ROSH REVIEW Dermatology UPDATED ACTUAL Questions and
CORRECT Answers
1. 24-year-old man Correct Answer ( A )
presents for eval- Explanation:
uation of a rash. This patient has pityriasis rosea. This is a mild skin eruption that is self-limited
The patient reports usually lasting 4 to 7 weeks. There is no clear etiology of the rash although
a mildly pruritic infection with Herpesvirus 7 or a fungus is suspected. Prior to the onset of
rash on his back the diffuse rash, patients may recall a herald patch described as a 2 to 5 cm
and trunk that pro- erythematous oval plaque similar to the smaller more diffuse lesions. The rash
gressively spread is described as following a "Christmas tree" pattern on the trunk, classically
over the last week. following the skin cleavage lines. There is no indicated treatment for pityriasis
You examine and rosea other than antihistamines for symptomatic relief if the rash is pruritic.
note the rash seen
above. Which of the A history of travel to the Southeast USA (D) before the onset of rash should
following historical raise an index of suspicion for an infectious etiology to the rash like Rocky
elements is most Mountain Spotted fever, a tick-borne illness caused by Rickettsia rickettsii.
likely to be ob- This illness occurs most commonly in late spring and early summer and is
tained upon further characterized by a rash that starts distally and spreads to the core.
questioning?
A larger 2 to 5
cm erythematous
patch preceded the
diffuse rash
Fever preceded the
onset of rash
Oral mucosal le-
sions preceded the
onset of rash
Travel to the South-
east USA occurred
a week before the
rash
,2. One Step Further Answer: No, the rash cannot be spread by direct contact.
Question: Is the
rash of pityriasis
rosea contagious?
3. An 18-year-old Correct Answer ( D )
obese woman pre- Explanation:
sents to your of- Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that
fice with a com- causes scarring, keloids, contractures and immobility. Originally believed to be
plaint of redness caused by a defect in the apocrine glands, it may also be due to a defect in
and pain in her the follicular epithelium. HS begins in adolescence or adulthood in otherwise
right axilla. Physi- healthy individuals. Risk factors for the development of HS include obesity,
cal exam reveals a genetics, smoking, diet and mechanical stress on the skin. Onset is insidious,
solitary nodule, ap- with the first presentation generally being erythema in an intertriginous skin
proximately 2 cm in area, most commonly the axilla. As the disease progresses, formation of sinus
size, with surround- tracts, multiple open comedomes and scarring occur. The initial presentation
ing inflammation can mimic other disorders and individuals often are diagnosed incorrectly with
and erythema. She recurrent furunculosis. Diagnosis is a clinical one. Treatment includes medical
tells you that she's management in the early stages and surgical intervention after the formation
had similar "boils" of abscesses or sinus tracts.
in the past. Which
of the following is
the most likely di-
agnosis?
Contact dermatitis
Dermoid cyst
Granuloma in-
guinale
Hidradenitis sup-
purativa
,4. One Step Further Answer: Acne inversa.
Question: What is
the other name for
hidradenitis suppu-
rativa?
5. A 60-year-old man Correct Answer ( C )
with a history of di- Explanation:
abetes presents to Onychomycosis is a fungal infection of the toenails or fingernails that can
your office with a involve any part of the nail including the plate, bed or matrix. There are several
complaint of thick- subtypes of onychomycosis, with the most common being distal subungual
ened and discol- onychomycosis. This type presents with the great toe being the first affected.
ored toenails. He A white, yellow or brown discoloration can be seen that eventually spreads
tells you that his to the entire nail. Onycholysis, the separation of the nail from the plate, may
toenails have had also be seen. Onychomycosis is initially a cosmetic concern, however with
this appearance for time it can cause pain, disfigurement, and decreased quality of life. Other nail
over a year, and dystrophies can present similarly to onychomycosis, therefore establishing the
now he is ex- presence of a fungal etiology is recommended prior to initiation of treatment.
periencing discom- Diagnosis is with potassium hydroxide (KOH) examination of nail scrapings.
fort when wearing Patients who are immunocompromised or who have diabetes mellitus are
tight-fitting shoes. at an increased risk of bacterial infections due to onychomycosis. Treatment
Physical exam re- should be considered in these patients to avoid sequelae.
veals hyperkerato-
sis and onycholy- Once a fungal etiology has been determined, first-line treatment is with oral
sis of bilateral great antimycotic agents such as terbinafine (A). Terbinafine can cause hepatotoxi-
and second toes. city, so pretreatment serum aminotransferases (B) should be measured prior
Which of the follow- to initiating therapy and then monitored during the course of treatment.
ing is the most ap-
propriate next step
in management?
