positive
.

181
 Section 2
: Paper

11A-o
1. year
57ld sian woma
Caucan present
ed with anine
month
history
ofa5x5cm
solit erythem
ary atous plaqu
e with
overlyi
ng sia
telangiecta
onher
right
.
shoulderShe
d no
di t hav
e an
y associa
ted pruritu
s orathy
.lymphadenop
Anincisional
biopsy
from
th plaq
e ue show
ed diffus
e derma
l ous
subcutanec
lymphocyti
infiltrate
that
spared
the
rmis
epide
and bcl
.
-6
d th
ane cell
s wer
e positi
ve for0
,CD2
-2 and
bc e for,CDCD5
negativ , CD10
Themostlikelydiagnosis
hereis
:

)
a Mycosisfungoides
.
-Hodgkin
Non lymphoma
skinmetastases
.
c)
Primacutaneo
ry us -cell lymphom
B a ofdiffuse
large
celllymphoma
.
type
ry cutaneo
Primaus -celllymphom
B a ofmarginal
zone
.
type
)
e y
Primar
us
cutaneo
-celi lymphom
B a ofthefollicle
centre
type
.
2 A21
1.1 year
-o ld Afro
-Caribbean
mand
reporte
afiveyear
history
ofpersistent
-
pain
lfupurul
ent draini
ng scal
p lesion
s accompan
ied byprogressiv
ely worsening
.
alopecia
sicalation
Phy examinreve
als pustul
,
es es and
nodul nt abscess
fluctua
,
es and
multiple
palpacervic
ble al lymp
h nodes
. Pus
waseasily
drained
from
some
oftheabscesses
and
e wer
there communica
ting s
sinuse
.
visible
r thiscondition
Fo , whichofthefollowing
statements
isincorrect
?
-fungal treatment
Anti isnotindicated
inthiscondition
.
a
Arthralgi
mayoccurinsome.cases
al cella
Bas carcinom
may
complicate
-standing disease
long .
ccus
Staphyloco
isoften
themost
commonly
cultured
pathogen
from
ily
secondar
infected
lesions
.
e pathogen
Thesis ofthisn
conditio
relates
toprimary
follicular
occlusion
.
disorder

182
Section 2
: Paper

1.13 A12
mld
-o onth healthyboy wasborn with alargepurplisherythematousraised
tumour with central telangiectasia surrounded by a pale halo on his left upper arm
which didnot increasein sizein the first eight months of hislife
. Atthe ageof oneyear
,
his mother noticed significant flattening ofthe lesion andfading of the halo
.

In thiscondition
, which of thefollowingstatementsisincorrect
?

Central ulceration isa possiblecomplication in the first few months of life

.
-Merritt
Kasabach syndrome occurs in some cases
.
)
c Thehistologyischaracterised
by smallcapillarylobulessurrounded
by dense
fibrous tissuewith abnormally thin walled blood vesselsin the centre
.
This entity is characteristically negative to the immunoreactive glucose
-1
transporter )(G. LUT
-1
)
e Treatment with oral steroids should be commenced during the first three
months of life
.

1.14Whichof thefollowing drugsismostlikelyto causedrug

-induced subacutelupus
?
erythematosus

.Bendrofluazide
.
Ciclosporin
)c .
Frusemide
)
d .
Ibuprofen
.
Paracetamol

1.15Sebaceousglandscanbe foundin which cystwallsof thefollowing

?

Epidermoidcysts
.
)
b Epidermoid cysts & eruptive vellus hair cysts
.
c) Eruptivevellushair cysts
.
Pilar cysts
.
Steatocystoma .
multiplex

1.16All of thefollowingdrugscanaggravatespontaneousurticaria except

:

.Aspirin
)
b Codeinephosphate
.
c) .
Ibuprofen
)
d .Montelukast
.
Ramipril

183
 Section 2
: Paper

1.17Whichof the followingstatementsregardingtopicalretinoidsisincorrect

?

Theiruseisassociated
withincreased
resistance
totheP.acnes
.
bacteria
Theycandown
-regulate tyrosinesynthesis
)c Theycanexhibit aneffecton .micro
-comedones
)
d Theycanreducepost
-inflammatory hyperpigmentation
.
Stimulation
ofcollagensynthesis
mayoccur
.

