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History & Physical/Dermatology A patient presents with a rash, characterized by red macules and edematous papules with a clearing center. This best describes which of the following? Answers A. erythema marginatum B. erythema multiforme C. varicella D. impetigo Explanations (u) A. Erythema marginatum is associated with rheumatic fever and is characterized by macular to maculopapular lesions. A clearing center is not found in the rash. (c) B. Target lesions, also termed iris lesions, are characteristic of erythema multiforme. The rash may be recurrent but typically resolves over 3-6 weeks. (u) C. The rash of varicella typically has maculopapules, vesicles, and scabs in various stages of development. A clearing center is not found in the rash. (u) D. The lesions of impetigo are pustules that form a honey-colored crust after rupturing. History & Physical/Dermatology In a patient suspected of having seborrheic dermatitis, the most common site of involvement would be the A. upper extremities. B. thighs. C. scalp. D. feet. Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. The most common site of involvement of seborrheic dermatitis is the scalp. Other common sites include the eyebrows, eyelids, nasolabial fold, and ears. (u) D. See C for explanation. Diagnostic Studies/Dermatology A 26 year-old male complains of intense itching, especially at night and after hot showers, for the past 4 days. On physical examination he has a few red papules and areas of excoriation on his volar wrists, between his fingers, and around his waist. Proper diagnosis should include which of the following tests? A. KOH prep B. Gram stain C. Skin scraping microscopy D. Tzanck prep Explanations (u) A. A KOH prep would be used to examine for evidence of a fungal infection. (u) B. A Gram stain would be used for a bacterial infection and would be inappropriate in this situation. (c) C. The history and exam is consistent with a scabies infection. Scrapings from the burrows should be examined for the presence of mites, eggs, and feces. (u) D. A Tzanck prep would be used to examine for giant multinucleated cells characteristic of a herpes infection. Diagnostic Studies/Dermatology A 35 year-old female who recently returned from a backpacking trip complains of fatigue, malaise, fever, chills, and arthralgias. Physical examination reveals a 6 cm annular lesion with a red border and a clear center on her mid-back. Which of the following laboratory tests would support your diagnosis? A. KOH prep of skin scrapings B. Blood cultures C. RAST testing D. Serologic antibody testing Explanations (u) A. Although the skin lesion may resemble a fungal infection, a fungal dermatophyte would not present with systemic symptoms. (u) B. Culturing of <i>Borrelia burgdorferi</i> from clinical specimens, with the exception of skin biopsies at the site of the lesion, have resulted in low yields. (u) C. RAST testing is utilized in evaluation of allergies and is not indicated in this situation. (c) D. Most people with Lyme Disease will have a positive serologic test after the first few weeks of infection and this would support the diagnosis. Diagnosis/Dermatology A 56 year-old, right hand dominant, carpenter presents to your clinic complaining of a prolonged bruise under his left thumbnail. He states that he first noticed it one year ago. Physical examination reveals a nontender left thumb with a 6 mm macular lesion located under the distal nail bed. It is mixed dark brown and black in color, with irregular borders. The most likely diagnosis is Answers A. lentigo. B. trauma. C. melanoma. D. nevus. Explanations (u) A. Lentigos are typically uniform in color with well-demarcated borders. (u) B. If the lesion was from trauma, it should have resolved well before one year. (c) C. Acral lentiginous melanoma may occur on the palm, sole, nail bed, or mucus membrane. This lesion is suspicious for a melanoma due to its irregular borders, being variegated in color, and its size. A biopsy is required and will insure the diagnosis. (u) D. A nevus usually has regular, well-demarcated borders. Diagnosis/Dermatology A mother brings in her 2 year-old child stating that the child has had a 3-day history of a nonproductive cough, thick copious rhinorrhea, conjunctivitis, and a fever to 103 degrees. Physical examination reveals a well-hydrated child, with numerous 1-2 mm white papules on both buccal mucosa, normal heart and breath sounds. This presentation is most consistent with early Answers A. rubeola. B. rubella. C. varicella. D. streptococcal pharyngitis Explanations (c) A. Rubeola (measles) is characterized by cough, coryza, and conjunctivitis, along with a fever as a prodrome. Koplik spots appear prior to the onset of the typical erythematous, maculopapular rash and are pathognomonic for rubeola. