Term
Which of the following is not a type of primary lesion?
1. Macule
2. Purpura
3. Scale
4. Ecchymosis
5. Plaque
6. Tumor |
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Definition
3. Scale is a secondary lesion with discrete keratinocyte epidermal accumulations.
1) Macule is a flat primary lesion that is <5 mm (vs. "patches" which are >5mm)
2 & 4) Purpura and Ecchymosis are hemorrhagic primary lesions that are > 5mm (vs. "Petechia," which is <5 mm)
5) Plaques are raised, non-filled lesions that are flat-topped and >5mm (vs. papules which are < 5mm)
6) Tumors are dome-shaped, raised primary lesions that are > 1cm (vs. "nodules," which are <1 cm) |
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Term
Which of the following is not a primary lesion?
1) Patch
2) Nodule
3) Urticaria
4) Lichenification
5) Bulla
6) Burrow |
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Definition
4- Lichenification is SECONDARY epidermal thickening with accentuated skin lines
1) Patches are flat primary lesions > 5mm (vs. "Macules", which are < 5mm)
2) Nodules are raised, dome shaped lesions that are <1
cm (vs. tumors, which are> 1cm)
3) Urticaria is primary, well defined erythema and edema that is transient and found in an allergic reaction.
5) Bullas are primary fluid-filled lesions that are > 1cm (vs. vesicles and pustules which are < 1cm)
6) Burrows are paths of scabies mite. |
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Term
| What are the major types of primary lesions? |
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Definition
1. Flat (no palpable component, i.e. if you close your eyes you can’t feel anything)
a. < 5 mm – macule
b. > 5 mm – patch
2. Raised (you can feel it)
a. < 5 mm – papule
b. > 5 mm flat topped – plaque
c. < 1 cm dome shaped and raised to at least 1 cm above the skin – nodule
d. > 1 cm dome shaped – tumor
3. Filled (serum, not pus)
a. < 1 cm – vesicle (serum)
b. < 1 cm – pustule (pus)
c. > 1 cm – bulla
4. Hemorrhagic (violaceous, not blanchable – overall called purpura)
a. < 5 mm – petechia
b. > 5 mm – purpura
c. >20 mm – ecchymosis (a bruise is one type of ecchymosis)
d. deep – hematoma
5. Miscellaneous Primary
a. Transient, well defined erythema and edema – urticaria/hive
b. Path of a scabies mite – burrow
c. Open comedone – dilated follicle with dark material in center
d. Closed comedone – Small, flesh colored papule on face |
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Term
Which of the following is not a Secondary lesion?
1. Bulla
2. Scale
3. Keloid
4. Stria
5. Dequamation/Exfoliation |
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Definition
1- Bullas are primary, fluid-filled lesions that are > 20 mm (vs. Vesicles and Pustules, which are <5mm)
2- Scale is discrete keratinocyte accumulations of the epidermis
3- Keloids are abnormally thick scars that extend beyond boundary of injury (vs. hypertrophic scars, which STAY within the injury boundary)
4- Stria are linear atrophy with fragmented collagen/elastin fibers (also called "Stretch marks')
5- Desquamation is shedding of sheets of keratinocytes |
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Term
| What are the 4 basic types of surface defects/breaks in the skin? |
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Definition
a.Linear break in skin – Fissure
b. Wider defect with partial thickness epidermal loss – Erosion
c. Wider defect with full thickness epidermal loss – Ulcer
d.Linear, fingernail induced trauma causing the above – Excoriation |
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Term
Which of the following is NOT a known contributor to acne development?
1. Pubery
2. Steroids and lithium
3. Greesy foods
4. Friction from cell phones
5. Abnormal proliferation and differentiation of keratinocytes |
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Definition
3.
Acne – multi-factorial disease of pilosebaceous unit:
1. Puberty – abnormal responsiveness to androgenic hormones (mainly DHT).
2. Drugs (steroids, lithium)
3. Family history (hereditary component)
4. Friction induced acne (cell phones)
5. Due to abnormal proliferation and differentiation of keratinocytes forms comedone plug
6. Secondary bacterial overgrowth |
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Term
| What are the primary and secondary lesions of acne? |
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Definition
1) Primary lesions (NOT inflammatory)
- comedo (single)
- comedones (plural) can be open (blackhead, due to reaction of fatty acids in oil to oxygen) or closed (whitenead),
2) Secondary lesions (Inflammatory):
- papules, pustules, nodules and cysts due to response to bacteria.
- Scars are the final stage of inflammatory acne |
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Term
Which of the following is NOT an accepted acne therapy?
1. Topical antimicrobials
2. Oral Tetracyclines
3. Oral Bactrim
4. Isotretinoin
5. Oral contraceptives
6. NSAIDS |
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Definition
6- not typically given
1.Topical:
a. Antimicrobials (benzoyl peroxide and antibiotics)
b. Antiproliferative (retinoic and azeleic acid)
2. Systemic:
a. Oral antibiotics
i. tetracycline group – contraindicated in children, cause severe sun sensitivity
ii. bactrim – high risk of TEN/SJS and other allergic reactions
b. Isotretinoin – shrinks sebaceous glands and normalizes keratinocytes turnover. It is extremely teratogenic (pregnancy prevention!)
c. Hormonal agents
i. Oral contraceptives
ii. Prednisone
iii. Spironolactone |
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Term
22 year old young woman presents with multiple erythematous papules, pustules on his face, chest and back. Additionally, he has 2 cysts on his back. She tried “everything” over the counter including tanning beds which she enjoys and wishes to continue. She wants to be treated with prescription medications, but does not want to do blood work every month. You made your treatment recommendations and need to advise her that:
1) She may develop sunburns during her next tanning session and needs to stop tanning
2) She needs to use 2 methods of contraception
3) The agent causes Cushionoid features
4) The agent causes hemorrhagic cystitis
5) The agent has no side effects |
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Definition
| 1- She is at risk for sunburn, which would be related to use of tetracycline antibiotics. This 22 year old female has severe inflammatory acne. Isotretinoin would be the most effective therapy for her. However, she is not willing to start isotretinoin, because of the need of monthly blood work for monitoring of the blood counts, liver function tests, cholesterol profile and pregnancy testing. The second best choice for inflammatory acne is antibiotics of tetracycline group. One of the side effects of this group of antibiotic drugs is increased UV sensitivity and high chance of sunburn. Two methods of contraception are required for isotretinoin, not antibiotics. Cyclophosphamide can cause hemorrhagic cystitis, it is not used for acne therapy. |
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Term
During follow-up visit for a patient with severe, inflammatory acne who is taking tetracyclin antibiotics, the patient reports about 50% improvement of his lesions, but is not completely satisfied with the results. She now is willing to undergo extensive monitoring with monthly blood work. You advise her that she:
1) Can consume alcohol as it does not interfere with this new drug.
2) May develop blue pigmentation in the scars with long-term drug use
3) May develop weight gain
4) May have increased diuresis
5) Needs to use 2 methods of contraception |
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Definition
5- Two methods of contraception are required while on isotretinoin due to its high teratogenicity.
- Minocycline is associated with blue pigmentation in scars.
- Spironoloctone is diuretic with anti-androgenic affects (an androgen receptor blocker) which is effective in acne due to hyper-androgenic states in women.
- Weight gain is not side effect of isotretinoin
- Alcohol is contraindicated because increases risk of hepato-toxicity. |
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Term
Which of the following was NOT definitively shown to be associated with acne:
1) Cell phone use
2) High chocolate consumption
3) Hyperandrogenic state
4) Lithium
5) Polycystic ovarian failure |
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Definition
| 2- Diet role in acne has not been demonstrated in large trials. All other choices have clear association with acne |
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Term
| What are the special requirements associated with taking the most effective anti-acne therapy? |
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Definition
| Isotretinoin shrinks the sebaceous gland and requires blood monitoring (monthly pregnancy testing) and 2 methods of contraception. |
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Term
Which of the following is FALSE regarding atopic dermatitis (Eczema)
1. Chronic relapsing skin disease of early infancy and childhood with impaired skin barrier function, but normal allergen sensitivity.
2. Association with mutations in the cornified protein, Filaggrin
3. >50% also develop allergic rhinitis or asthma later in life
4. Rash on face and/or extensors in infants and young children
5. Lichenfication in flexural areas in older children
6. Adults with h/x have sensitive skin that is especially prominent in the hands. |
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Definition
| 1. AD is chronic relapsing skin disease of early infancy and childhood with BOTH impaired skin barrier function and allergen sensitivity. |
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Term
All of the following are true about Allergic contact dermatitis EXCEPT:
1) Requires prior sensitization with haptens
2) Acutely presents with erythematous, indurated, scaly plaques or if severe, vesiculation and bullae in exposed areas
3) Chronically, you see see hypopigmented plaques on the hands, feet, eyelids and lips.
4) Can be caused by poison ivy, other flowers and neomycin. |
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Definition
| 3- Chronically, you see lichenified erythematous plaques with variable hyperkeratosis, scale and fissuring |
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Term
Which of the following is NOT a common cause of allergic contact dermatitis?
