04. KFP: Case Practice

Question 1

Treatment for chronic stable psoriasis on the trunk and limbs?

Answer 1

Liquor Picis Carbonis (LPC) 4-8% + salicyclic acid 3% cream or ointment topically, BD for 1 month

Question 2

Management of an acute flare of psoriasis?

Answer 2

Liquor Picis Carbonis (LPC) 4-8% + salicyclic acid 3% cream or ointment topically, BD for 1 month [tar preparation is preferred for maintenance because it is easier to apply over larger surfaces]

PLUS

Methylprednisone aceponate 0.1% cream, ointment or fatty ointment topically, daily until skin is clear (usually two to six weeks)

IF RESPONSE TO TREATMENT IS INADEQUATE AFTER 3 WEEKS, USE A MORE POTENT TOPICAL CORTICOSTEROID:
* betamethasone dipropionate 0.05% cream or ointment topically, daily until skin is clear (usually 2 to 6 weeks)

Question 3

Management of Psoriasis with only a few scattered plaques that do not respond to a tar preparation, or need longer term control with the topical corticosteroid?

Answer 3

Calcipotriol + betamethasone dipropionate 50 + 500microg/g Topically, daily until skin is clear (usually about six weeks)

Question 4

When using topical retinoids for the treatment of acne, what kind of topical vehicle do we use for dry and sensitive skin?

Answer 4

Topical retinoid creams

Question 5

When using topical retinoids for the treatment of acne, what kind of topical vehicle do we use for oily skin?

Answer 5

Topical retinoid gel

Question 6

What is the treatment for mild acne that is mainly comedonal with minimal inflammation?

Answer 6

Options (topical retinoids):
* adapalene 0.1% gel topically, daily at night for six weeks then review
* Tretinoin 0.025% cream topically, daily at night for six weeks then review
* Trifarotene 0.005% cream topically, daily at night for six weeks then review

Question 7

Management of:
1) Mild comedonal acne not responding to topical retinoid
2) Mild acne that is mainly comedonal but with some inflammatory papules and pustules

Answer 7

Benzoyl peroxide + adapalene 2.5% + 0.1% gel topically, daily for 6 weeks, then review

Question 8

Management of:
1) Mild comedonal acne not responding to topical retinoid
2) Mild acne that is mainly comedonal but with some inflammatory papules and pustules

that is not improving but well tolerated on topical combination therapy?

Answer 8

Benzoyl peroxide + adapalene 2.5% + 0.3% gel topically, daily for 6 weeks, then review

Question 9

Management of mild acne that is mainly inflammatory papules and pustules, with some comedones?

Answer 9

Benzoyl peroxide + Clindamycin 5% + 1% Gel topically, daily for six weeks then review

Question 10

What is the management of mild acne that is a mix of both comedonal an inflammatory papules and pustules?

Answer 10

Tretinoin + clindamycin 0.025% + 1% gel topically, daily at night for six weeks

Question 11

What counselling points would you discuss when starting a patient on topical retinoids?

Answer 11

• Introduce gradually because it can irritate the skin initially
• Apply every second night (after washing with a low irritant, ph balance, soap free cleanser) for the first two weeks, then apply every night
• Apply the product to the whole area affected by acne, not just to single lesions
• Remove the product by washing the face in the morning because topical retinoids can increase the skin sensitivity to sunlight
• Choose a cream formulation for patients with dry or sensitive skin, and gel formulation for those with oily skin

Question 12

What is the management for facial, flexural and scrotal seborrheic dermatitis?

Answer 12

• Use a low irritant skin cleanser
• Hydrocortisone+clotrimazole 1%+1% cream topically, once or twice daily until the skin is clear or for two weeks
• Facial seborrheic dermatitis: wash hair often with an anti yeast shampoo to reduce the yeast burden on the scalp (should contain ketoconazole, selenium sulfide, zinc pyrithione or coal tar)

Question 13

What’s the difference between the butterfly rash of facial seborrheic dermatitis versus systemic lupus erythematosus?

Answer 13

• Both are associated with erythema and scaling
• Facial seborrhoeic dermatitis: fix the medial aspect of cheeks, the nose and the nasal labial folds
• SLE: The rash usually spares the nasolabial folds

Question 14

What are reasonable investigations to order in an elderly patient with pruritus without a rash?

Answer 14

• Full blood count
• Renal function and electrolytes
• Liver function
• Fasting glucose
• Thyroid function studies

Question 15

Management of generalised itch?