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. Health Maintenance/Dermatology A person with atopic dermatitis should be advised to A. avoid cutaneous irritants. B. take hot water baths or showers. C. use a high potency glucocorticoid on skin after bathing. D. begin a prophylactic antibiotic. Explanations (c) A. Avoidance of cutaneous irritants, such as wool and other rough clothing, is the cornerstone of therapy for atopic dermatitis. (u) B. Patients should bathe in warm, tepid water, not hot water. (u) C. Topical glucocorticoids of low or medium potency in a cream or ointment base should be used on the skin immediately after bathing. (u) D. Prophylactic antibiotics are not indicated in the treatment of atopic dermatitis. Clinical Intervention/Dermatology An elderly woman presents to your clinic complaining of unilateral facial pain and painful lesions. She also complains of blurred vision in the ipsilateral eye. On examination she has several vesicles on an erythematous base, some of the lesions with crusts. They are distributed in a dermatomal pattern and involve the skin overlying the maxillary region and the tip of her nose. Which of the following is the next most appropriate intervention in the care of this patient? A. KOH prep B. Culture for bacteria C. Referral to an ophthalmologist D. Application of corticosteroids (u) A. A KOH prep examining for fungal elements is not indicated in this case. (u) B. While bacterial infection may occur along with the viral infection, a bacterial culture is not usually employed. (c) C. Immediate referral to an ophthalmologist is needed when herpes keratitis is suspected, as in this case. A fluorescein stain of the eye might reveal the typical dendritic corneal lesion. (h) D. Application of corticosteroids may cause proliferation of the virus and should only used by an ophthalmologist Clinical Intervention/Dermatology A 28 year-old female with diabetes mellitus type 2 sustains a partial thickness burn to her left upper arm and her chest when hot grease spilled on her at home. The burn to her arm is circumferential and the estimated total body surface burned is 18%. She has no allergies. The most appropriate treatment of this patient would include A. outpatient application of silver sulfadiazine. B. debridement of all intact blisters. C. IV cefazolin (Ancef, Kefzol). D. transfer to a burn center. (u) A. Although treatment may include silver sulfadiazine dressings, this patient should not be treated as an outpatient. Also see D for explanation. (u) B. Debridement of intact blisters remains controversial, however many authorities recommend leaving intact blisters intact and only debride ruptured blisters. (u) C. If used in the care of a burn patient, the antibiotic selected should have activity against Pseudomonas and S. aureus. Cefazolin does not have any antipseudomonal activity. (c) D. Reasons for transfer to a burn center include a partial thickness burn covering greater than 10% of total body surface area. In addition, burns in patients with pre-existing medical conditions, such as diabetes, that could complicate their management, prolong recovery, or affect their outcome, is also a reason for transfer to a burn center. Clinical Therapeutics/Dermatology Pharmacologic treatment of a cat bite in the person with no allergies consists of which of the following? Answers A. Trimethoprim-sulfamethoxazole (Bactrim) B. Cephalexin (Keflex) C. Ceftriaxone (Rocephin) D. Amoxicillin-clavulanate (Augmentin) Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Amoxicillin-clavulanate (Augmentin) has activity against Pasteurella multocida which is the causative agent in the majority of cat bite infections. Scientific