1: Sunburn

2: Lipoma
3: Multiple skin lesions in a Queensland family: (AMC Condition 051)
4: Squamous Cell Carcinoma
5: Marjolin Ulcer (Squamous Cell Carcinoma)
6: Suspicious Lesion (Malignant Melanoma)
7: Psoriasis in a 30yo man (Condition 92)
8: Cellulitis
9: Alopecia Areata
10: Skin Rash (Fungal)

1:
Patient in your GP practice in a small country town comes to you because she has
this rash on shoulder.

Task
o
o
o
DDx:
o
o
o
o
Hx:
o
o

Take history
Diagnosis
Management
Sunburn
Drug (photosensitivity) eg. amiodorone
Contact dermatitis
SLE Discoid eczema

Since when have you had this rash (1-2days)?

Is the rash anywhere else or just here? Is it getting worse or is it the
same (its peeling now?)?
o Is it hot/painful? (yes)
o Do you think anything started it? Did you go out in the sun? (yes
went to beach)
o Did you apply sunscreen? When did you apply it?
(In the morning)
o Whats the SPF? (SPF15) sun protection factor
o Have you taken any new drugs recently? (No)
o Have you changed any cosmetics? Perfumes (no)
o Any fever? Do you think you are feverish?
o Any other general symptoms?
o Tiredness? Pain in joints?
o Family History and personal history: of skin cancers, allergies,
eczema/dermatitis, autoimmune disease ?
Dx and Mx
o Most likely it looks like sunburn. Sunburn is caused by ultraviolet B
rays which penetrates the epidermis and superficial dermis which
causes skin damage. Unfortunately it increases the risk of developing
skin cancer.
o Minor: If mild erythema and minimal discomfort.
o Moderate: red hot and painful. Desquamations.
o Severe: If the patient also develops vesicles and bullae formation.
Headache and nausea. Admit the patient if severely dehydrated.

o
o
o

o
o

At this stage Ill give you steroid ointment (hydrocortisone 1%). It

should be used often 2-3 hours. If its painful give Panadol. Oil in the
water baths or bicarbonate of soda paste may help. If its really hot
gently apply cold compresses. Avoid using soap because it might
cause irritation. Drink lots of water because you are probably
dehydrated. Can use calamine lotion. Keep out of the sun until every
last sign of sunburn has gone.
Doctor but its peeling off.
Its the bodys way to get rid of the dead skin.
Next time you need to be very cautious.
Avoid sun from 10-2pm.
Use sunscreen SPF 30 is better.
SPF 30 filters out 96.3 % of rays, which is only 3% extra
from SPF15. SPF15 filters out 93.3% of the rays. Wear
long sleeves t shirt, broad-brimmed hats, sunglasses to
protect your eyes.
Slip-slop-slap-wrap
Slip into a t-shirt,
slop on sunscreen,
slap on a hat and
wrap on a pair of sunglasses.
Give reading material.
Review after a few days and she can come back to you if it get
worsens.

2:
Your next patient is a 50-year-old male patient presenting with a swelling on his
back.
Task
o Physical examination
(medial margin of the scapula on the right side,
3x5 cm, rounded and well-circumscribed, no
signs in inflammation, lobulated, no presence of
punctum, rubbery in consistency, movable, nontender, no change in temperature
o Diagnosis and management
DDx:
Lipoma
Neurofibromatosis
PEx:

I understand that you have come here because of a swelling on your

back. My task is to examine your swelling. For the examination, I
need you to remove your shirt and expose the swelling. During
examination I will touch the swelling and your back. If at any time you
feel any pain, please let me know and I will stop my examination. Is
that alright with you?
Consent and Wash Hands
How is your general health? Vital signs?
Inspection: site, size, shape and border, surface overlying the mass.
Can I see any punctum? Any ulceration?
Palpation: tenderness, temperature, consistency, mobility. Does it
move when the muscle is contracted? Fluctuation test (stabilize
swelling with 2 fingers and press in the center; determines if cystic or
solid swelling)? Because the fluctuation test is negative, I will not do
a transillumination.
Check any lumps and bumps in the body and regional lymph nodes.
Is it painful? Is it increasing in size?