Answer 15

• Wet dressings or Quick, cool showers (<2-3 minutes)
• Soap-free substitutes in the shower
• Patting dry skin (hence avoiding vigorous rubbing)
• Liberal use of emolllients on damp skin, after the shower (preferably out of the tub or jar rather than a pump)
• Avoiding excessive heating in winter
• Using a humidifier if possible to enhance ambient indoor humidity, especially in try, cold winter months
• Avoiding use of electric blankets in bed
• Minimising direct contact with woollen and synthetic garments
• Keeping fingernails trimmed short to minimise complications from scratching
• Calamine lotion (contains phenol, which cools the skin) - avoid on dry skin and limit to only a few days
• Topical treatments include antipruritic such as methol 1% in aqueous cream
• Trial antihistamines if predominantly urticarial symptoms

Question 16

Differentials for itch without rash?

Answer 16

Skin pathology
* Xerosis (dry skin)
* Scabies
* Dermographism
* Urticaria not apparent at time of examination

Nerve compression or neuropathy
* Notalgia paresthetica
* Meralgia paresthetica
* Brachioradial pruritus
* Vulvodynia

Systemic conditions
* End stage kidney disease
* Cholestasis
* Pregnancy
* Thyroid dysfunction
* Iron deficiency
* Coeliac disease
* Intestinal parasitic infections Eg strongyloidiasis (roundworm)

Adverse effects of drugs and topical irritants
* Opioids
* NSAIDs
* Statins
* Angiotensin converting enzyme inhibitors
* Diuretics
* Recreational drugs Eg methamphetamine
* Soaps, detergents, chlorine and other irritants

Malignancy and haematological disease
* Lymphoma, particularly hodgkin’s disease
* Leukaemia
* Polycythemia rubra vera
* Multiple myeloma
* Disseminated carcinoma

Neurological disorders
* Multiple sclerosis
* Brain tumour, abscess, infarct
* Parkinson disease

Psychological and psychiatric conditions
* Stress
* Anxiety
* Depression
* Phobic disorders eg delusional parasitosis
* Obsessive compulsive disorder
* Hypochondriasis

Question 17

Management of rash caused by dermographism?

Answer 17

Oral antihistamine

Question 18

Pharmacological management of each without rash in these settings?:
1) Itch without rash on trunk or limbs?
2) Itch without rash on face?
3) Itch without rash persisting despite improving skin consition, topical corticosteroid therapy and trial of oral antihistamine?

Answer 18

1) Itch without rash on trunk or limbs?
* Betamethasone valerate 0.02% cream topically, twice daily for two weeks

2) Itch without rash on face?
* Hydrocortisone 1% cream topically, twice daily for two weeks

3) Itch without rash persisting despite improving skin consition, topical corticosteroid therapy and trial of oral antihistamine?
* Doxepin 10 to 20 mg (adult only) PO, daily at night for 2 weeks - do not mix with a sedating antihistamine because this may result in increased adverse effects eg anticholinergic effects, sedation

Question 19

What are the indications for acyclovir in the setting of chickenpox?

Answer 19

• Premature neonates
• Neonates less than 7 days of age
• Immunocompromised children
• Children with systemic or central nervous system disease
• Unvaccinated child age > 12 years
• Severe eczema
• Chronic pulmonary disease
• Children on salicylate therapy
• Children on oral steroid therapy
• Secondary cases in household contacts, as these are usually more severe

Question 20

What is the management for contacts of chickenpox?

Answer 20

• Age 1 month - 1 year: if not at risk of complications, observation. If at risk, consider VZIG
• Age > 1 year: if within 5 days of exposure and no contraindications to vaccine, give VZV vaccine

Question 21

What is the vaccination course for chickenpox?

Answer 21

• Children <14 years are recommended to receive two doses of varicella containing vaccine (4 or more weeks apart)
• Usually, the first dose is given at 18 months of age as the MMRV vaccine
• But, children can receive varicella-containing vaccine from as young as 12 months of age (incase they are a contact)
• Note: MMRV vaccine is not recommended as the 1st dose of MMR-containing vaccine in children < 4 years due to the small but increased risk of fever

Question 22

What is the cause of slapped cheek rash (5th disease)?

Answer 22

Parvovirus B19

Question 23

Signs and symptoms of slapped cheek (5th disease)?