Concepts/Dermatology Which of the following is characterized by epidermal hyperplasia and an increase in the epidermal turnover? Answers A. Atopic dermatitis B. Tinea corporis C. Ecthyma D. Psoriasis Explanations (u) A. Inflammation in atopic dermatitis results in lichenification of the skin from itching, which leaves the skin dry and scaly when it resolves. The inflammation is the result of elevated T- lymphocyte activation, defective cell-mediated immunity, and IgE overproduction. Epidermal hyperplasia is not involved in atopic dermatitis. (u) B. Tinea corporis is a fungal infection and is does not have epidermal hyperplasia. (u) C. Erythema is the result of an infection from group A beta-hemolytic streptococcus and contaminated with staphylococci. Like atopic dermatitis and tinea corporis, ecthyma has no epidermal hyperplasia. (c) D. Psoriasis is characterized by an increased epidermal cell turnover, increased numbers of epidermal stem cells, and an abnormal differentiation of keratin . This leads to the classic scale associated with psoriasis. Health Maintenance/Dermatology Which of the following is considered a risk factor for the development of malignant melanoma? A. male gender B. inability to tan C. Japanese ethnicity D. brown-haired individuals Explanations (u) A. Incidence of malignant melanoma is equal in males and females. (c) B. Inability to tan and propensity to burn are risk factors for developing malignant melanoma. (u) C. Malignant melanomas are most common in Caucasians and are rarely seen in the Japanese population. (u) D. Red hair and freckling is one of the major risk factors for malignant melanoma, not brown hair. Clinical Intervention/Dermatology As a general rule, sutures in the face should be removed in A. 3 days. B. 5 days. C. 7 days. D. 10 days. Explanations (u) A. See B for explanation. (c) B. Sutures of the face should be removed in 5 days in order to allow for adequate healing and to limit the amount of scarring. (u) C. See B for explanation. (u) D. See B for explanation. Diagnosis/Dermatology A mother brings a 3 month-old infant to the office because she is concerned about a red, vascular, nodular growth on the child's back. It appears to be enlarging slightly and the vessels are slightly dilated. It seems to cause the child no discomfort. The most likely diagnosis is A. a hemangioma. B. a pigmented nevus. C. a salmon patch (stork bite). D. a malignant melanoma. (c) A. A hemangioma is a bright red to deep purple vascular nodule or plaque that often develops at birth, may enlarge, and may regress and disappear with aging. (u) B. A pigmented nevus is not a vascular lesion. (u) C. A salmon patch is a light red macule over the nape of the neck or the glabella. (u) D. A malignant melanoma presents as a hyperpigmented, asymmetric lesion with irregular borders and is typically seen in the adult population. History & Physical/Dermatology Erythema nodosum is characterized by A. subcutaneous red tender nodules. B. brown pigmentation on the lower extremities. C. tender lymph nodes in the groin. D. scaling red macules. Explanations (c) A. Erythema nodosum produces erythematous red tender nodules, especially on the shins. (u) B. Brown pigmentation on the lower extremities is a feature of chronic venous insufficiency. (u) C. Lymphovenereum granuloma is likely to produce tender lymph nodes in the groin as can acute infection in the lower extremities. (u) D. Scaling red macules are a feature of tinea corporis. Scientific Concepts/Dermatology Which of the following mediators is responsible for initiating the urticaric response? A.Cyclic AMP B. Prostaglandins C. Prednisone D. IgE Explanations (u) A. Increased levels of Cyclic AMP inhibit the histamine response. (u) B. Prostaglandins inhibit the release of histamine. (u) C. Prednisone is used to treat urticaria. (c) D. IgE triggers the release of histamine from mast cells that leads to urticaria. Clinical Therapeutics/Dermatology A 45 year-old female presents to the emergency department with generalized, hot, erythema of the skin. Physical exam reveals an oral temperature of 102 degrees Fahrenheit, purulent conjunctivitis, and mucosal erosions. Her skin is painful and separates from the dermis with touch. Which of the following is the most likely cause for this