CPD SPOT DIAGNOSIS ,

Self-Recorded CPD: Spot Dx – Dermatology – DER002

You can self-report this CPD/PDP activity by logging it online with the RACGP/ACRRM. The activity has been allocated 1 hour (0.5 hour EA and 0.5 hour RP). Certificates are not available for this CPD.

Test your clinical knowledge by taking the 6 quizzes below. If you select the wrong answer, have another go — you can try as many times as you like.

RACGP Activity Number: DER002

ACRRM Activity Number: DER002

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1. What’s behind this itchy rash?

What is the most likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> Jason, a 25-year-old financial adviser, presents to his GP regarding a mildly itchy rash on his back.His partner, Rose, first noticed the rash a few months ago and it has slightly progressed during that time. To them, the ‘net-like’ rash has seemed to get ‘darker’ in recent weeks.Jason remains unconcerned as he finds the rash largely unbothersome. However, given the progression he is now inquisitive as to the underlying cause.He is systemically well and has an unremarkable medical history and takes no medications. Aside from the rash shown below, his physical examination is normal.The couple got their first cat several months ago, but Jason reports he has never had any reactions to animals in the past. They have not been using any new products at home and Rose remains unaffected.Rose does not like the cold nights in winter, so she recently bought an electric blanket for the bed they share. They cannot think of anything else new in their habitat.Jason’s GP requests a panel of bloods including an FBC, EUC/LFT, CRP, ESR and a precautionary autoimmune screen, all of which are unremarkable. <ul> <li>a. Livedo reticularis</li> <li>b. Allergic contact dermatitis</li> <li>c. Poikiloderma vasculare atrophicans</li> <li>d. Erythema ab igne</li> </ul> </section> Photo: DermNet NZ

Author

Author: Dr Paul Muthiah is a GP and a former medical co-editor of Australian Doctor.

2. Can you shed some light on these pigmented patches?

What is the most likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> A 20-year-old woman with Greek heritage is referred to a dermatologist regarding localised bilateral areas of facial hyperpigmentation that have been present for the past five months.The lesions started three months after commencing an oral contraceptive pill containing levonorgestrel and ethinylestradiol. They worsen during the sugar pill interval by becoming erythematous and papular, without any systemic symptoms. She has associated pain in the roof of her mouth.Prior to starting the pill, her period was regular, every 28 days, with associated dysmenorrhoea requiring naproxen sodium 275mg tds for day 1-3, which she still requires during her pill withdrawal bleed.There is no relevant past medical history and no known drug allergies. She is a non-smoker/vaper, occasionally drinks alcohol and uses no other substances. Her mother has vitiligo and alopecia.On examination, there are well-demarcated round dusky-red to brown macules over the left and right cheeks (pictured). There is no mucosal involvement.&nbsp; <ul> <li>a. Melasma</li> <li>b. Fixed drug eruption</li> <li>c. Erythema multiforme</li> <li>d. Actinic lichen planus</li> </ul> </section>

Author

Author: Professor Dedee Murrell is head of the department of dermatology at St George Hospital, Sydney; and conjoint professor at the University of NSW. This article was co-authored by Dr Anna Wilson, an honorary unaccredited dermatology registrar at St George Hospital, Sydney; and Dr Renata Heck, a dermatologist from Hospital de Clinicas, Porto Alegre, Brazil.

3. What’s causing these puzzling itchy purple papules?

What is the most likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> A 41-year-old receptionist presents with a three-year history of spreading, small, itchy, purplish plaques over her hands, palms, wrists, anterior lower limbs and feet. These lesions first appeared as small purplish papules on her anterior lower limbs and later spread to her hands, palms, wrists and feet. On examination, there are discrete thickened plaques on the lower legs with hyperpigmented areas over the anterior wrists.In addition, she has several painful and itchy papules over her right shin, foot and left heel. Overlying these lesions are thin white coloured crossing lines. There is no associated hair loss, mouth or genital lesions. She has no significant medical history and takes no regular medications. <ul> <li>a. Chronic plaques psoriasis</li> <li>b. Lichen simplex chronicus</li> <li>c. Pityriasis rosea</li> <li>d. Lichen planus</li> </ul> </section>

Author

Author: Professor Dedee Murrell is head of dermatology at St George Hospital and conjoint professor at the University of NSW, Sydney. Co-authored by Dr Ben Koszegi, unaccredited dermatology registrar at St George Hospital, Sydney; and Patrick Han, medical student, University of NSW.