1) Nickel
2) Neomycin
3) Paraphenylenediamine in hair dye
4) Flowers
5) Peanut butter |
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Definition
| 5- peanut allergies are not typically associated |
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Term
| What are the cornerstones of treatment for Atopic and Allergic contact dermatitis? |
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Definition
1) Cutaneous hydration
- Reduced skin barrier function must be restored
- Aggravated in dry winter months
2) Topical glucocorticoids **
- Counsel patient about proper use
- 2x daily with break after 2 weeks
3) Systemic options include Anti-histamines (sedating/non-sedating combinations) for pruritis and Antibiotics (Cephalosporins, dicloxacillin, doxycycline (MRSA))
AVOID systemic steroids (Prednisone) if possible. |
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Term
All of the following are true regarding atopic dermatitis (AD) EXCEPT:
1) AD is due to abnormalities in skin barrier function and allergen sensitivity
2) Has been shown to be related to a mutation in protein called filaggrin
3) It is a classic presentation of a delayed type (type IV) hypersensitivity response to exogenous agents
4) There has been a greater than 3 fold increase in AD since 1960s
5) 1, 2 and 4 |
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Definition
| 3- Atopic dermatitis is Type I and Type III hypersensitivity, not DTH reaction. Type IV hypersensitivity or DTH is involved in contact dermatitis. |
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Term
The most common major feature shared by patients with atopic dermatitis (AD) is:
1) Dennie-Morgan folds
2) Keratosis pilaris
3) Lichenfication in flexural areas
4) Pityriasis alba
5) Pruritus |
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Definition
| 5- Pruritus is the most common and unifying feature of AD. Some think that it is a primary cause of the AD, all others – secondary. |
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Term
True or False: The pathogenesis of allergic contact dermatitis requires the presence of a small molecule called a hapten
True or False? |
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Definition
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Term
A patient presents to your office for evaluation of a rash. Physical exam demonstrates scaly, erythematous plaques limited to the face and in the groin area. You suspect allergic contact dermatitis. Your treatment plan includes:
1) No treatment necessary, just continued observation
2) Oral antibiotic therapy
3) Oral prednisone taper
4) Twice daily application of a low potency steroid like desonide
5) Twice daily application of a potent fluorinated steroids like clobetasol or betamethasone |
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Definition
| 4- A weak topical steroid cream is recommended. Potent topical steroids are contraindicated for use on the face and groin. While oral prednisone can be very effective in treating any dermatitis, usually long term nature of the dermatitis precludes its use long term due to significant side effects. Antibiotics can be used in case of superinfection of the dermatitis, but this was not a diagnosis here. |
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Term
Which of the following descriptions about Psoriasis are INCORRECT?
1. Tends to manifest between 20-30 and 50-60 years
2. Inverse Psoriasis will present with Erythematous plaques with minimal scale in skin folds and without satellite pustules.
3. Guttate Psoriasis occurs in people younger than 30 with abrupt onset of 1-10-mm pink papules following URI (group A b-hemolytic strep 2-3 weeks prior)
4. First-line therapy is methotrexate and infliximab |
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Definition
4. First-line treatment is
A Topical corticosteroid monotherapy
i. Class I (clobetasol 0.05% , betamethasone diproprionate 0.25%) and Class II (Fluocinonide 0.05%) – acral surfaces, recalcitrant plaques, scalp
ii. Class III and Class IV (Triamcinolone 0.5% and 0.1%) – trunk
iii. Class V and Class VI (desonide 0.05% and hydrocortisone 2.5%) – face, intertriginious areas, genitalia
b. Combination with steroid-sparing agent (Vitamin D, Retinoids and Tacrolimus)
Methotrexate and anti-TNF drugs are systemic therapy that are not first-line options.
Systemic Therapy:
a. Phototherapy
b. Methotrexate
c. Acitretin
d. Cyclosporin
e. TNF-alpha inhibitors
f. Ustekinumab |
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Term
| What are the 5 major clinical variants of Psoriasis? |
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Definition
Tend to manifest between 20-30 or 50-60 and diagnosed clinically or with skin-punch biopsy.
1) Plaque (most common)
- well-demarcated, scaly and erythematous plaques with symmetrical distribution on extensor surfaces (knees, elbows, buttocks)
2) Inverse
- Erythematous plaques with minimal scale found in skin folds (axillary, genital, perineal, ect)
- NO stellate pustules (differentiates from candidiasis)
3) Guttate (patients <30)
- Abrupt onset of 1-10 mm pink papules with fine scale on trunk and extremeties
- Preceded by URI (strep a, b-hemolytic) 2-3 w
4) Pustular
- Uncommon sterile postures due to large collections of PMNs in stratum corneum (pregnancy, rapid tethering of meds, hypocalcemia, infection)
- Seen on hands and feet
5) Nail (Seen in ALL forms- 35-50%)
- Nail pitting and leukonychia
- Oil spots, subungual hyperkeratosis and distal onycholysis (nail bed) |
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Term
Which of the following agents would be an appropriate first-line therapy for inverse psoriasis of the genitalia?
1. Clobestasol (0.05%)
2. Desonide (0.05%)
3. Fluocinonide (().05%)
4. Acitretin
5. Betamethasone (0.25%) |
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Definition
2. Less potent Class V (Desonide or hydrocortisone) topical corticosteroids are appropriate for lesions on the face, intertriginous areas or the GENITALIA
1. Clobestasol is a class 1 topical steroids appropriate for acral surfaces or the scalp (also betmethasone diproprionate or class 2 agents like Fluocinonide)
3. Class 2 agent for scalp or acral surfaces
4. Systemic therapy for second-line treatment
5. Class 1 agent for scalp or acral surface |
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Term
Patient presents with abrupt onset of 1-10 mm pink papules with an associated fine scale over their trunk 2 weeks after suffering an URI.
How should you treat?
1. Fluocinonide 0.05%
2. Desonide 0.05%
3. Hydrocortisone 2.5%
4. Triamcinolone 0.5% |
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Definition
4- This class III/IV topical corticosteroid agent is used to treat Psoriasis of the trunk
1 and 2 are class 1 (POTENT) steroids for the scalp, recalcitrant plaques and acral surfaces
3 is a Class V (mild) agent for treatment of genitalia, face or intertriginous areas. |
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Term
| When is system treatment of Psoriasis warranted and how is it performed. |
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Definition
Body surface area >5-10% with debilitating disease affecting palms, soles and/or genitalia.
1) Phototherapy (narrow band UV or ultraviolet A)
2) Methotrexate (supplement folate)
3) Short-term cyclosporine (nephrotoxicity and htn)
4) Acitretin (oral retinoid that is NOT immunosuppressive)
**Good for pustule, but needs blood monitoring**
5) Biologic (TNF, IL-12/23 inhibitor)
- Don't give with infection (screen HBV and TB) or history of MR |
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Term
A patient has severe pustular psoriasis and joint pain. Which of the following statements are true?
1) Acitretin is effective for this condition
2) Monotherapy with topical steroids would be appropriate
3) No treatment is necessary
4) Patient should have an evaluation with rheumatology for possible psoriatic arthritis
5) 1 and 4 |
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Definition
| 2: Monotherapy with topical steroids would be appropriate. Weak topical steroid cream is recommended. Potent topical steroids are contraindicated for use on the face and groin. While oral prednisone can be very effective in treating any dermatitis, usually long term nature of the dermatitis precludes its use long term due to significant side effects. |
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Term
This patient presents with one plaque of psoriasis around his umbilicus as shown in the photo. He denies any joint pain.
1) Acitretin is appropriate first line therapy for this condition
2) Monotherapy with topical steroids would be appropriate
3) Patient should have an evaluation with rheumatology for possible psoriatic arthritis
4) TNF-alpha inhibitor therapy should be initiated
5) 1 and 3 |
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Definition
| 2: Patient has unilesional disease and otherwise is asymptomatic. Systemic therapies are not appropriate as the risks outweigh the benefits. |
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Term
Patient presents to your office for evaluation. He has a history of inverse psoriasis that recently has become worse despite continuing his usual treatment regimen of topical steroids. What is the next appropriate step?
1) Closely examine the affected area to evaluate for satellite pustules associated with candidal intertrigo infection.
2) Give the patient a potent fluorinated topical steroid to apply to his axillae.
3) Recommend that the patient continue another two week trial of his current medication to see if things improve.
4) Recommend that the patient lose weight to decrease friction in the affected area.
5) None of the above. |
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Definition
| 1: closely examine the affected area to evaluate for satellite pustules associated with candidal intertrigo infection. Topical steroids decrease skin defenses against infection. Cutaneous candidiasis is frequent complication of long term steroid use. Potent topical steroids are contraindicated in occlusive zones due to significant increase in potency due to occlusion and increased risk of side effects, including severe skin atrophy. While weight loss may be a valid recommendation, this vignette does not provide enough information to conclude that the patient is overweight. |
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Term
All of the following are true regarding cyclosporine for the treatment of severe psoriasis EXCEPT?
1) Adverse drug reactions include nephrotoxicity and hypertension
2) Cyclosporine has a rapid onset of effect
3) Effective as short-term therapy or as a bridge to other maintenance
4) It is not immunosuppressive
5) Monthly LFTs, CBC, lipid profile, magnesium, uric acid and potassium should also be checked |
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Definition
| 4: Cyclosporine IS immunosuppressive. All others are true. |
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Term
A women with diagnosed ovarian cancer presents with a purple rash on her upper eyelids and shoulder that feels like "sand-paper."
You examine her hands and find papule lesions, ragged cuticles with globular vascular changes of the proximal nail fold.
Her thighs, knees and elbows are erythematous.
What is going on?