8 A22
1.1 year
-o ld manpresented
withmultiple
palpable
purpura
andpetechiae
on
hisbuttock
s andlegsthreeweeksfollowingasorethroat
. Healsohadsymptoms
of
abdominal pain and ankle swelling
.

In this condition
, whichofthefollowingstatementsiscorrect
?

)
a Directimmunofluorescenc
e willshowdeposition
ofbothIgMandigGperi
-
.
vascularly
ct immunofluoresc
Dire ence willshow
IgAdeposition
-vascularly
.peri
)c Pulmonaryhaemorrhageis thecommonestco
-morbidity in this condition
)
d Renalinvolvement is extremely uncommonand its presenceis often
.
transient
Theconditionisassociated
withahighermortalityrateinchildrencompared
to adults
.

1.19Whichof thefollowingfood allergiesaremostlikely to persistinto adulthood

whenseenin childhood(particularlyin thepresenceof atopicdermatitis
)?

.Egg
.
Milk
.
Peanuts
)
d .Soya
.
Wheat

1.20Whichof thefollowing drugsmayresultin resolutionof actinickeratoses

?

.
Capecitabine
.
Hydroxychloroquine
c) .Hydroxyurea
)
d .
Ramipril
.
Tacrolimus

184
Section 2
: Paper

1.21 In which of the following conditions is monoclonalgammopathyusually not

?
found

)
a Erythema elevatum diutinum
.
)
b Lichen planus
.
c) Necrobiotic xanthogranuloma
.
Schnitzler'ssyndrome
.
)
e .
Scleromyxoedema

1.22 Youpatch test a -o

year
37ld woman dueto worsening of her eczemadespite the
use of severaltopical treatments andfound that shehas a ++reaction to chlorocresol
.

Which of the following treatments cansheuse safely

?

)
a Betnovate .
Cream
DermovateCream
.
)c Dermovate Ointment
.
)
d Eumovate Cream
.
Fucibet Cream
.

. 23Which of the following choicesisthe major criterion for the diagnosisof systemic
1
?
mastocytosis

)
a Positivityto CD2
/CD25 on mastcells
.
Presenceof 25 % or more mast cells with atypical or spindle
-shaped
.
appearance
Presence
of c-kit mutations
.
Presenceof largemast cell infiltrate in the bone marrow
, spleenor liver
.
Raised serum tryptase levels
.

1.24In which ofthe following drug

-induced reactionsisfacial oedema acommon man
-
?
ifestation

)
a Acutegeneralizedexanthematouspustulosis
.
-induced
Drug lichenoid reaction
.
)
c Drug reaction with eosinophillia and systemic symptoms
.
sike
-lSerum
ickness .
reaction
-Johnson's
Stevens .
syndrome

185
 Section 2
: Paper

1.25Whichofthe followingconditionsis anexampleofnon

igE
-m ediated ?
reactions

)
a Colicky abdominalpain
.
)
b Eosinophilicoesophagitis
.
)
c Oralallergy syndrome
.
.Rhinitis
)
e .
Urticaria

6 Whic
1.2 h ofthefollowing
isnotaproposed
pathogenic
mechanism
foracne
vulgaris
?
e
Excessiv
sebumproduction
.
Follicularepidermalhyperproliferation
.
Granulomaformation
.
.
Inflammation
)
e ce
Presen
andactivity
ofpropionibacteriu
m .
acne
7 Whichofthefollowingchromosomal
1.2 aberrations
isassociated
withsevere
acne
?

.
xO
)b .
XX
)
c .XXX
)
d .
XY
.
XYY

8 A54
1.2 -year oldmanpresents
withasquamous
ceil.carcinoma
h
Whic ofthe followingisnot ariskfactorfor non
-melanoma skincancers
?

Actinickeratoses
.
)b Exposureto arsenic
.
)
c Fairskincolour
.
)
d s
Hodgkin'
.
lymphoma
Lighthair colour
.

186
Section 2
: Paper

1.29A 35
-year old patient with naevoidbasal
-cell carcinomasundromepresentswith
a cluster of basal cell carcinomas on the back
.