4. What’s behind this growth?

What is the most likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> Lennox, a 22-year-old boxer, presents with a new-onset growth under his left eye.It started shortly after his last bout, but he reports his left eye did not suffer any significant blows and he stopped his opponent in round one.He reports that the lesion is not tender to touch, and he has not experienced any visual changes. Lennox is worried as the growth started suddenly and grew to its current size over the last fortnight.He has an upcoming title fight and is desperate for its removal as it keeps bleeding upon minimal contact.Lennox has no medical history of note and uses no medications. <ul> <li>a. Cherry angioma</li> <li>b. Kaposi sarcoma</li> <li>c. Amelanotic melanoma</li> <li>d. Pyogenic granuloma</li> </ul> </section> Photo: DermNet NZ

Author

Author: Dr Paul Muthiah is a GP and a former medical co-editor of Australian Doctor.

5. Eyebrow rash raises suspicion

What is the most likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> Marcus, a five-year-old boy, presents to his GP with a lesion on his forehead covering his medial right eyebrow. His parents are increasingly concerned as they have seen multiple doctors and the lesion is worsening.&nbsp;Marcus’ parents report that the rash started as red patch of dry skin around his right eye four months ago.&nbsp;The initial GP advised that the rash was eczematous and started pimecrolimus 1% cream topically. This had no effect, and his parents arranged a repeat review — during which they were advised the rash was impetigo. Oral cefalexin and topical mupirocin were then issued. But again, these failed to help. His parents also tried topical clotrimazole but, upon seeing no improvement, sought the opinion of another GP.The second GP also thought it was eczematous and issued mometasone furoate cream, which was commenced 10 days ago. However, this appears to have worsened the lesion, resulting in the presentation seen in the picture below.Marcus has recently developed a low-grade fever and associated occipital lymphadenopathy. He is otherwise systemically well, with the rest of his examination being unremarkable. He has no significant medical history.&nbsp;The large circular erythematous scaling plaque above his right eye now contains scattered pustules on its lower border, and he has associated hair loss over his medial right eyebrow.When skin scrapings, organised by the last GP, are chased up, they reveal dermatophyte infection. <ul> <li>a. Impetigo</li> <li>b. Chronic lymphocytic leukaemia</li> <li>c. Kerion</li> <li>d. Folliculitis decalvans</li> </ul> </section> Photo: DermNet NZ

Author

Author: Dr Paul Muthiah is a GP and a former medical co-editor of Australian Doctor.

6. What is behind these painful blisters?

What is the most likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> An 86-year-old woman of Middle Eastern descent presents to hospital with a four-month history of worsening painful and pruritic blisters that are located mostly on the hands and feet.Her medical history is significant for type 2 diabetes, high cholesterol and hypertension. She has been on longstanding metformin, ACEI and statin therapy and recently started a gliptin for glycaemic control. She has no recorded allergies.On examination, there are tense blisters of different sizes, mostly appearing on an erythematous skin, as well as urticarial plaques and vesicles. The bullae have haemorrhagic and clear fluid. These are seen on the soles of the feet, dorsa of the hands and posterior upper limbs.Some erosions and excoriations are observed. Her back has erythema and excoriations. There is no mucosal involvement.She is afebrile and haemo-dynamically stable. <ul> <li>a. DRESS (drug reaction with eosinophilia and systemic symptoms) syndrome</li> <li>b. Bullous pemphigoid</li> <li>c. Epidermolysis bullosa acquisita</li> <li>d. Bullous impetigo</li> </ul> </section>

Author

Author: Professor Dedee Murrell is Head of dermatology at St George Hospital, Sydney; conjoint professor at the University of NSW. This quiz was co-authored by Dr Anna Wilson, dermatology registrar at St George Hospital, Sydney; and Thomas Daunizeau, medical student, Claude Bernard University Lyon 1, France.

References on request from kate.kelso@adg.com.au