Dx and Mx

From the examination, the lump is moving freely which means it is

not attached to the skin. The other findings suggest a subcutaneous
lump which we call as lipoma. It is the most common benign tumor of
fat cells. Let me assure you that it is not a nasty growth.
If its not causing any problems or you are not concerned about
cosmetic reasons, we can leave it. If not, I will arrange referral to the
surgeon to excise the lump.
Complications? It can get infected and gets painful or increasing in
size. If at any time it happens, please come back because we need
to excise it.
Reading material.

3:
You are working in a general practice in a small country town. A 58 year old farmer,
who lives with his family, 160km outside of town, comes to see you as he is
concerned about his family members, having seen a television program about skin
cancer. He has taken photographs of his familys various skin lesions and asks for
your advice about the need for them to seek medical attention, and whether
attendance is urgent. They are all very busy harvesting crops and will be so for
several weeks.

Photo number 5:
o Spider Naevus

Task
o
o
o

Indicate which lesions are likely to be benign, and which are likely to
be malignant or suspicious of malignancy.
Indicate which members of the family require(s) the most urgent
treatment
Indicate the mode of spread of any malignant lesions you diagnose.

o
o

Hello Patrick. Its very thoughtful of you to make photos and bring them with
you today. Lets start with three photos that we are not concerned about
Photo number 3:
o Seborrhoeic Keratosis

o
o

The condition what your father have is most likely Seborrhoeic

Keratosis. Also known as Seborrhoeic warts. Seborrhoeic Keratosis
are more common with advancing age and are most often found on
the trunk and the face. They are often said to have a painted on
appearance or look like a dried sultanas has been pressed on the
skin. They usually gradually get larger. And darker and increase in
number. Theres no risk associated with Seborrhoeic Keratosis and
surgery is recommended only for cosmetic purposes.

Your brother has Spider Naevus. Its a benign skin lesion. They are
described as spiders due to their appearance. Red central spot
resembling the body of a spider with fine radiating vessels looking
like legs of a spider. Almost all Spider Naevus occur on the upper
part of the body. Spider Naevus may be an indication of underlying
liver disease but can also occur in a healthy individuals. Its a benign
skin lesion. Ideally Id like to see your brother to organize LFT +/ultrasound.
Photo number 6:
o Melanocytic Dermal Naevus

o
o

Your daughter has a benign Melanocytic Dermal Naevus also known

as moles. They are common on head, neck and trunk. They are well
defined, slightly raised above the skin lesion with a variety in size
shape and amount of hair present.
Photo number 1:
o Squamous Cell Carcinoma of the lip

o
o

The condition which your son has is most likely Squamous Cell
Carcinoma. Typically, it presents as non-healing ulcer in one of a
higher risk sun expose area. Classically, farmers, lower lips, heads
and hands. This tumour can metastasize to lymph nodes. Treatment
is surgical excision. Overall prognosis after treatment is good. (Its
above 95% for 5 year survival) If <1cm: margin of 4mm to deep fat
layer.

Basal Cell Carcinoma

Rodent ulcers: rolled pearly edge; telangiectasia with
central ulcer
Usually in the mask area
Metastasis: no. but locally infiltrates the structure. Slow
growing with no pain
Treatment options:
Surgical excision with 3mm margin
Radiotherapy
Cryotherapy/ Curettage/ Electro cautery/ Photodynamic
therapy
Topical chemotherapy: imiquimod/5-FU
Follow-up: yearly

Photo number 4:
o Malignant Melanoma

Photos number 2:
o Basal Cell carcinoma

o
o

o
o

Your brother most likely has Basal Cell carcinoma. The most
common type of skin cancer. Its usually occur in people over 35yo.
More frequently in male, fair skin people on sun exposed areas. It
grows slowly over years. Do not metastasis but local spread can
cause problems. Nothing borrows like BCC. Your brother has nodular
BCC with classic pearly appearance. With small dilated vessel near
the surface of the skin. Treatment is surgical excision with atleast
1mm margin.