1) SLE
2) RA
3) DM
4) SCc
5) Gout |
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Definition
3) DM= autoimmune connective tissue disease with rash and muscle weakness due to myositis
a. Helioptrope (purple) rash of the upper eyelids, shawl sign (shoulders), sand-paper like quality of the rash. Hands – Gotron’s papules (pathognomonic). Ragged cuticles, periungual erythema, proximal nail fold with globular vascular changes with skip areas and scarring. Gotron’s sign: erythema on thighs and arms crossing the joints (knees and elbows). Mechanic hand is associated with lung disease.
b. DM is paraneoplastic syndrome in 25% of all cases. All patients need to be screened. Women – most common ovarian cancer, men – lung cancer, Asian men – naso-pharyngeal carcinoma.
c. DM sine myositis (without myositis) – also high risk of internal |
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Term
Which of the following is FALSE regarding dermatomyositis.
1. Women with DM tend to have ovarian cancer
2. Men with DM tend to have lung cancer
3. Flat-top papules on the distal fingers are pathognemoic
4. Sand-paper rash seen in shoulders, chest, knees and elbow
5. Multiple, fine, hair-pin-like nodules underneath the nail bed. |
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Definition
5- This is SLE. These would be globular in DM.
Gotron's papules and sign are common and DM is paraneoplastic |
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Term
A 46 year old white female presents to your primary care clinic complaining of a 4-month history of increasing muscle weakness with increased difficulty combing her hair and rising from a chair. You immediately note a violaceous poikilodermatous rash on her upper eyelids and violaceous plaques on her dorsal hands over her phalyngeal joints. In addition to confirming your suspected diagnostic, the most important first step is to:
1) Check fasting lipid profile
2) Obtain pelvic ultrasound
3) Obtain pulmonary function tests
4) Perform a colonscopy
5) Screen first degree relatives |
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Definition
| 1: obtain a pelvic ultrasound. This patient presents with classic signs and symptoms of dermatomyositis. In addition to confirming your diagnosis with muscle and skin biopsies, the most important first step is to evaluate for an associated neoplasm. Ovarian carcinoma is one of the most commonly associated neoplasms in females with dermatomyositis and should be screened for at diagnosis and routinely for two to three years following the diagnosis. Dermatomyositis is not associated with lipid abnormalities (answer 1). While colon carcinoma can be associated with dermatomyositis, ovarian carcinoma is a more common association (4). Screening of first degree relatives is not routinely recommended (5). While it is important to obtain pulmonary function tests in patients with dermatomyositis to evaluate for interstitial lung disease, this is not the most important first step (3). |
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Term
You are the 4th year medical student admitting a 36 year old African American female patient to the hospital with a pericardial effusion of unclear etiology. As you obtain your history, she notes that her medical history is only significant for discoid lupus diagnosed 3 years ago from a biopsy on her ear. Although the rash resolved with some scarring and discoloration, she has not had any other rash, systemic symptoms, or medical problems since that time. Your complete review of systems is significant only for cough, runny nose, and chest pain. The most likely cause of this patient’s pericardial effusion is:
1) Malignancy
2) Nephrotic syndrome
3) Systemic lupus erythematosus
4) Tuberculosis
5) Viral infection |
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Definition
| 5- The most likely cause of this patient’s pericardial effusion is a viral infection, especially given the patient’s associated upper respiratory symptoms. She has no other signs or symptoms apart from the pericardial effusion to suggest a diagnosis of acute systemic lupus at this time (answer 3). It is important to distinguish between cutaneous and systemic lupus erythematosus. Discoid lupus is one form of cutaneous lupus. Overall, only approximately 10% of patients with discoid lupus develop systemic lupus erythematosus. She has no findings to suggest the other diagnoses (1, 2, and 4), all of which can cause pericardial effusions. |
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Term
You are performing a routine physical examination on a healthy 45 year old health care executive. He has no medical problems and a complete review of symptoms is unremarkable. He has heard that there is a screening test for autoimmune connective tissue disease called an ANA (antinuclear antibody) and requests to have this test. You order the test and the results are positive with a titer of 1:160. You call the patient to inform him that:
1) He is unlikely to have an autoimmune connective tissue disease, despite the positive test results
2) He most likely has an autoimmune connective tissue disease
3) He should have a chest CT scan to evaluate for lymphoma
4) You are not sure whether he has an autoimmune connective tissue disease and he should come in immediately for further testing
5) None of the above |
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Definition
| 1. 5% of normal health adults will have an ANA titer of 1:160 or greater. The ANA ELISA test is an excellent screening test for a number of autoimmune connective tissue diseases, including lupus erythematosus, because of its high sensitivity. However, the test lacks specificity and may be elevated in a high percentage of healthy adults. Further testing for connective tissue disease is not indicated at this time because your physical examination and review of symptoms were unremarkable (answers 2 and 4). Although patients with an underlying malignancy may be more likely to have a positive ANA, there is nothing to suggest a diagnosis of lymphoma in this patient (answer 3). |
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Term
A 40 year old female patient presents to your primary care clinic complaining of episodic vasospasm of her fingers resulting in white, blue and red discoloration of her fingers secondary to cold exposure (Raynauds phenomenon). As you examine her hands, you notice that the skin from her fingers up to her wrists is very hard (indurated) and shiny. She has milder, similar changes on her forearms and upper arms. The most common cause of death in patients with this disease is:
1) Infection
2) Pulmonary disease
3) Renal failure
4) Skin ulceration
5) Stroke |
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Definition
| 2. This patient has systemic sclerosis (scleroderma). Although renal crisis was formerly the most common cause of death in patients with systemic sclerosis, the use of angiotensin-converting enzyme inhibitors have decreased the rates of renal failure in these patients. Pulmonary disease is now the most common cause of death in patients with systemic sclerosis. |
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Term
Which of the following connective tissue disease associations is incorrect?
1) Chronic cutaneous lupus with "Neopolitant ice-cream sign"
2) Rhematoid arthritis with vasculitis/ulceration and nodules.
3) Scleroderma with Raynaud's syndrome, telangictatic mats and Sclerdactyly
4) DM with smooth, hair-pin like rash at base of finger nails |
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Definition
4. In proximal nail fold, you see globular vascular changes with skip areas and scarring
Also see Helioptrope (purple) rash on upper eyelids and Gotron's papules/sign in the context of cancers (lung in men and ovarian in women). |
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Term
A 19 year old male college student presents to your emergency department with a severe headache, fevers, and chills. His pulse is 140 and blood pressure is 80/40. On examination he has multiple large purpuric lesions on his trunk. The reservoir of this infection is:
1) Household cats
2) Human skin
3) The human nasopharynx
4) Unknown
5) Unpasteurized milk |
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Definition
| 3: This patient has purpura fulminans from acute meningococcemia (due to Neisseria meningitides). This patient presents with classic features of meningococcemia. Patients can rapidly deteriorate if the correct diagnosis is not rapidly made. The only known reservoir for Neisseria meningitidis is the human nasopharynx (Answer 3). |
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Term
An elderly male patient presents to your clinic with non-palpable purpura on his lower extremities. He asks you to tell him what has caused this unusual eruption. What is the best way to respond?
1) “Since the lesions are not palpable and they are not bothering you, forget about them. They will likely go away on their own.”
2) “The lesions may represent a systemic vasculitis. You should be admitted to the hospital immediately for further evaluation.”
3) “The lesions most likely represent blood that has somehow gotten outside of your blood vessels and into your skin. There are a number of conditions that can cause this. Let me examine you first before we decide how to proceed.”
4) “Your platelet count may be low. Get your blood checked and give me a call tomorrow.” |
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Definition
| 3: The lesions most likely represent blood that has somehow gotten outside of your blood vessels and into your skin. There are a number of conditions that can cause this. Let me examine you first before we decide how to proceed.” There is a long list of possible causes of purpura. Rather than memorizing a list, it is best to think logically about what can allow red blood cells to extravasate out of blood vessels and into the skin. Based on the size of the lesions and other characteristics (inflammation, palpability and others) it is often possible to predict the etiology, but it is necessary to have a broad differential diagnosis regardless of the clinical appearance of purpura. Platelet deficiencies, abnormal platelet function, trauma, and vitamin C deficiency are perhaps the most likely etiologies in this case, but further evaluation is necessary to consider other etiologies including cutaneous vasculitis, abnormal coagulation, and embolization. If the patient is otherwise well, it is unlikely he will need to be admitted to the hospital (answer 2). It would be a mistake to ignore the lesions as they may represent a serious systemic disorder (answer 1). Although thrombocytopenia (answer 4) is a good guess, it is only one of many possibilities in this case. |
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Term
A 57 year old female is hospitalized for an atypical pneumonia. On her 5th hospital day she develops palpable purpura on her legs. A skin biopsy confirms small vessel vasculitis (also referred to as leukocytoclastic vasculitis or hypersensitivity vasculitis). Apart from her pulmonary symptoms, her review of symptoms is unremarkable and her laboratory testing (including liver function, renal function, and urinalysis) are all unremarkable. You suspect that the eruption was due to an antibiotic, and as you expect, the eruption gradually resolves over the next few weeks. Is further follow-up necessary?
1) Follow-up is only necessary if the rash reappears.
2) No.
3) Only if the patient has new or concerning symptoms.
