Question Explanation:

Answer:
A. Apply graduated compression bandages and use appropriate wound dressings. ✅

Detailed Explanation
Ms. Carter’s history and examination—progressive, non-pitting lower leg swelling, skin thickening with a warty (verrucous) surface, and a positive Stemmer sign—are diagnostic for chronic lymphoedema. Lymphoedema is a chronic, progressive disorder of lymphatic drainage that leads to protein-rich interstitial fluid accumulation, fibrosis, hyperkeratosis, and increased infection risk. The Stemmer sign is both highly sensitive and specific for lymphoedema.

Management Principles:

• Graduated Compression Therapy:

  • The cornerstone of lymphoedema management is the use of graduated compression bandages or garments, which apply the greatest pressure distally (at the ankle/foot) and progressively less proximally, thereby promoting lymphatic fluid movement and reducing limb volume.

  • Evidence strongly supports the effectiveness of compression therapy for reducing swelling, limb volume, pain, and heaviness, with effect noted within hours of application.

  • Compression is typically combined with wound care if appropriate (for skin changes), meticulous skin hygiene, regular moisturisation, and management of any breaks/ulcers in the skin.

• Other Key Elements:

  • Exercise and mobility (to activate muscle pump and enhance lymphatic flow)

  • Manual lymph drainage (MLD): a specialised physiotherapy technique, often used in addition to compression

  • Good skin care: daily cleaning, avoidance of cuts, scratches, and prompt treatment of minor injuries to reduce infection risk

  • Weight reduction and healthy lifestyle (as obesity worsens lymphoedema)

  • Education: patients should be advised about lifelong risk and prevention of triggers (e.g., avoid constrictive clothing, trauma, unnecessary limb procedures)

Other Answers Explained

• Corticosteroids: Not indicated unless there is concurrent eczema/dermatitis, and can worsen infection risk.

• Skin biopsy: Only if there is an atypical lesion; diagnosis is clinical in classic presentations.

• Antibiotics: Reserved for clinically evident cellulitis or secondary bacterial infection, not for primary lymphoedema management.

• Topical antifungals: Only used if tinea is confirmed.

• Diuretics: Ineffective in true lymphoedema and are not routinely recommended; reserved for management of coexisting cardiac/renal pathology.

• Immediate surgery: Not indicated unless there is acute infection not resolving with conventional management or another surgical problem.

Key Australian Guideline and Exam Points

• Graduated compression therapy is the gold-standard treatment for lymphoedema, supported by Level 1 evidence.

• Multidisciplinary assessment (consider lymphoedema practitioners, physiotherapists, podiatry, and wound care nurses) is recommended for optimal management.

• Meticulous skin care and patient education about long-term measures are essential for preventing complications (e.g., cellulitis).

• Surveillance and early management are critical, as chronic lymphoedema is irreversible, but complications can be significantly reduced with best-practice care.

References

• RACGP. LYMPHOEDEMA: Guide for Diagnosis and Management in GP Practice

• DermNet NZ. Lymphoedema—Diagnosis and Management

• StatPearls. Lymphedema

• Evidence summary: Managing lymphoedema: compression therapy. Cambridge Media, 2024

• LympheDIVAs. Graduated Compression for Lymphedema

• ACI NSW. Lymphoedema: A guide for clinical services

• Murtagh J. General Practice (8th ed.), 2022

• GP Institute of Australia. FRACGP AKT & KFP Guide, 2025

Question Explanation:

Correct Answer: A. Pityriasis rosea ✅

Detailed Explanation:
Pityriasis rosea is the most likely diagnosis given this scenario. It classically begins with a “herald patch”—a single, larger, round/oval lesion with a collarette of scale, presenting days to a week before a secondary eruption of multiple, similar, but smaller oval patches. The distribution typically involves the trunk and proximal limbs, aligning along skin tension lines (so-called “Christmas tree” distribution). The absence of systemic symptoms, absence of fever, and the self-limiting, slightly itchy nature are also characteristic. Pityriasis rosea is common in children and adolescents and is often misdiagnosed initially as allergy or fungal infection.

• B. Tinea corporis: ❌ Tinea typically produces round, annular, scaly plaques with central clearing, often singular or very few in number, not this widespread pattern or the preceding herald patch.

• C. Psoriasis: ❌ While psoriasis may produce well-demarcated, red, scaly plaques, chronicity, typical elbow/knee predilection, and absence of a herald patch or Christmas-tree pattern make this unlikely.

• D. Eczema: ❌ Atopic dermatitis is less common in children without history or family history of atopy, typically involves flexural surfaces, and is usually chronic, excoriated, and intensely pruritic.

• E. Drug eruption: ❌ Drug-induced rashes are often more polymorphic, symmetrical, and involve the face or mucosa; no medication change preceded the rash.

• F. Guttate psoriasis: ❌ Presents after a strep infection with drop-like scaly papules but without a herald patch or scale collarette.

• G. Viral exanthem: ❌ Viral exanthems may appear after systemic symptoms (fever, malaise, URTI), none of which are present here.

Australian guidelines (RACGP, Therapeutic Guidelines: Dermatology, GP Institutes Fellowship AKT KFP guide) recommend that pityriasis rosea be diagnosed clinically in children with the classic pattern, and parents reassured that it is benign and self-limiting, resolving over 6–12 weeks. Antihistamines and emollients may provide symptomatic relief; rarely is further testing or referral needed unless atypical features or persistence prompts reconsideration.

References:

1. Royal Australian College of General Practitioners (RACGP). "The itchy child: Pityriasis rosea in general practice."

2. Therapeutic Guidelines: Dermatology (current edition).

3. Medical Journal of Australia. "Pityriasis rosea: Clinical diagnosis and management in children."

4. GP Institute of Australia. FRACGP AKT & KFP Exam Preparation Guide (1st ed.).

5. Murtagh J. Murtagh’s General Practice (8th ed.), McGraw-Hill Education (Australia) Pty Ltd.

6. Australasian College of Dermatologists. “Clinical Practice Guideline for Diagnosis and Management of Paediatric Rash.”

7. Australian Prescriber. "Diagnosis and management of rashes in children."