Which of the following treatments is contra

-indicated in the treatment of thesebasa
!
cell carcinomas
?

Carbondioxidelaserablation
.
.Curettage
)c Photodynamic therapy
.
)
d .
Radiotherapy
)
e Topical imiquimod
.

1.30 A 35
-year old man presented with a6
-month history of mouth ulcers andpainful
blisteringeruptionon thetrunk accompaniedbypainful wartygrowthsoverthe groin
and axillae
. Widespread erythematous and annular plaques with flaccid blisters on
trunkandlimbsarepresentalongwith exophyticplaquesonthe axillae
, groinsand
-anal
peri .
skin Extensiveerosions are present on the buccal mucosa and papilloma
-
tous vegetatinglesions onthe anglesof the mouth
. Skinbiopsy showsintra
-epidermal
neutrophilic microabscesses
. Directimmunofluorescence shows epidermal intercellu
-
lar IgG staining and linear and granular C3at the dermal
-epidermal .
junction Indirect
ce
immunofluoresen
onratbladderepithelium
isnegative
.

What is the mostlikely diagnosis

?

)
a Epidermolysis bullosa acquisita
.
Paraneoplasticpemphigus
.
)
c Pemphigoidvegetans
.
)
d Pemphigusvegetans
.
)
e Pemphigusvulgaris
.

1.31Followingsurgeryfor excisionof a basalcell carcinoma

, an 85
-year old patient
presentswith asymmetricalsmile
.

Injury to the following nerve ismost likely

:

Buccal nerve
.
Marginal mandibular .
nerve
Maxillary nerve
.
Spinal accessory nerve
.
Temporal nerve
.

187
 Section2
: Paper

2 A35
1.3 -year oldwoman
hasresidual
telangiectasiae
anderythema
following
-
suc
cessftreatme
ul nt ofthepapulo
-pustular elementofrosacea
withiyinecycline
. Sheis
n fornt
kee treatmeofherfacial
ae
telangiectasi
anderythema
.
Which of the following is the best treatment
?

:Erbium Glasslaser
.
)
b :
Erbium YAGlaser
.
Fractional.lasers
Pulsed dye laser
.
QswitchedNd
:YAG .
laser

3 Whic
1.3 h ofthefollowing
canbeusedasadepigmenting
agent
inthetreatment
of
?
vitiligo

)
a Dibenzyl ether of hydroquinone
.
Monobenzyl
etherof hydroquinone
.
)c Pentabenzyletherof hydroquinone
.
)
d Tetrabenzylether of hydroquinone
.
)
e Tribenzy ether of hydroquinone
.

4 Whic
1.3 h ofthefollowing
isassociated
withflagellate
?
hyperpigmentation

)
a .
Aciclovir
.
Bleomycin
c) .Famciclovir
.
Ribavarin
.
Valaciclovir

5 Whic
1.3 h ofthefollowin
g isthesafest
method
ofadministering
adrugtoavoid
-sen
?
sitization

)
a .
Intramuscular
.
Intravenous
c) .
Oral
)
d .
Rectal
.
Topical

188
Section 2
: Paper

1.36 A 40
-year old man complains of recurrent burning eruption on the glans penis
.
Examination shows hyperpigmentation over the glans penis
. He has had recurrent -
ep
isodes over the past 2 years
.

Which of the following is most likely to be implicated

?

)
a .
Aspirin
.
Erythromycin
)
c .
Hydrochlorothiazide
.
Nifedipine
)
e .
Phenylepherine

1.37A 60
-year old manwasadmittedto ICUwith sepsis
. Afew dayslaterhedeveloped
pruritus and erythema over the upper trunk associatedwith angioedema
.

Which is the most likely causeof hissymptoms

?

.Cephalexin
.
Meropenem
.
Sulbactam
)
d .
Tobramycin
)
e .
Vancomycin

1.38 A45
-year old patient with Darier's disease is referred for evaluation of nail chang
-
.
es

Whichof the followingis not a recognized

featureof naildiseasein Darier's
?
disease

Coarse
.pitting
DistalV
-shaped nick
.
Fragilenails
.
Redand white longitudinal stripes
.
)
e Subungual hyperkeratosis
.

189
Section 2
: Paper

1.39 Which of the following is not true of Grover's disease

?