condition? A. Ampicillin B. Prednisolone C. Aspirin D. Hydrochlorothiazide (HCTZ) Explanations (c) A. Medications are most frequently implicated in toxic epidermal necrolysis. These usually include, analgesics (NSAIDs), antibiotics (Ampicillin) and anticonvulsants (Carbamazepine). (u) B. Systemic glucocorticoids may be used early in the treatment of this condition and are not a cause. (u) C. Aspirin is not linked to toxic epidermal necrolysis. (u) D. Hydrochlorothiazide diuretics are not associated with the production of toxic epidermal necrolysis. Diagnosis/Dermatology A patient presents with loss of pigmentation on the back of hands, face, and body folds due to the absence of epidermal melanocytes. There has been improvement with PUVA treatment. Which of the following is the most likely diagnosis? A. Pityriasis alba B. Tinea versicolor C. Vitiligo D. Melasma Explanations (u) A. Pityriasis alba is caused by dermal inflammation that becomes scaly and hypopigmented. (u) B. Tinea versicolor is a fungal infection of the skin presenting as oval or circular lesions (c) C. Vitiligo is the acquired loss of pigmentation due to the absence of epidermal melanocytes presenting on the back of hands, face, or body folds. (u) D. Melasma is an acquired brown hyperpigmentation involving the face and neck in women during their second or third trimester of pregnancy. Diagnostic Studies/Dermatology A 26 year-old female presents with several pruritic lesions on her dorsal forearms. The lesions are erythematous with vesicles, with a few beginning to weep. She works in a photography laboratory, but denies any other possible exposures. Which of the following is the most useful diagnostic test? A. VDRL serology B. KOH prep C. Patch testing D. Gram's stain Explanations (u) A. VDRL serology is useful in the diagnosis of syphilis, not contact dermatitis. (u) B. KOH prep is used for diagnosis of fungal infections, not contact dermatitis. (c) C. Patch testing with a suspected agent is usually positive in cases of allergic contact dermatitis. (u) D. Gram's stain is useful in the diagnosis of bacterial infections, not contact dermatitis. Diagnostic Studies/Dermatology A positive Wood's light examination (fluorescence) demonstrates A. viral infection with herpes zoster. B. bacterial infection with Treponema pallidum. C. parasitic infestation with Pediculus humanus. D. mycotic infection with Microsporum canis. Explanations (u) A. Lesions of herpes, Treponema, and Pediculus infections do not fluoresce. (u) B. See A for explanation. (u) C. See A for explanation. (c) D. Microsporum causes tinea capitis and fluoresces blue-green under Wood's light. History & Physical/Dermatology In which of the following patients would one most likely find acanthosis nigricans? A. A 55 year-old obese female with hyperinsulinemia B. A 55 year-old male with an enlarged spleen and pancytopenia C. A 24 year-old female with increased Lyme titers D. A 60 year-old male with increased triglycerides Explanations (c) A. Acanthosis nigricans is associated with patients who have hyperinsulinemia. (u) B. Hairy cell leukemia is associated with an enlarged spleen and pancytopenia. Acanthosis nigricans is not a cutaneous manifestation. (u) C. Erythema chronicum migrans is the characteristic lesion associated with Lyme disease. (u) D. Eruptive xanthelasma is associated with increased triglycerides. Clinical Intervention/Dermatology Which of the following interventions is the treatment of choice for actinic keratosis? A. Mohs surgery B. Cryotherapy C. Acid peels D. Radiation therapy Explanations (u) A. Mohs surgery and radiation therapy are not indicated in the treatment for actinic keratosis. (c) B. Cryotherapy is the treatment of choice for isolated superficial actinic keratosis. (u) C. Acid peels can be used to treat actinic keratosis but are not the treatment of choice. (u) D. See A for explanation. Diagnosis/Dermatology A 65 year-old male presents with multiple lesions on his back. He denies any pruritis. Physical examination reveals the presence of multiple scattered brown plaques with a raised, warty surface that appear to be stuck onto the skin and feel greasy. Which of the following is the most likely diagnosis? A. lentigines B. actinic keratosis C. keratoacanthomas D. seborrheic