The most concern is your wifes photo. Its a large lesion with
irregular boarder and pigmentation.
I suspect Malignant Melanoma. Malignant Melanoma is the
most serious condition which can spread locally via lymph
or blood. This lesion must be excised without delay.
Thickness of the melanoma is a major factor determine
prognosis.

4:
Your next patient is a 30-year-old patient old farmer who came for result of biopsy of
a skin lesion which was on the right temporal site.

Features:

2nd most common cancer of the skin

Arises from keratinocytes of the epidermis
Precursor/Premalignant lesions:
o Solar/ actinic keratosis
o Back of hand
o Sun-exposed areas
o (+) scaly lesions w/ hyperemic base that bleeds with
scratching

Treatment:
excision/cryotherapy
If w/o treatment, 15-20% progress to SCC
Bowen disease
Scaly red plaque w/ clearly defined margins
Not related to sun damage
Treatment:
excision/cryotherapy
Treatment: Wide excision
If lesions <1cm 5mm
If lesion >1cm >5mm
Metastasize to lymph nodes but prophylactic dissection does not give
any advantage
If in the outer sulcus SCC but if lesion inside BCC; if in helix
17x more likely to metastasize (do early wedge resection)
Ulcers of SCC also known as Marjolin ulcer
Hx:
How are you feeling?
o Any pain on the surgical site? John I dont have good news
for you. The result of the biopsy is not what we expected. It
shows that it is a squamous cell carcinoma which is a kind
of a skin cancer. It is a common condition.
Draw diagram:
o Epidermis and dermis. In your case, the epidermis has
started to divide in an uncontrolled manner. The ulcers are

superficial. As you are a farmer, the most likely cause for

your case is sunlight exposure. The other causes are burns
and scars. Are there any lumps and bumps in the body?
The specimen which we have taken is not with adequate margins so
I would refer you to a surgeon for further excision. If the lesion is
<1cm 5mm and if >1cm should be >5mm around the margin up to the
deep fat level.
Use sunscreen.
o If you stay longer in the sun apply it every four hourly. Try
to avoid sun exposure from 10am to 3pm. Wear longsleeved shirts and wide brimmed hat and sunglasses.
Avoid sunburns or any kinds of burns.
o Check yourself monthly for any lumps and bumps or any
other change in lesions.
Do I need radiotherapy?
o If we have taken out adequate margins, we dont need to
do that unless it is in a place where we cant get an
adequate margin.
Prognosis:
o The prognosis is good since we caught the lesion early.
We would like to do regular followup to check if there are
lumps and bumps in your body or if there are other
suspicious lesions that we need to take a look at.
Review

5:
Robert aged 55 years presents to your GP clinic with history of non-healing lesion
on the index finger of his left hand. He tells you he got a small burn while having
barbeque a few months ago. He had applied many ointments and had seen his
usual GP 2-3x but ulcer is not healing. Robert works in a factory and finds it hard to
carry on usual duties due to this wound. Robert is otherwise fit and healthy and lives
independently. He is a heavy smoker and drinks alcohol on weekends with his mate.
Task

Focused history
Physical examination
Differential diagnosis and management advise

2nd most common cancer of the skin

Arises from keratinocytes of the epidermis
Precursor/Premalignant lesions: Solar/actinic keratosis and bowen
disease, burns, chronic ulcers, leukoplakia or de novo

Usually >50 years, initially firm thickening of skin with surrounding

erythema; hard nodules soon ulcerate
Occurs on hands and forearms and head & neck
Ulcers have characteristic everted edge
SCCs of ear, lip, oral cavitiy, tongue and genitalia are serious and
need special management

Features

Features:

Treatment:

Wide excision with 4mm margin to deep fat level

Refer for specialized surgery and for radiotherapy if large, in difficult
site or lymphadenopathy
SCC of ear and lip wedge excision
Metastasize to lymph nodes but prophylactic dissection does not give
any advantage
If in the outer sulcus SCC but if lesion inside BCC; if in helix
17x more likely to metastasize (do early wedge resection)

