TopQBank Dermatology TDM Cases

Herpes Zoster

Clinical Case

A 67 year old woman presents with a painful blistering rash over the right chest for 4 days. She describes burning pain followed by grouped vesicles. PMHx type 2 diabetes and hypertension. Vitals normal. Exam shows unilateral vesicular lesions on an erythematous base in a thoracic dermatomal distribution not crossing the midline. Diagnosis herpes zoster suspected.

What is the MOST appropriate initial treatment

• A. Valacyclovir
• B. Cephalexin
• C. Fluconazole
• D. Topical corticosteroid
• E. Observation

Answer: A. Valacyclovir

Explanation: Antiviral therapy started early reduces symptom duration and complications

Which management steps are appropriate

• A. Start antiviral therapy
• B. Provide pain control
• C. Assess eye involvement
• D. Assess immunocompromised status
• E. Counsel lesion hygiene
• F. Monitor for postherpetic neuralgia
• G. Consider shingles vaccination later
• H. Start antibiotics routinely
• I. Review medication interactions
• J. Educate transmission precautions
• K. Follow clinical response
• L. Ignore pain severity

Answer: A. Start antiviral therapy; B. Provide pain control; C. Assess eye involvement; D. Assess immunocompromised status; E. Counsel lesion hygiene; F. Monitor for postherpetic neuralgia; G. Consider shingles vaccination later; I. Review medication interactions; J. Educate transmission precautions; K. Follow clinical response

Explanation: Management includes antiviral treatment pain management and complication prevention

Which valacyclovir regimen is MOST appropriate

• A. Valacyclovir 1000 mg PO TID for 7 days
• B. Valacyclovir once weekly
• C. Single dose valacyclovir
• D. Topical valacyclovir only
• E. No antiviral therapy

Answer: A. Valacyclovir 1000 mg PO TID for 7 days

Explanation: Standard antiviral therapy reduces viral replication and symptom duration

Which adverse effects should be discussed with valacyclovir

• A. Headache
• B. Nausea
• C. Abdominal pain
• D. Dizziness
• E. Renal toxicity
• F. Hypoglycemia
• G. Bradycardia
• H. Hyperkalemia
• I. Rash
• J. Vomiting

Answer: A. Headache; B. Nausea; C. Abdominal pain; D. Dizziness; E. Renal toxicity; I. Rash; J. Vomiting

Explanation: Patients should be counseled regarding common gastrointestinal and renal adverse effects

What patient counseling is MOST appropriate

• A. Stop medication when pain improves
• B. Complete antiviral therapy and seek urgent care for eye symptoms
• C. No follow up required
• D. Lesions are never contagious
• E. Vaccination is unnecessary

Answer: B. Complete antiviral therapy and seek urgent care for eye symptoms

Explanation: Ophthalmic involvement may threaten vision and requires urgent assessment

Hidradenitis Suppurativa

Clinical Case

A 34 year old woman presents with recurrent painful nodules and draining lesions in both axillae for 3 years. She reports frequent flares with scarring and malodorous discharge. She smokes one pack daily and has obesity. Vitals normal. Examination shows multiple inflamed nodules sinus tracts and scarring in the axillae. Diagnosis hidradenitis suppurativa confirmed.

What is the MOST appropriate initial treatment for mild to moderate disease

• A. Topical clindamycin
• B. Oral antifungal
• C. Topical corticosteroid only
• D. Observation
• E. Antiviral therapy

Answer: A. Topical clindamycin

Explanation: Topical clindamycin is a first line treatment for mild hidradenitis suppurativa

Which management steps are appropriate

• A. Encourage smoking cessation
• B. Recommend weight reduction
• C. Use topical clindamycin
• D. Assess disease severity
• E. Provide pain management
• F. Consider oral doxycycline for persistent disease
• G. Educate skin care
• H. Start antibiotics indefinitely
• I. Monitor quality of life
• J. Dermatology referral
• K. Assess depression symptoms
• L. Ignore scarring

