Consultant Dermatology oral assessment prep

Knowledge: This is toxic epidermal necrolysis, defined by detachment above 30% of body surface area, most likely caused by carbamazepine, a high-risk drug started within the typical 4 to 28 day window. HLA-B*15:02 is strongly associated with carbamazepine-induced SJS and TEN in people of South-East Asian ancestry. Her SCORTEN is 4, from heart rate, detachment, urea and bicarbonate, which predicts a high mortality. Differentials include staphylococcal scalded skin syndrome, generalised bullous fixed drug eruption, DRESS and acute generalised exanthematous pustulosis, and a skin biopsy with frozen section can help. Death usually results from sepsis, respiratory involvement and fluid and electrolyte loss.

Management: I would stop carbamazepine immediately and list it, and related aromatic anticonvulsants, as contraindicated. I would arrange admission to a burns unit or intensive care unit with experience in TEN. Supportive care includes a warm environment, careful fluid replacement guided by urine output, nutrition, pain control and non-adherent dressings, avoiding adhesive dressings. I would request ophthalmology review within 24 hours and daily thereafter, with lubricants and topical treatment to prevent scarring, plus oral, urogenital and respiratory assessment. I would take swabs and monitor for infection but avoid prophylactic systemic antibiotics. I would discuss immunomodulation, such as ciclosporin or etanercept, which some evidence supports, with the multidisciplinary team. I would choose a non-aromatic alternative for her neuralgia with neurology input. After recovery I would follow up eyes, skin pigmentation and psychological effects.

Ethics and communication: I would explain honestly that a prescribed medicine caused this reaction, without blaming the prescriber, and report it through the facility pharmacovigilance system. She should carry written allergy information. Because the HLA association is inherited, I would advise that relatives may benefit from testing before taking carbamazepine. I would document the timeline of drug exposure carefully.

Reference: Creamer D et al, UK Guidelines for the Management of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis in Adults (British Journal of Dermatology, 2016); Griffiths C et al, Rook's Textbook of Dermatology (10th ed, 2024)

Knowledge: This is at least a pT2b melanoma because it is 1 to 2 mm thick and ulcerated, but the true Breslow thickness may be greater because the deep margin is involved, which can upstage it. Without nodal or distant disease it is at least stage IIA under the AJCC 8th edition. Wide local excision is needed, with a clinical margin of 1 to 2 cm for this thickness, and sentinel lymph node biopsy should be offered because thickness exceeds 0.8 mm. If it is positive, completion dissection is no longer routine, because trials showed no survival benefit over ultrasound surveillance. Adjuvant immunotherapy is used in stage III disease and in higher-risk stage II disease.

Management: I would review the histology with the dermatopathologist, ask for deeper levels if possible and present the case at the skin cancer multidisciplinary meeting. I would examine his whole skin and regional nodes. I would plan wide local excision with sentinel lymph node biopsy at the same procedure, ideally within weeks. I would not order routine cross-sectional imaging for stage II disease unless symptoms or upstaging suggest it. If the sentinel node is positive, I would refer to medical oncology to discuss adjuvant immunotherapy. I would plan follow-up with skin and node examination every three to six months for the first years, teach self-examination and advise sun protection.

Ethics and communication: I would explain honestly that this was a melanoma and that the earlier treatment may have made staging less certain, without criticising the other clinic or speculating about fault. If I believe there was a clinical shortcoming, I would raise it through appropriate professional channels rather than with the patient. I would ensure his consent covers the risks of sentinel node biopsy and document everything.