Answer 23

• Prodrome: fever, headache, stomach upsets, aches and pains
• Bright red rash appears on the cheeks after a few days
• Secondary pink lace pattern rash may appear on chest, back, arms and legs
• The rashes can come and go for several weeks, or even months, especially if the skin is exposed to sunlight or after exercise

Question 24

How long is Slapped Cheek (5th disease) contagious for?

Answer 24

• Infectious period: until 24 hours after the fever has resolved - non-infectious after this period even while having a rash

Question 25

What is hairy tongue? What are its clinical features? What may cause it?

Answer 25

* It is a harmless condition characterised by a hairy enlargement and discoloration of the filiform papillae of the tongue * Coloured, usually brown or black, although brown, yellow and green have also been described * Usually asymptomatic in the main problem is it's unsightly appearance * Hairy tongue is due to defective shedding of surface cells * Potential causes: chlorhexidine mouthwash, after a course of antibiotics or in patients who have limited oral intake

Question 26

What is the management of hairy tongue?

Answer 26

It is usually self-limiting but treatment options include: * Avoiding smoking and excessive alcohol intake * Discontinuing responsible drugs * Encouraging good oral hygiene * Gentle tongue debridment, with a tongue scraper or soft toothbrush and solution containing 3% hydrogen peroxide Or baking soda * Antiseptic mouthwash * Topical antifungal if candida albicans is present * Topical retinoid

Question 27

What is a fixed drug eruption?

Answer 27

* Fixed drug eruption is a distinctive cutaneous allergic reaction that characteristically recurs at the same site on re-exposure * It is usually due to oral medications, most commonly with antimicrobials and non-steroidal anti inflammatory drugs

Question 28

What are the clinical features are fixed drug eruption?

Answer 28

Categories based on clinical morphology: * Localised pigmenting type * Bullous (localised or generalised) * Non-pigmenting * Generalised * Drug eruption typically presents as a single (or small number of) well defined, round or oval red or violaceous patch or plaque which may blister or ulcerate * It is usually asymptomatic but can be itchy or painful * Over days and weeks, the surface may become scaly or crusted before peeling, and the colour fades to leave brown post inflammatory hyperpigmentation * The patient remains systemically well * Common sites: Hands and feet, eyelids, and anogenital areas * On the 1st occasion, eruption may develop after weeks to years of regular ingestion of the drug, but subsequent episodes develope within minutes to hours of recommencing the implicated drug * With subsequent episodes, the original patch may enlarge and more patches may appear * The post inflammatory pigmentation darkens with each recurrence

Question 29

What is the treatment for fixed drug eruption?

Answer 29

* Discontinuation of suspected medication * Avoiding implicated medication indefinitely * Topical steroids or systemic corticosteroids * Generalised bullous fixed drug eruption requires intensive care or burns unit

Question 30

What is neonatal cephalic pustulosis (AKA neonatal acne)?

Answer 30

* It is a common transient eruption in infants age three to six weeks * It's caused by a temporary overgrowth of malassezia species (fungi) * Appearance: Tiny monomorphic pusutles, often on an erythematous base

Question 31

What is the difference between neonatal cephalic pustulosis versus infantile acne?

Answer 31

* Although there are tiny monomorphic pustules, often with an erythematous base, neonatal cephalic pustulosis does not have comedones (i.e. blackheads and whiteheads), whereas infantile acne does * Neonatal cephalic pustulosis is also limited to the face * Neonatal cephalic pustulosis presents much earlier at 3-6 weeks whereas infantile acne presents 6-16 months

Question 32

What is the treatment of neonatal cephalic pustulosis?

Answer 32

Resolves in a few weeks without treatment, however responds quickly to a topical imidazole Options: * Clotrimazole 1% cream topically, twice daily * Ketoconazole 2% cream topically, twice daily If lesions appear very inflamed or itchy, add: * Hydrocortisone 1% cream topically, twice daily until skin is clear (usually 2-3 days)

Question 33

What is granuloma annulare and its clinical features?

Answer 33

* Granuloma annulare is common inflammatory skin condition typified clinically by annular, smooth, discoloured papules and plaques, and necrobiotic granulomas on histology * The surface is smooth and the centre of each ring is often a little depressed * Localised granuloma annulare usually affects the fingers or the backs of both hands, but is also common on top of the foot or ankle, and over one or both elbows

Question 34

How would you differentiate between granuloma annulare and other ovoid rashes?