4) Yes, the patient should have an examination and repeat laboratory testing in the next 1-2 months. |
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Definition
| 4. Yes, the patient should have an examination and repeat laboratory testing in the next 1-2 months. There are a number of conditions that can cause small vessel vasculitis. The possibilities include Henoch-Schonlein purpura, infections, autoimmune connective tissue diseases, Churg-Strauss syndrome, Wegener’s granulomatosis and others. Although a drug exposure likely resulted in this patient’s eruption, clinical follow-up and repeat laboratory testing (for example in one month) is important given that other possible causes of the eruption have not been excluded. |
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Term
You are caring for a 24 year old male patient with active hepatitis B. He presents complaining of fevers, arthralgias, abdominal pain, and a painful ulceration on his leg. His blood pressure is 240/110. The presence of the following on an abdominal MRI helps to confirm the most likely diagnosis:
1) Abdominal aortic aneurysm
2) Hepatic cyst
3) Microaneurysms
4) Nephrolithaisis
5) Pancreatic head mass |
|
Definition
| The most likely clinical diagnosis is polyarteritis nodosa. This is a segmental vasculitis of predominantly medium-sized vessels that is classically associated with hepatitis B infection. Because medium sized vessels are affected, this form of vasculitis can present with cutaneous ulcerations in addition to palpable petechiae and purpura that are seen in small vessel vasculitis. Renovascular hypertension is common. Microaneurysms detected by MRI are highly suggestive of the diagnosis. The other answer choices are not associated with polyarteritis nodosa. |
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Term
Which of the following is NOT a common non-inflammatory form of purpura without a clot?
1. Heparin injections
2. Purpura fulminans
3. Scurvy,
4. Amyloidosis depositions |
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Definition
Pathological entity requires biopsy.
2. Purpura fulminans from sepsis involves a clot and has a poor prognosis. |
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Term
| What are the 2 types of non-inflammatory purpura with clots? |
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Definition
1) Pupura fulminans (Sepsis, poor prognosis)
2) Monoclonal cryoglobulinema (type 1, due to antibodies depositions in the blood vessels) |
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Term
Which of the following is NOT a form of inflammatory purpura from leukocytoclastic vasculitis?
1. Purpura in children with GI bleeding or hematuria
2. Vasculitis associated with skin nodules
3. Hives that last >24h, painful, and burning associated with concentric purpura and low complement levels
4. Clotting purpura associated with sepsis and a poor prognosis
5. Medium-size vasculitis associated with HBV |
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Definition
4- This is Purpura fulminans
1- Henoch Shonlein purpura (IgA)
2- Rheumatic vasculitis
3- Urticarial vasculitis (low-complement)
5- Polyarteritis nodosa (necrotizing granulomatous vasculitis of small and medium size vessels)
Other forms of NGV are Wegeners, Churg-strauss syndrome (allergic) and Microscopic polyangiitis. |
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Term
A five year old boy is brought by his parents with complaints of fever for 3 days, poor appetite, not feeling well, and sore throat. They brought him in today because they noticed a sore in his mouth, which is painful. On examination, the child appears sick, temp 102F. His mouth exam showed 3 ulcers on the back of his mouth. A skin exam showed 2 painful pustules – on his right palm and left sole. What is the most likely cause?
1) Coxsackievirus A16
2) HHV6
3) HPV16
4) Parvovirus B19
5) VZV |
|
Definition
1) This vignette describes hand-foot-and mouth disease. Majority cases in US are cause by Coxsackievirus A16.
- HHV6 causes Roseola Infantum and mononucleosis;
- parvovirus B19 causes erythema infectiosum
- VZV causes varicella and herpes zoster;
- HPV16 causes condyloma with high malignant potential. |
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Term
A ten month old girl with 3 days history of very high fevers (104 °F) without malaise is brought in today by her parents because she broke out in rash. The girl appears well; her temperature now is 99.8 °F. Her skin examination shows pink maculopapular exanthem without significant scaling. The rash is located mainly on the trunk, with some spreading to the legs and neck. You suspect a common childhood viral exanthem. Which of the following describes the virus which causes this illness?
1) Double stranded DNA virus which predisposes to squamous cell carcinoma
2) Double stranded DNA virus, which remains dormant in lymph nodes
3) Double stranded DNA virus, which remains dormant in neural ganglia
4) Single stranded DNA virus which remains dormant in lymph nodes
5) Single stranded DNA virus with tropism for erithroid cell progenitors |
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Definition
Double stranded DNA virus, which remains dormant in lymph nodes. The vignette describes roseola infantum, which is caused by HHV6 and HHV7, lymphotropic ds DNA viruses. The viruses can remain dormant in the lymph nodes for decades until the patient becomes immunosuppresed. Reactivation may cause mononucleosis.
- Neurotropic dsDNA viruses is varicella and HHV1, HHV2 herpes viruses.
- HPV viruses types 16, 18, 31, 33 are ds DNA viruses which predispose to SCC.
- Parvovirus B19 is a ssDNA virus with tropism for red cell progenitors (Erytheium infectiosum) |
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Term
You are seeing a healthy sexually active nineteen year old male for annual routine physical examination required by his college. His exam is only remarkable for several skin colored verrucous plaques on the penile shaft. You should:
1) Advise patient that this condition is extremely dangerous and surgery is needed
2) Ignore it, the finding is a normal variant
3) Provide counseling about sexually transmitted diseases and advise him to alert his partner
4) Provide vaccination against this condition
5) Report this condition to the Department of Health because it is required by law |
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Definition
| 3: Genital warts are a sexually transmitted disease. HPV 16, 18, 31, 33 can cause cervical and anal carcinoma in sexual partners of infected individuals. Counseling is important to inform the partners that regular checkups (Pap smear, etc) might be needed for surveillance. Surgery may be an adjuvant to other therapy but it is rarely leading to cure due to infection of non-involved skin. Vaccination is useful prior to infection. Genital warts are not on the list of the diseases which are required to report to Department of Health. |
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Term
Which of the following is FALSE regarding warts (condyloma)?
1. Caused by dsDNA viruses
2. Available vaccine
3. Certain viral forms can predispose to cervical and anal squamous cell cancer
4. Treated with anti-viral therapy. |
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Definition
4: These are treated with destruction (salicylic acid) or chemo/radiation and is difficult.
HPV is a dsDNA virus with an available vaccine that causes warts and types 16, 18, 31 and 33 can cause squamous cell cancer
HPV 1 – plantar warts
HPV 2 – periungual warts
HPV 3, 10 – flat warts
HPV 6, 11 – benign genital warts |
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Term
Which of the following regarding viral infections affecting the skin is FALSE?
1. HPV and Molluscum Pox viruses cause infections on the skin, while Cocksackievirus causes systemic infection.
2. Lymphotrophic dsDNA viruses cause high fevers in children who are feeling very well
3. HFM is caused by dsDNA viruses and produces a self-resolving rash
4. A ssDNA virus with tropism for erithroid progenitors causes the appearance of "slapped cheeks" in anemic patients
5. dsDNA virus in the herpes family initially causes lesions that look like “Dewdrops on rose petal” and appear at various developmental stages simultaneously |
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Definition
3- This describes Molluscum contagiousum, rather than HFM, which is caused by a ssRNA enteroviruses that are self-limited and either Cocksackie or Echoviruses.
1) True
2) Describes HHV6 and HHV7 causing Roseola Infantum
4) Describes Parvovirus B19 causing Erythema Infectiousum (slapped cheeks)
5) Describes VZV and which can be reactivated as H. Zoster (treated with anti-virals) |
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Term
What virus produces each of the following dermatological clinical pictures?
1. “Dewdrops on rose petal” initially, that progress to lesions of different stages simultaneously
2. Bright red cheeks for one week, followed by a diffuse rash
3. Child with high fever, but feels well. When fever resolves rash starts
4. Lesions on hands, feet and mouth.
5. Squamous cell carcinoma of anus. |
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Definition
1) VZV (dsDNA, herpes virus) treated with anti-virals
2) Erythema Infectiousum (slapped cheeks) caused by Parvovirus B19 (ssDNA virus with tropism for erythroid precursors)
3) Roseola infantum from HHV 6 or HHV 7 (dsDNA virus that is lyphotropic and self-limited)
4) HFM caused by Cocksackie virus A16 (ssRNA enterovirus that is self-limited)
5) HPV 16, 18, 31, 33 warts (dsDNA virus that causes skin infection, rather than systemic infection). |
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Term
Which of the following descriptions about fungal infections of the skin is FALSE?
1) Anthropophilic infections (human to human infection) are non-inflammatory
2) Scaling is a defense mechanism against fungus
3) Zoophilic and geophilic are inflammatory
4) Superficial fungal infections are treated with oral antifungal (griseofulvin and terbinafin)
5) Diagnosed by potassium hydroxide (10% KOH) preparations or by fungal culture |
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Definition
4) Superficial fungal infections are treated with topical antifungal creams (azoles and allylamines).
- Infections of the hair follicles and nails require oral antifungals (griseofulvin and terbinafine, respectively). |
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Term
| Why is KOH preparation used to diagnose fungal infections of the skin? |
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Definition
Get scale from advancing edge or involved lesion!
KOH dissolve keratin and leave fungus readily visible (fungus cell walls are made of chitin).
Fungal cultures are also useful. |
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Term
| What anti-fungal agents are available to treat infections of the skin? |
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Definition
Topicals are used to treat superfiscial infections and include azoles and allylamines
Oral agents are used for infections of the hair follicle or nails (griseofulvin and terbinafine, respectively).
1. The azole group (ketoconazole, miconazole, econazole, clotrimazole)
- Inhibit 14-lanosterol demethylase, fungistatic.
2. The allylamine group (terbinafine, butenafine)
- Inhibit squalene epoxidase, fungicidal.