Reference: NCCN Clinical Practice Guidelines in Oncology: Melanoma: Cutaneous; Gershenwald JE et al, Melanoma Staging: Evidence-Based Changes in the AJCC 8th Edition Cancer Staging Manual (CA: A Cancer Journal for Clinicians, 2017); Faries MB et al, Completion Dissection or Observation for Sentinel-Node Metastasis in Melanoma (MSLT-II, New England Journal of Medicine, 2017)

Knowledge: The combination of chronic oral erosions followed by flaccid cutaneous blisters with a positive Nikolsky sign suggests mucocutaneous pemphigus vulgaris. Confirmation requires a lesional biopsy for histology showing suprabasal acantholysis, perilesional biopsy for direct immunofluorescence showing intercellular IgG and C3, and serology for desmoglein 3 and desmoglein 1 antibodies. Differentials include paraneoplastic pemphigus, bullous pemphigoid, mucous membrane pemphigoid, erythema multiforme and drug-induced pemphigus. Current guidelines recommend rituximab with oral prednisolone as first-line treatment for moderate to severe pemphigus, because it achieves higher remission rates and allows lower steroid doses. Infection and steroid toxicity are leading causes of death.

Management: I would take both biopsies and serology, then start prednisolone at about 1 mg/kg daily for severe disease while rituximab is arranged. Before rituximab I would screen for hepatitis B, hepatitis C, HIV and tuberculosis, check immunoglobulins and update non-live vaccines. I would give rituximab as two 1 g infusions two weeks apart, with a maintenance dose later according to response. I would add gastric protection, bone protection with calcium and vitamin D, and consider Pneumocystis prophylaxis. I would work with the diabetes team to adjust insulin and monitor glucose closely. I would treat oral lesions with topical steroids and analgesic mouthwash, involve a dietitian and refer to an ophthalmologist and ENT if mucosal involvement extends. I would monitor disease activity and taper steroids as control is achieved.

Ethics and communication: I would explain the diagnosis, the long-term nature of treatment and the risks of rituximab and steroids, and obtain informed consent. On fasting, I would explain that the medical risks of fasting during induction are significant and advise against it at present, while respecting that the decision is his. I would liaise courteously with his dentist, who may see similar cases again.

Reference: Joly P et al, Updated S2K Guidelines on the Management of Pemphigus Vulgaris and Foliaceus Initiated by the European Academy of Dermatology and Venereology (JEADV, 2020); Joly P et al, First-Line Rituximab Combined with Short-Term Prednisone versus Prednisone Alone for Pemphigus (Ritux 3, Lancet, 2017)

Knowledge: He meets common criteria for biologic therapy, with severe psoriasis, major quality of life impact and failure or intolerance of conventional systemic treatment. Possible psoriatic arthritis favours an agent that treats both skin and joints, such as an IL-17 inhibitor, an IL-23 inhibitor or a TNF inhibitor. The positive interferon-gamma release assay indicates latent tuberculosis, which needs preventive treatment before starting a biologic, and TNF inhibitors carry the highest reactivation risk. Core antibody positivity with negative surface antigen indicates past hepatitis B infection, which can reactivate under immunosuppression. Paternal exposure to most biologics is not known to harm the foetus, unlike paternal methotrexate, which was traditionally stopped before conception.

Management: I would refer him to the tuberculosis service for preventive treatment and agree with them when the biologic can safely start. I would check hepatitis B viral load and surface antibody and discuss with hepatology whether to monitor or to give antiviral prophylaxis. I would arrange rheumatology assessment of his joints. I would offer an IL-17 or IL-23 inhibitor, discussing efficacy, dosing intervals and side effects, such as candidiasis with IL-17 inhibitors. I would update non-live vaccines and avoid live vaccines during treatment. I would reassure him that available data do not suggest harm from paternal exposure, while noting the limits of the evidence. I would measure PASI and DLQI at baseline and at 12 to 16 weeks and monitor for tuberculosis symptoms and hepatitis B reactivation.

Ethics and communication: Consent should cover infection risks, the need for monitoring and the uncertain areas of the evidence. I would respect the couple's family planning and discuss it without judgement. Cost and insurance approval may affect choice, so I would be open about this and document why I chose a particular agent.