)
a Ahistoryofsun
-exposure isoftenforthcoming
.
2
ATP2A
mutations
similar
toDarier's
disease
have
beenidentified
.
n resembl
Ca e Darier's
disease
onhistology
.
)
d sFeature
ofHailey
-Hailey disease maybeseenonhistology
.
)
e The rashcanbepersistentin somepatients
.

0 Whic
1.4 h ofthefollowing
typesofporokeratoses
isnotassociated
withmalignant
epithelial neoplasm
?

Diffuse superficialactinic keratosis

.
)
b Linear porokeratosis
.
Porokeratosisof Mibelli
.
is
Porokeratos
palmaris
etplantaris
.
disseminate
Punctateporokeratosis
.

1 Fog
1.4 o selvage
m isasubtype
ofwhichofthefollowing
?
IgA pemphigus
.
)
b Paraneoplasticpemphigus
.
)
c Pemphiguserythematosus
.
)
d Pemphigus foliaceous
.
Pemphigusvulgaris
.

1.42 Which of the following statements isincorrect

?

ea pigoesophag
Guin us ismore
sensitive
fordetecting
pemphigus
foliaceous
.
antibodies
)
b IgGstaining
ispresentonthecellsurface
ofepidermal
cellsinpemphigus
.
vulgaris
ey oesophag
Monkus ismore
sensitive
fordetecting
pemphigus
vulgaris
anti
.
bodies
)
d s
Pemphiguvulgarisandfoliaceousdisplaysimilardirectimmunofluores
cencefindings
.
e isnocorrelatio
Ther n between
thetitreofcirculating
-cell
anti surface
anti
bodyanddisease
activityinpemphigus
vulgaris
andfoliaceous
.

190
Section 2
: Paper

1.43 Which of the following statements istrue regarding drug

-induced ?
pemphigus

Direct immunofluoresence is negative

.
Patients do not exhibit auto
-antibodies to desmoglein 1 and desmoglein 3
.
)
c s
Pemphigu
foliaceousisthe commonest
morphological
.
pattern
Remissionafter drug withdrawal is uncommon
.
Seen commonlyafter penicillin administration
.

1.44 In which of the following syndromes are multiple fibrofolliculomas a pathogno

-
monic feature
?

Hubé
Birt
-D ogg .
syndrome
)
b Cowden syndrome
.
)c Darier's disease
.
)
d Gardnersyndrome
.
)
e Von Hippel Lindau syndrome
.

1.45 A
-45 year old woman presents with a few months history of diffuse hair loss .
She complains oflosing a lot of hair whilst combing
. Her past medical history includes
breast cancerfor which shehas recently received chemotherapy
. Examinationshows
diffuse non
-scarring .
alopecia

What is the likely diagnosis

?

Alopecia areata
.
)
b Anagen effluvium
.
Catagen effluvium
.
)
d Lichen plano pilaris
.
)
e Telogen effluvium
.

1.46 In which of the following is Miescher radial granuloma a histopathological fea

-
?
ture

)
a aeficiency
1
Alpha
-d ntitrypsin .
panniculitis
)
b Cutaneous vasculitis
.
Erythema nodosum
.
)
d Neutrophilic lobular panniculitis
.
)
e .
Tuberculosis

191
 Section 2
: Paper

47 Whic
1. h ofthefollowin
g isassociat
ed with,black
necrotic
palatal
ulceration
ininsu
-
-dependent
lin diabeticswith poor diabeticcontrol
?

)
a .
Coccidiomycosis
.
Cryptococcus
.
Histoplasmosis
)
d .
Mucormycosis
-c. occidioidomycosis
Para

1.4 A35
8 year
-o ld EastTimorian
immigrant
presents
withmultiple
,numerous
-
varia
-sized erythemato
ble us anddusky
annular
,
macules-defined patches
ill and-well
de
ted plaqu
marcaes scatter
ed s thetrunk
acros , ,
arms
proximal
legsandtheface
. He
s
complainof handandfeetnumbness
.

Whichof thefollowing isthe mostlikely diagnosis

?

)a Kaposi sarcoma
.
)
b .Leprosy
.
Phaeohyphomycosis
.
Syphilis
)
e Tuberculosisverrucacutis
.