3. Griseofulvin (Hair follicles)
- Disrupts microtubule formation, fungicidal. |
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Term
Which of the following descriptions of Tinea Versicolor is FALSE?
1) Caused by an overgrowth of yeast Pityrosporum ovale, which is normally found in low levels in the human skin.
2) Presents as hypo- and hyperpigmented scaly macules
3) Treated with topical allylamine creams and shampoo
4) Produced by organism that thrives on lipids, such as sebum. |
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Definition
| 3) Topical creams MUST be azoles (fungistatic inhibiters of 14-lanosterol demethylase) |
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Term
Which dermatophytes cause each of the following skin infections?
1) Tinea corporis (ring worm of stratum corneum):
2) Tinea capitis (ring worm of scalp)
3) Onychomycosis (infection of toe nails)
4) Tinea Pedis (feet) |
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Definition
1) Trichophyton rubrum, Microsporum canis, and Trichophyton mentagrophytes.
2) Trichophyton tonsurans (common in AA and children)
- MUST be treated by Griseofulvin
3) Trichophyton rubrum and Trichophyton mentagrophytes
4) - Moccasin type: Trichophyton rubrum
- Interdigital type: Trichophyton mentagrophytes var. interdigitale
- Bullous type (RARE): Trichophyton mentagrophytes var. mentagrophyte |
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Term
How is Tinea Capitas treated?
What about Tinea Pedis and Onychomycosis |
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Definition
Diagnose them by getting ACTIVE edge of scale.
Both are fungicidal
1) For hair: Griseofulvin (microtubule)
2) For nails: Terbinafin (Inhibit squalene epoxidase) |
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Term
| What are the most common dermatophytes involves in skin infections? |
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Definition
MOST commonly involve Trichophyton rubrum and Trichophyton mentagrophytes.
If h/x of animal, think Microsporum canis.
T. capitus= Trichophyton tonsurans
T. versicolor= Pyryrosporum ovale |
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Term
A 9-year old girl presents with an annular scaly erythematous pruritic plaque with the central clearing on her cheek for about 2 weeks. She is otherwise well. Her exam is unremarkable except for couple linear scratch marks on her arms from her cat. They do not appear infected and heal well. To confirm your diagnosis you should:
1) Perform a punch biopsy
2) Perform a scraping of the center of the lesion
3) Perform a scraping of the edge of the lesion
4) Perform a shave biopsy
5) Perform an excisional biopsy |
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Definition
The vignette describes tinea corporis, a superficial fungal infection. The infectious agent is located at the edge of the involved plaque, thus scraping of the edge is most likely to provide diagnosis. Biopsy may be diagnostic, but it is too invasive. Scarping of the center is not useful as center is cleared of infection.
Treat it with topical azole or allylamine if superficial |
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Term
The most likely cause of the above lesion in the girl with Tinea corporus is:
1) Microsporum canis
2) Microsporum felis
3) Squamous cell carcinoma
4) Trichophyton tonsurans
5) Viral exanthema |
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Definition
| The vignette provides information of potential animal contact in patient with fungal infection. It is not viral and not malignant. T. tonsurans causes tinea capitis. M. felis does not exist. |
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Term
In a patient with superficial fungal infection who is immunocompromised it is best to use which of the following antifungal agents:
1) Butenafine - because it inhibits squalene epoxidase and is fungistatic
2) Clotrimazole – because it inhibits 14-lanosterol demethylase and is fungistatic
3) Econazole – because it inhibits squalene epoxidase and is fungistatic
4) Ketoconazole – because it inhibits squalene epoxidase and is fungicidal
5) Terbinafine – because it inhibits squalene epoxidase and is fungicidal |
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Definition
| Terbinafine inhibits squalene epoxidase and is fungicidal. All others are azoles; they inhibit 14-lanosterol demethylase and are fungistatic, thus less preferred in immunocompromised patients. |
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Term
Which of the following descriptions pertaining to gram (+) Pyodermas is INCORRECT?
1) Most commonly caused by strep or staph
2) Most strep infections require oral therapy and sometimes surgical drainage (in case of furuncle/carbuncle and abscess)
3) Scalded skin syndrome is caused by group 2 staph, which produces exfoliate toxins A and B
4) Staph toxic shock syndrome is caused by TSST-1 exotoxin
5) Strep makes exotoxins A, B and C , and A produces the most severe disease. |
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Definition
| 2) This is true of staph infections |
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Term
| What are the 6 major skin lesions that can be produced by staph infection? |
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Definition
Besides superficial impetigo, majority require oral therapy and sometimes surgical drainage (furuncle/carbuncle and abscess)
1. Impetigo: Superficial skin infection
2. Ecthyma: Ulcerative impetigo, deeper, similar management
3. Cellulitis: Infection of dermis and subcutis. Red indurated and swollen skin, painful, hot to touch
4. Folliculitis: Superficial infection of a single hair follicle
5. Furuncle/Carbuncle
a. Furuncle: Deep infection of a single hair follicle and surrounding tissue
b. Carbuncle: Deep infection of contiguous hair follicles and surrounding tissue
6. Abscess: Deep infection – enclosed liquefied collection of pus under the skin |
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Term
| What is staph "scalded skin syndrome" and how do you treat? |
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Definition
Due to Staph aureus, group 2 (phage 71, 55, 3A and 3C) affecting young kids or immunocompromised/renal failure adults.
- Produces circulating exfoliative toxins A and B – causes superficial sloughing of the epidermis (intraepidermal)
- Treat with oral antibiotics, treat skin infection |
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Term
A patient with sudden onset fever, diarrhea, vomitting and pharyngitis has skin with scarlatiniform eruption, strawberry tongue, palmo-plantar erythema, red conjunctiva.
What is going on? |
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Definition
Staph toxic shock syndrome with TSST-1 exotoxin and foreign body (left over from surgery)
Treat with supportive ICU care and beta-lactamase resistant antibiotics |
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Term
| How do the toxic shock syndromes produced by strep and staph infection differ? |
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Definition
Staph is foreign body with TSST-1, while Strep is GAS, with M protein super-antigen and cytokine storm.
1) Staph Toxic Shock Syndrome
- Due to infected foreign objects inside the body
- Produces exotoxin (TSST-1) at the site of infection which causes distant systemic symptoms (fever, pharyngitis, vomiting, diarrhea, myalgias)
- Skin: scarlatiniform eruption, strawberry tongue, palmo-plantar erythema, red conjunctiva
- Therapy: remove foreign body, may need ICU admission, i.v. antibiotics (β-lactamase resistant)
2) Strep toxic shock-like syndrome
- may be fulminant disease with rapid demise.
- Caused by group A strep (GAS or strep pyogenes), where M-protein is a virulent factor.
- Toxin acts as super-antigen and links T-cell receptors and antigen presenting cells nonspecifically causing generalized activations of T-cells and “cytokines storm” responsible for mediating shock and tissue injury. |
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Term
| Patient presents with mild erythema on the lower extremities with seemingly "out of proportion" pain. You notice pallor as well. What do you do quickly? |
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Definition
| Call surgery, this sounds like Nec Fasc. |
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Term
Which of the following is characteristic of impetigo?
1) Exfoliative toxins A and B
2) Infection of contiguous hair follicles and tissues
3) Infection of dermis and subcutis
4) Infection of epidermis and superficial dermis
5) Strep. pyogenes
6) Strawberry tongue |
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Definition
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Term
Which of the following is characteristic of cellulitis?
1) Exfoliative toxins A and B
2) Infection of contiguous hair follicles and tissues
3) Infection of dermis and subcutis
4) Infection of epidermis and superficial dermis
5) Strep. pyogenes
6) Strawberry tongue |
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Definition
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Term
Which of the following is characteristic of a carbuncle?
1) Infection of contiguous hair follicles and tissues
2) Infection of dermis and subcutis
3) Infection of epidermis and superficial dermis
4) Strep. pyogenes
5) Strawberry tongue |
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Definition
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Term
Which of the following is associated with of Staph scalded skin syndrome?
1) Exfoliative toxins A and B
2) Infection of contiguous hair follicles and tissues
3) Infection of dermis and subcutis
4) Infection of epidermis and superficial dermis
5) Strep. pyogenes
6) Strawberry tongue |
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Definition
|
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Term
Which of the following is characteristic of Staph toxic shock syndrome?