Begin treat-
, ment with oral
terbinafine
Check serum
aminotransferases
Potassium hydrox-
ide examination of
toenail scrapings
Watchful waiting
6. One Step Further Answer: Dermatophyte infection.
Question: What is
the most common
etiology of ony-
chomycosis?
7. A 18-year-old Correct Answer ( B )
woman presents Explanation:
with a diffuse papu- Pityriasis rosea is a common acute eruption usually affecting children and
losquamous rash. young adults; the cause is unknown. It is characterized by the formation of an
The rash began one initial herald patch, followed by the development of a diffuse papulosquamous
month prior when rash. Pityriasis rosea is diflcult to identify until the appearance of characteristic,
she noticed a large smaller, secondary lesions that follow Langer's lines. The rash of pityriasis rosea
patch on her neck typically lasts 8 to 12 weeks, with complete resolution in most patients. An
that was followed important goal of treatment is to control pruritus, which may be severe; zinc
by the diffuse papu- oxide, calamine lotion, topical steroids, and oral antihistamines are usually
losquamous rash. helpful. Systemic steroids are generally not recommended. Patients should
You inform the pa- be reassured about the self-limited nature of pityriasis rosea. Persistence
tient that the rash of the rash or pruritus beyond 12 weeks should prompt reconsideration of
will last 5-8 weeks the original diagnosis, consideration of biopsy to confirm the diagnosis, and
and prescribe her questioning the patient again about use of medications that may cause a rash
cetirizine. Which of similar to that of pityriasis rosea.
the following is the
CORRECT Answers
1. 24-year-old man Correct Answer ( A )
presents for eval- Explanation:
uation of a rash. This patient has pityriasis rosea. This is a mild skin eruption that is self-limited
The patient reports usually lasting 4 to 7 weeks. There is no clear etiology of the rash although
a mildly pruritic infection with Herpesvirus 7 or a fungus is suspected. Prior to the onset of
rash on his back the diffuse rash, patients may recall a herald patch described as a 2 to 5 cm
and trunk that pro- erythematous oval plaque similar to the smaller more diffuse lesions. The rash
gressively spread is described as following a "Christmas tree" pattern on the trunk, classically
over the last week. following the skin cleavage lines. There is no indicated treatment for pityriasis
You examine and rosea other than antihistamines for symptomatic relief if the rash is pruritic.
note the rash seen
above. Which of the A history of travel to the Southeast USA (D) before the onset of rash should
following historical raise an index of suspicion for an infectious etiology to the rash like Rocky
elements is most Mountain Spotted fever, a tick-borne illness caused by Rickettsia rickettsii.
likely to be ob- This illness occurs most commonly in late spring and early summer and is
tained upon further characterized by a rash that starts distally and spreads to the core.
questioning?
A larger 2 to 5
cm erythematous
patch preceded the
diffuse rash
Fever preceded the
onset of rash
Oral mucosal le-
sions preceded the
onset of rash
Travel to the South-
east USA occurred
a week before the
rash
,2. One Step Further Answer: No, the rash cannot be spread by direct contact.
Question: Is the
rash of pityriasis
rosea contagious?