6:
Variant 1:
Thompson aged 54 years presents to your GP clinic with flu-like symptoms. While
you were examining him, you noticed a pigmented lesion on his back. The lesion is
irregular in shape and measures about 1x1.13 cm in diameter. When you tell
Thompson about this lesion, he becomes quite worried and seeks your advice what
to do next.
Task
o Further history
o Examination findings
o Investigations and treatment advise
Variant 2:
A typical picture of melanoma with the report which shows its a superficial
spreading with .4mm in depth. Level two in Clarks classification.
Task
o Explain this condition
o Outline further management plan.
DDx:
Thrombosed hemangioma
Dermatofibroma (button like nodule)
Pigmented seborrheic keratosis
Pigmented BCC
Junctional and compound nevi
Blue nevi
Dysplastic nevi
Lentigines
Features
1/3 of melanomas arise from pre-existing nevus
Most aggressive tumor
Risk factors
Presence of many moles (especially atypical dysplastic nevi)
History of previous melanoma (5x)
Family History
History of many sunburn
Sun-sensitive skin/fair complexion
Age and sex (increasing age and male)
Tanning (solarium treatments)

RED Flags
New or changing lesion
Rapidly growing nodule of any color
o Non-healing lump or ulcer
o ugly duckling syndrome: prominent pigment lesion that
stands out from any other
o Lesion that concerns the patient
o Dermoscopic changes on follow-up or poor dermoscopicclinical correlation
ABCDE:
o Asymmetry
o Border
o Color
o Diameter (mostly more than >5mm )
o Elevation/evolution
o Firm
o Growth pattern in last 4 weeks
Others:
o ulceration or itching;
o development of satellite nodules;
o lymph nodes
Dermatoscope:
o check symmetry,
o meshwork (reticular),
o white and blue structures (skin adhesions)
Biopsy:
o Pigmented lesion: excision biopsy
o Non-pigmented lesion: punch or shave biopsy

Any suspicious lesion 2mm

o BCC 3mm
o SCC 4mm
o Melanoma 5mm (if in situ) and look for re-excisions on
right table

Clark

Excision
o Thickness: <1mm (1cm), 1-4mm (1-2cm), >4mm (2cm)
o Level/Depth: <1.5mm (1cm); >1.5mm (2cm)

Breslow
(mm)
0

Involvement

<0.76

into the upper layer of the

dermis

95%

1cm

III

0.76-1.5

Fills the whole upper layer of

the dermis/whole Papilary
layer.

70-98%

1cm

IV

1.5-4.0

to the deeper layer of the

dermis/Reticulary

55-85%

2cm

>4mm

Subcutaneous tissue

30-60%

2cm

I (in
situ)
II

Prognosis

Epidermis

Margin Reexcision
5mm

Prognostic indicators:
o Depth of invasion
o Level (epidermis, reticular/papillary dermis, etc)
o Site: head, neck, trunk
o Gender: Male
o Age >50 years
o Amelanocytic melanoma
o Ulceration
5-year Survival rate based on depth:
o 0 mm - very good
o <0.76 mm 95%
o 0.76 1.5mm 70-95%
o 1.51 4mm 55-85%
o >4mm 30-60%
Types:
o Hutchinson melanotic freckle (lentigo maligna)
commonly in elderly; slow-growing intraepidermal lesion
mainly on sun-exposed areas
o Superficial spreading melanoma most common type;
striking color variation; always grows laterally/radially

o
o

Nodular melanoma grows vertically; blueberry

appearance
Acral lentiginous melanoma occurs on palms and soles;
poorer prognosis; variety which can be seen in darkskinned people
Amelanocytic melanoma

Hx:

1-2mm: 4-monthly review x 2 yrs then 6-monthly

x 2 years then yearly x 10 years
>2mm: regular reviews by GP and derma x 10
years
Do CXR annually
Support Groups
Refer to psychologist
Reading material. Review.

o
o
o

o
o
o
o
o
o

o
o

Since when? ABCDE? Occupation? Sun exposure?