Answer: A. Encourage smoking cessation; B. Recommend weight reduction; C. Use topical clindamycin; D. Assess disease severity; E. Provide pain management; F. Consider oral doxycycline for persistent disease; G. Educate skin care; I. Monitor quality of life; J. Dermatology referral; K. Assess depression symptoms

Explanation: Management includes lifestyle modification symptom control and escalation based on severity

Which treatment is MOST appropriate if disease remains active despite topical therapy

• A. Oral doxycycline
• B. Antifungal cream
• C. Observation
• D. Antiviral therapy
• E. No escalation

Answer: A. Oral doxycycline

Explanation: Oral tetracycline therapy is commonly used for persistent inflammatory disease

Which adverse effects should be discussed with doxycycline

• A. Photosensitivity
• B. Esophagitis
• C. Gastrointestinal upset
• D. Rash
• E. Nausea
• F. Hypoglycemia
• G. Bradycardia
• H. Hyperkalemia
• I. Vomiting
• J. Dizziness

Answer: A. Photosensitivity; B. Esophagitis; C. Gastrointestinal upset; D. Rash; E. Nausea; I. Vomiting; J. Dizziness

Explanation: Patients should receive counseling on sun exposure and proper medication administration

What patient counseling is MOST appropriate

• A. Smoking has no effect on disease
• B. Smoking cessation and weight reduction may improve disease control
• C. Stop treatment when one lesion improves
• D. No follow up required
• E. Surgery is always first line

Answer: B. Smoking cessation and weight reduction may improve disease control

Explanation: Lifestyle modification is an important component of long term management

Impetigo

Clinical Case

A 7 year old boy is brought to clinic with a 5 day history of itchy crusted lesions around the nose and mouth. Several classmates have similar skin infections. He is otherwise well with no fever. Examination shows multiple honey colored crusted plaques around the nares and upper lip. No abscess or cellulitis is present. Diagnosis nonbullous impetigo confirmed.

What is the MOST appropriate first line treatment for localized impetigo

• A. Topical mupirocin
• B. Oral acyclovir
• C. Topical corticosteroid
• D. Oral antifungal
• E. Observation

Answer: A. Topical mupirocin

Explanation: Localized nonbullous impetigo is effectively treated with topical mupirocin

Which management steps are appropriate

• A. Use topical mupirocin
• B. Encourage hand hygiene
• C. Avoid sharing towels
• D. Clean crusted lesions gently
• E. Monitor for spread
• F. Exclude from school until treatment started
• G. Educate family contacts
• H. Start antiviral therapy
• I. Assess for cellulitis
• J. Counsel nail trimming
• K. Follow treatment response
• L. Ignore outbreaks

Answer: A. Use topical mupirocin; B. Encourage hand hygiene; C. Avoid sharing towels; D. Clean crusted lesions gently; E. Monitor for spread; F. Exclude from school until treatment started; G. Educate family contacts; I. Assess for cellulitis; J. Counsel nail trimming; K. Follow treatment response

Explanation: Management includes topical therapy infection control and monitoring for complications

Which treatment is MOST appropriate if lesions are extensive or numerous

• A. Oral cephalexin
• B. Oral fluconazole
• C. Topical steroid
• D. Observation
• E. Antiviral therapy

Answer: A. Oral cephalexin

Explanation: Extensive impetigo often requires oral antibiotic therapy

Which adverse effects should be discussed with cephalexin

• A. Diarrhea
• B. Nausea
• C. Rash
• D. Allergic reaction
• E. Clostridioides difficile infection
• F. Hypoglycemia
• G. Bradycardia
• H. Hyperkalemia
• I. Vomiting
• J. Headache

Answer: A. Diarrhea; B. Nausea; C. Rash; D. Allergic reaction; E. Clostridioides difficile infection; I. Vomiting

Explanation: Patients should be counseled regarding gastrointestinal and allergic adverse effects

What patient counseling is MOST appropriate

• A. Continue sharing towels
• B. Complete treatment and maintain good hygiene to prevent spread
• C. Stop treatment when crusting improves slightly
• D. No follow up needed
• E. Scratching prevents infection

Answer: B. Complete treatment and maintain good hygiene to prevent spread

Explanation: Good hygiene and adherence reduce transmission and recurrence