9 Whic
1.4 h ofthefollowing
istheinvestigation
ofchoice
infibromatosis
?
colli
Excisional.biopsy
)
b Fineneedleaspiration
.
cytology
Incisionalbiopsy
.
)d Magneticresonance
.imaging
)
e .
Ultrasound

1.50 h
Whic ofthefollowing
isnotafeature
ofConradi
-Hünermann ?
syndrome
.
Cataracts
)b Frequentfractures
.
)
c .
Hyperpigmentation
Ichthyosiformscalingerythroderma
.
)
e Stippledcalcificationsof the epiphyses
.

192
Section 2
: Paper

1.51 -y
2ear
A 6 old lady was referred for patch testing with persistent hand and facial
eczemafor the last year
, which respondsonly partially to topical steroids and emol
-
.
lients Shehad strong positive reactions to formaldehyde 1% onpatch testing
.

Avoidance advice should be given for which of the following chemicals

?

)
a Epoxy resin
.
)
b .Mercaptobenzothiazole
Neomycin Sulphate
.
)
d Nickel sulphate
.
)
e Quaternium 15.

1.52A45
-year old woman presentedwith red
, puritic andswollenrashon the peri
-
orbital area
, scalpand forehead
. Shehad applied ahair dye 2 daysbefore the onset of
therash
. Patchtestingdemonstratesthat sheis allergicto para
-phenylamine diamine
(PPD
).

PPDcancross
-react with the following
:

.
Benzocaine
)
b .
Cobalt
.Formaldehyde
.
Latex
)
e Neomycinsulphate
.

1.53 A neonate is born with distinctive features of harlequin ichthyosis

. Thegenede
-
fect is
?

)
a .
ABCA12
.ATP2C1
c) .
FLG
)
d .
NEMO
)
e .
TGM1

193
 Section 2
: Paper

4 An8
1.5 -year oldboypresente
d withhismother
withahistory
ofextreme
-
photosen
sitivitwithaburnin
y g andpainful
n
sensatio
withinminutes
following
sunexposure
.
e ha
H d onsever
al occasio
,
ns beennotedtohave
swelling
ofthehands following
sun
.
ure
expos s elde
Hi r brothe
r has
similar
s
symptomandiscurrently
taking
-carotene
beta
.
tablets

The enzymedefect in this condition is

:

)
a Coproporphyrinogenoxidase
.
.
Ferrochelatase
Protoporphyrinogen
.
oxidase
Uroporphyrinogen
.
decarboxylase
)
e Uroporphyrinogen synthase
.

5 A55
1.5 -year oldlady
isundergoi
ng excision
ofanatypical
naevus
onher.shoulder
u areaboutto inject2
Yo % lignocainewith adrenaline
. -indication
Contra forthis anaes
-
thetic would include
?

)
a .Aspirin
.
Codeine
)
c .
Paracetamol
.
Propranolol
)
e .
Warfarin

1.5 A40
6 -year oldmanhashadtwosebaceous carcinomasexcised
withinthelast3
s andreports
year thatbothhisfatherandsisterhavehadseveral
sebaceous-
carcino
s andsebaceous
ma adenomas
.excised

e mostcommonmalignancy
Th associated
withthis disorder:is

Brain tumour
.
Breast cancer
.
)c Colorectal .
cancer
)
d .
Melanoma
Squamouscell carcinoma
.

194
Section 2
: Paper

1.57Q
-Switched alexandritelaserisreportedto be usefulfor removalof greentattoos
.
Thewave length of Q
-Switched alexandrite laseris
:

404 nm
.
)b 694 nm
.
)
c 755 nm
.
2940 nm
.
10600 nm
.

1.58 In the United Kingdom

, Imiquimod cream()aldara isnot licensed for treatment of
which of the following conditions
?

Actinic keratoses
.
Bowen'sdisease
.
Genital warts
.
)
d Superficial basal cell carcinoma
.
)
e Noneof theabove
.

1.59 A 36
-year old man has been treated successfullywith a systemic agent for his
blistering disorder and reports a gradual weaknessof hisright foot
, resulting in him
trippingoverseveraltimes
. Onexamination
, therewasdemonstrable
motorweakness
,
withintactsensation
.