Answer 34

There is a lack of surface scale compared to other scaly rashes such as discoid eczema or psoriasis or tinea

Question 35

What is the management of granuloma annulare?

Answer 35

Lesions usually clear spontaneously, but may persist for months or years Options - topical corticosteroid with or without occlusive dressings * Betamethasone dipropionate 0.05% ointment topically, twice daily for a minimum of four to six weeks * Mometasone furoate 0.1% ointment topically, twice daily for a minimum of four to six weeks

Question 36

What is the management of onychomycosis?

Answer 36

* First line: terbinafine 250mg orally, once daily until clinical clearance * Measure liver function test at baseline and at 4-6 weeks (but earlier at two weeks in high risk patients or if clinically indicated) * Review after 3 months of treatment (note: most nails with extensive onychomycosis still look abnormal after 3 months of treatment because a new nail takes 9-12 months to grow) * Make a scratch with a scalpel blade at the proximal end of the dystrophy after three months of treatment so the patient can follow the scratches the nail grows out

Question 37

What are the clinical features of flexural psoriasis?

Answer 37

* Shiny and smooth due to the moist nature of the skin folds - therefore it is different to the usual silvery scale of plaque psoriasis * There may be a crack or fissure in the depth of the skin crease * The deep red colour and well defined borders characteristic of psoriasis may still be obvious

Question 38

How can you differentiate between flexural psoriasis and seborrheic dermatitis in skin folds?

Answer 38

Seborrheic dermatitis in skin folds tends to present as thin salmon-pink patches that are less well defined than psoriasis

Question 39

What is the management of flexural psoriasis, including genital psoriasis?

Answer 39

Initial: methylprednisolone aceponate 0.1% ointment or fatty ointment topically, daily until skin is clear (may take several weeks), but for no longer than two weeks in a child wearing nappies * For a child who was still wearing nappies, add an anticandidal cream to the topical corticosteroid eg nystatin Maintenance (when there is some rash but no excoriation or inflammation): * LPC 2% in emulsifying ointment topically, daily * For a child who was still wearing nappies, LPC can be formulated in zinc cream

Question 40

What are some differentials for intertrigo (rash in the flexures)?

Answer 40

Flexural psoriasis - well defined, smooth or shiny red patches; symmetrical Seborrheic dermatitis - ill-defined salmon pink thin patches Atopic dermatitis - very itchy Thrush - rapid development, itchy, moist, peeling, red and white skin Erythrasma - Corynebacterium minutissimum; persistent brown patches Tinea - slowly spreads over weeks to months; irregular annular plaques

Question 41

Characteristics of rash: varicella?

Answer 41

* Affects: scalp, eyelids, knows, mouth * Pleomorphism of rash * Centripetal distribution - more focused on trunk * Pruritic rash

Question 42

Characteristics of rash: erythema infectiosum?

Answer 42

* Erythematous slapped cheek appearance in well child * Erythematous rash, mainly on forearms and thighs * Possible lymphadenopathy

Question 43

Characteristics of rash: rubella?

Answer 43

* Rash firsts appears on neck and face * Scattered rash on body * Postauricular lymphadenopathy

Question 44

Characteristics of rash: Scarlet fever?

Answer 44

* Circumoral pallor - around the mouth * Strawberry tongue * Background erythema with tiny fine superimposed puncta (scarlet spots) * Pastia lines - the accumulation of papules along the flexures

Question 45

Characteristics of rash: measles?

Answer 45

* Red, watering eyes (conjunctivitis) * Runny nose (coryza) * Blotchy maculopapular rash

Question 46

What is the cause of roseola infantum?

Answer 46

Virus from the herpes group

Question 47

Clinical features of roseola infantum (sixth disease/exanthem subitum)?

Answer 47

* Usually lasts around four days * Symptoms are so mild that parents do not realise their child is infected * Affects children aged between six months - 2 years * Sudden high fever, usually last between 3-5 days * Raised red rash can develop when temperature returns to normal * Rash usually appears on the body and spreads through the arms and legs; it is rarely seen on the face

Question 48

When is roseola infantum infectious?

Answer 48

* Children with roseola infantum can only spread the infection before the fever and/or rash occur * Once a child has symptoms, they are no longer contagious

Question 49

Clinical presentation of shingles?

Answer 49

* It is characterised by rash that presents with blisters in a dermatomal distribution on an erythematous base * The blisters erupt over a week and then he'll over two weeks

Question 50

When is antiviral therapy indicated in shingles?