1) Exfoliative toxins A and B
2) Infection of contiguous hair follicles and tissues
3) Infection of dermis and subcutis
4) Infection of epidermis and superficial dermis
5) Strep. pyogenes
6) Strawberry tongue |
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Definition
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Term
An obtunded 44 year old white male alcoholic is brought in to the Emergency Department. On physical exam you notice significant peritoneal effusion and his sun-exposed skin with cuts, bruises, scars, milia, hyperpigmentation, and vesicles. These cutaneous findings are due to:
1) Alcoholic cardiomyopathy and uroporphyrinogen decarboxylase deficiency
2) Alcoholic hepatitis and cirrhosis
3) Alcoholic hepatitis and enzyme uroporphyrinogen decarboxylase deficiency
4) Alcoholic hepatitis and uroporphyrinogen decarboxylase overproduction
5) Renal insufficiency and uroporphyrinogen decarboxylase deficiency |
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Definition
| 3: The findings are associated with Porphiria Cutanea Tarda (PCT). PCT is more common in men in the 40s. PCT involves sun exposed skin. Cutaneous findings include skin fragility, blisters, scarring, and milia on the dorsal hands and forearms. Fragility includes easy bruising and easy tearing of the epidermis. There can be a burning sensation of the skin of the dorsal hands, but most patients are asymptomatic except for painful erosions and ulcers that develop at sites of minor trauma. PCT is caused by a deficiency of the enzyme uroporphyrinogen decarboxylase (UROD). Deficiency of the enzyme leads to accumulation of uroporphyrins, which cause cutaneous damage after absorbing ultraviolet radiation. UROD is mainly present in the liver. Most patients with PCT have chronic liver damage, and this chronic damage leads to decreased UROD activity. The types of liver disease that are common include hemochromatosis, alcoholism, and hepatitis C. |
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Term
The choice of therapy for the cutaneous condition in Porphiria Cutanea Tarda (PCT) is:
1) Antibiotics
2) Blood transfusion
3) Paracentesis
4) Peritoneal dialysis
5) Phlebotomy |
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Definition
| 5- UROD participates in the fifth step in the heme biosynthetic pathway, resulting in conversion of uroporphyrinogen to coproporphyrinogen. A deficiency in this enzyme leads to accumulations of uroporphyrinogen and inability to excrete products of heme degradation in feces (the main route of excretion). Build up of heme causes iron overload leading to end-organ damage. The most effective treatment for PCT is phlebotomy. Phlebotomy is probably also effective because it increases the need for heme; thus, fewer precursors accumulate, because patients have only a partial, not complete, deficiency of UROD. |
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Term
A 49 year old morbidly obese white male presented to the Emergency Department for severe acute abdominal pain in the upper abdomen, radiating to the back, nausea and vomiting. He remembers that the doctor said that his sugar and his blood fat were abnormal a while ago, but has not followed up since then. The pain started immediately after he ate Primanti Brothers sandwich few hours ago and does not get better. His skin revealed small (1-4 mm) yellow, orange, or pink papules most prominent on extensor areas. What do you expect his laboratory findings show?
1) High urine uroporphyrinogen decarboxylase
2) High vitamin A levels
3) Low vitamin C levels
4) Serum triglycerides lower than 100 mg/dl (normal is <200)
5) Serum triglycerides over 1500 mg/dl (normal is <200)
The most likely reason for cutaneous findings in the patient with acute abdominal pain in question above is most likely due to:
1) Abdominal ischemia
2) Acute pancreatitis
3) High vitamin A levels
4) Low vitamin C levels
5) Sudden increases in triglyceride in the setting of uncontrolled diabetes and dietary indiscretion |
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Definition
5) The patient described in this question has morbid obesity, poorly controlled diabetes, and high risk for sudden hypertriglyceridemia due dietary indiscretion leading to sudden onset of eruptive xanthogranuloma (EX).
2) Triglycerides are deposited in the skin and an inflammatory reaction occurs to the deposited triglycerides, resulting in the pink-red-orange color and the itch. With EX, triglyceride levels are at least 1000 mg/dl. |
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Term
Which of the following descriptions of nutritional deficiencies with dermatological manifestations is INCORRECT?
1. Niacin= dermatitis, dementia, diarrhea.
2. Riboflavin= Plaque lesions on hands and knees and perifollicular purpura
3. Vitamin C= Corkscrew hair, perifollicular purpura, generalized ecchymosis, bleeding gingiva
4) Zinc= Eczematous periorificial dermatitis, alopecia, and diarrhea. |
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Definition
2
1) True: 3 D's of Pellegra with Dermatitis on sun exposed areas. Niacin deficiency can be cause by poor diet (corn), carcinoid, other.
3) True. Scurvy because of deficiency in vitamin C, which is Important in collagen synthesis.
4) True. Zinc deficiency causing Acrodermatitis enteropathica, which can be congenital (autosomal recessive) and acquired.
- Mimics diaper dermatitis, candidiasis, langerhans cell histiocytosis |
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Term
Patient presents with blisters on his dorsal hands, some of which have healed with scarring, hyperpigmentation and hypertrichosis.
He works as a construction worker and has a history of hepatitis.
What metabolic disease is most likely the cause of these lesions? |
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Definition
Porphiria cutanea tarda (PCT) – defect in Uro decarboxylase, an enzyme in heme production.
Can be inherited and acquired. Patients develop photosensitivity of sun exposed skin – hence, there are blisters on the dorsal hands, which heal with scarring, hyperpigmentation and hypertrichosis.
- Liver disorders can cause acquired form of PCT. |
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Term
Match each of the following descriptions with an accompanying metabolic disorder.
1. Pinched purpura around eyes and subcutaneous papules.
2. Blisters on the dorsal hands that have begun to scar over, along with sun sensitivity.
3. Tuberous, tendious, subperiosteal xanthomata, with xanthomatous plaques.
4. Sudden eruption of small (1-4 mm) yellow, orange, or pink papules that are slightly itchy following fatty meal |
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Definition
1. Systemic amyloidosis
2. Porphiria cutanea tarda (PCT) – defect in Uro decarboxylase, an enzyme in heme production.
3. Familial hypercholesterolemia - a genetic disorder characterized by high mostly LDL cholesterol and early cardiovascular disease.
4. Eruptive xanthoma - hypertriglyceridemia and diabetes
- Triglycerides >1000 get deposited in skin and cause inflammatory reaction. |
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Term
| How do you treat the condition that presents as a sudden eruption of small (1-4 mm) yellow, orange, or pink papules that are slightly itchy following fatty meal? |
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Definition
Eruptive Xanthoma
The only effective treatment of EX is normalizing serum triglyceride levels, typically through drug therapy with gemfibrozil, niacin, or statins. This not only improves EX, but also helps prevent pancreatitis and stroke associated with extremely elevated triglyceride levels. |
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Term
| What types of skin lesions tend to appear in patients with poorly controlled diabetes? |
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Definition
1) Diabetic dermopathy – small brown atrophic patches on pretibial surfaces
- due to micro-angiopathy
2) Necrobiosis lipoidica diabeticorum – large, yellow-brown, sharply bordered, hard, shiny plaques. In active lesions, there is often a red to violaceous, inflamed border to the plaques.
- Due to micro-angiopathy and ischemic damage to dermal collagen, and an inflammatory reaction against the damaged collagen
- Topical, intra-lesional, and systemic steroids are often used if the plaques have active, inflamed borders.
- Anticoagulants (aspirin) or other agents intended to improve microcirculation (pentoxifylline, ticlodipine) are often used.
3) Neuropathic Ulcers – located on the pressure points, due to microvascular insufficiency and neuronal death. There may be complete sensory loss of the skin. |
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Term
| Which auto-immune endocrine disorder is associated with ophthalmopathy, acropachy, and pretibial myxedema? |
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Definition
| Grave’s Disease – due to antibodies against TSH receptor, stimulating thyroid hormone secretion. |
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Term
| Describe the 4 major forms of cold-related dermatological responses to physical trauma. |
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Definition
Cold related injury is influenced by temperature, humidity and type of exposure. Normally skin reacts to cold by vasoconstriction, which may result in reticulate pattern (livido reticularis).
1) Frostbite – various degrees- blistering and necrosis
2) Non-freezing injury – Trench foot – long exposure to above freezing temperatures in wet conditions.
3) Cold panniculitis (“popsicle panniculitis” in kids)
- damage to fat underneath normal skin
4) Raynaud’s phenomenon |
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Term
| What are the possible long-term sequele associated with radiation burns? |
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Definition
Mechanism: Free radicals (ionizing radiation) or DNA damage and skin death/scarring.
1) radiation recall
2) pigmentation/sensation changes
3) ulceration
4) increased risk of malignancy. |
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Term
| What are the major forms of sports-related physical injury that produce dermatologic manifestations? |
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Definition
1) Friction – clavus (callus/corn); friction blister, dystrophic nails (“runner’s nails”)
2) Infections from contact sports:
- Viral – “herpes gladiatorum” (wrestlers)
- Bacterial – Methicillin resistant Staph aureus (MRSA)- football, basketball
- Fungal – “ringworm” (anywhere on the body) caused by dermatophytes
- “Jock itch” – Candida intertrigo produces dermatitis
- Allergic contact dermatitis due to specific exposures (rubber, leather, tape, glue) |
|
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Term
| Describe the classification system for staging burns. |
|
Definition
Decubitus ulcer pressure injuries are staged similarly
1) Epithelium
- red, dry, painful
2) Epidermal + partial dermal
- red, wet, very painful
3) Full dermal
- dry, leathery and waxy
4) Underlying soft tissue and bone |
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Term
What newborn dermatosis is describe by each of the following?
1) Benign condition with eosinophilia and eos around hair follicles, producing a blotchy rash
2) Benign superfiscial sterile pustules which rupture and leave hyperpigmented macules in African-American infants.
3) Produces diaper dermatitis with superficial pustules (so called satellite lesions)
4) Lesions produced because of immature/occluded sweat glands leading to sweat retention |
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Definition
1) Erythema Toxicum Neonatorun
2) Transient Neonatal Pustular Melanosis
3) Candidiasis- treat with topical azole cream
OR
HSV- treat IV acyclovir
4) Milaria
- Superficial (epidermis) – miliaria crystallina
- Mid dermis – miliaria rubra
- Deep dermal – miliaria profunda |
|
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Term
| What is Scabies and how may it relate to Acropostulosis? |
|
Definition
1) Scabies are very small mites.
- Need to treat the entire body with permethrin cream and treat all contacts.