Do you have any lumps and bumps? Any weight loss? Any
problem with Lungs? SOB? Offer Chest XRay.
Metastasis: Lungs, Liver, Brain, Bone and Intestine. Did
you notice any mass in the tummy? Any tummy pain? Any
headache? Any bone pain?
Family history of skin cancers?
Physical Examination
General appearance and BMI
Vital Signs
Head to toe examination: Backs of ears, neck, back and
back of arms, buttocks and back of legs
With patient facing you: Anterior hairline, front of ears,
forehead, cheeks and neck, anterior chest, abdomen, pubic
hairs, Anterior surface of legs
Maggy lamp , Lymph nodes, Chest, Abdomen: liver and
spleen
Investigations:
FBE, UE, LFTs, Chest X-Ray, CT scan/MRI:
Chest abdomen and brain. Bone scan, LN
biopsy.

o
o
o

Suspicious nevus

Excisional biopsy (23mm margin)

Benign nevus

Malignant Melanoma

Dermatofibroma

Mx:
o
o
o
o

Avoid going out from 10-2pm, 11-3pm. Wear the wide

brimmed hat
Wear clothes cover your body and head, neck and ear.
Stay in the shade.
Self-examination: If theres any change in the: Shape
(asymmetry), size, colour(black blue white) , borders,
bleeding, itch, diameter, elevation, ulcer. Look for any
lumps and bumps.
Metastasis: lung, brain, liver, small intestine
Checking for Metastasis:
Sentinel lymph node biopsy
CT chest, abdomen and pelvis
Follow ups:
If lesion <1mm: 6 monthly review for 2 yrs then
annually

Melanoma in-situ/
Lentigo Maligna

>1.5 mm depth
(re-excise up to 2 cm
margin)

(re-exciseto 5mm
margin)
<1.5 mm depth

(Re-excise 1 cm
margin)

7:
You are working in a general practice. You are seeing a 30yo man who works as a
bank teller. He has consulted you about a rash on the extensor surfaces of both
elbows and both knees, over the sternal and lower back areas, and in the scalp. It
first appeared after a motor accident six months ago in which he suffered a fractured
femur. The patient remembers that his father, now deceased, used to be bothered
by a chronic rash.
It has been getting steadily worse over the last few months with some improvement
following the last few months with some improvement following the use of cream
obtained from the local pharmacist (Egopsoryl TA). This has helped the rash on his
body but not on elbows, knees and in the hair.
Examination has revealed the typical lesions of plaque type psoriasis. The plaques
vary in size from a few mm to several cm. They are raised, pink and covered with a
silvery waxy scale. The nails are not affected. The level of severity for this patients
psoriasis should be regarded as moderately severe.
You are about to discuss the disease and its management with the patient. The
photograph shows details of the skin lesions on the knees. Explain the nature of the
condition.

Task
o
o

Draw a picture: Upper part of the skin called epidermis and the lower dermis two
lines are enough
The cells proliferate over here in the epidermis. The vessels dilate
and some inflammation comes at the level of the dermis causing the
skin to become thick (white plaque and scale). The redness is
because of the dilatation of the vessels.
Typical age is 10-60yo. Affects 2-4% of population in Australia.
No lab investigation to diagnose this condition but we can do skin
biopsy if required. There are some general measures and some
drugs can be used.
Any stress, reduce the stress. Stop the drugs and alcohol. Risk
factors? Stop all of them. Sunlight has the protective effect.
The drugs that you can advice the patient:
o Topical steroid. (Main stay of the treatment)
o Dithranol.
o Tar: messy and smelly, staining.
o Calcipotril (Vit D derivative): use with combination.
o Emollients (to protect the irritation of the skin): can use
frequently.
o Keratolytics (soften the scales) salicylic acid.

It depends on your condition and its extent of the lesions. When it is

on the face the drug on face/genital area: low dose of topical steroid:
low potency 2% hydrocortisone).

On the body:
o High potency steroid betamethaxone.
o Dithranol: Causes irritation and burning, staining. Use for
extensive condition
o If there are small plaques that can be mild to moderate:
use intra lesional steroid.
o If the condition is extensive/not responding to the drugs:
Methotrexate/Cyclosporine
It depends how your condition is progressing. If mild or not extensive,
we can start from mild steroid with emollient. If the condition is
getting worse we can change the drugs to high potency.