Answer 50

* Immunocompetent adults and adolescents who present within 72 hours of onset of rash * All immunocompromise adults in adolescence (including those with hiv infection) regardless of duration of rash

Question 51

What are the first line options for pharmacotherapy in shingles?

Answer 51

* Valaciclovir 1g orally, 8hourly for seven days * Famciclovir 500mg orally, 8hourly for seven days. For immunocompromise patients, the duration is 10 days

Question 52

What are the options for pain management in shingles?

Answer 52

Neuropathic pain: * Lidocaine 5% patches - They cannot be used on broken skin or lesions * Gabapentinoids two, or as an alternative to, lidocaine 5% patches Nociceptive: * Mild: paracetamol or non steroidal anti inflammatory drugs * Moderate to severe: Prednisolone 50mg orally, in the morning for seven days

Question 53

What is erythema nodosum?

Answer 53

* Erythema nodosum is a type of panniculitis (an inflammatory disorder affecting subcutaneous fat) from a hypersensitivity reaction * It presents as tender erythematous indurated plaques and nodules, usually on the shins * Lesions typically resolve over two to three weeks, leaving discoloration but no scarring

Question 54

What are the causes of erythema nodosum?

Answer 54

Idiopathic (55% of cases) Infection: * Throat infections eg streptococcal disease or viral infection * Chlamydia infection * Primary tuberculosis * GIT bacteria: Yersinia, Campylobacter, Salmonella * Fungal infection eg histoplasmosis, coccidioidomycosis * Parasitic infection eg amoebiasis, giardiasis Drugs: * Amoxicillin * Oral contraceptive * Non steroidal anti inflammatory drugs * Sulfonamides Inflammatory * Inflammatory bowel disease * Sarcoidosis * Malignancy * Lymphoma * Leukaemia Other: * Pregnancy

Question 55

What are some investigations you may consider for the workup of erythema nodosum?

Answer 55

* FBC, ESR, EUC, LFT, * Throat swab * Streptococcal serology (ASOT, Anti-DNAse B) * Chest XR * Biopsy is usually not required but if done, needs to be deep and include fat - biopsy of inflammatory lesions on the lower legs is often associated with scarring and slow healing

Question 56

What is the management for erythema nodosum?

Answer 56

Usually heals over two to three weeks If symptoms are severe and the patient has no contraindications: * Prednisolone 25mg daily PO for 2 weeks, then taper the dose according to response

Question 57

What is the cause of cutaneous lupus erythematosus?

Answer 57

* Genetic susceptibility * Environmental factors: cigarette smoking, sun exposure, medications * Innate and adaptive immune responses: autoantibodies

Question 58

What is the characteristic rash of localised acute cutaneous lupus erythematosus?

Answer 58

Malar butterfly rash - redness and swelling over both cheeks, sparing the nasolabial folds, lasting hours to days

Question 59

What is the characteristic rash of generalised acute cutaneous lupus erythematosus?

Answer 59

Diffuse or papular erythema of the face, upper limbs (sparing the knuckles), and trunk resembling a morbilliform drug eruption or viral exanthem

Question 60

What are some clinical features of nail psoriasis?

Answer 60

* Nail pitting: Superficial depressions in the nail plate * Leukonychia: 1-2mm wide white bands that involve more than one nail and are due to the internal desquamation of parakeratotic cells * Oil spots or salmon patches: Translucid discoloured red-yellow patches located on the nail plate * Onycholysis: separation of the nail plate from nail bed * Subungal hyperkeratosis: yellow and oily nails that result from raising the nail plate off the nail bed as a result of deposition of keratinocytes * Splinter haemorrhages: small, linear structures, 2-3mm long, at the distal end of the nail plate

Question 61

What might nail psoriasis indicate?

Answer 61

* It is highly associated with psoriatic arthritis even in the absence of skin involvement * It is a market for more severe skin manifestations as well as joint involvement

Question 62

What is the management of nail psoriasis?

Answer 62

Cool therapy for psoriasis of the nails is difficult and often unsuccessful For a motivated patient, try: * Calcipotriol + betamethasone diproprionate 50+500microg/g ointment topically, in proximal nail fold and under nail, nocte for up to 3 months For psoriasis presenting as onycholysis or subungal hyperkeratosis, an alternative is to use a potent topical corticosteroid lotion: * Mometasone furoate 0.01% lotion topically, once daily under the nail for up to 3 months If treatment is unsuccessful, refer for dermatologist advice

Question 63

What may dermoscopic features of subungual haemorrhage include?