Reference: Smith CH et al, British Association of Dermatologists Guidelines for Biologic Therapy for Psoriasis 2023: A Pragmatic Update (British Journal of Dermatology, 2024); Menter A et al, Joint AAD-NPF Guidelines of Care for the Management and Treatment of Psoriasis with Biologics (Journal of the American Academy of Dermatology, 2019)

Knowledge: Blanching, pain and livedo after filler injection indicate vascular occlusion, most likely by intravascular injection or compression of the dorsal nasal or angular artery territory, which can progress to skin necrosis within hours. The most serious complication is blindness, caused by retrograde embolism to the ophthalmic artery, which is why vision must be checked repeatedly. Hyaluronidase breaks down hyaluronic acid filler and is the main treatment. High-dose pulsed protocols flood the affected territory and repeat doses until perfusion returns, because single small doses often fail. Warm compresses alone are not enough.

Management: I would stop the injection immediately and give hyaluronidase without waiting for a skin test, flooding the whole affected area. I would repeat it about every hour until capillary refill and colour return. I would give aspirin if there is no contraindication and use gentle massage and warmth as supportive measures only. I would check vision, eye movements and pupils repeatedly and arrange emergency ophthalmology referral if any visual change occurs, as blindness needs immediate specialist care. I would arrange daily review until healing is clear, with photographs, and treat any wound or infection that develops. I would complete an incident report and review the technique and training with my colleague afterwards.

Ethics and communication: The patient must be told honestly what has happened and what is being done, because she needs to understand the treatment and the risks, and concealing it would be a professional failure. As the supervising consultant, I share responsibility, and I would support my colleague while making clear that disclosure is not optional. I would document the event, treatment, discussion and consent for hyaluronidase. Proper consent before aesthetic procedures should already include the risk of vascular occlusion and blindness.

Reference: DeLorenzi C, New High Dose Pulsed Hyaluronidase Protocol for Hyaluronic Acid Filler Vascular Adverse Events (Aesthetic Surgery Journal, 2017); King M et al, Management of a Vascular Occlusion Associated with Cosmetic Injections (Journal of Clinical and Aesthetic Dermatology, 2020); Federal Decree-Law No. 4 of 2016 on Medical Liability (UAE)

Knowledge: This is a segmental infantile haemangioma, and it is high risk because of its size, facial segmental pattern and periocular involvement, which threatens amblyopia through occlusion or astigmatism. Segmental facial haemangiomas larger than 5 cm are associated with PHACE syndrome, which includes posterior fossa malformations, arterial anomalies of the head and neck, cardiac defects such as coarctation of the aorta, and eye abnormalities. Rapid growth occurs mainly in the first three months, so treatment should start as early as possible. Oral propranolol is the first-line treatment and is effective for most infants. Its main risks are hypoglycaemia, bradycardia, hypotension and bronchospasm.

Management: I would refer her for urgent ophthalmology assessment within days. I would arrange PHACE investigations, including MRI and MR angiography of the head and neck, echocardiography and full eye examination, before or shortly after starting treatment, depending on local practice and cardiac findings. I would start propranolol at about 1 mg/kg/day in divided doses and increase it to a target of 2 to 3 mg/kg/day, monitoring heart rate and blood pressure. I would advise giving each dose with or after a feed and withholding it during poor feeding, vomiting or illness to reduce hypoglycaemia. Treatment usually continues until about one year of age, followed by gradual withdrawal. I would review her with serial photographs and monitor for ulceration.

Ethics and communication: Because she is a minor, consent comes from her parents, so I would explain the benefits, risks and alternatives in plain language and address the father's concerns directly. I would give written instructions on dosing and warning signs. If the parents declined treatment, I would explain the risk to her vision clearly, document the discussion and keep them engaged rather than end the relationship.

Reference: Krowchuk DP et al, Clinical Practice Guideline for the Management of Infantile Hemangiomas (Pediatrics, 2019); Griffiths C et al, Rook's Textbook of Dermatology (10th ed, 2024)