- Lindane is contraindicated due to neurotoxicity.
2) When Acropostulosis is seen in neonate, it may represent a hypersensitivity reaction to scabies |
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Term
| How do you definitively diagnose Incontinentia Pigmenty and how does it present? |
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Definition
X-linked dominant, mutation in NEMO gene (more common in females)
1) Diagnose with biopsy and gene testing, and check for extracutaneous manifestations
2) Blisters → verrucous lesions →hyperpigmented whorls → hypopigmentation |
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Term
Neonate presents with papules and postules of undefined origin.
What diagnostic tests can you run to narrow down your diagnosis? |
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Definition
1) Culture: Impetigo
2) KOH: Candidiasis, Pityrosporum overgrowth
3) Tzank smear: Viral
4) Smear
- Eosinophils: Erythema toxicum
- Neutrophils and eosinophils: TNPM, infantile acropustulosis
5) Mineral oil scraping: Scabies
6) Biopsy: Incontinentia pigmenti |
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Term
A 5 day old boy is brought in for generalized “rash” which developed “all over his body”. The child feeds and sleeps well and does not appear to be irritated. He is bundled up with numerous blankets. The child’s exam is unremarkable with normal vital signs. His skin has normal color, but feels warm. He has numerous clear pinpoint vesicles which and few erythemotous papules with greatest concentration in axillaea, groin and trunk. His face is spared. Your advice to parents:
Admit to the hospital for supportive care
1) Consult infectious diseases specialist
2_ Discharge on antibiotics
3) To give acetaminophen and schedule a follow up
4) To unwrap the child and keep him cool as this condition is related to child’s overheating and immaturity of sweat gland |
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Definition
| The vignette describes miliaria. It is due to overheating of a child. Keeping the child cool and frequent cool baths recommended. The condition is not infectious and therapy with antibiotics is not necessary. |
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Term
A 3 week old girl is brought in with worsening diaper dermatitis for 2 weeks. On exam, diaper area reveals red and moist plaque with numerous smaller similar papules and plaques at the periphery (satellite lesions). You therapy should include:
1) Admission to the hospital and I.V. antifungal medications
2) Antibacterial wash after each diaper change
3) Antiviral medication i.v. as soon as possible
4) Oral antibiotics for bacterial infection
5) Topical antifungal (ketoconazole cream) |
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Definition
| 5: Satellite lesions with diaper rash means the patient has candida diaper dermatitis. |
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Term
Which of the following is NOT a risk factor for developing melanoma?
1. Smoking
2. Atypical nevi (moles)
3. First degree relative h/x
4. Childhood blistering sunburns
5. Fair skin and eyes. |
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Definition
1. Not classically associated.
Abnormal moles, first-degree relatives, childhood sunburns and fair phenoytype are all associated. |
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Term
| What are the ABCDE's of melanoma? |
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Definition
1. Asymmetry
2. Boarder irregularity
3. Color variation
4. Large diameter
5. Evolution |
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Term
| What are the 5 major types of melanoma? Which is most common? |
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Definition
1. Superficially spreading (70% MOST common)
- follows ABCDE rule
- median age ~40. Men/ trunk, women/legs.
2. Nodular melanoma – up to 20% .
- Rapid growth
- ulcerates, bleeds.
- In vertical growth phase from the beginning.
- High metastatic potential.
3. Lentigo malignant melanoma – 15%
- Elderly patients with history of chronic sun exposure.
- Most common on head and neck
- Slowly growing (decades), rarely metastasize.
4. Acral-lentigenous melanoma (rare)
- Most common type in darker skin individuals.
5. Amelanotic melanoma – no pigment.
- May look pink or red. Any subtype. |
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Term
| Describe a basic diagnostic workup strategy for suspected melanoma |
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Definition
1) Total body photography, dermatoscopy and excisional biopsy (if depth >1mm, you need a sentinal node biopsy)
2) Pathological evaluation
- Breslow thickness (depth of invasion of primary tumor) – the most important prognostic predictor; radial vs. vertical growth phase.
- Ulceration
- Number of mitoses
3) Sentinel lymph node biopsy in melanomas with unfavorable features (ulcer, mitoses) and depth >1 mm.
- If positive, followed by complete nodal dissection of the nodal basin.
- Evaluation for metastatic disease
4) CT and PET scans
5) LDH measurement |
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Term
Risk factor for melanoma include all of the following, EXCEPT:
1) Childhood sunburns
2) Fair skin and blue eyes
3) History of eczema
4) Numerous dysplastic nevi
5) Prior history of skin cancer and melanoma |
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Definition
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Term
The most important predictor of patient survival in melanoma is:
1) Depth of primary melanoma invasion (Breslow)
2) Horizontal growth phase
3) Mitoses
4) Ulceration
5) Vertical growth phase |
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Definition
| 1. Breslow depth is the most significant prognostic factor of all listed. |
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Term
If melanoma is suspected the most appropriate diagnostic procedure is:
1) Excisional biopsy
2) KOH scraping
3) Punch biopsy
4) Shave biopsy
5) Skin culture |
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Definition
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Term
Sentinel lymph node involvement is highly predictive of patients’ survival:
1) true
2) false |
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Definition
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Term
Which of the following is an INCORRECT description of basal cell carcinoma of the skin?
1. May take years to grow
2. Induced by UV light
3. Pink pearly papule with rolled borders and central ulceration
4. Commonly metastasize
5. Diagnosed by shave biopsy |
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Definition
4. These tumors rarely metastasize
They do grow indolently in response to UV exposure over time and present as pink, pearly papules with rolled borders. |
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Term
Which of the following is NOT an appropriate therapeutic approach for basal cell carcinoma?
1. Mohs surgery – evaluating 100% of the margin for high risk tumors and tumors of the head and neck
2. ED&C for non-surgical candidates
3. Excision with appropriate margins
4. Topical Vemurafenib
5. Topical 5-FU and photodynamic therapy |
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Definition
Pink, pearly papules that come about after UV exposure and tend not to metastasize.
4: Vemurafenib - bRAF inhibitor. bRAF mutations are common in patients with melanoma who have history of blistering sunburns. |
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Term
| What are the general treatment options for melanoma? |
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Definition
1) Wide local excision- margins depend on invasion depth
i. In situ – 5 mm
ii. <1 mm – 10 mm
iii. 1-2mm – 10-20 mm
iv. >2 mm – 20 mm
2. Complete nodal excision if sentinel lymph node is positive
3. Adjuvent INF-a in patients who are currently clear, but in whom cancer was previously detected in the lymph node or single metastasis and was successfully removed
4. In case of metastasis
i Ipilimumab – anti-CTLA4 antibody
ii. Vemurafenib - bRAF inhibitor.
iii. IL-2 – results in 6% of patients with complete and durable response to therapy. Extremely toxic.
iv. Temozolomide and Dacarbazine – no change in outcome, used for symptomatic relief. |
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Term
Which of the following is NOT a known risk factor for SCC?
1) Xeroderma pigmentosum
2) UV light
3) Arsenic
4) HSV
5) Scars, inflammation and infection
6) HPV |
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Definition
2nd most common cause of skin cancer death
4. HSV is not documented
Risk Factors
a. Xeroderma pigmentosum (DNA disorder, patients unable to repair DNA damage done by UV light)
b. UV light
c. Arsenic
d. Scars, inflammation and infection
e. Blistering disorders
f. Occupational exposure
g. Immune suppression
h. HPV |
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Term
| How is SCC diagnosed and treated? What are the major variants? |
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Definition
2-6% risk of metastasis (more than BCC)
1) 2 Variants diagnosed by shave biopsy
a. Keratoacanthoma
b. Verrucous carcinoma, radiation is contraindicated
2) Treatment (same as BCC)
a. Mohs surgery – evaluating 100% of the margin for high risk tumors and tumors of the head and neck
b. ED&C (moderate cure rates, for patients who are not surgical candidates)
c. Excision with appropriate margins
d. Radiation, cryosurgery
e. Topicals (Imiquimod, 5-FU, and photodynamic therapy) |
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Term
A 53 year old male presents with “non-healing sore” on the nose for 6 months. It is getting bigger and bleeds at times. On exam there is a pearly plaque with heaped up borders, telangictasia and central ulceration. What is the most appropriate diagnostic procedure?
1) Dermoscopy
2) Excisional biopsy
3) KOH scraping
4) Punch biopsy
5) Shave biopsy |
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Definition
| 5: The description provided is classic description of nodular basal cell carcinoma. It is superficial skin cancer. The best way to diagnose it is by shave biopsy – it provides wide sampling, but does not go deep into the skin. Punch biopsy is preferable for deep cutaneous tumors or rashes. Excisional biopsy and KOH scraping are inappropriate techniques for this diagnosis. Dermoscopy may aid in diagnosis, but tissue biopsy is gold standard |
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Term
What is the most appropriate therapy for nodular BCC
1) Electro-dissecation and curettage
2) Elliptical excision
3) Mohs surgery
4) Shave excision
5) Topical steroid – mid-potency |
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Definition
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Term
| What 2 skin diseases involve auto-antibodies against the epidermal skin layer proteins? |
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Definition
Pemphigus diseases (as opposed to pemphigoid)
1. Pemphigus vulgaris – erosions on mucous memberaines, flaccid bullae, hemorrhagic erosions and crusts. Very painful. Without therapy 100% lethal.