Explain the nature of his condition to the patient

Advise the patient about management

Always Refer to the dermatologist. Dermatologist might do

phototherapy.

You can start with Dithranol/emollient/tar give the patient overnight

and wear old clothes for 3 weeks as it can stain. In the morning take
a shower and use topical steroid.

5% of cases can cause arthropathy (nail) topical steroid.

Types:
o Plaque type,
o Exfoliative,
o Pustular,
o Guttate,
o Nail
One of the complication is infection:
o Group A streptococcal
It is most unlikely that psoriasis will appear on the face.
What causes this?
o Unknown, but the risk factors are stress, drugs, extensive
sunburn.
Can it be cured?
o Not curable but controllable (wax and wanes)
Can it spread to other part of the body?
o Less likely to the face. Extensor part of the body, most
likely in the areas that are covered by the clothes.
Is it infectious?
o No
Can it affect my health?
o Yes: arthritis
Can I pass it on to my children?
o Yes it has genetic predisposition and tends to run in the
family.
Medications:
o Beta blockers, OCP, alcohol, chloroquine, lithium, NSAIDs.
The hormonal changes and also predisposes to psoriasis.
Can it be because of the accident?
o Yes stress is one of the risk factors.

8:
Variant 1:
A 65-year-old man is in the ED where you are working as HMO, complaining of pain
in his right lower leg for the last 2 days. It is also swollen and feels warm to touch. A
picture of the area is also given.

Variant 2:
George aged 65 years presents to your surgery with his wife Anastasia. He had pain
and swelling of the right leg for a few days due to a fall. Today, his wife noticed that
the swelling and redness has increased and that George had a fever. His wife tells
you he looks quite unwell and had refused his breakfast. George had type 2 DM for
the last 10 years and is on Metformin 1gm BID. He had no other significant medical
or surgical problems. He lives with his wife and is an occasional smoker but drinks
everyday.
Task
o History
(small area of redness in lower limb that has
increased in two days and very painful and
swollen and warm to touch; I was gardening and
I think I injured it but there is no obvious injury)
o Physical examination
(unwell, increased temperature, inguinal LN
palpable and tender, involved area is warm,
swollen, red, and tender to touch; pulses and
sensation normal)
o Diagnosis and management

Features
o Inflammation of subcutaneous tissue
o Cause: streptococcus pyogenes or staphylococcus aureus
o Clinical presentation
o Redness
o Swelling
o Increased temperature
o Pain/tenderness
Risk factors:
o trauma/crack, insect bite, ulcers, may have no signs of
injury

DDx:
o
o
o
o
History:
o
o
o
o
o
o
o
o
o
o
o
o
o

Necrotizing fasciitis
DVT
Pyoderma Gangrenosum
Erythema multiforme
Can you tell me more about it??
Is it painful? How severe is the pain? Painkillers?
Did you injure the legs before this happened?
Did you notice any discharge? Are you able to walk?
Did this happen for the first time?
Do you feel feverish? Any N/V?
Any lumps or bumps in the body?
How is your general health?
Any history of clots in the legs?
Any recent history of long travel or prolonged
immobilization?
Do you have diabetes? Since when? Do you take any
medications?
Peripheral vascular disease? Are you on any medication?
Allergy? SADMA?

Physical examination
o General appearance
o Vital signs
o Lower leg: redness, tenderness, swelling, is the border
elevated or sharply demarcated, regional
lymphadenopathy? Is tenderness disproportional to
examination findings? Lower leg sensation? Vibration?
Pulses and Buerger sign (for PVD)?
Mx:
o You most likely have cellulitis. It is the infection of the skin
in the subcutaneous tissue caused by bugs that can enter
through a break in the skin (S. pyogenes or S. aureus).
o I will admit you to the hospital and arrange surgical
consultation for further management.
o I would like to do some investigation: FBE, inflammatory
markers, blood culture, skin lesion culture and Doppler
ultrasound to rule out DVT.