3. An 18-year-old Correct Answer ( D )
obese woman pre- Explanation:
sents to your of- Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that
fice with a com- causes scarring, keloids, contractures and immobility. Originally believed to be
plaint of redness caused by a defect in the apocrine glands, it may also be due to a defect in
and pain in her the follicular epithelium. HS begins in adolescence or adulthood in otherwise
right axilla. Physi- healthy individuals. Risk factors for the development of HS include obesity,
cal exam reveals a genetics, smoking, diet and mechanical stress on the skin. Onset is insidious,
solitary nodule, ap- with the first presentation generally being erythema in an intertriginous skin
proximately 2 cm in area, most commonly the axilla. As the disease progresses, formation of sinus
size, with surround- tracts, multiple open comedomes and scarring occur. The initial presentation
ing inflammation can mimic other disorders and individuals often are diagnosed incorrectly with
and erythema. She recurrent furunculosis. Diagnosis is a clinical one. Treatment includes medical
tells you that she's management in the early stages and surgical intervention after the formation
had similar "boils" of abscesses or sinus tracts.
in the past. Which
of the following is
the most likely di-
agnosis?
Contact dermatitis
Dermoid cyst
Granuloma in-
guinale
Hidradenitis sup-
purativa
,4. One Step Further Answer: Acne inversa.
Question: What is
the other name for
hidradenitis suppu-
rativa?
5. A 60-year-old man Correct Answer ( C )
with a history of di- Explanation:
abetes presents to Onychomycosis is a fungal infection of the toenails or fingernails that can
your office with a involve any part of the nail including the plate, bed or matrix. There are several
complaint of thick- subtypes of onychomycosis, with the most common being distal subungual
ened and discol- onychomycosis. This type presents with the great toe being the first affected.
ored toenails. He A white, yellow or brown discoloration can be seen that eventually spreads
tells you that his to the entire nail. Onycholysis, the separation of the nail from the plate, may
toenails have had also be seen. Onychomycosis is initially a cosmetic concern, however with
this appearance for time it can cause pain, disfigurement, and decreased quality of life. Other nail
over a year, and dystrophies can present similarly to onychomycosis, therefore establishing the
now he is ex- presence of a fungal etiology is recommended prior to initiation of treatment.
periencing discom- Diagnosis is with potassium hydroxide (KOH) examination of nail scrapings.
fort when wearing Patients who are immunocompromised or who have diabetes mellitus are
tight-fitting shoes. at an increased risk of bacterial infections due to onychomycosis. Treatment
Physical exam re- should be considered in these patients to avoid sequelae.
veals hyperkerato-
sis and onycholy- Once a fungal etiology has been determined, first-line treatment is with oral
sis of bilateral great antimycotic agents such as terbinafine (A). Terbinafine can cause hepatotoxi-
and second toes. city, so pretreatment serum aminotransferases (B) should be measured prior
Which of the follow- to initiating therapy and then monitored during the course of treatment.
ing is the most ap-
propriate next step
in management?
Begin treat-
, ment with oral
terbinafine
Check serum
aminotransferases
Potassium hydrox-
ide examination of
toenail scrapings
Watchful waiting
6. One Step Further Answer: Dermatophyte infection.
Question: What is
the most common
etiology of ony-
chomycosis?
7. A 18-year-old Correct Answer ( B )
woman presents Explanation:
with a diffuse papu- Pityriasis rosea is a common acute eruption usually affecting children and
losquamous rash. young adults; the cause is unknown. It is characterized by the formation of an
The rash began one initial herald patch, followed by the development of a diffuse papulosquamous
month prior when rash. Pityriasis rosea is diflcult to identify until the appearance of characteristic,
she noticed a large smaller, secondary lesions that follow Langer's lines. The rash of pityriasis rosea
patch on her neck typically lasts 8 to 12 weeks, with complete resolution in most patients. An
that was followed important goal of treatment is to control pruritus, which may be severe; zinc
by the diffuse papu- oxide, calamine lotion, topical steroids, and oral antihistamines are usually
losquamous rash. helpful. Systemic steroids are generally not recommended. Patients should
You inform the pa- be reassured about the self-limited nature of pityriasis rosea. Persistence
tient that the rash of the rash or pruritus beyond 12 weeks should prompt reconsideration of
will last 5-8 weeks the original diagnosis, consideration of biopsy to confirm the diagnosis, and
and prescribe her questioning the patient again about use of medications that may cause a rash
cetirizine. Which of similar to that of pityriasis rosea.
the following is the