Answer 63

* Homogenous or variable colours (reddish, purple, brown, or black) * Peripheral globular structures (clods) and streaks * Roundish shape with peripheral fading * Linear white marks on the nail plate due to loss of transparency * Distal yellowing of the nail plate * Lack of malignant features - irregularity in pigmentation, irregularity in the midth and spacing of the pigmented bands, ulceration or bleeding, Hutchinson sign where there is pigmentation in the skin proximal to the nail plate

Question 64

What are some differential diagnosis for nail pigmentation?

Answer 64

* Subungal haemorrhage * Nail unit melanoma originating from the proximal nail matrix * Benign melanonychia due to a melanocytic naevus or lentigo in the proximal nail matrix * Nail fold infection e.g. pseudomonas, dermatophyte, yeast, mould * Drug-induced nail diseases - usually affects multiple nails * Exogeneous pigment e.g. henna, potassium permanganate, ink, dye * Inflammatory skin disease eg psoriasis, eczema, lichen planus

Question 65

What are some features of nail unit melanoma?

Answer 65

* Appears as a pigmented linear or triangular band along the entire length of the nail plate * Irregularity in pigmentation (light brown, dark brown, grey, or black) * Irregularity in the width and spacing of the pigmented bands * Ulceration or bleeding * Hutchinson sign (pigmentation in the skin proximal to the nail plate) and micro-Hutchinson sign (skin pigmentation visible on dermoscopy but not on clinical examination) * Nail dystrophy (cracking or deformity of the nail)

Question 66

What is oral hairy leukoplakia?

Answer 66

Oral hairy leukoplakia is an epstein barr virus infection of the tongue with a characteristic corrugated or shaggy appearance seen most commonly in immunocompromised patients

Question 67

What are the clinical features of oral hairy leukoplakia?

Answer 67

* Asymptomatic white plaques on the lateral tongue which do not wipe off * Can be unilateral or bilateral * Rarely also seen elsewhere in the oropharynx but not on other mucosal surfaces

Question 68

What are some differential diagnosis for oral hairy leukoplakia?

Answer 68

* Oral candidiasis * Oral lichen planus * Geographic tongue

Question 69

What are the complications of oral hairy leukoplakia?

Answer 69

* Oral hairy leukoplakia associated with HIV infection is a sign of severe immunosuppression and progression to AIDS * Secondary candida cases can obscure the clinical and histological features of OHL * OHL is not a pre-malignant lesion

Question 70

How is oral hairy leukoplakia diagnosed?

Answer 70

* Diagnosis should be confirmed on biopsy * In situ hybridization for EBV DNA or RNA can also be performed under surface scraping or smear

Question 71

What are some common risk factors for oral candidiasis?

Answer 71

Local Factors: * Dentures * Saliva gland hypofunction * Could steroid inhalers * Poor oral hygiene * Smoking Systemic factors * Immune compromise e.e. poorly controlled diabetes, HIV/AIDS * Drugs e.g. Systemic corticosteroids, antibiotics

Question 72

What are the first line pharmacotherapy options for oral candidiasis

Answer 72

* Amphotericin B 10mg lozenge sucked (then swallowed), four times daily, after food, for 7-14 days; continue treatment for 2-3 days after symptoms resolve * Miconazole 2% gel 2.5mL topically (then swallowed), four times daily, after food, for 7-14 days; continue treatment for 7 days after symptoms resolve

Question 73

What is pseudofolliculitis barbae?

Answer 73

* It is a common inflammatory reaction of the hair follicle, most often on the face as a result of shaving * It is caused by intrafollicular or transfollicular penetration of tight curly hair

Question 74

What is the treatment and prevention for pseudofolliculitis barbae?

Answer 74

General Measures: * Ensure proper shaving technique - shave in the direction of the follicle; do not stretch the skin; use short strokes; use sharp blades; avoid shaving in the same area twice * Washing the skin with warm water and soap-free cleanser before shaving * Reduce shaving activity e.g. only every other day Specific Measures: * Topical acne treatments such as benzoyl peroxide and tretinoin are used to suppress follicular hyperkeratosis - benzoyl peroxide 5% gel or solution topically, twice daily * Topical steroid cream and/or topical antimicrobials - reduce mild inflammation and itching - benzoyl peroxide + clindamycin 5% + 1% gel topically, once daily

Question 75

What is folliculitis barbae?