keratosis Explanations (u) A. Lentigines most commonly are seen on the dorsum of the hand and appear as flat brown spots, often with sharp borders. (u) B. Actinic keratosis usually present as small patches of flesh-colored, pink or yellow-brown lesions often with an erythematous component. The lesions are better felt than seen, having a rough, sandpaper feel and are often tender to palpation. (u) C. Keratoacanthomas usually occur as an isolated lesion on the face appearing as an erythematous, dome- shaped nodule with a central keratinaceous plug. (c) D. Seborrheic keratosis is a common benign plaque in the elderly that characteristically has a velvety or warty surface associated with a stuck on appearance and greasy feel. Diagnostic Studies/Dermatology A 34 year-old female presents with complaints of a skin rash associated with a low-grade fever, malaise and anorexia. She denies any pruritis. Physical examination reveals the presence of a diffuse maculopapular rash involving the palms and soles associated with generalized lymphadenopathy. Which of the following will confirm the suspected diagnosis? A. VDRL B. patch testing C. acetowhitening D. Gram stain and culture Explanations (c) A. This patient most likely has secondary syphilis. Serological tests, like the VDRL, are usually positive during this stage with high titers. (u) B. Patch testing is utilized to identify a causative agent and confirm a diagnosis of allergic contact dermatitis. (u) C. Acetowhitening helps in the detection of subclinical penile or vulvar warts. (u) D. Gram stain and culture should be performed on lesions suspected to have a bacterial origin. Health Maintenance/Dermatology According to the Advisory Committee on Immunization Practices, which of the following is the recommended age range for the first or initial MMR (measles, mumps and rubella) vaccination? A. 2-4 months B. 12-15 months C. 4-6 years D. 11-12 year Explanations (h) A. MMR vaccination is not approved for use in infants below the age of 12 months. (c) B. The recommended age range for the initial vaccination against MMR is 12-15 months. (u) C. The second dose of the MMR vaccine is routinely recommended to be administered between 4-6 years of age. (u) D. Any child not previously vaccinated by 11-12 years of age may receive the vaccine. This is considered to be a "catch-up" immunization and is not the recommended age range for the initial vaccination. Clinical Therapeutics/Dermatology What scabicide has been associated with neurotoxicity in infants and young children? A. lindane (Kwell) B. crotamiton (Eurax) C. 10% sulfur ointment D. permethrin (Elimite) Explanations (c) A. Lindane (Kwell) is concentrated in the CNS and toxicity from systemic absorption in infants has been reported. (u) B. Crotamiton (Eurax) is not associated with CNS toxicity and is an effective scabicide. Its primary side effects include dermatitis and conjunctivitis. (u) C. Sulfur ointment is no longer used because newer agents have been developed and is not neurotoxic. (u) D. Permethrin (Elimite) is the drug of choice for the treatment of scabies and is not associated with neurotoxicity. Clinical Intervention/Dermatology A mother brings in her 3 month-old infant and states that she has noticed a rash on her infant's scalp. Physical examination reveals the presence of erythematous and scaling crusty lesions involving the vertex of the scalp. Which of the following is the most appropriate initial intervention? A. selenium sulfide shampoo B. permethrin 1% cream rinse C. warm olive oil compresses D. scrubbing of scalp with hexachlorophene Explanations (u) A. While selenium sulfide shampoos can be used in treatment of scalp seborrheic dermatitis in adults, it is not recommended for use in infants and young children. (u) B. Permethrin 1% cream rinse is utilized in the treatment of pediculosis, not seborrheic dermatitis. (c) C. This infant most likely has scalp seborrheic dermatitis ("cradle cap"). Initial treatment consists of warm olive oil compresses to remove any crusts followed by use of baby shampoo or mild hydrocortisone cream. (u) D. Hexachlorophene is a bacteriostatic skin cleanser which is not indicated in the treatment of seborrheic dermatitis. It is also not recommended for use in infants and young children.