Which of the following drugsis most likely to be implicated in this case

?

)
a .Dapsone
.
Diclofenac
c) .
Hydroxychloroquine
Intravenousimmunoglobulins
.
)
e Mycophenolate Mofetil
.

1.60 A45
-year oldmanisadmittedwith severedesquamationof his skinfollowingin
-
gestion of phenytoin for epilepsy
. Yourconsultant decidesto start him on intravenous
.
immunoglobulin

In the UnitedKingdom
, intravenousimmunoglobulinsare licensedfor usein which of
the following conditions
?

Bullouspemphigoid
.
Erythema multiforme
.
Kawasaki disease
.
Linear IgAdisease
.
Toxic epidermal necrolysis
.

195
 Section 2
: Paper

1 A34
1.6 -year oldladypresented
withalong
-standing painfululceronthelateralas
-
tpecoftherightlowerlegwhichhasbeen
present
for6monthsanddicnotrespond
to
us dressin
vario gs andcompressi
on .
bandages
Onexamination
, therewasevidence
of
o reticular
livedis onthelowerlegs
andthepatient
gives
ahistory
ofaprevious
-
pulmo
y embolis
nar m andtwospontaneous
.
miscarriages
Laboratory
examination
showed
mild thrombocytosis
.

The most likely diagnosishere is

:

)
a Antiphospholipid syndrome
.
)
b .
Cryoglobulinaemia
-Schönlein
Henoch .
purpura
Polyarteritis nodosa
.
)
e Venous .
ulcer

1.6 A56
2 -year oldmanpresente
d withbilateral
eczema
affecting
thedorsal
aspects
of
s fee
hi t and hasbeen
tpresen
since
hestarted
wearing
apairofnewshoes
. Ithasbeen
treatedwithtopicalsteroidsandhewasreferredforpatchtesting
.

The most likely allergenin this casewould be

:

)
a Formaldehyde 1
%.
)
b Neomycin sulphate
.
Nickelsulphate
.
)
d Potassiumdichromate
.
Quaternium15
.

1.63 A28
-year oldmanwhohasbeenonpenicillamine
forseveral
years
presented
with anasymptomatic
annulareruptionontherightsideof theneckwhichconsistsof
c
keratoti .
papules
Thereisnoassociated
scalingorerythema
.
The most likely diagnosis is
:

Elastosis
perforansserpiginosa
.
)
b Erythemaannulare centrifugum
.
Granulomaannulare
.
.Psoriasis
)
e Tinea corporis
.

196
Section 2
: Paper

1.64 A 37
-year old lady was referredto the dermatologydepartmentwith a 3
-year
history of urticarial lesions that failed to respond to various anti
-histamines given by
her GP
. Further history reveals that the individual wheals persistfor daysbefore they
.
disappear This often leaves post
-inflammatory .
pigmentation Thereis also associated
bone pain and an associated paraproteinaemia
.

The most likely diagnosis here is

:

-Wells
Muckle .
syndrome
)
b Necrobiotic xanthogranuloma
.
)
c Ordinary spontaneous urticaria
.
)
d Schnitzler's syndrome
.
)
e Urticarial vasculitis
.

1.65 A 34
-year old lady has been troubled with persistent acneover the last 10years
with hirsutism
, hair lossandmenstrualirregularities
. Polycysticovariansyndromehas
been excludedby various hormonal testingandimagingby the gynaecologist
. Sheison
a numberof medications
, one of which couldbethe causeofher symptoms
.

Which of the following medications is most likely to be associated with these

?
symptoms

.
Ibuprofen
.
Lithium
)
c .
Minocycline
.
Prednisolone
Sodium valproate
.

1.66A64
-year oldmanhastwo patchesof Bowen'sdiseaseontheleft lowerleg
, previ
-
ously treated with cryotherapywith little success
. A consultant dermatologist suggest
-
d treatme
e nt withphotodynami
c therapy
andtheuseofmethyl
levulenic
acid).
(MAL
What should be the approximateapplication time of the MAL for treatment with a light
?
source

)
a 30 minutes
.
1 hour
.
3 hours
.
6 hours
.
24 hours
.

197