Answer 75

* Folliculitis barbae is an itchy and sometimes tender papulopustular eruption of hair follicles in skin * Most often due to staphylococcus aureus

Question 76

What is the treatment for folliculitis barbae?

Answer 76

General Measures: * Encourage use of disposable razors or cleaning electric shavers with alcohol based antiseptic solution Specific Measures: * Topical antibiotics e.g. clindamycin, mupirocin - limited folliculitis barbae * Oral antibiotics e.g. flucloxacillin or doxycycline - more wide-spread or refractory folliculitis barbae * Antiviral and antifungal topical therapies if viral or fungal causes are suspected * Typical hydrocortisone cream may be helpful to reduce inflammation and itching

Question 77

How would you assess someone's blood alcohol content on physical examination?

Answer 77

* Dysarthria / nystagmus / ataxia / unsteady gait / incoordination - cerebellar impairment * Condusion / GCS / Level of consciousness / incoherent thoughts * Impaired judgment * Tachycardia / hypotension * Respiratory depression * Memory impairment

Question 78

Investigations to assess the impact of excessive alcohol intake?

Answer 78

* FBC * LFT * EUC * Albumin * INR * Ferritin * Vitamin B12 * CMP

Question 79

Non-pharmacological management for alcohol reduction?

Answer 79

* Try drinking only at meal times * Substitute every other drink of alcohol with a non alcoholic beverage * Use smaller glass sizes * Drink lower alcohol content beverages * Limit going to places or occasions where drinking is commonplace * Keep less alcohol at home * Monitor alcohol intake or count drinks * Keep a drinking diary to monitor circumstance or mood around drinking * Sign up for alcoholics anonymous for ongoing support * See a psychologist for cognitive behavioural therapy

Question 80

Pharmacological management of longterm alcohol reduction with the aim of abstinence?

Answer 80

* Disulfiram daily PO - 100mg * Acamprosate TDS PO - 666mg * Naltrexone daily PO - initially 25mg

Question 81

Congenital causes of hypotonia without other obvious physical examination findings?

Answer 81

* Prader-Willi syndrome * Klinefelter syndrome * Spinal muscular atrophy * Muscular dystrophy * Global developmental delay

Question 82

What conditions are tested for on newborn bloodspot/Guthrie test?

Answer 82

* Phenylketonuria * Hypothyroidism * Cystic fibrosis * Congenital adrenal hyperplasia

Question 83

Clinical features of Prader-Willi syndrome in infancy?

Answer 83

* Hypotonia * Feeding difficulties or poor weight gain * Genital hypoplasia * Reduced foetal movements * Motor developmental delay * Weak cry

Question 84

Clinical features of normal pressure hydrocephalus?

Answer 84

* Wacky: dementia * Wobbly: wide based gait * Wet: urinary incontinence

Question 85

Aspects of examination you would look for in female urinary incontinence?

Answer 85

* Elevated BMI * Abdominal mass * PV exam for pelvic organ prolapse * Assessment of pelvic floor muscle strength * Cough test for urinary incontinence * Lower limb neurological examination for weakness * Gait assessment - for glue footed / wide based gait - normal pressure hydrocephalus

Question 86

Non-pharmacological management of urinary incontinence?

Answer 86

* Refer to physiotherapist for pelvic floor strengthening * Commence bladder training / timed urinary voices / avoid going to the toilet as a precaution * Reduce/eliminate caffeine intake * Aim healthy BMI between 18-25 * Eat adeqaute dietary fibre to minimise constipation

Question 87

Pharmacotherapy for urinary incontinence?

Answer 87

* Oxybutynin 5mg TDS PO * Solifenacin 5-10mg daily PO * Mirabegron 25-50mg daily PO

Question 88

Truncal rash differentials

Answer 88

* Pityriasis rosea * Guttate psoriasis * Tinea corporis * Discoid eczema * Non-specific viral exanthem * Seborrhoeic dermatitis * Secondary syphilis

Question 89

What condition has a herald patch?

Answer 89

Pityriasis rosea

Question 90

Differentials for recurrent pregnancy loss?