2. Pemphigus foliaceous – similar to vulgaris, but it is more superficial. Not as severe as vulgaris |
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Term
| What 4 skin diseases involve auto-antibodies against the epidermal-dermal skin junction proteins? |
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Definition
Pemphigoid group (bullous pemphigoid 1 and 2, laminins, Type VII collagen, integrins)
1. Bullous pemphigoid (most common) – large, tense bullae. Patients are very itchy.
2. Mucous membrane (cicatricial) pemphigoid
– conjunctival scarring may lead to blindness, esophagus, larynx may be affected resulting in stenosis.
- Need aggressive therapy.
3. Linear IgA – annualr lesions, bullae form a ring.
4. Epidermolysis Bullosa Aquisita (EBA) – bullae, hemorrhagic crusts, erosions on acral skin. Very painful and can affect daily activities of the patient. |
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Term
Which of the following does NOT involve autoantibody attack of the epidermal-dermal junction?
1. Bullous pemphigoid
2. Pemphigus vulgaris
3. Linear IgA
4. Epidermolysis Bullosa Aquisita
5. Mucous membrane (cicatricial) pemphigoid |
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Definition
2: Pemphigus vulgaris involves epidermus – erosions on mucous memberanes, flaccid bullae, hemorrhagic erosions and crusts. Very painful.
- Without therapy 100% lethal. |
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Term
| How are the autoimmune, blistering skin diseases diagnosed? |
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Definition
All immunobullous diseases are rare.
Pemphigus is painful
Pemphigoid is itchy
1) Pemphigus
– immunofluorescence (IF) shows deposition of antibodies on keratinocytes (hence, there is a fishnet pattern of IF
– the epidermal keratinocytes are outlined in pemphigus.
2) Pemphigoid IF shows immunoglobulin deposition at the dermo-epidermal junctions (DEJ). |
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Term
| How are the autoimmune, blistering conditions of the skin treated? |
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Definition
Corticosteroids is Mainstay
Rituximab is also effective
Try steroid-sparing agents (cyclophosphamide, MM)
Options
1) Corticosteroids
2) Anti-inflammatory drugs (Nicotinamines, antibiotics, etc) are not as effective
3) Steroid –sparing agents: Azathiorine, mycophenolate mofetil, cyclophosphomide
4) For IgA mediated diseases Dapsone is effective
5) IVIG and plasmapheresis were reported to be effective, but used with limited success
6) Rituximab is very effective. It is anti-CD20 antibody which targets and depletes B-cells. |
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Term
An 86 year old female patient presents to your primary care clinic with multiple tense blisters on her chest, back, and arms. The blisters are filled with clear fluid. She has no lesions on her conjunctiva or in her mouth. You press on the edge of one blister and it does NOT extend to adjacent skin. Select the correct diagnosis and level of blistering in this patient.
1) Bullous pemphigoid: intraepidermal
2) Bullous pemphigoid: subepidermal
3) Pemphigus vulgaris: intraepidermal
4) Pemphigus vulgaris: subepidermal
5) Staph scalded skin syndrome: subepidermal |
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Definition
| 2: Bullous pemphigoid: subepidermal. Bullous pemphigoid is an autoimmune blistering disorder that causes subepidermal (below the epidermis at the dermal-epidermal junction) blisters that are tense and not easily extended to adjacent skin. All answers with intraepidermal blistering (answers 1 and 3) can automatically be excluded because intraepidermal blisters are classically flaccid and readily dissect into surrounding normal tissue. Answers 4 and 5 are incorrect because both of these diagnoses cause intraepidermal blisters, not subepidermal blisters. |
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Term
You are an emergency department physician at a remote rural hospital. A patient presents with new-onset diffuse cutaneous blistering of unclear etiology. As part of your exam and review of systems, you should carefully document all of the following except:
1) Arthralgias
2) Conjunctiva irritation
3) Dysphagia
4) Dysuria
5) Vaginal pain |
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Definition
| 1: When evaluating a patient with a blistering disorder of unclear etiology, it is important to remember that many blistering diseases can affect a number of different epithelial surfaces. Failure to pay close attention to all mucosal surfaces can result in multiple preventable morbidities, including conjunctival scarring, blindness, and urethral strictures. Most immunobullous disorders do not have associated arthralgias. Therefore this is the correct answer for this question and the item that is least relevant to document. |
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Term
A patient presents to your clinic with extremely itchy papules on her elbows, buttocks, and scalp. On your review of systems, she endorses frequent bloating, abdominal pain, and occasional diarrhea. This patient most likely has antibodies directed against:
1) Desmoglein 3
2) Intrinsic factor
3) Tissue transglutaminase
4) Type IV collagen
5) Undefined nuclear antigen |
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Definition
| 3: This patient has dermatitis herpetiformis which is frequently associated with celiac disease (gluten-sensitive enteropathy). In celiac disease, patients have antibodies directed against tissue transglutaminase within the lamina propria of the small intestines. Desmoglein 3 antibodies are found in pemphigus vulgaris (answer 1). Antibodies to type IV collagen are found in Goodpasture disease (4). Intrinsic factor antibodies are found in pernicious anemia |
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Term
Your patient has a suspected autoimmune blistering disease. You review the results of his skin biopsy which reveal a split at the dermo-epidermal junction (between the dermis and epidermis). What is your diagnosis?
1) Bullous pemphigoid
2) I can’t tell—I need more information
3) Linear IgA bullous dermatosis
4) Paraneoplastic pemphigus
5) Toxic epidermal necrolysis |
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Definition
| 2: The level of the cleavage plane in the skin is the first step in evaluating a blistering disorder. However, multiple different and clinically distinct disorders can all have cleavage planes in the same layer of the skin. All the answer choices above have a cleavage plane at the dermo-epidermal junction! Direct immunofluorescence testing is generally the next test performed. This tells you whether the separation is antibody mediated (for example, there are no antibodies in toxic epidermal necrolysis) and also tells you what types of antibodies are involved (eg IgA vs IgG). Information from immunofluorescence is often essential to making a definitive diagnosis in immunobullous disorders. |
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Term
| What are the possible dermatological manifestations of ADRs? |
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Definition
1) Most commonly Morbilliform and Maculopapillary
- mild and need to substitute agent, unless very mild
2) DRESS- similar to 1, but with organ association
3) TEN/SJS- Life threatening (MUST STOP drug)
- Sulfa, aromatic anticonvulsants, allopurinol
- TEN (30% of skin), SJS (10$ of skin)
- Cause epidermal blisters (superficial) of 2 or more mucosal surfaces.
4) Vasculitis
- Palpable purpura, vesicles, bullae
5) Fixed drug reaction (same medication on same spot)
- Round dusky purple spots
- Sulfa common
6) Anticoagulant-induced skin necrosis in "fatty areas"
- Coumadin without prior heparinization
- transient Protein C and S deficiency association (hypercoaguable)
- Treat with heparin and debridement
7) AGEP: Rash and fever syndrome like DRESS
- stop drug
8) Acral erythema
- Painful, usually from chemo (cytarabine)
- Difficult to treat if cannot stop drug. |
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Term
| What is the most common cutaneous drug reaction? |
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Definition
Exanthematous drug eruption (DIFFERENT from DRESS, because there is no fever, eosinophilia lymphadenopathy or systemic involvement- hepatitis, nephritis or pneumonitis)
Itchy, but generally mild papular eruption
CAN "treat though" if med must be continued |
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Term
| What life-threatening drug reactions commonly occur to Sulfa drugs, Aromatic anticonvulsants and allopurinol? |
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Definition
Sloughing necrosis of oral and opathlmic mucosa within 2-5 days
Require supportive case (steroids or IVIG?) in the burn unit
1) Stephen-Johnson syndrome
- Hits < 10%
2) Toxic epidermal necrolysis (>30%)
- More widespread necrotic bullae development |
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Term
A 35-year old white female presents to her primary care physician because she is bothered by recurrent purple mark in her groin – it comes about once a month around the time of her period and is “itchy and burns”. Otherwise she is healthy and does not take any drugs besides occasional aspirin for menstrual cramps. On examination, she is a well appearing white female in no distress. Her right lower abdomen revealed an oval shaped dusky purple 5-cm plaque. There are no other lesions anywhere else. The most likely culprit for this lesion is:
1) Allergy to sanitary products
2) Aspirin
3) Decreased immune status
4) Menses
5) Polycystic ovarian failure |
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Definition
| 2- The vignette describes a fixed drug reaction. The only possible culprit here is Aspirin. |
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Term
A 17 year old white man presents to his primary care physician (PCP) 10 days after he prescribed him Bactrim for his severe nodulo-cystic acne. The teenager is complaining that he feels ill, has read and painful eyes and developed a mouth sore. He noticed his skin is red and feels “painful”, his palms have round dusky and painful “marks”. On exam, the patient is ill appearing and low grade fever, he has conjunctivitis, swelling of the eyelids; his mouth has several shallow ulcers. There is generalized macular erythema over most of his body with edema. There are targetoid lesions on his palms and soles. His PCP should:
1) Continue Bactrim or switch to another antibiotic (Staph Scalded Skin Syndrome)
2) Do nothing. Patient has viral exanthema not related to other conditions
3) Draw blood work and send patient home with follow up appointment tomorrow
4) Start antiviral medication for erythema multiforme due to oral HSV
5) Stop Bactrim immediately, initiate emergent admission to the burn unit for toxic epidermal necrolysis (TEN) |
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Definition
| This patient has a generalized “drug rash”, severe malaise, and 2 mucosal surfaces involved with the process. TEN is likely. |
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