While waiting for the culture, we will start you on IV

antibiotics particularly Flucloxacillin or
phenoxymethylpenicillin (IV cefazolin or cefalexin if
allergic).
o I will give you painkillers particularly panadeine and I would
advise you to take a rest and elevate the limbs. I will mark
the area of redness and inspect it on a daily basis to check
resolution.
o If with wound: Wound dressing
o If diabetic: Foot care
Necrotizing fasciitis:
o Pain out of proportion to symptoms
o Patient systemically unwell fever, N/V, tachycardia,
hypotension, shock
o Can lead to gangrene of adjacent organs and septicemia
o (+) crepitus (crackling sound due to gas, grinding bones
etc.)
o Clostridium
o MRI/CT scan
Treatment:
o surgical debridement
o Penicillin + Gentamycin + Metronidazole
o Managed in high-dependency unit
o Hyperbaric oxygen
o

9:
You are an HMO working in a primary care clinic attached to a teaching hospital.
Your next patient is a 38-year-old man whos consulting you because of hair loss.
One of the eyebrows is also affected. The patient is very concerned about his future,
diagnosis and treatment.
Task
History
o (started 2-3 weeks, path of baldness, stress (+) due to
baldness, affecting performance, having healthy balanced
diet, general health normal; no FHx of baldness)
Diagnosis and Management
DDx:
Alopecia areata
Androgenetic alopecia: (genetic predisposition 20%, gradual,
temporal recession [males] and not central widening; crown loss
[females])
Drug-induced: (anabolic steroids, testosterone, OCPs, danazol,
lithium)
Telogen effluvium acute excessive hair loss 2-3 months after a
stressor whether physical or emotional; self-limiting; 3-6 months;
thinning is all over the scalp
Zinc and iron deficiency
Thyroid eye problems (outer 1/3)
Trichotillomania
Hx:
I understand it is a very distressing situation for you but let me assure
you that we can do a lot of things about it.
Since when did you start having hair loss? Was it sudden or gradual?
Have you lost hair from anywhere else? How about your diet?
Are you taking a healthy balanced diet? Any acne or change in voice? Do you have any weather preferences or mass in your neck? Any
family history of similar conditions?
Are you on any medications like anabolic steroids? SADMA? How is
it affecting your life? Hows your mood? Any change is weight, loss
of appetite? Hows your sleep?

Dx nd Mx:

You have a condition called alopecia areata. We would like to do

some tests which include FBE, iron studies, zinc levels, TFTs,
hormone levels if indicated. The cause is unknown, but it can also be
autoimmune, familial or due to severe stress.
At this stage, I would like to give you some topical therapies potent
topical steroids (OD/BID), intralesional corticosteroids for small
lesions (triamcinolone), topical dithranol, minoxidil (very high
relapse).
I will refer you to the dermatologist. She might consider doing
phototherapy (UV light).
What is the chance of recovery?
o In 6 months, there is 33% chance of regrowth and 50%
chance in 1 year with therapy.
Will I get bald?
o We cannot say for certain. Dont worry even if the outcome
is not good, we can do a lot of things such as wigs, stem
cell therapy, etc.
How long will it take to improve?
o The course is variable from person to person.
Does it have anything to do with my glands?
o NO. It has nothing to do with your glands.
Referral. Review once results are back. Reading material

10:
Nadia, 28 years old presents to your GP clinic complaining of a rash on her nose.

Task
o

o
o
o

(rash for 3 months; given hydrocortisone 2x a

day; no discharge and not itchy; no medications
and generally healthy; has 3 kids)
Examination
Differential diagnosis and diagnosis
Management

Hx
o

History

When? Where? Does it spread? Anything increase or

decrease spread? Past history? contact with person having
similar symptoms? Itchy? Any previous consultation or
medications? Any pets (cats or dogs) at home?

DDx:
o Eczema
o Tinea of the face
o Cutaneous lupus
Investigations
o Skin scraping (fungal hyphae)
o Fungal culture
o Skin biopsy might be indicated
Management
o Antifungal
o Oral Griseofulvin (not used anymore medical archeology
only), ketoconazole (yes)
o Topical antifungals
o Examine elsewhere to check for primary infection (feet)
o Refer to dermatology.