Answer 90

* Antiphospholipid syndrome * Hypothyroidism * Diabetes mellitus type 2 - if poorly controlled * Uterine leiomyoma * Septate uterus * Idiopathic * Chromosomal abnormality in either partner

Question 91

Female investigations for recurrent pregnancy loss?

Answer 91

* Pelvic USS with sonohysterography * Karyotype * TSH * Fasting glucose * Anti-beta2 glycoprotein * Lupus anticoagulant * Anticardiolipin antibodies

Question 92

Advice for recurrent pregnancy loss?

Answer 92

* Referral to fertility specialist for further treatment of recurrent pregnancy loss * Test for anti-TPO antibody * Suggest waiting until after next normal period before trying to conceive again * Advise to limit caffeine intake to maximum 3 serves per day * Advise weight loss aiming for BMI 18.5 - 25 * Offer emotional support or provide contact information for pregnancy loss support services - pink elephant/PANDA * Cease smoking and alcohol and illict substance use

Question 93

History questions to assess for risk factors for minimal trauma fracture?

Answer 93

* How much alcohol do you drink? * Do you smoke? * Do you get adequate sunlight exposure / 15 min per day of sunlight exposure / take regular vitamin D supplements? * Do you have a sedentary lifestyle or low levels of physical activity? * Menopause before 45 years old? * Family history of minimal trauma fracture / osteoporosis? * Do you have atleast 4 serves of dairy or 1300mg of calcium/day?

Question 94

Differentials for delayed menstruation?

Answer 94

* Hypothalamic amenorrhoea or functional amenorrhoea - excess exercise, low BMI, psychological stress, severe chronic illness * Constitutional delay in puberty * Polycycstic ovarian syndrome * Hypothyroidism * Hyperprolactinaemia or prolactinoma * Turner syndrome * Imperforate hymen or transvaginal septum * Vaginal agenesis - Mullerian dysgenesis * Non-classical congenital adrenal hyperplasia OR Cushing syndrome - adrenal disease

Question 95

History questions to ask when evaluating delayed menarche?

Answer 95

* Family history of delayed menarche - constitutional delay in puberty * Undergone pubertal growth spurt or breast development or axillary/pubic hair development - clue for oestrogen deficiency * Significant difference in height compared to other family members - Turner's syndrome are short * Problems with acne or hirsutism - PCOS * Any galactorrhoea or recurrent headache or visual changes - pituitary mass/prolactinoma * Cold intolerance or unintentional weight gain - hypothyroidism * Cyclical abdominal pain - imperforate hymen * Body image concerns or frequeny/intensity of physical activity or caloric restriction or intentional weight loss - screening for anorexia nervosa causing functional amenorrhoea

Question 96

Differentials for short stature in 5 year old boy with normal exam, slightly behind in class, meeting milestones and not losing weight?

Answer 96

* Constitutional growth delay * Genetic short stature * Hypothyroidism * Hypopituitarism * Growth hormone deficiency * Coeliac disease

Question 97

Investigations for slow weight gain?

Answer 97

* Urine MCS and culture * FBC, ferritin, EUC, TSH, LFT, glucose * Coeliac serology and total IgA * Micronutrients - including vitamin B12 * Stool microscopy, fat globules, fatty acid crystals * Children older than 12 months: ESR, faecal calprotectin

Question 98

Differentials for hand rash?

Answer 98

* Contact irritant/allergic dermatitis * Eczema (+/-infected) or nummular eczema * Tinea manuum * Photophytodermatitis * Palmoplantar psoriasis

Question 99

Clinical features of lithium toxicity?

Answer 99

* GI: nausea, vomiting, diarrhoea * CNS: tremor, hyperreflexia, ataxia and dysarthria * CVS: QT prolongation and hypotension

Question 100

Management options for chronic regional pain syndrome?

Answer 100

* Reduce opioids * Commence SNRI e.g. duloxetine * Commence gabapentinoid e.g. pregabalin * Commence corticosteroids e.g. prednisone * Commence anti-epileptic e.g. topiramate

Question 101

Differentials for transient unilateral vision loss?

Answer 101

* Giant cell arteritis * Carotid artery disease or thromboembolism * Retinal vein occlusion * Retinal vasospasm/retinal migraine * Optic nerve compression by a lesion * Idiopathic amaurosis fugax

Question 102

Differentials for bitemporal hemianopia with intracranial mass?

Answer 102

* Pituitary adenoma * Craniopharyngioma * Meningioma * Malignant sellar tumour - lymphoma * Benign sellar mass - cyst